Log in to MyACC
Guideline-Based Management of NSTEMI and Survival Stratified by Risk
Study Questions:
Is the use of guideline-indicated treatments for non–ST-segment elevation myocardial infarction (NSTEMI) in a real-world setting associated with improved survival across the spectrum of risk, as estimated by the GRACE score?
Methods:
The authors examined the Myocardial Ischemia National Audit Project (MINAP), which prospectively collects information on treatments provided and survival in patients hospitalized with acute coronary syndromes in hospitals in England and Wales. They included 389,507 patients (median age 73 years, 37% women) discharged with a diagnosis of NSTEMI after excluding patients who died in the hospital (7%) or with no survival data (5%). Patients were deemed to have received guideline-based therapy if all 13 Class I-recommended interventions in the management of NSTEMI (electrocardiography, pre-admit aspirin, echocardiography, receipt of an aldosterone antagonist, coronary angiography, discharge aspirin, P2Y12 inhibitor, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, beta-blockers, and statin, in addition to smoking cessation and dietary counseling) were documented and mapped to MINAP data. The GRACE score was calculated to estimate risk of death, and the primary outcome was all-cause mortality after discharge.
Results:
In total, 44,530 (11.5%) patients received optimal care, with the median proportion of eligible care received being 70.0%. Care interventions most frequently not provided were receipt of aldosterone antagonists during admission (9,426 [82.5%]), smoking cessation advice (133,726 [80.6%]), dietary advice (254,869 [68.1%]), and echocardiography (181,831 [46.7%]). Interestingly, both receipt of optimal care and the proportion of care decreased with higher GRACE risk score category, and the greatest decrease was observed for coronary angiography (85.4%, 65.7%, and 38.0%). Across all GRACE risk score groups for time periods from 0-3 years post-discharge, mortality was higher for patients who did not receive optimal care. This association persisted in the overall cohort after adjustment for GRACE risk score. Improved longer-term survival (>3 years) was evident in the high-risk NSTEMI group only. Specifically, an invasive coronary strategy had the most significant impact on survival across all groups of ischemic risk.
Conclusions:
Guideline-indicated treatment was less frequent among patients with high-risk NSTEMI, but when provided, was associated with improved survival that persisted over the longer-term.
Perspective:
This interesting study sheds light on the long-term impact of guideline-based care in patients with NSTEMI, with certain counterintuitive results reported. While the advantages of using large, nationwide databases such as MINAP are obvious, interpretation of the findings in this case is challenging given the broad nature of a discharge diagnosis of “NSTEMI”; which may have represented situations extending from myocardial infarction related to plaque rupture to elevations in cardiac enzymes secondary to kidney disease or heart failure—clinical scenarios where unstable angina/NSTEMI guidelines may not apply. This study represents an excellent example of where adoption of the Fourth Universal Definition of Acute Myocardial Infarction in documentation would have led to more easily interpretable results.
Keywords: Acute Coronary Syndrome, Aldosterone, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Aspirin, Coronary Angiography, Coronary Artery Disease, Diet, Echocardiography, Electrocardiography, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Kidney Diseases, Mineralocorticoid Receptor Antagonists, Myocardial Infarction, Myocardial Ischemia, Quality of Health Care, Risk Assessment, Secondary Prevention, Smoking Cessation
< Back to Listings
