Non‐ST‐Elevation Myocardial Infarction in the United States: Contemporary Trends in Incidence, Utilization of the Early Invasive Strategy, and In‐Hospital Outcomes

Q: What are the key findings of this study?

From 2002 to 2011, early invasive strategy utilization in NSTEMI increased while risk-adjusted in-hospital mortality decreased from 5.5% to 3.9%.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Non-ST-elevation myocardial infarction (NSTEMI) (n=3981119). Intervention: Calendar year / Early invasive strategy (coronary angiography with or without PCI or CABG on day 0 or day 0-1) vs. Reference year 2002 / No early invasive strategy. Primary outcome: All-cause, in-hospital mortality (temporal trend from 2002 to 2011) (OR 0.976 per year, 95% CI 0.974-0.978, p=<0.001).

Q: What does this research mean for the field?

Between 2002 and 2011 in the United States, utilization of an early invasive strategy for NSTEMI significantly increased, accompanied by a decrease in risk-adjusted in-hospital mortality. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Sahil Khera; Dhaval Kolte; Wilbert S. Aronow; Chandrasekar Palaniswamy; Kathir Subramanian; Taimoor Hashim; Marjan Mujib; Diwakar Jain; Rajiv Paudel; Ali Ahmed; William H. Frishman; Deepak L. Bhatt; Julio A. Panza; Gregg C. Fonarow

doi:10.1161/jaha.114.000995

July 29, 2014Journal of the American Heart AssociationOpen Access

Non‐ST‐Elevation Myocardial Infarction in the United States: Contemporary Trends in Incidence, Utilization of the Early Invasive Strategy, and In‐Hospital Outcomes

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Key result

Rising early invasive strategy in NSTEMI linked to ~2% lower annual in-hospital mortality.

OR 0.976 per year
95% CI 0.974-0.978
P<0.001
n=3,981,119

Why the study?

How have the incidence of NSTEMI, utilization of early invasive strategy, and in-hospital mortality changed over time among US adults hospitalized with NSTEMI from 2002 to 2011?

Study Design

Type

Cohort (n=3,981,119)

Multicenter

Yes

Structured PICO

How have the incidence of NSTEMI, utilization of early invasive strategy, and in-hospital mortality changed over time among US adults hospitalized with NSTEMI from 2002 to 2011?

P

Population

3,981,119 adults aged ≥40 years hospitalized with a principal diagnosis of NSTEMI in the United States from 2002 to 2011, evaluated for in-hospital outcomes.

E

Exposure

Temporal progression by calendar year (2002 to 2011) and utilization of early invasive strategy (EIS), defined as coronary angiography with or without revascularization (PCI or CABG) on day 0 (within 24 hours) or day 0 or 1 (within 48 hours of admission).

C

Comparator

Reference calendar year 2002 (for temporal trend analyses) and patients not receiving early invasive strategy (No EIS within day 0 or 1).

O

Outcome

All-cause, in-hospital mortality (defined as death during the hospitalization encounter in the NIS database).hard clinical

Main Result

Odds Ratio: 0.976 (95% CI 0.974–0.978)

Absolute Event Rate: 3.9% vs 5.5%

p-value: p=<0.001

This nationwide US analysis demonstrates that from 2002 to 2011, the proportion of AMI admissions due to NSTEMI increased alongside greater adoption of guideline-recommended early invasive management and significant reductions in in-hospital mortality and length of stay.

Limitations

Retrospective observational design with potential for selection bias and residual measured and unmeasured confounding
Administrative database subject to potential miscoding of diagnostic and procedure codes
Widespread troponin utilization may have increased NSTEMI diagnoses and decreased case severity or included non-ACS troponin elevations
Clinical presentation and medication utilization variables are not available in the database
Procedure timing is recorded in days rather than hours, and outcomes are limited to in-hospital events without cause-of-death differentiation
Retrospective, observational study with possibility of selection bias and residual measured and unmeasured confounding
Administrative database with potential for unrecognized miscoding of diagnostic and procedure codes
Widespread troponin utilization may have contributed to increased NSTEMI diagnosis and decreased case severity
Lack of clinical presentation and medication utilization variables in the database
Timing of procedure is recorded in days (assuming day 0 is ≤24 hours and day 0 or 1 is ≤48 hours) rather than hours, and outcomes are limited to in-hospital events without cause of death differentiation

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Implication

Declining NSTEMI mortality paralleled rising early invasive strategy use; extends observational trends but leaves causal effects open for trials.

Abstract

BACKGROUND: There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States. METHODS AND RESULTS: We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978). CONCLUSIONS: There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay.

Discussion

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Cite This Study

Khera et al. (2014) conducted a cohort in Non-ST-elevation myocardial infarction (NSTEMI) (n=3,981,119). Calendar year / Early invasive strategy (coronary angiography with or without PCI or CABG on day 0 or day 0-1) vs. Reference year 2002 / No early invasive strategy was evaluated on All-cause, in-hospital mortality (temporal trend from 2002 to 2011) (OR 0.976 per year, 95% CI 0.974-0.978, p=<0.001). From 2002 to 2011, early invasive strategy utilization in NSTEMI increased while risk-adjusted in-hospital mortality decreased from 5.5% to 3.9%.

synapsesocial.com/papers/6a82f9cd8847014bd698f858 https://doi.org/10.1161/jaha.114.000995

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Non‐ST‐Elevation Myocardial Infarction in the United States: Contemporary Trends in Incidence, Utilization of the Early Invasive Strategy, and In‐Hospital Outcomes

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Non‐ST‐Elevation Myocardial Infarction in the United States: Contemporary Trends in Incidence, Utilization of the Early Invasive Strategy, and In‐Hospital Outcomes

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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