Clinical characteristics and improvement of the guideline-based management of acute myocardial infarction in China: a national retrospective analysis.
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SUBMITTER: Wang L
PROVIDER: S-EPMC5542290 | biostudies-other | 2017 Jul
REPOSITORIES: biostudies-other
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Project description:BackgroundDespite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011.MethodsIn a retrospective analysis of hospital records, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for STEMI in 3 years (2001, 2006, and 2011). In the first stage, we used a simple random-sampling procedure stratified by economic-geographical region to generate a list of participating hospitals. In the second stage we obtained case data for rates of STEMI, treatments, and baseline characteristics from patients attending each sampled hospital with a systematic sampling approach. We weighted our findings to estimate nationally representative rates and assess changes from 2001 to 2011. This study is registered with ClinicalTrials.gov, number NCT01624883.FindingsWe sampled 175 hospitals (162 participated in the study) and 18,631 acute myocardial infarction admissions, of which 13,815 were STEMI admissions. 12,264 patients were included in analysis of treatments, procedures, and tests, and 11,986 were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100,000 people increased (from 3·5 in 2001, to 7·9 in 2006, to 15·4 in 2011; ptrend<0·0001) and the prevalence of risk factors-including smoking, hypertension, diabetes, and dyslipidaemia-increased. We noted significant increases in use of aspirin within 24 h (79·7% [95% CI 77·9-81·5] in 2001 vs 91·2% [90·5-91·8] in 2011, ptrend<0·0001) and clopidogrel (1·5% [95% CI 1·0-2·1] in 2001 vs 82·1% [81·1-83·0] in 2011, ptrend<0·0001) in patients without documented contraindications. Despite an increase in the use of primary percutaneous coronary intervention (10·6% [95% CI 8·6-12·6] in 2001 vs 28·1% [26·6-29·7] in 2011, ptrend<0·0001), the proportion of patients who did not receive reperfusion did not significantly change (45·3% [95% CI 42·1-48·5] in 2001 vs 44·8% [43·1-46·5] in 2011, ptrend=0·69). The median length of hospital stay decreased from 12 days (IQR 7-18) in 2001 to 10 days (6-14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between 2001 and 2011 (odds ratio 0·82, 95% CI 0·62-1·10, ptrend=0·07).InterpretationDuring the past decade in China, hospital admissions for STEMI have risen; in these patients, comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some treatments, but important gaps persist and in-hospital mortality has not decreased. National efforts are needed to improve the care and outcomes for patients with STEMI in China.FundingNational Health and Family Planning Commission of China.
| S-EPMC4415374 | biostudies-literature
Project description:China is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization.We used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported.The weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n?=?1,901), 11 and 12.6 days in 2006 (n?=?3,553), and 11 and 11.9 days in 2011 (n?=?7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p?=?0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS.Despite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.
| S-EPMC4360951 | biostudies-literature
Project description:Background Acute myocardial infarction (AMI) is one of the leading causes of mortality worldwide, whereas social support is a known predictor of the prognosis after AMI. As a common factor influencing social support, the impact of marital status on care quality, in-hospital mortality, and long-term prognosis of patients with AMI remains largely unknown. Methods and Results The present study analyzed data from the CAMI (China Acute Myocardial Infarction) registry involving 19 912 patients with AMI admitted at 108 hospitals in China between January 2013 and September 2014 and aimed to evaluate marital status-based differences in acute management, medical therapies, and short-term and long-term outcomes. The primary end point was 2-year all-cause death. The secondary end points included in-hospital death and 2-year major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke). After multivariable adjustment, 1210 (6.1%) unmarried patients received less reperfusion treatment in patients with both ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction (adjusted odds ratio [OR], 0.520 [95% CI, 0.437-0.618]; P<0.0001; adjusted OR, 0.489 [95% CI, 0.364-0.656]; P<0.0001). Being unmarried was not associated with poorer in-hospital outcome but with long-term all-cause mortality and major adverse cardiac and cerebrovascular events in both ST-segment-elevation myocardial infarction (adjusted hazard ratio [HR], 1.225 [95% CI, 1.031-1.456]; P=0.0209; adjusted HR, 1.277 [95% CI, 1.089-1.498]; P=0.0027) and non-ST-segment-elevation myocardial infarction (adjusted HR, 1.302 [95% CI, 1.036-1.638]; P=0.0239; adjusted HR, 1.368 [95% CI, 1.105-1.694]; P=0.0040) populations. Conclusions The present study suggests that being unmarried is independently related to less reperfusion received, but could not explain the higher in-hospital mortality rate after covariate adjustment. Being unmarried is associated with a substantially increased risk of adverse events over at least the first 24 months after AMI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01874691.
| S-EPMC9851450 | biostudies-literature
Project description:Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90-day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention (P=0.04) or coronary artery bypass grafting (P=0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all-cause mortality rate for patients with an early RMI was 49% (95% CI, 40%-57%) compared with 22% (95% CI, 21%-23%) for patients without an early RMI (P<0.0001). Conclusions Early RMI is a life-threatening condition with nearly 50% mortality within 5 years. Stent-related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.
