Temporal Trends in the Clinical Acuity of Patients with ST-Segment Elevation Myocardial Infarction
Udhay Krishnan1, Josef A Brejt1, Joshua Schulman-Marcus2
1Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, NY.
Insights
Risk-adjusted mortality for ST-segment elevation myocardial infarction (STEMI) declined despite increasing patient comorbidities and extreme-risk features. Improvements in care systems explain the improved outcomes in STEMI patients undergoing percutaneous coronary intervention (PCI).
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Despite advances in ST-elevation myocardial infarction (STEMI) care, risk-adjusted mortality has not improved.
- This suggests STEMI patient acuity may be increasing beyond current mortality model capabilities.
- Investigating changes in patient characteristics and outcomes is crucial.
Purpose of the Study:
- To examine changes in clinical characteristics of STEMI patients.
- To assess trends in in-hospital mortality for STEMI patients treated with early percutaneous coronary intervention (PCI).
Main Methods:
- Retrospective analysis of a nationwide inpatient database (2004-2012).
- Identified STEMI patients undergoing PCI within 24 hours of admission.
- Primary outcome: in-hospital mortality.
Main Results:
- Unadjusted in-hospital mortality increased from 3.9% to 4.7% (2004-2012).
- Proportion of patients with ≥3 comorbidities rose significantly (14.8% to 29.0%).
- Presentation with intubation or cardiac arrest increased (3.2% to 7.8%) and strongly predicted mortality. Risk-adjusted mortality decreased over time (OR 0.95).
Conclusions:
- Risk-adjusted in-hospital mortality declined during a period of improved STEMI care.
- Increased comorbidities and extreme-risk presentations may mask overall mortality improvements.
- These factors explain the apparent "null" effect on mortality despite timely reperfusion.
Background:
Despite advances in ST-segment elevation myocardial infarction (STEMI) systems of care over the last decade, studies have shown no improvement in risk-adjusted mortality. It has been hypothesized that the population presenting to the catheterization laboratory has become sicker over time, in ways not accurately captured by current mortality models. The objective of this study was to examine changes in the clinical characteristics and in-hospital case fatality rate of the STEMI population treated with early percutaneous coronary intervention (PCI).
Methods:
We conducted a retrospective analysis of a nationwide inpatient database for the period 2004-2012. All patients with a diagnosis of STEMI who underwent PCI within 24 hours of admission were identified. The primary outcome was in-hospital mortality.
Results:
From 2004 to 2012 there was a consistent increase in unadjusted in-hospital mortality (3.9% in 2004 and 4.7% in 2012, odds ratioyear 1.03; 95% confidence interval 1.01-1.04). During this time there was an increase in the proportion of patients with ≥3 Elixhauser comorbidities (14.8% vs 29.0%, Ptrend < .001). Intubation or cardiac arrest on presentation increased from 3.2% to 7.8% (Ptrend < .001) and had a strong, independent association with mortality. After multivariable adjustment using a model that incorporated the increasing trend in intubation/cardiac arrest, mortality decreased over time (odds ratioyear 0.95; 95% confidence interval 0.94-0.97).
Conclusions:
During a period that corresponds to improvement in STEMI quality of care, risk-adjusted in-hospital mortality declined. An increase in comorbidities, and more importantly in the proportion of patients presenting with extreme-risk features, may explain the overall "null" effect regarding in-hospital mortality despite improvements in timely reperfusion.
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