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Correlates of Declining Mortality NSTEMI

Hall et al report an analysis of mortality trends for NSTEMI (2003-2013). The data source was derived from the Myocardial Ischaemia National Audit Project (247 hospitals in England and Wales). The crude mortality showed declining mortality. The authors systematically examine models examining the association of this trend: including patient factors, pharmacotherapy and the invasive strategy. Sophisticated statistical methods were used. The authors found that use of the invasive strategy was correlated with the decline. The change in baseline risk and increased pharmacotherapy did not explain all of the decline.

Abstract

IMPORTANCE

International studies report a decline in mortality following non–ST-elevation
myocardial infarction (NSTEMI). Whether this is due to lower baseline risk or increased utilization of guideline-indicated treatments is unknown.

OBJECTIVE

To determine whether changes in characteristics of patients with NSTEMI are
associated with improvements in outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Data on patients with NSTEMI in 247 hospitals in England andWales were obtained from the Myocardial Ischaemia National Audit Project between January 1, 2003, and June 30, 2013 (final follow-up, December 31, 2013).

EXPOSURES

Baseline demographics, clinical risk (GRACE risk score), and pharmacological and invasive coronary treatments.

MAIN OUTCOMES AND MEASURES

Adjusted all-cause 180-day postdischarge mortality time trends estimated using flexible parametric survival modeling.

RESULTS

Among 389 057 patients with NSTEMI (median age, 72.7 years [IQR, 61.7-81.2
years]; 63.1%men), there were 113 586 deaths (29.2%). From 2003-2004 to 2012-2013, proportions with intermediate to high GRACE risk decreased (87.2%vs 82.0%); proportions with lowest risk increased (4.2%vs 7.6%; P= .01 for trend). The prevalence of diabetes, hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, chronic renal failure, previous invasive coronary strategy, and current or ex-smoking status increased
(all P < .001). Unadjusted all-cause mortality rates at 180 days decreased from 10.8%to 7.6% (unadjusted hazard ratio [HR], 0.968 [95%CI, 0.966-0.971]; difference in absolute mortality rate per 100 patients [AMR/100], −1.81 [95%CI, −1.95 to −1.67]). These findings were not substantially changed when adjusted additively by baseline GRACE risk score (HR, 0.975 [95%CI, 0.972-0.977]; AMR/100, −0.18 [95%CI, −0.21 to −0.16]), sex and socioeconomic
status (HR, 0.975 [95%CI, 0.973-0.978]; difference in AMR/100, −0.24 [95%CI, −0.27 to −0.21]), comorbidities (HR, 0.973 [95%CI, 0.970-0.976]; difference in AMR/100, −0.44 [95%CI, −0.49 to −0.39]), and pharmacological therapies (HR, 0.972 [95%CI,0.964-0.980]; difference in AMR/100, −0.53 [95%CI, −0.70 to −0.36]). However, the direction of association was reversed after further adjustment for use of an invasive coronary strategy (HR, 1.02 [95%CI, 1.01-1.03]; difference in AMR/100, 0.59 [95%CI, 0.33-0.86]),
which was associated with a relative decrease in mortality of 46.1% (95%CI, 38.9%-52.0%).

CONCLUSIONS AND RELEVANCE

Among patients hospitalized with NSTEMI in England and Wales, improvements in all-cause mortality were observed between 2003 and 2013. This was significantly associated with use of an invasive coronary strategy and not entirely related to a decline in baseline clinical risk or increased use of pharmacological therapies.

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