Association of Changes in Clinical Characteristics and Management With Improvement in Survival Among Patients With ST-Elevation Myocardial Infarction

Study Questions:

What factors have led to the improvements in outcomes after ST-segment elevation myocardial infarction (STEMI)?

Methods:

This was a retrospective analysis of four nationwide French registries that included patients with STEMI (positive troponins and electrocardiogram changes or symptoms) admitted alive to coronary critical care units within 48 hours of symptom onset. Mortality at 30 days was assessed and risk factors for the primary outcome were assessed.

Results:

Of the 6,707 patients enrolled with an STEMI, mean age decreased from 66.2 (14.0) years to 63.3 (14.5) years, and smoking and obesity increased from 32% to 41% and 14% to 20%, respectively. The risk of 30-day mortality decreased from 13.7% in 1995 to 4.4% in 2010 (adjusted hazard ratio for death, 0.39; 95% confidence interval [CI], 0.29-0.53). This correlated with a reduction in time from symptom onset to hospital presentation and admission, a decrease in the percentage of patients admitted to community hospitals, and an increase in admission to hospitals with more experience. There was also an increase in coronary angiogram utilization, reperfusion therapy, and evidence-based pharmacologic therapy (beta-blockers, angiotensin-converting enzyme inhibitors, statins, antithrombotic medications). Complications after STEMI decreased with time, including cardiogenic shock (adjusted odds ratio [OR], 0.66; 95% CI, 0.48-0.92), recurrent MI (adjusted OR, 0.51; 95% CI, 0.29-0.90), and cardiac arrest (adjusted OR, 0.68; 95% CI, 0.46-0.60).

Conclusions:

Reduction in mortality after STEMI in France was accompanied by changes in patient clinical characteristics and patient management with evidence-based medicine.

Perspective:

Improvements in MI management and patient health knowledge have contributed to improvements in patient outcomes in France. The authors argue that the age decrease over time in STEMI patients is due to primary prevention strategies in those (mainly elder patients) identified with MI risk factors over the 15-year study. What is concerning, however, is the time-related increase in tobacco abuse and obesity. While 30-day survival after MI may have increased (due to prompt medical intervention), we may see in years to come reduced long-term survival and increased incident heart failure and sudden cardiac death from long-standing coronary artery disease.

Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Myocardial Infarction, Shock, Coronary Care Units, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Risk Factors, Electrocardiography, Evidence-Based Medicine, France, Death, Coronary Angiography, Heart Failure, Obesity, Troponin


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