A nationwide causal mediation analysis of survival following ST-elevation myocardial infarction
Tatendashe Bernadette Dondo1, Marlous Hall1, Theresa Munyombwe1
1Clinical and Population Sciences Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
Insights
Improvements in survival following ST-elevation myocardial infarction (STEMI) were driven by increased use of primary percutaneous coronary intervention (PCI) and P2Y12 inhibitors. Primary PCI significantly contributed to better STEMI survival rates at both 6 months and 1 year.
Area of Science:
- Cardiology
- Public Health
- Clinical Research
Background:
- International studies indicate a decrease in mortality rates for ST-elevation myocardial infarction (STEMI).
- The specific factors contributing to improved STEMI survival, such as changes in patient demographics and treatment patterns, remain unclear.
Purpose of the Study:
- To investigate the extent to which temporal changes in patient characteristics and treatment utilization explain the observed improvements in STEMI survival.
- To quantify the relative contributions of specific treatments to enhanced STEMI survival over time.
Main Methods:
- A cohort study utilizing national registry data from the Myocardial Ischaemia National Audit Project (MINAP) in England and Wales (2004-2013).
- Analysis included 232,353 STEMI survivors, employing flexible parametric survival modeling and causal mediation analysis.
- The study assessed the impact of temporal shifts in patient factors and treatments on STEMI survival at 6 months and 1 year.
Main Results:
- Unadjusted survival at 6 months and 1 year improved annually by 0.9% and 1.0%, respectively.
- Increased uptake of primary percutaneous coronary intervention (PCI) and P2Y12 inhibitor prescriptions were significantly linked to improved 1-year survival.
- Primary PCI accounted for 13.2% of 1-year survival improvements, while P2Y12 inhibitors contributed 5.3% at 6 months.
Conclusions:
- Survival improvements in ST-elevation myocardial infarction (STEMI) in England and Wales between 2004 and 2013 were significantly attributed to the increased adoption of primary PCI.
- The enhanced use of P2Y12 inhibitors also played a role in improving STEMI survival at 6 months.
- Primary PCI was a key driver for improved STEMI survival at both 6 months and 1 year during the study period.
Objective:
International studies report a decline in mortality following ST-elevation myocardial infarction (STEMI). The extent to which the observed improvements in STEMI survival are explained by temporal changes in patient characteristics and utilisation of treatments is unknown.
Methods:
Cohort study using national registry data from the Myocardial Ischaemia National Audit Project between first January 2004 and 30th June 2013. 232 353 survivors of hospitalisation with STEMI as recorded in 247 hospitals in England and Wales. Flexible parametric survival modelling and causal mediation analysis were used to estimate the relative contribution of temporal changes in treatments and patient characteristics on improved STEMI survival.
Results:
Over the study period, unadjusted survival at 6 months and 1 year improved by 0.9% and 1.0% on average per year (HR: 0.991, 95% CI: 0.988 to 0.994 and HR: 0.990, 95% CI: 0.987 to 0.993, respectively). The uptake of primary percutaneous coronary intervention (PCI) (HR: 1.025, 95% CI: 1.021 to 1.028) and increased prescription of P2Y12 inhibitors (HR: 1.035, 95% CI: 1.031 to 1.039) were significantly associated with improvements in 1-year survival. Primary PCI explained 16.8% (95% CI: 10.8% to 31.6%) and 13.2% (9.2% to 21.9%) of the temporal survival improvements at 6 months and 1 year, respectively, whereas P2Y12 inhibitor prescription explained 5.3% (3.6% to 8.8%) of the temporal improvements at 6 months but not at 1 year.
Conclusions:
For STEMI in England and Wales, improvements in survival between 2004 and 2013 were significantly explained by the uptake of primary PCI and increased use of P2Y12 inhibitors at 6 months and primary PCI only at 1 year.
Trial Registration Number:
NCT03749694.
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