Differential disparities in coronary revascularization across serious mental illness subtypes: A Nationwide analysis of 6.2 million myocardial infarction hospitalizations

BACKGROUND: Patients with serious mental illness (SMI) have elevated cardiovascular mortality. We examined whether coronary revascularization rates differ across SMI subtypes among patients hospitalized for acute myocardial infarction (AMI). METHODS: We analyzed the National Inpatient Sample (2016-2023), including adults with AMI, excluding inter-hospital transfers, palliative care encounters, and type 2 myocardial infarction. SMI subtypes were classified hierarchically into mutually exclusive groups. Survey-weighted logistic regression estimated adjusted odds ratios (aOR) for revascularization, adjusting for demographics, comorbidities, hospital region, and year. Prespecified sensitivity analyses assessed temporal trends, age- and sex-stratified associations, and models excluding substance use disorder. RESULTS: Among 6,215,139 weighted AMI hospitalizations, 125,905 (2.0%) involved patients with SMI. SMI was associated with lower revascularization odds (aOR 0.56, 95% CI 0.54-0.58), with substantial variation by subtype: schizophrenia (aOR 0.38, 95% CI 0.36-0.41), schizoaffective disorder (aOR 0.41, 95% CI 0.37-0.45), and bipolar disorder (aOR 0.68, 95% CI 0.66-0.71). Subtype-specific disparities extended to same-day PCI timeliness among STEMI patients. Schizophrenia was associated with higher in-hospital mortality (aOR 1.23, 95% CI 1.11-1.36), schizoaffective disorder was not, and bipolar disorder was associated with modestly lower mortality (aOR 0.88, 95% CI 0.81-0.95). CONCLUSIONS: Patients with schizophrenia and schizoaffective disorder had approximately 60% lower revascularization odds versus approximately 30% lower odds among those with bipolar disorder. These patterns were robust across sensitivity analyses and suggest that diagnostic heterogeneity within SMI should be considered in efforts to reduce cardiovascular care inequities.