Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study

Clinical and economic impact of ferric carboxymaltose treatment for iron deficiency in patients stabilized following acute heart failure: a multinational study

OBJECTIVE

To estimate clinical events and evaluate the financial implications of introducing ferric carboxymaltose (FCM) to treat iron deficiency (ID) at discharge in patients hospitalized for acute heart failure (AHF) with left ventricular ejection fraction (LVEF) <50% in the UK, Switzerland and Italy.

METHODS

A decision analytic cost-offset model was developed to evaluate the costs associated with introducing FCM for all eligible patients in three countries compared to a world without FCM, over a five-year time horizon. Data from AFFIRM-AHF clinical trial were used to model clinical outcomes, using an established cohort state-transition Markov model. Country-specific prevalence estimates were derived using data from real-world studies to extrapolate number of events and consequent cost totals to the population at risk on a national scale.

RESULTS

The cost-offset modeling demonstrated that FCM is projected to be a cost-saving intervention in all three country settings over a five-year time horizon. Savings were driven primarily by reduced hospitalizations and avoided cardiovascular deaths, with net cost savings of -£14,008,238, -CHF25,456,455 and -€105,295,146 incurred to the UK, Switzerland and Italy, respectively.

LIMITATIONS

Although AFFIRM-AHF was a multinational trial, efficacy data per country was not sufficiently large to enable country-specific analysis, therefore overall clinical parameters have been assumed to apply to all countries.

CONCLUSIONS

This study provides further evidence of the potential cost savings achievable by treating ID with FCM at discharge in patients hospitalized for AHF with LVEF <50%. The value of FCM treatment within the healthcare systems of the UK, Switzerland and Italy was demonstrated even within a limited time frame of one year, with consistent cost savings indicated over a longer term.

Modelling the cost-effectiveness of person-centred care for patients with acute coronary syndrome

BACKGROUND

Person-centred care has been shown to be cost-effective compared to usual care for several diseases, including acute coronary syndrome, in a short-term time perspective (< 2 years). The cost-effectiveness of person-centred care in a longer time perspective is largely unknown.

OBJECTIVES

To estimate the mid-term cost-effectiveness of person-centred care compared to usual care for patients (< 65) with acute coronary syndrome, using a 2-year and a 5-year time perspective.

METHODS

The mid-term cost-effectiveness of person-centred care compared to usual care was estimated by projecting the outcomes observed in a randomized-controlled trial together with data from health registers and data from the scientific literature, 3 years beyond the 2-year follow-up, using the developed simulation model. Probabilistic sensitivity analyses were performed using Monte Carlo simulation.

RESULTS

Person-centred care entails lower costs and improved effectiveness as compared to usual care, for a 2-year time and a 5-year perspective. Monte Carlo simulations suggest that the likelihoods of the person-centred care being cost-effective compared to usual care were between 80 and 99% and between 75 and 90% for a 2-year and a 5-year time perspective (using a 500,000 SEK/QALY willingness-to-pay threshold).

CONCLUSIONS

Person-centred care was less costly and more effective compared to usual care in a 2-year and a 5-year time perspective for patients with acute coronary syndrome under the age of 65.

Clinical Profile and Management of Patients with Incident and Recurrent Acute Myocardial Infarction in Albania - a Call for More Focus on Prevention Strategies

Background

The clinical profile of acute myocardial infarction (AMI) patients reflects the burden of risk factors in the general population. Differences between incident (first) and recurrent (repeated) events and their impact on treatment are poorly described. We studied potential differences in the clinical profile and in-hospital treatment between patients hospitalised with an incident and recurrent AMI.

Methods

A total of 324 patients admitted in the Coronary Care Unit of ‘Mother Teresa’ hospital, Tirana, Albania (2013-2014), were included in the study. Information on AMI type, complications and risk factors was obtained from patient’s medical file.

Logistic regression analyses were used to explore differences between the incident and recurrent AMIs regarding clinical profile and in-hospital treatment.

Results

Of all patients, 50 (15.4%) had a prior AMI. Compared to incident cases, recurrent cases were older (P=0.01), more often women (P=0.01), less educated (P=0.01), and smoked less (P=0.03). Recurrent cases experienced more often heart failure (HF) (OR=2.48; 95% CI: 1.31–4.70), impaired left ventricular ejection fraction (OR=1.97; 95% CI:1.05–3.71), and multivessel disease (OR=6.32; 95% CI: 1.43–28.03) than incident cases. In-hospital use of beta-blockers was less frequent among recurrent compared to incident cases (OR=0.45; 95% CI: 0.24–0.85), while no statistically significant differences between groups were observed regarding angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, statin, aspirin or invasive procedures.

