Sex-related differences in the management and outcomes of patients hospitalized with ST-elevation myocardial infarction: a comparison within four European myocardial infarction registries.

Aims: Data on how differences in risk factors, treatments, and outcomes differ between sexes in European countries are scarce. We aimed to study sex-related differences regarding baseline characteristics, in-hospital managements, and mortality of ST-elevation myocardial infarction (STEMI) patients in different European countries. Methods and results: Patients over the age of 18 with STEMI who were treated in hospitals in 2014-17 and registered in one of the national myocardial infarction registers in Estonia (n = 5817), Hungary (n = 30 787), Norway (n = 33 054), and Sweden (n = 49 533) were included. Cardiovascular risk factors, hospital treatment, and recommendation of discharge medications were obtained from the infarction registries. The primary outcome was mortality, in-hospital, after 30 days and after 1 year. Logistic and cox regression models were used to study the associations of sex and outcomes in the respective countries. Women were older than men (70-78 and 62-68 years, respectively) and received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment, and evidence-based drugs to a lesser extent than men, in all countries. The crude mortality in-hospital rates (10.9-15.9 and 6.5-8.9%, respectively) at 30 days (13.0-19.9 and 8.2-10.9%, respectively) and at 1 year (20.3-28.1 and 12.4-17.2%, respectively) after hospitalization were higher in women than in men. In all countries, the sex-specific differences in mortality were attenuated in the adjusted analysis for 1-year mortality. Conclusion: Despite improved awareness of the sex-specific inequalities on managing patients with acute myocardial infarction in Europe, country-level data from this study show that women still receive less guideline-recommended management.

Comparison of management and outcomes of ST-segment elevation myocardial infarction patients in Estonia, Hungary, Norway, and Sweden according to national ongoing registries.

AIMS: Describe the characteristics, management and outcomes of hospitalized ST-segment elevation myocardial infarction (STEMI) patients according to national ongoing myocardial infarction registries in Estonia, Hungary, Norway, and Sweden. METHODS AND RESULTS: Country-level aggregated data was used to study baseline characteristics, use of in-hospital procedures, medications at discharge, in-hospital complications, 30-day and 1-year mortality for all patients admitted with STEMI during 2014-2017 using data from EMIR (Estonia; n = 4584), HUMIR (Hungary; n = 23 685), NORMI (Norway; n = 12 414, data for 2013-2016), and SWEDEHEART (Sweden; n = 23 342). Estonia and Hungary had a higher proportion of women, patients with hypertension, diabetes, and peripheral artery disease compared to Norway and Sweden. Rates of reperfusion varied from 75.7% in Estonia to 84.0% in Sweden. Rates of recommendation of discharge medications were generally high and similar. However, Estonia demonstrated the lowest rates of dual antiplatelet therapy (78.1%) and statins (86.5%). Norway had the lowest rates of beta-blockers (80.5%) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (61.5%). The 30-day mortality rates ranged between 9.9% and 13.4% remaining lowest in Sweden. One-year mortality rates ranged from 14.8% in Sweden and 16.0% in Norway to 20.6% in Hungary and 21.1% in Estonia. Age-adjusted lethality rates were highest for Hungary and lowest for Sweden. CONCLUSION: This inter-country comparison of data from four national ongoing European registries provides new insights into the risk factors, management and outcomes of patients with STEMI. There are several possible reasons for the findings, including coverage of the registries and variability of baseline-characteristics' definitions that need to be further explored.

Differences in characteristics, treatments and outcomes in patients with non-ST-elevation myocardial infarction: novel insights from four national European continuous real-world registries.

AIMS: To study baseline characteristics, in-hospital managements and mortality of non-ST-elevation myocardial infarction (NSTEMI) patients in different European countries. METHODS AND RESULTS: NSTEMI patients enrolled in the national myocardial infarction (MI) registries [EMIR; n = 5817 (Estonia), HUMIR; n = 30 787 (Hungary), NORMI; n = 33 054 (Norway), and SWEDEHEART; n = 49 533 (Sweden)] from 2014 to 2017 were included and presented as aggregated data. The median age at admission ranged from 70 to 75 years. Current smoking status was numerically higher in Norway (24%), Estonia (22%), and Hungary (19%), as compared to Sweden (17%). Patients in Hungary had a high rate of diabetes mellitus (37%) and hypertension (84%). The proportion of performed coronary angiographies (58% vs. 75%) and percutaneous coronary interventions (38% vs. 56%), differed most between Norway and Hungary. Prescription of dual antiplatelet therapy at hospital discharge ranged from 60% (Estonia) to 81% (Hungary). In-hospital death ranged from 3.5% (Sweden) to 9% (Estonia). The crude mortality rate at 1 month was 12% in Norway and 5% in Sweden (5%), whereas the 1-year mortality rates were similar (20-23%) in Hungary, Estonia, and Norway and 15% in Sweden. CONCLUSION: Cross-comparisons of four national European MI registries provide important data on differences in risk factors and treatment regiments that may explain some of the observed differences in death rates. A unified European continuous MI registry could be an option to better understand how implementation of guideline-recommended therapy can be used to reduce the burden of cardiovascular disease.

