Gender differences in the decrease of in-hospital mortality in patients with acute myocardial infarction during the last 20 years in Switzerland.
ABSTRACT: To assess temporal trends of in-hospital mortality in patients with acute myocardial infarction (AMI) enrolled in the Swiss nationwide registry (AMIS Plus) over the last 20 years with regard to gender, age and in-hospital treatment.All patients with AMI from 1997 to 2016 were stratified according to ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI), and gender using logistic regression analyses.Among 51?725 patients, 30?398 (59%) had STEMI and 21?327 (41%) had NSTEMI; 73% were men (63.9±12.8 years) and 27% were women (71.7±12.5 years). Over 20 years, crude in-hospital STEMI mortality decreased from 9.8% to 5.5% in men and from 18.3% to 6.9% in women. In patients with NSTEMI, it decreased from 7.1% to 2.1% in men and from 11.0% to 3.6% in women. After adjustment for age, mortality decreased per additional admission year by 3% in men with STEMI (OR 0.97, 95%?CI 0.96 to 0.98, P<0.001), by 5% in women with STEMI (OR 0.95, 95%?CI 0.93 to 0.96, P<0.001), by 6% in men with NSTEMI (OR 0.94, 95%?CI 0.93 to 0.96, P<0.001) and by 5% in women with NSTEMI (OR 0.95, 95%?CI 0.93 to 0.97, P<0.001). In patients <60 years, a decrease in mortality was seen in women with STEMI (OR 0.94, 95%?CI 0.90 to 0.99, P=0.025) and NSTEMI (OR 0.87, 95%?CI 0.80 to 0.94, P<0.001) but not in men with STEMI (OR 1.01, 95%?CI 0.98 to 1.04, P=0.46) and NSTEMI (OR 0.98, 95%?CI 0.94 to 1.03, P=0.41). The mortality decrease in patients with AMI was closely associated with the increase in reperfusion therapy.From 1997 to 2016, in-hospital mortality of patients with AMI in Switzerland has halved and was more pronounced in women, particularly in the age category <60 years.NCT01305785; Results.
Project description:BACKGROUND:Studies of sex-based differences in older adults with acute myocardial infarction (AMI) have yielded mixed results. We, therefore, sought to evaluate sex-based differences in presentation characteristics, treatments, functional impairments, and in-hospital complications in a large, well-characterized population of older adults (?75 years) hospitalized with AMI. METHODS AND RESULTS:We analyzed data from participants enrolled in SILVER-AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction)-a prospective observational study consisting of 3041 older patients (44% women) hospitalized for AMI. Participants were stratified by AMI subtype (ST-segment-elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and subsequently evaluated for sex-based differences in clinical presentation, functional impairments, management, and in-hospital complications. Among the study sample, women were slightly older than men (NSTEMI: 82.1 versus 81.3, P<0.001; STEMI: 82.2 versus 80.6, P<0.001) and had lower rates of prior coronary disease. Women in the NSTEMI subgroup presented less frequently with chest pain as their primary symptom. Age-associated functional impairments at baseline were more common in women in both AMI subgroups (cognitive impairment, NSTEMI: 20.6% versus 14.3%, P<0.001; STEMI: 20.6% versus 12.4%, P=0.001; activities of daily living disability, NSTEMI: 19.7% versus 11.4%, P<0.001; STEMI: 14.8% versus 6.4%, P<0.001; impaired functional mobility, NSTEMI: 44.5% versus 30.7%, P<0.001; STEMI: 39.4% versus 22.0%, P<0.001). Women with AMI had lower rates of obstructive coronary disease (NSTEMI: P<0.001; STEMI: P=0.02), driven by lower rates of 3-vessel or left main disease than men (STEMI: 38.8% versus 58.7%; STEMI: 24.3% versus 32.1%), and underwent revascularization less commonly (NSTEMI: 55.6% versus 63.6%, P<0.001; STEMI: 87.3% versus 93.3%, P=0.01). Rates of bleeding were higher among women with STEMI (26.2% versus 15.6%, P<0.001) but not NSTEMI (17.8% versus 15.7%, P=0.21). Women had a higher frequency of bleeding following percutaneous coronary intervention with both NSTEMI (11.0% versus 7.8%, P=0.04) and STEMI (22.6% versus 14.8%, P=0.02). CONCLUSIONS:Among older adults hospitalized with AMI, women had a higher prevalence of age-related functional impairments and, among the STEMI subgroup, a higher incidence of overall bleeding events, which was driven by higher rates of nonmajor bleeding events and bleeding following percutaneous coronary intervention. These differences may have important implications for in-hospital and posthospitalization needs.
