ESC: Better, faster care results in less STEMI deaths in France
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The overall rate of death in patients hospitalized with STEMI decreased from 1995 to 2010 in France, with possible factors associated with this decline including an increase in the proportion of STEMI patients who were women younger than age 60, and an increase in the use of reperfusion therapy and recommended therapeutic measures following an MI, according to a study presented Aug. 27 at the European Society of Cardiology Congress in Munich.

The study was simultaneously published in the Journal of the American Medical Association.

“Several sources, including registries specific to acute MI [AMI] and large administrative or billing databases, have shown a decrease in mortality in patients with STEMI over the past 10 to 15 years. This decline is usually attributed to increased use and improved delivery of reperfusion therapy, in particular primary PCI,” the study authors wrote. “We hypothesized that, beyond primary PCI, other factors such as temporal changes in patient population characteristics may account for part of the observed reduction in mortality of patients with STEMI.”

Thus, Etienne Puymirat, MD, of the Hôpital Européen Georges Pompidou in Paris, and colleagues conducted this study to assess the association between changes in early mortality following STEMI and patient management and risk profile. The researchers analyzed data from four one-month French nationwide registries, conducted five years apart (in 1995, 2000, 2005 and 2010), which included a total of 6,707 STEMI patients admitted to intensive care or coronary care units.

During the study period, the average age of patients with STEMI declined from 66.2 years to 63.3 years, and history of cardiovascular disease, such as heart attack, heart failure, peripheral artery disease, stroke or transient ischemic attack also decreased.

The proportion of younger women (60 years or less) with STEMI increased from 11.8 percent to 25.5 percent. That, according to the researchers, is consistent with their increased prevalence of smoking (from 37.3 percent to 73.1 percent) and obesity (from 17.6 percent to 27.1 percent). The proportion of younger patients developing STEMI despite not having hypertension, diabetes or hypercholesterolemia increased markedly, particularly in younger women.

The study authors also found that the use of reperfusion therapy increased over time, from 49.4 percent to 74.7 percent, with more frequent use of primary PCI (11.9 percent to 60.8 percent). The use of evidence-based treatments during the first 48 hours from admission increased gradually over the 15-year period, including the early use of beta-blockers, ACE inhibitors or angiotensin-receptor blockers and statins. Also, there was increasing early use of antiplatelet agents and low-molecular-weight heparin.

The 30-day mortality rate decreased from 13.7 percent in 1995 to 4.4 percent in 2010; mortality decreased from 9.8 percent to 2.6 percent in men and from 23.7 percent to 9.8 percent in women. “Consistent with the decrease in mortality, major hospital complications of STEMI also decreased over this time period,” wrote the authors.

In addition, time from symptom onset to hospital admission decreased, with a shorter time from onset to first call, and broader use of mobile intensive care units.

“This change [in mortality] is explained largely by major improvements in the delivery of care for AMI, including the more frequent implementation of reperfusion therapy, the more frequent use of primary PCI, as a reperfusion method, and use of potent adjunctive evidence-based therapies (including antithrombotic agents, statins, beta-blockers and ACE inhibitors or angiotensin-receptor blockers),” Puymirat et al wrote. “It may also be related to changes in patient behavior, such as faster calls for medical assistance after symptom onset and more frequent use of the pre-hospital mobile intensive care system, as well as changes in the general organization of care for STEMI patients, with the concentration of care provision in a smaller number of institutions, treating larger numbers of patients.”

They also added that this progressive decline in early mortality has been observed and is consistent in the nationwide surveys and many other sources in the U.S. and Europe.

However, Puymirat and colleagues acknowledged the limitations in their observational study, including that none of the registries considered was population-based. Also, the French national healthcare policy and the volume and structure of the centers included in the registries may have changed over the 15-year span of the study.

They concluded that future reductions in the incidence and mortality related to acute MI will need specific targeting of preventive measures toward younger women and possibly younger men.