2020 Update of the quality indicators for acute myocardial infarction: a position paper of the Association for Acute Cardiovascular Care: the study group for quality indicators from the ACVC and the NSTE-ACS guideline group.

AIMS: Quality indicators (QIs) are tools to improve the delivery of evidence-base medicine. In 2017, the European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) developed a set of QIs for acute myocardial infarction (AMI), which have been evaluated at national and international levels and across different populations. However, an update of these QIs is needed in light of the accumulated experience and the changes in the supporting evidence. METHODS AND RESULTS: The ESC methodology for the QI development was used to update the 2017 ACVC QIs. We identified key domains of AMI care, conducted a literature review, developed a list of candidate QIs, and used a modified Delphi method to select the final set of indicators. The same seven domains of AMI care identified by the 2017 Study Group were retained for this update. For each domain, main and secondary QIs were developed reflecting the essential and complementary aspects of care, respectively. Overall, 26 QIs are proposed in this document, compared to 20 in the 2017 set. New QIs are proposed in this document (e.g. the centre use of high-sensitivity troponin), some were retained or modified (e.g. the in-hospital risk assessment), and others were retired in accordance with the changes in evidence [e.g. the proportion of patients with non-ST segment elevation myocardial infarction (NSTEMI) treated with fondaparinux] and the feasibility assessments (e.g. the proportion of patients with NSTEMI whom risk assessment is performed using the GRACE and CRUSADE risk scores). CONCLUSION: Updated QIs for the management of AMI were developed according to contemporary knowledge and accumulated experience. These QIs may be applied to evaluate and improve the quality of AMI care.

The risk-treatment paradox in non-ST-elevation myocardial infarction patients according to their estimated GRACE risk.

BACKGROUND: The purpose was to describe the treatment and outcomes of non-ST-elevation myocardial infarction (NSTEMI) in Estonia according to patients' estimated mortality risk by the Global Registry of Acute Coronary Events (GRACE) score and investigate if inequalities in treatment had an impact on prognosis. METHODS: We performed a linkage between Estonian Myocardial Infarction Registry, Population Registry and Estonian Health Insurance Fund. All NSTEMI patients 2012-2014 were stratified into low (<4%), intermediate (4-12%), or high (>12%) mortality risk according to GRACE. All-cause mortality and composite endpoint of death, recurrent myocardial infarction, stroke or unplanned revascularization were compared between optimally - defined as concomitant in-hospital use of medicines from recommended groups and coronary angiography - and suboptimally managed patients, using the Cox regression. RESULTS: Out of 3803 NSTEMI patients (median age 73 years, 44% women) 20% were classified into low, 35% into intermediate and 45% into high risk category. In these groups, respectively, 62%, 46% and 23% of patients received optimal in-hospital management. Over the mean follow-up of 2.4 years the association between suboptimal in-hospital management and outcomes was the following: in the low risk group mortality hazard ratio (HR) 1.6 (95% confidence interval 0.8-3.2), composite endpoint HR 1.2 (0.8-1.8); in the intermediate risk group mortality HR 2.4 (1.7-3.3), composite endpoint HR 1.8 (1.4-2.3); and in the high risk group mortality HR 2.2 (1.8-2.8), composite endpoint HR 1.6 (1.3-2.0). CONCLUSIONS: Higher risk NSTEMI patients received less guideline-recommended in-hospital management, which was associated with a worse prognosis.

Improved treatment and prognosis after acute myocardial infarction in Estonia: cross-sectional study from a high risk country.

BACKGROUND: The aim of the study was to explore trends in short- and long-term mortality after hospitalization for acute myocardial infarction (AMI) over the period 2001─2011 in Estonian secondary and tertiary care hospitals while adjusting for changes in baseline characteristics. METHODS: In this nationwide cross-sectional study random samples of patients hospitalized due to AMI in years 2001, 2007 and 2011 were identified and followed for 1 year. Trends in 30-day and 1-year all-cause mortality were analysed using Cox proportional hazards regression model. RESULTS: The final analysis included 423, 687 and 665 patients in years 2001, 2007 and 2011 respectively. During the study period, the prevalence of most comorbidities remained unchanged while the in-hospital and outpatient treatment improved significantly. For example, the proportion of tertiary care hospital AMI patients who underwent revascularization was almost three times higher in 2011 compared to 2001. The proportion of secondary care patients who were referred to a tertiary care centre for more advanced care increased from 5.8 to 40.1 % (p for trend <0.001). Meanwhile, the 1-year mortality rates decreased from 29.5 to 20.2 % (adjusted p = 0.004) in the tertiary and from 32.4 to 23.1 % (adjusted p = 0.006) in the secondary care. The decrease in the 30-day mortality rates was statistically significant only in the secondary care hospitals. CONCLUSIONS: The use of evidence-based treatments in Estonian AMI patients improved between 2001 and 2011. At the same time, we observed a significant reduction in the long-term mortality rates, both for patients primarily hospitalized into secondary as well as into tertiary care hospitals.

Sex-specific outcomes of diabetic patients with acute myocardial infarction who have undergone percutaneous coronary intervention: a register linkage study.