Project description:Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI).Retrospective cohort study.1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006.126 172 STEMI and 235 257 NSTEMI patients.Hospital death.For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p<0.0001 for the age-sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age <50 years, age 50-59, age 60-69, age 70-79 and age 80-89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15-20%, while a better survival of older NSTEMI women compared with men persisted.Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.
Project description:Background The study sought to assess the prognostic impact of acute myocardial infarction ( AMI ) with and without ST -segment-elevation myocardial infarction ( STEMI and NSTEMI ) in patients with ventricular tachyarrhythmias and sudden cardiac arrest ( SCA ) on admission. Methods and Results A large retrospective registry was used including all consecutive patients presenting with ventricular tachycardia ( VT ), fibrillation ( VF ), and sudden cardiac arrest ( SCA ) on admission from 2002 to 2016. AMI versus non- AMI and STEMI versus NSTEMI were compared applying multivariable Cox regression models and propensity-score matching for evaluation of the primary prognostic end point defined as long-term all-cause mortality at 2.5 years. Secondary end points were 30 days all-cause mortality, cardiac death at 24 hours, in hospital death, and recurrent percutaneous coronary intervention (re- PCI ) at 2.5 years. In 2813 unmatched high-risk patients with ventricular tachyarrhythmias and SCA , AMI was present in 29% (10% STEMI , 19% NSTEMI ) with higher rates of VF (54% versus 31%) and SCA (35% versus 26%), whereas VT rates were higher in non- AMI (56% versus 30%) ( P < 0.05). AMI -related VT ?48 hours was associated with higher mortality (log rank P = 0.001). Multivariable Cox regression models revealed non- AMI (hazard ratio = 1.458; P = 0.001) and NSTEMI (hazard ratio = 1.460; P = 0.036) associated with increasing long-term all-cause mortality at 2.5 years, which was also proven after propensity-score matching (non- AMI versus AMI : 55% versus 43%, log rank P = 0.001, hazard ratio = 1.349; NSTEMI versus STEMI : 45% versus 34%, log rank P = 0.047, hazard ratio = 1.372). Secondary end points including 30 days and in-hospital mortality, as well as re- PCI were higher in non- AMI patients. Conclusions In high-risk patients presenting with ventricular tachyarrhythmias and SCA , non- AMI revealed higher mortality than AMI , respectively NSTEMI than STEMI , alongside AMI -related VT ?48 hours.
Project description:BACKGROUND:Atypical clinical presentation in acute myocardial infarction (AMI) patients is not uncommon; most studies suggest that it is associated with unfavorable prognosis. HYPOTHESIS:Long-term clinical impact differs according to predominant symptom presentation (typical chest pain, atypical chest pain, syncope, cardiac arrest, or dyspnea) in AMI patients. METHODS:FAST-MI 2010, a nationwide French registry, included 4169 patients with AMI in 213 centers at the end of 2010 (76% of active centers). Demographics, medical history, hospital management, and outcomes were compared according to predominant symptom presentation. RESULTS:Typical chest pain with no other symptom was reported in 3020 patients (68% in STEMI patients, 76% in NSTEMI patients). Atypical chest pain, dyspnea, syncope, and cardiac arrest were reported in 11%, 11%, 5%, and 1%, respectively. Patients with atypical clinical presentation had a higher cardiovascular risk profile and received fewer medications and a less invasive strategy. Using Cox multivariate analysis, atypical chest pain was not associated with higher death rate at 3 years (HR: 0.96, 95% CI: 0.69-1.33, P = 0.78), whereas cardiac arrest (HR: 2.44, 95% CI: 1.00-5.97, P = 0.05), syncope (HR: 1.70, 95% CI: 1.18-2.46, P = 0.005), and dyspnea (HR: 1.66, 95% CI: 1.31-2.10, P < 0.001) were associated with higher long-term mortality compared with patients with typical isolated chest pain. Similar trends were observed in STEMI and NSTEMI populations. CONCLUSIONS:Atypical clinical presentation is observed in about 20% of AMI patients. Cardiac arrest, dyspnea, and syncope represent independent predictors of long-term mortality in STEMI and NSTEMI populations.
