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Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study.

ABSTRACT: BACKGROUND:Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities. METHODS:We used data of 693,388 AMI patients recorded in the Myocardial Ischaemia National Audit Project (MINAP), 2003-2013. We investigated the association between comorbidities and receipt of optimal care for AMI (receipt of all eligible guideline-indicated treatments), and the effect of receipt of optimal care for comorbid AMI patients on long-term survival using flexible parametric survival models. RESULTS:A total of 412,809 [59.5%] patients with AMI had at least one comorbidity, including hypertension (302,388 [48.7%]), diabetes (122,228 [19.4%]), chronic obstructive pulmonary disease (COPD, 89,221 [14.9%]), cerebrovascular disease (51,883 [8.6%]), chronic heart failure (33,813 [5.6%]), chronic renal failure (31,029 [5.0%]) and peripheral vascular disease (27,627 [4.6%]). Receipt of optimal care was associated with greatest survival benefit for patients without comorbidities (HR 0.53, 95% CI 0.51-0.56) followed by patients with hypertension (HR 0.60, 95% CI 0.58-0.62), diabetes (HR 0.83, 95% CI 0.80-0.87), peripheral vascular disease (HR 0.85, 95% CI 0.79-0.91), renal failure (HR 0.89, 95% CI 0.84-0.94) and COPD (HR 0.90, 95% CI 0.87-0.94). For patients with heart failure and cerebrovascular disease, optimal care for AMI was not associated with improved survival. CONCLUSIONS:Overall, guideline-indicated care was associated with improved long-term survival. However, this was not the case in AMI patients with concomitant heart failure or cerebrovascular disease. There is therefore a need for novel treatments to improve outcomes for AMI patients with pre-existing heart failure or cerebrovascular disease.

SUBMITTER: Yadegarfar ME

PROVIDER: S-EPMC7444071 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study.

Yadegarfar Mohammad E ME Gale Chris P CP Dondo Tatendashe B TB Wilkinson Chris G CG Cowie Martin R MR Hall Marlous M

BMC medicine 20200824 1

<h4>Background</h4>Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities.<h4>Methods</h4>We used data of 693,388 AMI p ...[more]

PMID: 32829713

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Project description:Liver cirrhotic predisposes patients to coagulopathy and bleeding. Little is known about outcomes of acute myocardial infarction (AMI) in cirrhotic patients.Data from Taiwan National Health Insurance Research Database during 2001 to 2013 were retrieved for patients admitted with cirrhosis and AMI. We excluded patients with missing information, <20 years old, previous AMI, previous coronary intervention, and liver transplant. Patients were separated into cirrhotic and non-cirrhotic. Primary outcomes included all-cause mortality, recurrent myocardial infarction (MI), major cardiac and cerebrovascular events (MACCE: recurrent MI, revascularization, ischemic stroke, and heart failure), and liver outcomes (hepatic encephalopathy, ascites tapping, spontaneous peritonitis, and esophageal varices bleeding).A total of 3217 cirrhotic patients and 6434 non-cirrhotic patients were analyzed, with a mean follow up of 2.8 ± 3.3 years. In cirrhotic patients with AMI, subsequent coronary and cerebrovascular events were lower in comparison to non-cirrhotic patients, with higher all-cause mortality observed from adverse liver related outcomes and bleeding. There were significantly lower cumulative incidence of both recurrent MI and MACCE in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (hazard ratio [HR] 0.82, confidence interval [CI] 0.71-0.94, P = .006 and HR 0.86, 95% CI 0.79-0.92, P < .001, respectively). There was significantly higher cumulative incidence of liver related outcome in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 2.27, 95% CI 2.06-2.51, P < .001). And there was significantly higher all-cause mortality in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 1.30, 95% CI 1.23-1.38, P < .001).In cirrhotic cohort with AMI, a decreased in coronary and cerebrovascular events were observed. However, these patients also had higher all-cause mortality due to adverse liver outcomes and bleeding.

Project description:BackgroundThis study assessed sex differences in treatments, all-cause mortality, relative survival, and excess mortality following acute myocardial infarction.Methods and resultsA population-based cohort of all hospitals providing acute myocardial infarction care in Sweden (SWEDEHEART [Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies]) from 2003 to 2013 was included in the analysis. Excess mortality rate ratios (EMRRs), adjusted for clinical characteristics and guideline-indicated treatments after matching by age, sex, and year to background mortality data, were estimated. Although there were no sex differences in all-cause mortality adjusted for age, year of hospitalization, and comorbidities for ST-segment-elevation myocardial infarction (STEMI) and non-STEMI at 1 year (mortality rate ratio: 1.01 [95% confidence interval (CI), 0.96-1.05] and 0.97 [95% CI, 0.95-0.99], respectively) and 5 years (mortality rate ratio: 1.03 [95% CI, 0.99-1.07] and 0.97 [95% CI, 0.95-0.99], respectively), excess mortality was higher among women compared with men for STEMI and non-STEMI at 1 year (EMRR: 1.89 [95% CI, 1.66-2.16] and 1.20 [95% CI, 1.16-1.24], respectively) and 5 years (EMRR: 1.60 [95% CI, 1.48-1.72] and 1.26 [95% CI, 1.21-1.32], respectively). After further adjustment for the use of guideline-indicated treatments, excess mortality among women with non-STEMI was not significant at 1 year (EMRR: 1.01 [95% CI, 0.97-1.04]) and slightly higher at 5 years (EMRR: 1.07 [95% CI, 1.02-1.12]). For STEMI, adjustment for treatments attenuated the excess mortality for women at 1 year (EMRR: 1.43 [95% CI, 1.26-1.62]) and 5 years (EMRR: 1.31 [95% CI, 1.19-1.43]).ConclusionsWomen with acute myocardial infarction did not have statistically different all-cause mortality, but had higher excess mortality compared with men that was attenuated after adjustment for the use of guideline-indicated treatments. This suggests that improved adherence to guideline recommendations for the treatment of acute myocardial infarction may reduce premature cardiovascular death among women.Clinical trial registrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT02952417.

Project description:Background: There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.Methods and findings: This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; ?-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.Conclusions: Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.Trial registration: ClinicalTrials.gov NCT03037255.

Dataset Information

Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study.

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Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study.

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