Better primary, secondary prevention needed to reduce prehospital MI death
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Prehospital deaths are a larger contributor to MI mortality, and how it varies within and across high-income countries, than hospital case fatality, highlighting a need for more early intervention efforts, data show.
“We have improved MI mortality after hospital admission by leaps and bounds; however, death rates are still 160% higher in some parts of the country than others,” Perviz Asaria, PhD, MRCP, MPH, a consultant cardiologist at Imperial College London, told Healio. “More than half of those deaths happen before the patient even makes it to hospital. Prehospital deaths are 60% higher in women and 75% higher in men in the worst compared with the best areas. We need to focus research and evaluation on early interventions to reduce prehospital death.”
Assessing linked databases
Asaria and colleagues analyzed linked data from national databases on hospitalizations and deaths with acute MI as a primary hospital diagnosis or underlying cause of death from 2015 to 2018. Researchers used geographical identifiers to estimate MI event rate, defined as the number of events per 100,000, death rate, total case fatality, prehospital fatality and hospital case fatality, defined as the proportion of admissions due to MI that resulted in death within 28 days of admission, for men and women aged 45 years and older across 326 districts in England.
The findings were published in The Lancet Public Health.
Difference between prehospital, hospital case fatalities
From 2015 to 2018, there were 293,715 MI hospitalizations and 87,966 MI-related deaths in England among people aged 45 years or older. The national age-standardized death rates were 63 per 100,000 population in women and 126 per 100,000 in men. Event rates were 233 per 100,000 in women and 512 per 100,000 in men.
After age standardization, 15% of events in women and 16.9% of events in men resulted in death before hospitalization. The hospital case fatality rate was 10.8% for women and 10.6% for men.
Across districts, the 99th-to-1st percentile ratio of age-standardized MI death rates was 2.63 (95% credible interval [CrI], 2.45-2.83) for women and 2.56 (95% CrI, 2.37-2.76) for men; death rates were highest in parts of northern England. The main contributor to this variation was MI event rate, with a 99th-to-1st percentile ratio of 2.55 (95% CrI, 2.39-2.72) for women and 2.17 (95% CrI, 2.08-2.27) for men across districts.
The researchers observed that the prehospital fatality rate was greater than hospital case fatality rate for every district. Prehospital fatality had a 99th-to-1st percentile ratio of 1.6 (95% CrI, 1.5-1.7) for women and 1.75 (95% CrI, 1.66-1.86) for men across districts and made a greater contribution to variation in total case fatality than hospital case fatality, which had a 99th-to-1st percentile ratio of 1.39 (95% CrI, 1.29-1.49) and 1.49 (95% CrI, 1.39-1.6). The contribution of case fatality to variation in deaths across districts was largest among women aged 55 to 64 years and aged 65 to 74 years and among men aged 55 to 64, 65 to 74 years, and 75 to 84 years.
The prehospital fatality rate was slightly higher in men than in women for most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65 to 74 years.
“Interestingly, in some areas that benefit from low case fatality, rates are still driven into high mortality rankings by the sheer weight of case numbers they experience,” Asaria told Healio. “Event rates are the biggest driver of the variation in mortality — 155% and 117% higher in women and men in the worst compared with the best districts. Ultimately, if we reduce the numbers of events occurring within each district, we will make the biggest impacts. That requires a re-focus on prevention.”
For more information:
Perviz Asaria, PhD, MRCP, MPH, can be reached at p.asaria@imperial.ac.uk.
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