ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data

Abstract

Summary Background Despite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011. Methods In a retrospective analysis of hospital records, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for STEMI in 3 years (2001, 2006, and 2011). In the first stage, we used a simple random-sampling procedure stratified by economic–geographical region to generate a list of participating hospitals. In the second stage we obtained case data for rates of STEMI, treatments, and baseline characteristics from patients attending each sampled hospital with a systematic sampling approach. We weighted our findings to estimate nationally representative rates and assess changes from 2001 to 2011. This study is registered with ClinicalTrials.gov, number NCT01624883. Findings We sampled 175 hospitals (162 participated in the study) and 18 631 acute myocardial infarction admissions, of which 13 815 were STEMI admissions. 12 264 patients were included in analysis of treatments, procedures, and tests, and 11 986 were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100 000 people increased (from 3·5 in 2001, to 7·9 in 2006, to 15·4 in 2011; ptrend<0·0001) and the prevalence of risk factors—including smoking, hypertension, diabetes, and dyslipidaemia—increased. We noted significant increases in use of aspirin within 24 h (79·7% [95% CI 77·9–81·5] in 2001 vs 91·2% [90·5–91·8] in 2011, ptrend<0·0001) and clopidogrel (1·5% [95% CI 1·0–2·1] in 2001 vs 82·1% [81·1–83·0] in 2011, ptrend<0·0001) in patients without documented contraindications. Despite an increase in the use of primary percutaneous coronary intervention (10·6% [95% CI 8·6–12·6] in 2001 vs 28·1% [26·6–29·7] in 2011, ptrend<0·0001), the proportion of patients who did not receive reperfusion did not significantly change (45·3% [95% CI 42·1–48·5] in 2001 vs 44·8% [43·1–46·5] in 2011, ptrend=0·69). The median length of hospital stay decreased from 12 days (IQR 7–18) in 2001 to 10 days (6–14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between 2001 and 2011 (odds ratio 0·82, 95% CI 0·62–1·10, ptrend=0·07). Interpretation During the past decade in China, hospital admissions for STEMI have risen; in these patients, comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some treatments, but important gaps persist and inhospital mortality has not decreased. National efforts are needed to improve the care and outcomes for patients with STEMI in China.

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

“…Identifying the determinants of IHM and PCI use among AMI patients is likely to be important in developing targeted interventions to improve access to PCI and to reduce AMI mortality 23. Previous studies, however, used data from a specific region or selected hospitals24, 25, 26, 27, 28 or focused on patients with ST‐segment–elevation myocardial infarction (STEMI) 29, 30, 31, 32, 33, 34. Given the marked geographic, economic, demographic, and cultural diversity in China, a nationwide investigation using representative samples is needed.…”

Effects of recombinant human brain natriuretic peptide on the prognosis of patients with acute anterior myocardial infarction undergoing primary percutaneous coronary intervention: a prospective, multi-center, randomized clinical trial

“…Although some patients received PCI within the effective time window after onset, there was no obvious decrease in the in-hospital mortality rate and major complications in AMI patients in China for the past 10 years. The in-hospital mortality rate was within 5-15% (2). Therefore, further investigations are warranted to optimize its therapeutic benefits for AMI and develop novel therapies to decrease the mortality rate of AMI.…”

Quality of Care in Chinese Hospitals: Processes and Outcomes After ST‐segment Elevation Myocardial Infarction

“…Despite the benefits of PCI, equal proportion of patients in 2011 received PCI and fibrinolysis, and it has been shown that urokinase, a drug for which there are little data demonstrating effectiveness in STEMI, is the preferred fibrinolytic agent in China 18. In addition to the possibility of suboptimal use of reperfusion, there may be other care processes that we did not measure in this analyses, such as the use of traditional Chinese medicines in 70% of STEMI patients,2 contributing to outcomes. Nonetheless, the relationship between hospitals' performance on process measures and risk‐standardized outcomes is known to be complex 19, 20.…”

“…Given that care for life‐threatening conditions, such as ST‐elevation myocardial infarction (STEMI), is provided by hospitals, understanding the performance of these organizations can inform quality improvement efforts. A handful of studies of Chinese patients have revealed gaps in the care provided to individual patients with acute coronary syndromes 1, 2. Although these studies have provided an important foundation for quality improvement efforts, patient‐level analyses pool data across hospitals, which means that variation in performance among individual institutions cannot be detected.…”

“…First, China is experiencing an epidemic of cardiovascular disease, with the rate of hospital admission for STEMI quadrupling from 2001 to 2011 2. Second, there are established guidelines in China and internationally that recommend several evidence‐based interventions for patients with STEMI,3, 4 thereby enabling the use of process measures as actionable metrics of hospital performance.…”