Impact of the admitting ward on care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI) : insights from a national registry

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Phenotypical differences in the characteristics of a population affects both the mortality and the performance of a risk-scoring model

This commentary refers to ‘Ethnicity-dependent performance of the Global Registry of Acute Coronary Events risk score for prediction of non-ST-segment elevation myocardial infarction in-hospital mortality: nationwide cohort study’, by S.M. Moledina et al., https://doi.org/10.1093/eurheartj/ehac052 and the discussion piece ‘Refitting the predictor variables included in a model in a new cohort usually exaggerates its calibration performance’, by Y.-M. He, https://doi.org/10.1093/eurheartj/ehac476. We thank He et al. for their interest in our article and note their observation that the application of a risk-scoring model on a new population often results in deterioration in the calibration of the model while maintaining its discriminative ability. It is important to note that the original (Global Registry of Acute Coronary Events) GRACE risk-scoring model was validated in 14 countries with predominantly Caucasian populations.1 While our population was highly heterogeneous, there were clear phenotypically differences between ethnic minorities compared with White patients. Notably, ethnic minority patients tended to present with non-ST segment elevation myocardial infarction on average 5 years younger than White patients and had worse cardiometabolic risk factor profile with significantly increased frequency of diabetes mellitus, hypertension, and hypercholesterolaemia.2 With the GRACE score previously being validated in patients from the MINAP database, the optimal calibration in White patients (who formed the majority of subjects) was not unexpected

Impact of QRS Duration on Non-ST-Segment Elevation Myocardial Infarction (from a National Registry)

QRS duration (QRSd) is ill-defined and under-researched as a prognosticator in patients with non-ST-segment myocardial infarction (NSTEMI). We analyzed 240,866 adult (≥18 years) hospitalizations with non-ST-segment elevation myocardial infarction using data from the United Kingdom Myocardial Infarction National Audit Project. Clinical characteristics and all-cause in-hospital mortality were analyzed according to QRSd, with 38,023 patients presenting with a QRSd &gt;120 ms and 202,842 patients with a QRSd &lt;120 ms. Patients with a QRSd &gt;120 ms were more frequently older (median age of 79 years vs 71 years, p &lt;0.001), and of white ethnicity (93% vs 91%, p &lt;0.001). Patients with a QRSd &lt;120 ms had higher frequency of use of aspirin (97% vs 95%, p &lt;0.001), P2Y12 inhibitor (93% vs 89%, p &lt;0.001), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (82% vs 81%, p &lt;0.001) and β blockers (83% vs 78%, p &lt;0.001). Invasive management strategies were more likely to be used in patients with QRSd &lt;120 ms including invasive coronary angiography (72% vs 54%, p &lt;0.001), percutaneous coronary intervention (46% vs 33%, p &lt;0.001) and coronary artery bypass graft surgery (8% vs 6%, p &lt;0.001). In a propensity score matching analysis, there were no differences between the 2 groups in the adjusted rates of in-hospital all-cause mortality (odds ratio 0.94, 95% confidence interval 0.86 to 1.01) or major adverse cardiac events (odds ratio 0.94, 95% confidence interval 0.85 to 1.02) during the index admission. In conclusion, prolonged QRSd &gt;120 ms in the context of non-ST-segment myocardial infarction is not associated with worse in-hospital mortality or the outcomes of major adverse cardiac events.</p

The quality of care and long-term mortality of out of hospital cardiac arrest survivors after acute myocardial infarction: a nationwide cohort study.

The long-terms outcomes of out of hospital cardiac arrest (OHCA) survivors are not well known. Using the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics (ONS) mortality data, we analysed 661 326 England, Wales and Northern-Ireland AMI patients; 14 127 (2%) suffered OHCA and survived beyond thirty-days of hospitalisation. Patients dying within thirty-days of admission were excluded. Mean follow-up for patients included was 1 500 days. Cox regression models were fitted, adjusting for demographics and management strategy. OHCA survivors were younger (in years) (64 (interquartile range [IQR] 54-72) vs. 70 (IQR 59-80), P < 0.001), more often underwent invasive coronary angiography (88% vs. 71%, P < 0.001) and percutaneous coronary intervention (72% vs. 45%, P < 0.001). Overall, risk of mortality for OHCA patients that survived past 30-days was lower than patients that did not suffer cardiac arrest (adjusted hazard ratio [HR] 0.91; 95% CI; 0.87-0.95, P < 0.001). 'Excellent care' according to the mean opportunity-based quality indicator (OBQI) score compared to 'Poor care', predicted reduced risk of long-term mortality post OHCA, for all-patients (HR: 0.77, CI; 0.76-0.78, P < 0.001), more for STEMI patients (HR: 0.73, CI; 0.71-0.75, P < 0.001), but less significantly in NSTEMI patients (HR: 0.79, CI; 0.78-0.81, P < 0.001). Out of hospital cardiac arrest (OHCA) patients remain at significant risk of mortality in-hospital. However, if surviving over thirty-days post arrest, OHCA survivors have good longer-term survival up to ten-years compared to the general AMI population. Higher quality inpatient care appears to improve long-term survival in all OHCA patients, more so in STEMI. [Abstract copyright: © The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.