Project description:Comparable data on trends of hospitalization rates for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) remain unavailable in representative Asian populations.To examine the temporal trends of hospitalization for acute myocardial infarction (AMI) and its subtypes in Beijing.Patients hospitalized for AMI in Beijing from January 1, 2007 to December 31, 2012 were identified from the validated Hospital Discharge Information System. Trends in hospitalization rates, in-hospital mortality, length of stay (LOS), and hospitalization costs were analyzed by regression models for total AMI and for STEMI and NSTEMI separately. In total, 77,943 patients were admitted for AMI in Beijing during the 6 years, among whom 67.5% were males and 62.4% had STEMI. During the period, the rate of AMI hospitalization per 100,000 population increased by 31.2% (from 55.8 to 73.3 per 100,000 population) after age standardization, with a slight decrease in STEMI but a 3-fold increase in NSTEMI. The ratio of STEMI to NSTEMI decreased dramatically from 6.5:1.0 to 1.3:1.0. The age-standardized in-hospital mortality decreased from 11.2% to 8.6%, with a significant decreasing trend evident for STEMI in males and females (P?<?0.001) and for NSTEMI in males (P?=?0.02). The rate of percutaneous coronary intervention increased from 28.7% to 55.6% among STEMI patients. The total cost for AMI hospitalization increased by 56.8% after adjusting for inflation, although the LOS decreased by 1 day.The hospitalization burden for AMI has been increasing in Beijing with a transition from STEMI to NSTEMI. Diverse temporal trends in AMI subtypes from the unselected "real-world" data in Beijing may help to guide the management of AMI in China and other developing countries.
Project description:BACKGROUND:Prior acute coronary syndrome (ACS) registries in Saudi Arabia might not have accurately described the true demographics and cardiac care of patients with ACS. We aimed to evaluate the clinical characteristics, management, and outcomes of a representative sample of patients with acute myocardial infarction (AMI) in Saudi Arabia. METHODS:We conducted a 1-month snap-shot, prospective, multi-center registry study in 50 hospitals from various health care sectors in Saudi Arabia. We followed patients for 1 month and 1 year after hospital discharge. Patients with AMI included those with or without ST-segment elevation (STEMI or NSTEMI, respectively). This program survey will be repeated every 5 years. RESULTS:Between May 2015 and January 2017, we enrolled 2233 patients with ACS (mean age was 56 [standard deviation = 13] years; 55.6% were Saudi citizens, 85.7% were men, and 65.9% had STEMI). Coronary artery disease risk factors were high; 52.7% had diabetes mellitus and 51.2% had hypertension. Emergency Medical Services (EMS) was utilized in only 5.2% of cases. Revascularization for patients with STEMI included thrombolytic therapy (29%), primary percutaneous coronary intervention (PCI); (42.5%), neither (29%), or a pharmaco-invasive approach (3%). Non-Saudis with STEMI were less likely to undergo primary PCI compared to Saudis (35.8% vs. 48.7%; respectively, p <0.001), and women were less likely than men to achieve a door-to-balloon time of <90 min (42% vs. 65%; respectively, p = 0.003). Around half of the patients with NSTEMI did not undergo a coronary angiogram. All-cause mortality rates were 4%, 5.8%, and 8.1%, in-hospital, at 1 month, and at 1 year, respectively. These rates were significantly higher in women than in men. CONCLUSIONS:There is an urgent need for primary prevention programs, improving the EMS infrastructure and utilization, and establishing organized ACS network programs. AMI care needs further improvement, particularly for women and non-Saudis.
