Comorbidity Clusters and in-hospital Outcomes in Patients Admitted With Acute Myocardial Infarction in the Usa: a National Population-based Study

Salwa S. Zghebi, Martin K. Rutter, Louise Y. Sun, Waqas Ullah, Muhammad Rashid, Darren M. Ashcroft, Douglas T. Steinke, Stephen Weng, Evangelos Kontopantelis, Mamas A. Mamas


The prevalence of multimorbidity in patients with acute myocardial infarction (AMI) is increasing. It is unclear whether comorbidities cluster into distinct phenogroups and whether are associated with clinical trajectories.


Coronary heart disease (CHD) is the leading cause of mortality worldwide [1, 2], with over 800,000 patients sustaining an acute myocardial infarction (AMI) each year in the US [1]. Multimorbidity (or comorbidity) is defined as the co-existence of two or more comorbidities in the same individual [3]. The number of people living with multiple long-term conditions has increased in recent years driven by increased life expectancy and improved healthcare [3]. In the US, the prevalence of multimorbidity and affects more than one quarter of adults [4, 5].

Materials and method

Data were derived from the US Nationwide Inpatient Sample (NIS) which is the largest all-payer data on inpatient stays from all US hospitals participating in the Healthcare Cost and Utilization Project (HCUP). Sponsored by the US Agency for Healthcare Research and Quality (AHRQ), the NIS data is the largest available all-payer data on inpatient stays from US states participating in the Healthcare Cost and Utilization Project (HCUP), covering over 97% of the US population [17].


Overall, mean (±SD) age was 67 (±13) years, 38% were females, and 76% were White and 12% were Black (Table 1). Patients in Class 2 were the youngest (62 ± 13 years) and had the highest male proportion (66%, 66–67%) and the highest proportion on Medicaid as the primary expected payer (10%, 10–11%)


Using a representative cohort of 416,655 AMI admissions from a national US inpatient database, we identified distinct phenogroups defined by varying comorbidity profiles via latent classes. While a few comorbidities were dominant across all classes, such as HTN and CHD, each class had the highest prevalence of ≥1 specific comorbidity, resulting in five unique phenogroups.


Patients admitted with AMI have a high comorbidity burden, including non-cardiometabolic comorbidities, which we defined into five distinct phenogroups that are highly predictive of specific adverse outcomes. The grouping of some comorbidities in specific classes is likely driven by shared pathophysiology or due to health disparities, at least partially driven by age and race.

Citation: Zghebi SS, Rutter MK, Sun LY, Ullah W, Rashid M, Ashcroft DM, et al. (2023) Comorbidity clusters and in-hospital outcomes in patients admitted with acute myocardial infarction in the USA: A national population-based study. PLoS ONE 18(10): e0293314.

Editor: Amirmohammad Khalaji, Tehran University of Medical Sciences, ISLAMIC REPUBLIC OF IRAN

Received: July 14, 2023; Accepted: October 9, 2023; Published: October 26, 2023

Copyright: © 2023 Zghebi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The third party data underlying the results presented in this study are available upon request from the Healthcare Cost and Utilization Project (HCUP) - National (Nationwide) Inpatient Sample (NIS) via their website ( All interested researchers can access the data through HCUP directly. The authors of this study are not permitted to share the data or make it publicly available as per the data use agreement with HCUP. The authors did not have any special access privileges to this data.

Funding: This study is funded by The University of Manchester as part of the Presidential Fellowship provided to SSZ. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: SSZ, LYS, EK, MKR, DS, DMA MAM, MR declare no competing interests. SW is a currently an employee of GSK. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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