Temporal Trends in the Clinical Acuity of Patients with ST-Segment Elevation Myocardial Infarction.
Am J Med. 2017 Aug 08;:
Authors: Krishnan U, Brejt JA, Schulman-Marcus J, Swaminathan RV, Feldman DN, Goyal P, Wong SC, Minutello RM, Bergman G, Singh H, Kim LK
BACKGROUND: Despite advances in ST-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 lab has become sicker over time, in ways not accurately captured by current mortality models.
OBJECTIVE: 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 from 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 2004-2012, there was a consistent increase in unadjusted in-hospital mortality (3.9% in 2004 and 4.7% in 2012, ORyear 1.03; 95% confidence interval [CI]: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. (ORyear 0.95; 95% CI: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.
PMID: 28801225 [PubMed – as supplied by publisher]
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