Conclusion

A more severe clinical expression of the disease and underutilisation of treatment among recurrent AMIs are likely to explain their poorer prognosis compared to incident AMIs.

The changing epidemiology of myocardial infarction in Olmsted County, Minnesota, 1995-2012

BACKGROUND

Contemporary data on the epidemiology of myocardial infarction in the population are limited and derived primarily from cohorts of hospitalized myocardial infarction patients. We assessed temporal trends in incident and recurrent myocardial infarction, with further partitioning of the rates into prehospital deaths and hospitalized events, in a geographically defined community.

METHODS

All myocardial infarction events recorded among Olmsted County, Minnesota residents aged 25 years and older from 1995-2012, including prehospital deaths, were classified into incident and recurrent. Standardized rates were calculated and temporal trends compared.

RESULTS

Altogether, 5258 myocardial infarctions occurred, including 1448 (27.5%) recurrences; 430 (8.2%) prehospital deaths were recorded. Among hospitalized events, recurrent myocardial infarction was associated with greater mortality risk than incident myocardial infarction (age-, sex-, and year-adjusted hazard ratio, 1.49; 95% confidence interval, 1.37-1.61). Although the overall rate of myocardial infarction declined over time (average annual percent change, -3.3), the magnitude of the decline varied widely. Incident hospitalized myocardial infarction rate fell 2.7%/y, compared with decreases of 1.5%/y in recurrent hospitalized myocardial infarction, 14.1%/y in prehospital fatal incident myocardial infarction, and 12.3%/y in prehospital fatal recurrent myocardial infarction (all P for diverging trends < .05). These trends resulted in an increasing proportion of recurrences among hospitalized myocardial infarctions (25.3% in 1995-2000, 26.8% in 2001-2006, and 29.0% in 2007-2012, Ptrend = .02).

CONCLUSIONS

Over the past 18 years, a heterogeneous decline in myocardial infarction rates occurred in Olmsted County, resulting in transitions from incident to recurrent events and from prehospital deaths to hospitalized myocardial infarctions. Recurrent myocardial infarction confers a worse prognosis, thereby stressing the need to optimize prevention strategies in the population.

National trends in recurrent AMI hospitalizations 1 year after acute myocardial infarction in Medicare beneficiaries: 1999-2010

BACKGROUND

There are few data characterizing temporal changes in hospitalization for recurrent acute myocardial infarction (AMI) after AMI.

METHODS AND RESULTS

Using a national sample of 2 305 441 Medicare beneficiaries hospitalized for AMI from 1999 to 2010, we evaluated changes in the incidence of 1-year recurrent AMI hospitalization and mortality using Cox proportional hazards models. The observed recurrent AMI hospitalization rate declined from 12.1% (95% CI 11.9 to 12.2) in 1999 to 8.9% (95% CI 8.8 to 9.1) in 2010, a relative decline of 26.4%. The observed recurrent AMI hospitalization rate declined by a relative 27.7% in whites, from 11.9% (95% CI 11.8 to 12.1) to 8.6% (95% CI 8.5 to 8.8) versus a relative decline in blacks of 13.6% from 13.2% (95% CI 12.6 to 13.8) to 11.4% (95% CI 10.9 to 12.0). The risk-adjusted rate of annual decline in recurrent AMI hospitalizations was 4.1% (HR 0.959; 95% CI 0.958 to 0.961), and whites experienced a higher rate of decline (HR 0.957, 95% CI 0.956 to 0.959) than blacks (HR 0.974, 95% CI 0.970 to 0.979).The overall, observed 1-year mortality rate after hospitalization for recurrent AMI declined from 32.4% in 1999 to 29.7% in 2010, a relative decline of 8.3% (P<0.05). In adjusted analyses, 1-year mortality after recurrent AMI hospitalization declined 1.8% per year (HR, 0.982; 95% CI 0.980 to 0.985).

CONCLUSIONS

In a national sample of Medicare beneficiaries hospitalized for AMI from 1999 to 2010, hospitalization for recurrent AMI decreased, as did subsequent mortality, albeit to a lesser extent. The risk of recurrent AMI hospitalization declined less in black patients than in whites, increasing observed racial disparities by the end of the study period.