BACKGROUND: The presence of diabetes mellitus poses a challenge in the treatment of patients with acute myocardial infarction (AMI). We aimed to evaluate the sex-specific outcomes of diabetic and non-diabetic patients with AMI who have undergone percutaneous coronary intervention (PCI). METHODS: Data of the Estonian Myocardial Infarction Registry for years 2006-2009 were linked with the Health Insurance Fund database and the Population Registry. Hazard ratios (HRs) with the 95% confidence intervals (CIs) for the primary composite outcome (non-fatal AMI, revascularization, or death whichever occurred first) and for the secondary outcome (all cause mortality) were calculated comparing diabetic with non-diabetic patients by sex. RESULTS: In the final study population (n=1652), 14.6% of the men and 24.0% of the women had diabetes. Overall, the diabetics had higher rates of cardiovascular risk factors, co-morbidities, and 3-4 vessel disease among both men and women (p<0.01). Among women, the diabetic patients were younger, they presented later and less often with typical symptoms of chest pain than the non-diabetics (p<0.01). Women with diabetes received aspirin and reperfusion for ST-segment elevation AMI less often than those without diabetes (p<0.01). During a follow-up of over two years, in multivariate analysis, diabetes was associated with worse outcomes only in women: the adjusted HR for the primary outcome 1.44 (95% CI 1.05-1.96) and for the secondary outcome 1.83 (95% CI 1.17-2.89). These results were largely driven by a high (12.0%) mortality during hospitalization of diabetic women. CONCLUSIONS: Diabetic women with AMI who have undergone PCI are a high-risk group warranting special attention in treatment strategies, especially during hospitalization. There is a need to improve the expertise to detect AMI earlier, decrease disparities in management, and find targeted PCI strategies with adjunctive antithrombotic regimes in women with diabetes.

Changes in treatment and mortality of acute myocardial infarction in Estonian tertiary and secondary care hospitals in 2001 and 2007.

BACKGROUND: High quality care for acute myocardial infarction (AMI) improves patient outcomes. Still, AMI patients are treated in hospitals with unequal access to percutaneous coronary intervention. The study compares changes in treatment and 30-day and 3-year mortality of AMI patients hospitalized into tertiary and secondary care hospitals in Estonia in 2001 and 2007. RESULTS: Final analysis included 423 cases in 2001 (210 from tertiary and 213 from secondary care hospitals) and 687 cases in 2007 (327 from tertiary and 360 from secondary care hospitals). The study sample in 2007 was older and had twice more often diabetes mellitus. The patients in the tertiary care hospitals underwent reperfusion for ST-elevation myocardial infarction, cardiac catheterization and revascularisation up to twice as often in 2007 as in 2001. In the secondary care, patient transfer for further invasive treatment into tertiary care hospitals increased (P < 0.001). Prescription rates of evidence-based medications for in-hospital and for outpatient use were higher in 2007 in both types of hospitals. However, better treatment did not improve significantly the short- and long-term mortality within a hospital type in crude and baseline-adjusted analysis. Still, in 2007 a mortality gap between the two hospital types was observed (P < 0.010). CONCLUSIONS: AMI treatment improved in both types of hospitals, while the improvement was more pronounced in tertiary care. Still, better treatment did not result in a significantly lower mortality. Higher age and cardiovascular risk are posing a challenge for AMI treatment.

Better outcomes for acute myocardial infarction patients first admitted to PCI hospitals in Estonia.

OBJECTIVE: The objective of this study was to compare process of care, in-hospital outcomes, and 1-year mortality of patients with acute myocardial infarction (AMI) first admitted to hospitals with and without percutaneous coronary intervention (PCI) facilities in Estonia in 2007. METHODS: We conducted a retrospective cross-sectional study on a random sample of hospitalized AMI patients. Data on process of care and in-hospital outcomes were abstracted from patient records in 16 hospitals according to a standardized study form. RESULTS: Patients first admitted to PCI hospitals (n = 327) had higher rates of overall use of coronary angiography (78.3% vs. 24.7%; P < 0.001), revascularization (64.2% vs. 20.6%; P < 0.001), and echocardiography (85.3% vs. 65.3%, P < 0.001) than those first admitted to non-PCI hospitals (n = 360). Among the non-PCI hospital patients those selected for cardiac catheterization were younger, healthier, and had better clinical status on presentation. Patients admitted to PCI hospitals had higher prescription rates of in-hospital and discharge evidence-based medications except for beta-blockers. PCI hospitals' patients had lower in-hospital mortality (11.3% vs. 19.2%, P = 0.004) and 1-year mortality (24.5% vs. 34.7%, P = 0.003), results remained significant after adjustment for baseline characteristics (odds ratio 0.47; 95% confidence interval 0.28-0.78, hazard ratio 0.66; 95% confidence interval 0.48-0.90). CONCLUSIONS: There are disparities in process of care, in-hospital and 1-year mortality between patients first admitted to PCI vs. non-PCI hospitals in Estonia. Patients admitted to non-PCI hospitals should undergo more vigorous risk stratification using invasive and non-invasive methods; use of evidence-based medicine should be encouraged even if cardiac revascularization is not done.