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Improving outcome in acute myocardial infarction
Linköping University, Department of Medicine and Care, Cardiology. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Despite common guidelines there are vanatlons in the treatment of acute myocardial infarction (AMI) between hospitals in Sweden. Uncertainties remain regarding the efficacy of early statin therapy and early revascularisation in AMI patients. In the elderly patients also the role of fibrinolytic therapy has been questioned.

Methods: We created a national quality assurance register named RIKS-HIA including all patients admitted to participating hospitals' ICCU. The database accumulates information about baseline characteristics, interventions, complications and outcome in consecutive patients. The merging of the database with the Cause of Death Register provides  opportunity to compare the effects of treatments on long-term outcome. Multivariate Cox regression analysis and propensity score was used to evaluate outcome in AMI patients of the studied interventions, and to compare activity level between different hospitals.

Results: After patient characteristics were taken into account there were still significant differences between the hospitals in some treatment modalities that remained over time. There was no correlation between hospital size and activity level. In 19 599 in-hospital survivors after their first registry-recorded AMI at an age below 80 years early statin treatment was associated with a 25 % relative risk reduction of I-year mortality. In 21 912 patients with first registry-recorded AMI younger than 80 years and alive at day 14, early revascularisation was associated with a 50 % relative reduction of I-year mortality. For both therapies the effects were homogeneous among all subgroups based on age, gender, baseline characteristics, previous disease manifestations and medication. Fibrinolytic therapy in ST-segment elevation myocardial infarction patients 75 years of age and older showed a net benefit of 13% in outcome when non-fatal intracranial haemorrhage and I-year survival were analysed.

Conclusion: The results indicates the need of continuous quality assurance, and strategies to reduce the differences in AMI therapy between hospitals. They lend support to early statin and early revascularisation regimens in AMI patients. Fibrinolytic therapy is recommended also in the elderly patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2002. , 73 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 740
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-27543Local ID: 12202ISBN: 91-7373-189-7 (print)OAI: oai:DiVA.org:liu-27543DiVA: diva2:248095
Public defence
2002-11-07, Elsa Brändströmsalen, Campus US, Linköpings universtiet, Linköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-19Bibliographically approved
List of papers
1. New perspectives on observed variations in treatment of acute myocardial infarction between different hospitals based on multivariable analyses of a large prospective cohort
Open this publication in new window or tab >>New perspectives on observed variations in treatment of acute myocardial infarction between different hospitals based on multivariable analyses of a large prospective cohort
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aim: To investigate the differences in treatment of acute myocardial infarction (AMI) between different hospitals within one country, and the causes of these differences.

Method: The Register of Information and Knowledge about Swedish Heart Intensive care Admissions recorded every CCU admitted patient in 67 hospitals 1999-2000. The use often generally recommended treatments and examinations in patients with AMI were compared between the hospitals after 23 different background characteristics were encountered for by propensity score analyses.

Results: 32954 primary admissions for AMI were included. After adjustment for patient characteristics there were few significant deviations between hospitals in the proportion treated with acute reperlusion, aspirin, beta-blockade or ACE-inhibition at discharge. There were, however, 3 to more than 10 fold differences between hospitals in the proportion of patients treated with intravenous B-blockers, intravenous nitroglycerin, intravenous or subcutaneous anticoagulants, and discharge lipid lowering medication and even larger discrepancies in the use of in echocardiography and coronary angiography. There was a significant (r=0.668;p<0.001) correlation between hospital average rank between the years but no correlation between hospital size and the hospital's average rank for the adjusted use of these treatments (r-0.003 and p=0.98).

Conclusion: After differences between the patients background characteristics and chance findings have been taken into account, most hospitals provide similar regimens concerning treatment modalities where there is strong evidence for efficacy. The remaining large treatment variations mainly concern treatment where the indications and evidence are in development or where uncertainties remain or where there are differences in immediately available treatment facilities. In order to ascertain the quality and equality of treatment in acute myocardial infarction continuous quality control of treatments and outcomes are essential especially in areas with a rapid development of new treatments and in centres with limited resources.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81625 (URN)
Available from: 2012-09-19 Created: 2012-09-19 Last updated: 2012-09-19Bibliographically approved
2. Early statin treatment following acute myocardial infarction and 1-year survival
Open this publication in new window or tab >>Early statin treatment following acute myocardial infarction and 1-year survival
2001 (English)In: Journal of the American Medical Association (JAMA), ISSN 0098-7484, E-ISSN 1538-3598, Vol. 285, no 4, 430-436 p.Article in journal (Refereed) Published
Abstract [en]

CONTEXT:

Randomized trials have established statin treatment as secondary prevention in coronary artery disease, but it is unclear whether early treatment with statins following acute myocardial infarction (AMI) influences survival.

OBJECTIVE:

To evaluate the association between statin treatment initiated before or at the time of hospital discharge and 1-year mortality after AMI.

DESIGN AND SETTING:

Prospective cohort study using data from the Swedish Register of Cardiac Intensive Care on patients admitted to the coronary care units of 58 Swedish hospitals in 1995-1998. One-year mortality data were obtained from the Swedish National Cause of Death Register.

