Relations between implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years: experiences from SWEDEHEART registry 1995 to 2014

Szummer, Karolina; Wallentin, Lars; Lindhagen, Lars; Alfredsson, Joakim; Erlinge, David; Held, Claes; James, Stefan; Kellerth, Thomas; Lindahl, Bertil; Ravn-Fischer, Annica; Rydberg, Erik; Yndigegn, Troels; Jernberg, Tomas

doi:10.1093/eurheartj/ehy554

Cited by 115 publications

(88 citation statements)

References 34 publications

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“…[9][10][11] Results from the French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction (FAST-MI) and the Swedish Websystem for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry showed that the 6-month and 1-year mortality of patients with STEMI or NSTEMI have generally decreased since 1995. 11,12 However, since 2010, there has been no improvement in the 6-month mortality of patients with NSTEMI, regardless of whether or not they received percutaneous coronary intervention (PCI); in striking contrast, mortality has continued to decline in patients with STEMI during this time. 11…”

Section: Disease Burden Of Non-st-segment Elevation Myocardial Infamentioning

confidence: 99%

“…19 For patients with NSTEMI who are elderly and have a high comorbidity burden, conservative treatment could be a reasonable approach. 16,19 1.3 | Invasive strategy and P2Y 12 inhibitor treatment evidence for NSTEMI An early invasive strategy of cardiac catheterization has a central role in the management of patients with NSTEMI because it facilitates:…”

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

“…21 Registry data from six Arabian Gulf countries showed that patients with NSTEMI managed with PCI and CABG had better outcomes than those treated conservatively. 22 Guideline-indicated treatment of patients with NSTEMI with potent P2Y 12 In TRITON-TIMI 38, prasugrel showed a reduction in the primary composite efficacy endpoint of cardiovascular death, MI, or stroke vs. clopidogrel in the NSTEMI patient subgroup (HR: 0.85; 95% CI: 0.73-0.97). 23,24 Prasugrel was associated with increased non-CABG major bleeding compared with clopidogrel (HR: 1.40; 95% CI:…”

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

“…Prasugrel is contraindicated in patients with previous intracranial hemorrhage, previous ischemic stroke or transient ischemic attack, or ongoing bleeds. [13][14][15][16][17][18] Clopidogrel is a less potent P2Y 12 inhibitor than ticagrelor and prasugrel; it is recommended for patients who cannot receive ticagrelor or prasugrel, or who require oral anticoagulation. [13][14][15][16][17][18] Clinical risk scores, such as the DAPT score, can help guide decisions around whether to continue antiplatelet therapy beyond 1 year, by providing a risk-benefit ratio based on age, smoking status, comorbidity, and medical history.…”

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

“…Another study, investigating geographic variation in guidelineindicated treatments for patients with NSTEMI in the English National Health Service, using data from the MINAP registry, showed that the proportion of patients receiving optimal care was only 13.5%; with P2Y 12 inhibitor and coronary angiography treatments among the least provided care, and over half (58.1%) of patients not being under the care of a cardiologist 56. The provision of both coronary angiography (median, 57.4%; interquartile range [IQR], 48.8%-66.7%) and P2Y12…”

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confidence: 99%

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Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Ahrens

Zúñiga

et al. 2019

Clinical Cardiology

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Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

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Section: Disease Burden Of Non-st-segment Elevation Myocardial Infamentioning

confidence: 99%

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

Section: Guideline Recommendations For Invasive and Antiplatelet Trmentioning

confidence: 99%

mentioning

confidence: 99%

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Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Ahrens

Zúñiga

et al. 2019

Clinical Cardiology

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Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes

Georgiopoulos,

Kraler,

Mueller-Hennessen

et al. 2023

JAMA Cardiol

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ImportanceThe Global Registry of Acute Coronary Events (GRACE) risk score, a guideline-recommended risk stratification tool for patients presenting with acute coronary syndromes (ACS), does not consider the extent of myocardial injury.ObjectiveTo assess the incremental predictive value of a modified GRACE score incorporating high-sensitivity cardiac troponin (hs-cTn) T at presentation, a surrogate of the extent of myocardial injury.Design, Setting, and ParticipantsThis retrospectively designed longitudinal cohort study examined 3 independent cohorts of 9803 patients with ACS enrolled from September 2009 to December 2017; 2 ACS derivation cohorts (Heidelberg ACS cohort and Newcastle STEMI cohort) and an ACS validation cohort (SPUM-ACS study). The Heidelberg ACS cohort included 2535 and the SPUM-ACS study 4288 consecutive patients presenting with a working diagnosis of ACS. The Newcastle STEMI cohort included 2980 consecutive patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Data were analyzed from March to June 2023.ExposuresIn-hospital, 30-day, and 1-year mortality risk estimates derived from an updated risk score that incorporates continuous hs-cTn T at presentation (modified GRACE).Main Outcomes and MeasuresThe predictive value of continuous hs-cTn T and modified GRACE risk score compared with the original GRACE risk score. Study end points were all-cause mortality during hospitalization and at 30 days and 1 year after the index event.ResultsOf 9450 included patients, 7313 (77.4%) were male, and the mean (SD) age at presentation was 64.2 (12.6) years. Using continuous rather than binary hs-cTn T conferred improved discrimination and reclassification compared with the original GRACE score (in-hospital mortality: area under the receiver operating characteristic curve [AUC], 0.835 vs 0.741; continuous net reclassification improvement [NRI], 0.208; 30-day mortality: AUC, 0.828 vs 0.740; NRI, 0.312; 1-year mortality: AUC, 0.785 vs 0.778; NRI, 0.078) in the derivation cohort. These findings were confirmed in the validation cohort. In the pooled population of 9450 patients, modified GRACE risk score showed superior performance compared with the original GRACE risk score in terms of reclassification and discrimination for in-hospital mortality end point (AUC, 0.878 vs 0.780; NRI, 0.097), 30-day mortality end point (AUC, 0.858 vs 0.771; NRI, 0.08), and 1-year mortality end point (AUC, 0.813 vs 0.797; NRI, 0.056).Conclusions and RelevanceIn this study, using continuous rather than binary hs-cTn T at presentation, a proxy of the extent of myocardial injury, in the GRACE risk score improved the mortality risk prediction in patients with ACS.

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Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy

et al. 2022

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IMPORTANCE Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVESTo compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTSA cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURESThe incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTSOf 86 736 patients discharged after MI in 2012 years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event.The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant

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Relations between implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years: experiences from SWEDEHEART registry 1995 to 2014

Cited by 115 publications

References 34 publications

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes

Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy

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