| S-EPMC8475017 | biostudies-literature
Project description:BackgroundStatin therapy is among the most effective treatments to improve short- and long-term mortality after acute myocardial infarction. The use of statin, and the intensity of their use, has not been described in acute myocardial infarction patients in China, a country with a rapidly growing burden of cardiovascular disease.Methods and resultsUsing a nationally representative sample of patients with acute myocardial infarction admitted to 162 Chinese hospitals in 2001, 2006 and 2011, we identified 14,958 patients eligible for statin therapy to determine rates of statin use and the intensity of statin therapy, defined as those statin regimens with expected low-density lipoprotein cholesterol lowering of at least 40%, to identify factors associated with the use of statin therapy. Statin use among hospitalized patients with acute myocardial infarction increased from 27.9% in 2001 to 72.5% in 2006, and 88.8% in 2011 (P<0.001 for trend). Regional variation in statin use correspondingly decreased over time. Among treated patients, those receiving intensive statin therapy increased from 1.0% in 2001 to 24.2% in 2006 to 57.2% in 2011(P<0.001 for trend). Patients without low-density lipoprotein cholesterol measured were less likely to be treated with statin or to receive intensive therapy.ConclusionsThe use of statin therapy has dramatically increased over the past decade in Chinese patients with acute myocardial infarction. However, half of patients still did not receive intensive statin therapy in 2011.Given that guidelines strongly endorse intensive statin therapy for acute myocardial infarction patients, initiatives promoting the use of statin therapy, with attention to treatment intensity, would support further improvements in practice.
| S-EPMC4825974 | biostudies-literature
Project description:BackgroundType-II MI is defined as myocardial infarction (MI) secondary to ischemia due to either increased oxygen demand or decreased supply. This categorization has been used for the last five years, yet, little is known about patient characteristics and clinical outcomes. In the current work we assessed the epidemiology, causes, management and outcomes of type II MI patients.MethodsA comparative analysis was performed between patients with type-I and type-II MI who participated in two prospective national Acute Coronary Syndrome Israeli Surveys (ACSIS) performed in 2008 and 2010.ResultsThe surveys included 2818 patients with acute MI of whom 127 (4.5%) had type-II MI. The main causes of type-II MI were anemia (31%), sepsis (24%), and arrhythmia (17%). Patients with type-II MI tended to be older (75.6±12 vs. 63.8±13, p<0.0001), female majority (43.3% vs. 22.3%, p<0.0001), had more frequently impaired functional level (45.7% vs. 17%, p<0.0001) and a higher GRACE risk score (150±32 vs. 110±35, p<0.0001). Patients with type-II MI were significantly less often referred for coronary interventions (36% vs. 89%, p<0.0001) and less frequently prescribed guideline-directed medical therapy. Mortality rates were substantially higher among patients with type-II MI both at thirty-day (13.6% vs. 4.9%, p<0.0001) and at one-year (23.9% vs. 8.6%, p<0.0001) follow-ups.ConclusionsPatients with type-II compared to type-I MI have distinct demographics, increased prevalence of multiple comorbidities, a high-risk cardiovascular profile and an overall worse outcome. The complex medical condition of this cohort imposes a great therapeutic challenge and specific guidelines with recommended medical treatment and invasive strategies are warranted.
| S-EPMC3879301 | biostudies-literature
Project description:Despite improvements in the treatment of myocardial infarction (MI), risk-associated management disparities may exist. We investigated this issue including temporal trends in a large MI cohort (n = 179,291) registered 2005-2017 in SWEDEHEART. Multivariable models were used to study the associations between risk categories according to the GRACE 2.0 score and coronary procedures (timely reperfusion, invasive assessment ≤ 3 days, in-hospital coronary revascularization), pharmacological treatments (P2Y12-blockers, betablockers, renin-angiotensin-aldosterone-system [RAAS]-inhibitors, statins), structured follow-up and secondary prevention (smoking cessation, physical exercise training). High-risk patients (n = 76,295 [42.6%]) experienced less frequent medical interventions compared to low/intermediate-risk patients apart from betablocker treatment. Overall, intervention rates increased over time with more pronounced increases seen in high-risk patients compared to lower-risk patients for in-hospital coronary revascularization (+ 23.6% vs. + 12.5% in patients < 80 years) and medication with P2Y12-blockers (+ 22.2% vs. + 7.8%). However, less pronounced temporal increases were noted in high-risk patients for medication with RAAS-blockers (+ 8.5% vs. + 13.0%) and structured follow-up (+ 31.6% vs. + 36.3%); pinteraction < 0.001 for all. In conclusion, management of high-risk patients with MI is improving. However, the lower rates of follow-up and of RAAS-inhibitor prescription are a concern. Our data emphasize the need of continuous quality improvement initiatives.