Project description:Conflicting information exists about whether sex differences modulate short-term mortality following acute coronary syndromes (ACS).To investigate the relationship between sex and 30-day mortality in ACS, and to determine whether this relationship was modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates.A convenience sample of patients pooled from 11 independent, international, randomized ACS clinical trials between 1993 and 2006 whose databases are maintained at the Duke Clinical Research Institute, Durham, North Carolina. Of 136 247 patients, 38 048 (28%) were women; 102 004 (26% women) with ST-segment elevation myocardial infarction (STEMI), 14 466 (29% women) with non-STEMI (NSTEMI), and 19 777 (40% women) with unstable angina.Thirty-day mortality following ACS.Thirty-day mortality was 9.6% in women and 5.3% in men (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.83-2.00). After multivariable adjustment, mortality was not significantly different between women and men (adjusted OR, 1.06; 95% CI, 0.99-1.15). A significant sex by type of ACS interaction was demonstrated (P < .001). In STEMI, 30-day mortality was higher among women (adjusted OR, 1.15; 95% CI, 1.06-1.24), whereas in NSTEMI (adjusted OR, 0.77; 95% CI, 0.63-0.95) and unstable angina, mortality was lower among women (adjusted OR, 0.55; 95% CI, 0.43-0.70). In a cohort of 35 128 patients with angiographic data, women more often had nonobstructive (15% vs 8%) and less often had 2-vessel (25% vs 28%) and 3-vessel (23% vs 26%) coronary disease, regardless of ACS type. After additional adjustment for angiographic disease severity, 30-day mortality among women was not significantly different than men, regardless of ACS type. The relationship between sex and 30-day mortality was similar across the levels of angiographic disease severity (P for interaction = .70).Sex-based differences existed in 30-day mortality among patients with ACS and vary depending on clinical presentation. However, these differences appear to be largely explained by clinical differences at presentation and severity of angiographically documented disease.
Project description:Aim:Inflammation-based Glasgow Prognostic Scores (GPS) have been reported to predict the prognosis of patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). The goal of this study was to investigate whether three kinds of GPSs can effectively predict major cardiovascular adverse events (MACEs) in STEMI or non-ST-segment elevation myocardial infarction (NSTEMI) patients undergoing PPCI, elective PCI (EPCI) or conservative drug therapy during hospitalization. Methods:In this retrospective cohort study, patients with acute myocardial infarction (AMI) were divided into 0, 1 or 2 score according to the GPSs. Logistic regression and receiver operating characteristic (ROC) curve analysis were performed to assess the predictive value of GPSs for MACE and all-cause mortality during hospitalization. Three kinds of GPSs, Inflammation-based Glasgow Prognostic Score (GPS), modified GPS (MGPS) and high-sensitivity CRP-modified GPS (HS-MGPS) and Global Registry of Acute Coronary Events (GRACE) score were applied in this study. Results:A total of 188 patients were enrolled. The ROC curve with MACE showed that the AUC of GPS (0.820 (95% confidence interval (CI) [0.754-0.885]), P < 0.001) was larger than that of MGPS (0.789 (95% CI [0.715-0.863]), P < 0.001), HS-MGPS (0.787 (95% CI [0.717-0.856]), P < 0.001) and GRACE score (0.743 (95% CI [0.672-0.814]), P < 0.001). The ROC curve with all-cause mortality showed that the AUC of GPS (0.696 (95% CI [0.561-0.831]), P = 0.005) was similar to the HS-MGPS (0.698 (95% CI [0.569-0.826]), P = 0.005) and higher than the MGPS (0.668 (95% CI [0.525-0.812]), P = 0.016), but lower than the GRACE score (0.812 (95% CI [0.734-0.889]), P < 0.001). Multivariate logistic regression analysis showed that the GPS was an independent risk factor for the incidence of MACE during hospitalization. Compared with the odds ratio (OR) value for a GPS of 0, the OR for a GPS of 1 was 7.173 (95% CI [2.425-21.216]), P < 0.001), and that for a GPS of 2 was 18.636 (95% CI [5.813-59.746]), P < 0.001), but not an independent risk factor for all-cause mortality (P = 0.302). GRACE score was an independent risk factor for MACE (1.019 (95% CI [1.004-1.035]), P = 0.015) and all-cause mortality (1.040 (95% CI [1.017-1.064]), P = 0.001). In the subgroups classified according to the type of AMI, the presence of disease interference GPSs and the type of PCI, the ability of GPS to predict the occurrence of MACE seemed to be greater than that of MGPS and HS-MGPS. Conclusion:The GPS has a good predictive value for the occurrence of MACE during hospitalization in patients with AMI, regardless of STEMI or NSTEMI, the choice of PCI mode and the presence or absence of diseases that interfere with GPS. However, GPS is less predictive of all-cause mortality during hospitalization than GRACE score, which may be due to the interference of patients with other diseases.
