Alcohol use in STEMI patients: a complicated clinical course with paradoxically improved survival

Background Comorbid alcohol use complicates the clinical profile of acute coronary syndromes, often serving as a proxy for polysubstance use and social vulnerability. However, its independent impact on survival and resource utilisation following STEMI remains poorly defined. Purpose To analyze the clinical impact of alcohol use in a nationwide STEMI cohort to determine survival, in-hospital complications, and readmissions compared to non-alcohol users. Methods We analyzed the Nationwide Readmissions Database (2019-2022) to identify adult STEMI hospitalizations. The cohort was stratified by comorbid alcohol use. We performed 1:1 propensity score matching (PSM) [nearest neighbor, caliper 0.2] to balance age, sex, payer status, hospital characteristics, and Elixhauser comorbidities. Doubly robust multivariable regression combining PSM with covariate adjustment was utilized to assess in-hospital mortality, 30-day readmission, length of stay (LOS), hospital charges, and routine home discharge. Results Of 569,574 weighted STEMI hospitalizations (median age 64; 30.4% female), 22,571 (4.0%) had comorbid Alcohol Use. Compared with controls, the Alcohol Use cohort presented with higher acuity, including significantly elevated rates of cardiac arrest (10.5% vs 8.0%), ventricular tachycardia/fibrillation (24.4% vs 19.9%), and sepsis (3.2% vs 2.3%; all P<.05). In doubly robust multivariable analysis, Alcohol Use was associated with lower in-hospital mortality (aOR 0.86; 95% CI 0.77-0.95; P=.005). However, survival advantage was accompanied by prolonged length of stay (Ratio 1.14; 95% CI 1.11-1.17), increased hospital charges (Ratio 1.05; 95% CI 1.03-1.08), and reduced odds of routine home discharge (aOR 0.91; 95% CI 0.85-0.98; all P<.05). Adjusted 30-day readmission risk showed an increased trend (aOR 1.09; 95% CI 0.99-1.21; P=.069), with heart failure being the leading cause of readmission (25.1%). Conclusion STEMI in the context of alcohol use lends a high-acuity phenotype associated with significantly elevated rates of cardiac arrest, ventricular arrhythmia, and sepsis/septic shock. While alcohol use in this population significantly increases hospital charges and length of stay, these patients demonstrate superior in-hospital survival. Increased resource utilisation and prolonged length of stay likely reflect intensive management required for this critical presentation, necessitating a comprehensive approach that addresses both clinical stabilization and complex discharge needs.