Effect of implementing routine early invasive strategy on one-year mortality in patients with acute myocardial
Erlend Aune1, Knut Endresen, Keith A A Fox
1Department of Cardiology, Vestfold Hospital Trust, Toensberg, Norway. erlend.aune@siv.no
Insights
Implementing an early invasive strategy for acute myocardial infarction (AMI) significantly reduced 1-year mortality by 41% compared to a conservative approach. This approach involved timely percutaneous coronary intervention and improved secondary prevention.
Area of Science:
- Cardiology
- Clinical Medicine
- Public Health
Background:
- Acute myocardial infarction (AMI) management strategies significantly impact patient outcomes.
- Comparing early invasive versus conservative approaches is crucial for optimizing AMI care.
- Previous studies suggested benefits of early intervention, but long-term mortality data in unselected populations require further investigation.
Purpose of the Study:
- To evaluate the long-term mortality impact of an early invasive strategy versus a conservative approach in unselected acute myocardial infarction (AMI) patients.
- To determine if routine transfer to a high-volume percutaneous coronary intervention (PCI) center improves survival post-AMI.
Main Methods:
- Prospective observational cohort study comparing AMI patients from 2003 (conservative) and 2006 (invasive cohort).
- Data collected on patient demographics, medical history, treatment received, and 1-year mortality.
- Statistical analysis included multivariable adjustment for confounders and Global Registry of Acute Coronary Events (GRACE) risk score.
Main Results:
- The invasive cohort (IC) demonstrated an 11% absolute and 41% relative reduction in 1-year mortality compared to the conservative cohort (p = 0.001).
- Adjusted analyses confirmed reduced mortality in the IC (HR 0.54-0.67).
- The IC showed increased primary PCI for STEMI (57% vs 3%) and early PCI for NSTEMI (25% vs 4%), with greater use of clopidogrel, aspirin, and statins.
Conclusions:
- Routine transfer for early invasive therapy in AMI patients is associated with substantial long-term mortality reduction.
- The observed survival benefit is linked to increased timely PCI and improved secondary prevention medication adherence.
- While effective, potential unmeasured confounders warrant consideration in interpreting the full extent of the outcome difference.
Abstract:
The aim of the present study was to investigate whether the implementation of an early invasive strategy for unselected patients with acute myocardial infarction (AMI) would be associated with reduced long-term mortality compared to a conservative approach. In this prospective observational cohort study of consecutive patients admitted for AMI in 2003 (conservative cohort, n = 311) and 2006 (invasive cohort [IC], n = 307), an 11% absolute and 41% relative reduction in 1-year mortality was found for patients with AMI in the IC compared to the conservative cohort (p = 0.001). These findings were consistent after adjustment for age, gender, previous AMI, previous stroke, diabetes, smoking status, previous left ventricular systolic dysfunction, and serum creatinine at admission (hazard ratio 0.54, 95% confidence interval 0.38 to 0.78) and Global Registry of Acute Coronary Events risk score (hazard ratio 0.67, 95% confidence interval 0.46 to 0.97). More patients with ST-segment elevation myocardial infarction received primary percutaneous coronary intervention in the IC (57% vs 3%, p <0.001), and a sixfold (25% vs 4%, p <0.001) increase in early percutaneous coronary intervention (<72 hours) for patients with non-ST-segment elevation myocardial infarction was observed. A greater proportion of patients in the IC received clopidogrel, aspirin, and statins during follow-up; otherwise, the secondary prevention measures were similar in the 2 cohorts. In conclusion, the introduction of a strategy for routine transfer to a high-volume percutaneous coronary intervention center for early invasive therapy was accompanied by a substantial reduction in mortality among unselected patients with AMI. Differences in unmeasured confounders might have accounted for a part of the difference in outcome.
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