Project description:Women have been reported to suffer from impaired outcome after acute myocardial infarction (AMI). The aim of our study was to determine the impact of sex and age on utilization of inpatient healthcare and outcome in patients with AMI (STEMI and NSTEMI) in a real-life setting. We performed a routine-data-based analysis of 203 106 nationwide inpatients hospitalized with STEMI and NSTEMI, focusing on sex differences regarding risk constellation, treatments, and in-hospital outcome. A logistic regression model was designed to evaluate the use of coronary angiography and interventions and their sex-related impact on mortality (within 30 days). Compared with males, female STEMI patients (25 146, vs 52 965 males) were older and had a higher incidence of diabetes mellitus (27.4% vs 20.6%), heart failure (32.8% vs 26.2%), and chronic kidney disease (19.1% vs 13.5%, respectively; all P < 0.05), and had higher observed in-hospital mortality (STEMI, 16.9% vs 9.9%; NSTEMI, 11.7% vs 8.7%). Females were less likely to receive coronary angiography in STEMI in the age groups <60 and ? 80 years (odds ratio: 0.8, 95% confidence interval: 0.76-0.83, P < 0.05), despite similar mortality risk reduction. Estimated overall in-hospital mortality showed no differences with respect to sex in STEMI for age groups 40 to 79 years. However, females age ? 80 years had slightly higher in-hospital mortality after adjustment. The increased observed in-hospital mortality in females was attributed to the impact of more unfavorable risk and age distribution. Coronary angiography was associated with lower in-hospital mortality; particularly, older females were less frequently treated.
Project description:OBJECTIVES:In Barbados, high case fatality rates have been reported after myocardial infarction (MI) with higher rates in women than men. To explore this inequality, we examined documented pharmacological interventions for ST-segment elevated myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable and chronic angina in women and men. DESIGN:Prospective cohort registry data for STEMI and NSTEMI and retrospective chart review for unstable and chronic angina. SETTING:Tertiary care (acute coronary syndromes) and primary care (chronic angina) centres in Barbados. PARTICIPANTS:For the years 2009-2016, a total of 1018 patients with STEMI or NSTEMI were identified via the prospective study. For unstable and chronic angina, 136 and 272 notes were reviewed respectively for the years 2010-2014. OUTCOME MEASURES:The proportions of patients prescribed recommended medication during the first 24 hours after an acute event, at discharge and for chronic care were calculated. Prescribed proportions were analysed by gender after adjustment for age. RESULTS:Between 2009 and 2016, for the acute management of patients with NSTEMI and STEMI, only two (aspirin and clopidogrel) of six drugs had documented prescription rates of 80% or more. Patients with STEMI (n=552) had higher prescription rates than NSTEMI (n=466), with gender differences being more pronounced in the former. Among patients with STEMI, after adjustment for age, diabetes, hypertension and smoking, men were more likely to receive fibrinolytics acutely, OR 2.28 (95% CI 1.24 to 4.21). Compared with men, a higher proportion of women were discharged on all recommended treatments; this was only statistically significant for beta-blockers: age-adjusted OR 1.87 (95% CI 1.16 to 3.00). There were no statistically significant differences in documented prescription of drugs for chronic angina. CONCLUSION:Following acute MI in Barbados, the proportion of patients with documented recommended treatment is relatively low. Although women were less likely to receive appropriate acute care than men, by discharge gender differences were reversed.