Trends In ST-elevation Myocardial Infarction Hospitalisation Among Young Adults: A Binational Analysis

Background ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients that suffer STEMI under the age of fifty, that are not well characterized in studies. Methods &amp; Results We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010-2017 and the National Inpatient Sample (NIS) from the United States (US) between 2010-2018. After exclusion criteria, there were 32,719 STEMI patients aged ≤50 from MINAP, and 238,952 patients’ ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010-2012) to 17.6% (2016-2017) (UK) and 22.8% (2010-2012) to 23.1% (2016-2018) (US). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (US). Invasive coronary angiography (ICA) rates increased in UK (2010-2012: 89.0%, 2016-2017: 94.3%), while decreased in US (2010-2012: 88.9%, 2016-2018: 86.2% (US). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016-2017 compared to 2010-2012 (OR:1.21, 95% CI:0.60-2.40), but there was a decrease in the US in 2016-2018 compared to 2010-2012 (OR: 0.84, 95% CI: 0.79-0.90). Conclusion The demographics of young STEMI patients have temporally changed in the UK and US, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries

Socioeconomic disparities in the management and outcomes of acute myocardial infarction

Background: Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear. Methods: Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and ‘ethnic-minority’ patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality. Results: More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001). Conclusion: Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction:a nationwide cohort study

BACKGROUND: Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe. METHODS & RESULTS: We identified 280,588 admissions with NSTEMI in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258,364) and Black, Asian and Minority Ethnic (BAME) patients (n = 22,194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs 54%, P < 0.001), hypercholesterolemia (49% vs 34%, P < 0.001) and diabetes (48% vs 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs 43%, P < 0.001) and coronary artery bypass graft surgery (9% vs 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality (OR:0.91, CI: 0.76-1.06, P = 0.23), major bleeding (OR: 0.99, CI: 0.75 - 1.25, P = 0.95), reinfarction (OR: 1.15, CI: 0.84 - 1.46, P = 0.34) and major adverse cardiovascular events (MACE) (OR:0.94, CI: 0.80-1.07, P = 0.35). CONCLUSION: BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI

Association of admitting physician specialty and care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI):insights from a national registry

BACKGROUND: Little is known about the association between admitting physician specialty and care quality and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI). METHODS & RESULTS: We identified 288,420 patients hospitalised with NSTEMI between 2010-2017 in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP) database. The cohort was dichotomised according to care under a non-cardiologist (n?=?146,722) and care under a cardiologist (n?=?141,698) within the first 24?hours of admission to hospital. Patients admitted under a cardiologist were significantly younger (70-years vs 75 years, P?<?0.001), and less likely to be female (32% vs 39%, P?<?0.001). Independent factors associated with admission under a cardiologist included: prior history of percutaneous coronary intervention (PCI) (OR:1.04, 95% CI:1.01-1.07, P?=?0.04), hypercholesterolaemia (OR: 1.17, 95% CI: 1.15-1.20, P?<?0.001), hypertension (OR: 1.03, 95% CI: 1.01-1.04, P?=?0.01) and admission to an interventional centre (OR: 3.90, 95% CI: 3.79 - 4.00, P?<?0.001). Patients admitted under cardiology were more likely to receive optimal pharmacotherapy, undergo invasive coronary angiography (79% vs 60%, P?<?0.001), and receive revascularization in the form of percutaneous coronary intervention (PCI) (52% vs 36%, P?<?0.001). Following propensity score matching, odds of in-hospital all-cause mortality (OR:0.81, 95% CI: 0.79-0.85, P?<?0.001), reinfarction (OR:0.78, 95% CI: 0.66-0.91, P?=?0.001) and major adverse cardiovascular events (MACE) (OR: 0.81, 95% CI: 0.78-0.84, P?<?0.001) were lower in patients admitted under a cardiologist. CONCLUSION: Patients with NSTEMI admitted under a cardiologist within 24?hours of hospital admission were more likely to receive guideline directed management and had better clinical outcomes

Ethnicity-dependent performance of the Global Registry of Acute Coronary Events risk score for prediction of non-ST-segment elevation myocardial infarction in-hospital mortality: nationwide cohort study

Background: The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with acute coronary syndrome with or without ST-segment elevation. Little is known about its performance at predicting in-hospital mortality for ethnic minority patients. Methods and Results: We identified 326,160 admissions with non-ST-segment elevation myocardial infarction (NSTEMI) in the Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White (n = 299,184) and ethnic minorities (excluding White minorities) (n=26,976). We calculated the GRACE score for in-hospital mortality and assessed ethnic group baseline characteristics by low, intermediate and high risk. Performance of the GRACE risk score was estimated by discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plots). Ethnic minorities presented younger and had increased prevalence of cardiometabolic risk factors in all GRACE risk groups. The GRACE risk score for White (AUC 0.87, 95% confidence interval [CI] 0.86-0.87) and ethnic minority (AUC 0.87, 95% CI 0.86-0.88) patients had good discrimination. However, whilst the GRACE risk model was well calibrated in White patients (expected to observed (E:O) in-hospital death rate ratio 0.99; slope 1.00), it overestimated risk in ethnic minority patients (E:O ratio 1.29; slope: 0.94). Conclusion: The GRACE risk score provided good discrimination overall for in-hospital mortality, but was not well calibrated and overestimated risk for ethnic minorities with NSTEMI