PATIENTS:

Patients with first registry-recorded AMI who were younger than 80 years and who were discharged alive from the hospital, including 5528 who received statins at or before discharge and 14 071 who did not.

MAIN OUTCOME MEASURE:

Relative risk of 1-year mortality according to statin treatment.

RESULTS:

At 1 year, unadjusted mortality was 9.3% (1307 deaths) in the no-statin group and 4.0% (219 deaths) in the statin treatment group. In regression analysis adjusting for confounding factors and propensity score for statin use, early statin treatment was associated with a reduction in 1-year mortality (relative risk, 0.75; 95% confidence interval, 0.63-0.89; P =.001) in hospital survivors of AMI. This reduction in mortality was similar among all subgroups based on age, sex, baseline characteristics, previous disease manifestations, and medications.

CONCLUSIONS:

Early initiation of statin treatment in patients with AMI is associated with reduced 1-year mortality. These results emphasize the importance of implementing the results of randomized statin trials in unselected AMI patients.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-27148 (URN)11242427 (PubMedID)11796 (Local ID)11796 (Archive number)11796 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-19Bibliographically approved
3. Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study
Open this publication in new window or tab >>Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study
2002 (English)In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 359, no 9320, 1805-1811 p.Article in journal (Refereed) Published
Abstract [en]

Background

Randomised trials of early revascularisation in acute coronary syndromes have yielded conflicting results with respect to effects on survival. We assessed the association between revascularisation within 14 days after the index event and 1-year mortality in individuals who survived for at least 14 days after an acute myocardial infarction.

Methods

We studied a prospective cohort of patients admitted to the coronary care units of 61 Swedish hospitals between 1995 and 1998. We obtained 1-year mortality data from the Swedish National Cause of Death Register. We assessed 21 912 individuals with first registry-recorded acute myocardial infarction, who were younger than age 80 years, and alive at day 14. Relative risk of 1-year mortality in patients who had revascularisation (n=2554) or those who did not (n=19 358) within 14 days was calculated by Cox regression analysis, adjusting for multiple covariates that affect mortality and with a propensity score that adjusted for covariates that affected the likelihood of early revascularisation.

Findings

At 1 year, unadjusted mortality was 9·0% (1751 deaths) in the conservative group and 3·3% (84 deaths) in the early revascularisation group. In the Cox regression analysis early revascularisation was associated with a reduction in 1-year mortality (relative risk 0·47; 95% Cl 0·37–0·60; p <0·001). This relative reduction of mortality was similar in all subgroups irrespective of age, sex, baseline characteristics, previous disease manifestations, or treatment.

Interpretation

Early revascularisation in individuals with acute myocardial infarction is associated with substantial reduction in 1-year mortality. Our findings lend support to the use of an invasive approach early after an acute myocardial infarction.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-27151 (URN)10.1016/S0140-6736(02)08710-X (DOI)11799 (Local ID)11799 (Archive number)11799 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-19Bibliographically approved
4. Fibrinolytic therapy in patients 75 years and older with ST-wegment–elevation myocardial infarction: one-year follow-up of a large prospective cohort
Open this publication in new window or tab >>Fibrinolytic therapy in patients 75 years and older with ST-wegment–elevation myocardial infarction: one-year follow-up of a large prospective cohort
2003 (English)In: Archives of Internal Medicine, ISSN 0003-9926, E-ISSN 1538-3679, Vol. 163, no 8, 965-971 p.Article in journal (Refereed) Published
Abstract [en]

Background  Fibrinolytic therapy reportedly may not be beneficial in acute ST-segment–elevation myocardial infarction (STEMI) in patients who are 75 years and older.

Methods  The association between fibrinolytic therapy and 1-year mortality and bleeding complications in an unselected large cohort of patients with STEMI was evaluated by means of propensity and Cox regression analysis adjusting for multiple factors known to influence fibrinolytic therapy as well as survival. The Register of Information and Knowledge About Swedish Heart Intensive Care Admissions recorded every patient admitted to a coronary care unit in 64 hospitals during 1995 through 1999. One-year mortality was obtained by merging with the National Cause of Death Register.

Results  A total of 6891 patients 75 years and older with first registry-recorded STEMI were included, of whom 3897 received fibrinolytic therapy and 2994 received no such treatment. Fibrinolytic therapy was associated with a 13% adjusted relative reduction in the composite of mortality and cerebral bleeding complications after 1 year (95% confidence interval, 0.80-0.94; P = .001). This effect seemed homogeneous among all subgroups based on age, sex, coronary risk factors, and previous disease manifestations.

Conclusions  Fibrinolytic therapy in patients with STEMI who are 75 years and older is associated with a reduction in the composite of mortality and cerebral bleedings after 1 year. These results from an unselected coronary care unit population support the use of fibrinolytic therapy in elderly patients.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-46621 (URN)10.1001/archinte.163.8.965 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2012-09-19Bibliographically approved

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