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SWEDEHEART: New treatments improved survival, reduced new events in non-STEMI
ANAHEIM, Calif. — The use of new evidence-based treatments such as PCI led to improved long-term survival and a reduction in HF and new ischemic events in patients who were admitted to the hospital for a non-STEMI during the past 20 years, according to data presented at the American Heart Association Scientific Sessions.
Karolina Szummer, MD, PhD, of the Karolinska Institutet in Stockholm, and colleagues analyzed data from 205,693 patients with non-STEMI who were registered in the SWEDEHEART registry between 1995 and 2014. Treatments, outcomes and patient characteristics were continuously monitored. Other assessments included 1-year mortality, 1-year outcomes and long-term mortality, in addition to event and mortality rates up to 20 years.
Both the age (median, 74 years) and number of men (63%) were comparable throughout the study. The number of patients with diabetes increased from 1995-1996 (23.4%) to 2013-2014 (28.8%). Hypertension also increased during that period, from 37.1% to 67.9%.
“This might not only reflect an increase in hypertension diagnosis, but also the definition within the registry,” Szummer said during the presentation.
From 1995-1996 to 2013-2014, increases were observed in the use of aspirin, beta-blockers, ACE inhibitors, statins, PCI, coronary angiography, CABG and dual antiplatelet therapy at diagnosis and discharge for non-STEMI.
Crude 1-year all-cause mortality decreased from 26% to 14.8% during the study, and CV death decreased from 23% to 10%, both of which decreased by about half. Mortality for the background population was similar throughout the period.
The standardized incidence rate ratio for mortality decreased from 5.53 in 1995-1996 (95% CI, 5.3-5.77) to 3.03 in 2013-2014 (95% CI, 2.89-3.19), but it was still about three times higher than a comparable population. The greatest differences were seen after adjusting for baseline characteristics and in-hospital PCI.
“The largest jumps ... seem to indicate that the invasive treatments have something to do with this,” Szummer said.
Throughout the study period, 1-year outcomes decreased, including new MI (15% to 10%), HF readmissions (10% to 7%) and new stroke (4% to 3%).
In-hospital outcomes also decreased significantly during the study, which remained after adjustment. One-year mortality decreased from 12% to 4%, and MI decreased from 3% to less than 1%.
There was some relative change in all patients with regard to in-hospital CV death and MI after adjusting for age and sex (RR = 0.81; 95% CI, 0.81-0.82) and baseline characteristics (RR = 0.85; 95% CI, 0.84-0.86), but the largest change was seen after adjusting for in-hospital PCI (RR = 0.89; 95% CI, 0.88-0.9). The risk of 1-year CV death and MI in patients who survived in-hospital changed very little after adjusting for age and sex (RR = 0.92; 95% CI, 0.91-0.92) and baseline characteristics (RR = 0.92; 95% CI, 0.92-0.93).
The effect persisted for patients in-hospital and who were discharged. The rate of mortality was high in those admitted between 1995 and 1996, but it decreased over time. Similar effects were seen for MI, HF and stroke.
“If we continue this way with the increased uptake of the guidelines, we can expect to further improve outcomes,” Szummer said. – by Darlene Dobkowski
Reference:
Szummer K, et al. LBS.06. Evaluating quality improvement and patient-centered care interventions. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, Calif.
Disclosure : Szummer reports no relevant financial disclosures.
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This was a remarkable, interesting analysis. The first thing that I think when I see this sort of analysis is how rich their datasets are in Sweden; they’re really able to get full capture of all these non-STEMI patients.
The good news is that with the advent of these very efficacious therapies for non-STEMI, we seem to see real improvements with clinical outcomes over a relatively short time period.
There certainly are limitations to the analysis, in particular the limitation that they acknowledge about coding. It’s very challenging to know how many of these patients were the same sort of patients that were having non-STEMIs in the beginning of the analytic period. It is a real issue because troponin assays, for example, changed over that time period. And some patients had type 2 MI, where the value of PCI is not established.
Overall, these results are very helpful because it provides real-world confirmation that the therapies for non-STEMI are working to help patients.
It would always be helpful for analyses done both in the United States and those in other countries to understand in greater detail how the epidemiology of non-STEMI has changed over time.
When interpreting these kind of results, it’s critically important to understand are the patients coming in with non-STEMI the same patients that they were a while ago, and this has to do with new troponin assays. It has to do with changing epidemiology of disease, thinking about plaque rupture and thrombosis vs. erosion, things like demand events like type 2 MI.
Understanding how MI itself is changing over time is important for interpreting these kinds of results.