Trends in acute myocardial infarction event rates and risk of recurrences after an incident event in Norway 1994 to 2009 (from a Cardiovascular Disease in Norway Project)

We explored trends in acute myocardial infarction (AMI) event rates in Norway during 1994 to 2009 and trends in the 6-month, 1-year, and 3-year risk of recurrences after an incident AMI during 2001 to 2008 in men and women ≥25 years. Trends in AMI event rates (incident and recurrent) were analyzed using joinpoint regression analyses and expressed as annual percentage change (APC) in rates. Trends in AMI recurrences were explored using conditional risk models for ordered events in Cox regression. Analyses were stratified by gender and age group. Overall, AMI rates were stable during 1994 to 2002 but declined during 2002 to 2009 (APC = -2.0; 95% confidence interval [CI] -3.1 to -0.9 in men; APC = -2.1; 95% CI -3.8 to -0.5 in women). In the younger age group, rates declined during the whole study period in men (APC = -0.6; 95% CI -1.0 to -0.3) but not in women. Among older patients, no changes were observed during 1994 to 2002, whereas rates declined during 2002 to 2009 (APC = -2.6; 95% CI -3.8 to -1.4 in men; APC = -2.4; 95% CI -4.0 to -0.7 in women). During 2001 to 2008, in the older age group, the 6-month, 1-year, and 3-year risks of recurrences were reduced annually by 4.7%, 4.3%, and 5.4% in men and 5.2%, 5.0%, and 5.7% in women (all ptrend <0.001), respectively. No changes were observed in the younger age group. In conclusion, favorable trends in AMI event rates and recurrences observed in Norway were mostly seen among patients aged 65+ years, whereas less favorable trends were observed among younger patients, especially among women.

Long-Term Survival and Recurrence After Acute Myocardial Infarction in England, 2004 to 2010

Background—

There are limited population-based national data on prognosis in survivors of acute myocardial infarction (AMI), particularly on long-term survival and the risk of recurrence.

Methods and Results—

Record linkage of hospital and mortality data identified 387 452 individuals in England who were admitted to hospital with a main diagnosis of AMI between 2004 and 2010 and who survived for at least 30 days. Seven years after an AMI, the risk of death from any cause in survivors of first or recurrent AMI was, respectively, 2 and 3 times higher than that in the English general population of equivalent age. For all survivors of a first AMI, the risk of a second AMI was highest during the first year and the cumulative risk increased more gradually thereafter. For men, 1- and 7-year cumulative risks were 5.6% (95% confidence interval [CI], 5.5–5.7) and 13.9% (95% CI, 13.7–14.1); for women, they were 7.2% (95% CI, 7.1–7.4) and 16.2% (95% CI, 16.0–16.5). Older age, higher deprivation, no revascularization procedures, and presence of comorbidities were associated with higher recurrence risk.

Conclusions—

Survivors of both first and recurrent AMI remained at a significantly higher risk of death compared with the general population for at least 7 years after the event. For survivors of first AMI, the influence of predisposing factors for second AMI lessened with time after the initial event. The results reinforce the importance of acute clinical care and secondary prevention in improving long-term prognosis of hospitalized AMI patients.

[Mortality of myocardial infarction]

Coronary disease is a major cause of death and disability. From 1975 to 2000, coronary mortality was reduced by half. Better treatments and reduction of risk factors are the main causes. This phenomenon is observed in most developed countries, but mortality from coronary heart disease continues to increase in developing countries. In-hospital mortality of ST elevation myocardial infarction (STEMI) is in the range of 7 to 10% in registries. In infarction without ST segment elevation (NSTEMI), in-hospital mortality is around 5%. More recent studies found a similar in-hospital mortality for STEMI and NSTEMI. Because of patient selection and monitoring, mortality in clinical trials is much lower. After adjustment for the extent of coronary disease, age, risk factors, history of myocardial infarction, the excess mortality observed in women is fading. Many clinical, biological and laboratory parameters are associated with mortality in myocardial infarction. They refer to the immediate risk of death (ventricular rhythm disturbances, shock…), the extent of infarction (number of leads with ST elevation on the ECG, release of biomarkers, ejection fraction…), the presence of heart failure, the failure of reperfusion and the patient's baseline risk (age, renal function…). Risk scores, and more specifically the GRACE risk score, synthesize these different markers to predict the risk of death in a given patient. However, their use for the treatment of myocardial only concerns NSTEMI. Only a limited number of mechanical or pharmacological interventions reduces mortality of heart attack. The main benefits are observed with reperfusion by thrombolysis or primary angioplasty in STEMI, aspirin, heparin, beta-blockers, angiotensin converting enzyme inhibitors. Some medications such as bivalirudin and fondaparinux reduce mortality by decreasing the incidence of hemorrhagic complications. The guidelines classify interventions according to their benefit and especially their ability to reduce mortality. Organized care systems that improve implementation of guidelines also reduce mortality. Finally, some new therapeutic approaches such as post-conditioning and new therapeutic classes offer encouraging prospects for further reducing the mortality of myocardial infarction.