| S-EPMC8716523 | biostudies-literature
Project description:ObjectiveYoung women form a minority but an important group of patients with acute myocardial infarction (MI) as it can potentially cause devastating physical and socioeconomic impact. This study was aimed to investigate the characteristics and outcomes of young women with MI in Malaysia.DesignThis is a retrospective analysis of women with ST-elevation MI (STEMI) and non-STEMI (NSTEMI) from 18 hospitals across Malaysia using the Malaysian National Cardiovascular Database registry-acute coronary syndrome (NCVD-ACS).ParticipantsWomen patients diagnosed with acute MI from year 2006 to 2013 were identified and divided into young (age ≤ 45, n=292) and older women (age >45, n=5580).Primary outcome measureComparison of demographics, clinical characteristics and in-hospital management was performed between young and older women. In-hospital and 30-day all-cause mortality were examined.ResultsYoung women (mean age 39±4.68) made up 5% of women with MI and were predominantly of Malay ethnicities (53.8%). They have a higher tendency to present as STEMI compared with older women. Young women have significantly higher rates of family history of premature coronary artery disease (CAD) (20.5% vs 7.8% p<0.0001). The prevalence of risk factors, such as hypertension, diabetes and dyslipidaemia was high in both groups. The primary reperfusion strategy was thrombolysis with no significant differences observed in the choice of intervention for both groups. Other than aspirin, rates of prescriptions for evidence-based medications were similar with >80% prescribed statins and aspirin. The all-cause mortality rates of young women were lower for both in-hospital and 30 days, especially in those with STEMI with adjusted mortality ratio to the older group, was 1:9.84.ConclusionYoung women with MI were over-represented by Malays and those with a family history of premature CAD. Preventive measures are needed to reduce cardiovascular risks in young women. Although in-hospital management was similar, short-term mortality outcomes favoured young compared with older women.
| S-EPMC6886979 | biostudies-literature
Project description:BackgroundCardiovascular diseases are rising as a cause of death and disability in China. To improve outcomes for patients with these conditions, the Chinese government, academic researchers, clinicians, and >200 hospitals have created China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE), a national network for research and performance improvement. The first study from China PEACE, the Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study), is designed to promote improvements in acute myocardial infarction (AMI) quality of care by generating knowledge about the characteristics, treatments, and outcomes of patients hospitalized with AMI across a representative sample of Chinese hospitals during the past decade.Methods and resultsThe China PEACE-Retrospective AMI Study will examine >18 000 patient records from 162 hospitals identified using a 2-stage cluster sampling design within economic-geographic regions. Records were chosen from 2001, 2006, and 2011 to identify temporal trends. Data quality will be monitored by a central coordinating center and will, in particular, address case ascertainment, data abstraction, and data management. Analyses will examine patient characteristics, diagnostic testing patterns, in-hospital treatments, in-hospital outcomes, and variation in results by time and site of care. In addition to publications, data will be shared with participating hospitals and the Chinese government to develop strategies to promote quality improvement.ConclusionsThe China PEACE-Retrospective AMI Study is the first to leverage the China PEACE platform to better understand AMI across representative sites of care and during the past decade in China. The China PEACE collaboration among government, academicians, clinicians, and hospitals is poised to translate research about trends and patterns of AMI practices and outcomes into improved care for patients.Clinical trial registrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT01624883.
| S-EPMC4054693 | biostudies-literature
Project description:BackgroundThe incidence, clinical outcomes and antithrombotic treatment spectrum of atrial fibrillation (AF) in patients hospitalized with acute myocardial infarction (AMI) have not been well studied in Chinese population.MethodsTwenty-six thousand five hundred ninety-two consecutive patients diagnosed with AMI were enrolled in CAMI registry from January 2013 to September 2014. After excluding 343 patients with uncertain AF status and 1,591 patients transferred out during hospitalization, 24,658 patients were finally included in this study and involved in analysis.ResultsIn the CAMI registry, 740 (3.0%) patients were recorded with AF prevalence during hospitalization. Higher-risk baseline clinical profile was observed in patients with AF. These patients were less likely to receive reperfusion/revascularization than those without AF. The in-hospital mortality (including death and treatment withdrawal) was significantly higher in patients with AF than that of without AF (25.2% vs. 7.2%, respectively; p < 0.01). The case of composite of adverse events was similar, which included death, treatment withdrawal, re-infarction, heart failure or stroke (42.1% vs. 16.0%, p <0.01). In multivariate logistic regression analysis, AF was an independent predictor for in-hospital mortality (odds ratio, 1.88; 95% confidence interval: 1.27-2.78) and the composite of adverse events (odds ratio, 2.11; 95% CI: 1.63-2.72). Only 5.1% of patients with AF were treated with warfarin, and 1.7% were treated with both warfarin and dual antiplatelet therapy.ConclusionsThe analysis was based on the CAMI registry in China. The patients hospitalized for AMI who developed AF were at significantly higher risk for in-hospital mortality and other adverse events. However, the anticoagulants including warfarin have been largely underused post hospital discharge.Trial registrationClinical Trial Registration: Identifier: NCT01874691 .
| S-EPMC5210261 | biostudies-literature