August 22, 2018Open Access
View Full PaperRelations between implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years: experiences from SWEDEHEART registry 1995 to 2014
Structured PICO
Does the implementation of evidence-based treatments and invasive procedures improve survival and reduce cardiovascular events in patients with NSTEMI?
P
Population
205,693 patients with non-ST-elevation myocardial infarction (NSTEMI) between 1995 and 2014 from the nationwide SWEDEHEART registry in Sweden.
I
Intervention
Gradual uptake and widespread use of in-hospital coronary interventions (PCI or CABG) and evidence-based long-term medications (dual antiplatelet medication, statins, ACEi/ARB) over a 20-year period.
C
Comparator
Historical comparison (earlier vs later years of the registry) and a control population.
O
Outcome
1-year mortality and composite of 1-year cardiovascular death or myocardial infarction (MI).hard clinical
The substantial improvement in long-term survival and reduction in cardiovascular events in NSTEMI patients over the last 20 years is mainly explained by the increased use of coronary interventions and evidence-based medications.
Abstract
Aims: We assessed the changes in short- and long-term outcomes and their relation to implementation of new evidence-based treatments in all patients with non-ST-elevation myocardial infarction (NSTEMI) in Sweden over 20 years. Methods and results: Cases with NSTEMI (n = 205 693) between 1995 and 2014 were included from the nationwide Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry. During 20 years in-hospital invasive procedures increased from 1.9% to 73.2%, percutaneous coronary intervention or coronary artery bypass grafting 6.5% to 58.1%, dual antiplatelet medication 0% to 72.7%, statins 13.3% to 85.6%, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker 36.8% to 75.5%. The standardized 1-year mortality ratio compared with a control population decreased from 5.53 95% confidence interval (CI) 5.30-5.75 to 3.03 (95% CI 2.89-3.19). If patients admitted the first 2 years were modelled to receive the same invasive treatments as the last 2 years the expected mortality/myocardial infarction (MI) rate would be reduced from 33.0% to 25.0%. After adjusting for differences in baseline characteristics, the change of 1-year cardiovascular death/MI corresponded to a linearly decreasing odds ratio trend of 0.930 (95% CI 0.926-0.935) per 2-year period. This trend was substantially attenuated 0.970 (95% CI 0.964-0.975) after adjusting for changes in coronary interventions, and almost eliminated 0.988 (95% CI 0.982-0.994) after also adjusting for changes in discharge medications. Conclusion: In NSTEMI patients during the last 20 years, there has been a substantial improvement in long-term survival and reduction in the risk of new cardiovascular events. These improvements seem mainly explained by the gradual uptake and widespread use of in-hospital coronary interventions and evidence-based long-term medications.