Comparison of outcome of recurrent versus first ST-segment elevation myocardial infarction (from national Israel surveys 1998 to 2006)

Patients with recurrent acute myocardial infarction (AMI), who represent ≤35% of hospitalized patients with AMI, are at an increased risk of complications and death. Our study purpose was to compare the treatment and outcome of patients hospitalized with recurrent acute ST-segment elevation myocardial infarction (STEMI) from 1998 to 2006 with those of patients with a first STEMI. We performed 5 biennial nationwide 2-month surveys during 1998 to 2006, collecting data prospectively from all patients hospitalized for AMI or acute coronary syndrome in all 25 coronary care units in Israel. The present cohort included 4,543 patients with STEMI, 3,679 (76%) with first and 864 (24%) with recurrent STEMI. The patients with recurrent STEMI were older (66 ± 13 vs 62 ± 13 years), had greater rates of diabetes, hypertension, and previous angina, had a worse Killip class on admission, and experienced more in-hospital complications. The all-cause hospital crude mortality rate was 8.1% in patients with recurrent STEMI versus 5.5% in those with a first STEMI (adjusted odds ratio 1.71 95% confidence interval 1.19 to 2.44), and the 1-year mortality rate was 18.9% versus 10.9%, respectively (hazard ratio 1.85, 95% confidence interval 1.41 to 2.43). From 1998 to 2006, an insignificant trend toward a 1-year mortality reduction among patients with recurrent STEMI was seen and those with a first STEMI had a significant mortality decrease. In conclusion, patients admitted for recurrent STEMI have worse in-hospital and 1-year outcomes that did not improve during the study period. An improved therapeutic approach is needed for these high-risk patients.

Temporal decline in the prognostic impact of a recurrent acute myocardial infarction 1985 to 2002

OBJECTIVE

To investigate trends in case-fatality and prognostic impact from recurrent acute myocardial infarction (re-AMI) during 1985-2002.

DESIGN

Retrospective cohort study using nationwide administrative data from Denmark.

SETTINGS

National registries on hospital admissions and causes of death were linked to identify patients with first AMI, re-AMI and subsequent prognosis.

PATIENTS

Patients > or =30 years old with a discharge diagnosis of AMI during 1985-2002 were tracked for first hospital admission for re-AMI 1 year after discharge.

MAIN OUTCOME MEASURES

One-year case-fatality.

RESULTS

166 472 patients were identified with a first AMI; 14 123 developed re-AMI. One-year crude case-fatality from first AMI/re-AMI was 39% versus 43% in 1985-1989 and 25% versus 29% in 2000-2002, respectively. In 1985-89, 35 795 patients survived to discharge (71%); of these 2.5% experienced reinfarction within 30 days (early reinfarction) and an additional 9.0% reinfarction within days 31-365 (late re-AMI). Re-AMI carried a poor prognosis in 1985-1989 compared to no re-AMI with age- and sex-adjusted relative risk of 1-year case-fatality of 7.5 (95% CI: 6.9 to 8.5) from early re-AMI and 11.7 (95% CI: 11.0 to 12.4) from late re-AMI. In 2000-2002, 23 552 patients (86%) survived to discharge; 4.4% had early re-AMI and 6.6% late re-AMI. Adjusted relative risk of 1-year case-fatality had declined to 2.1 (95% CI: 1.9 to 2.5) from early re-AMI and 5.6 (95% CI: 5.1 to 6.2) from late re-AMI compared to patients without reinfarction.

CONCLUSION

Prognosis after AMI has improved substantially during the latest two decades and extends to patients with re-AMI.