Health outcomes after myocardial infarction: A population study of 56 million people in England

Background The occurrence of a range of health outcomes following myocardial infarction (MI) is unknown. Therefore, this study aimed to determine the long-term risk of major health outcomes following MI and generate sociodemographic stratified risk charts in order to inform care recommendations in the post-MI period and underpin shared decision making. Methods and findings This nationwide cohort study includes all individuals aged ≥18 years admitted to one of 229 National Health Service (NHS) Trusts in England between 1 January 2008 and 31 January 2017 (final follow-up 27 March 2017). We analysed 11 non-fatal health outcomes (subsequent MI and first hospitalisation for heart failure, atrial fibrillation, cerebrovascular disease, peripheral arterial disease, severe bleeding, renal failure, diabetes mellitus, dementia, depression, and cancer) and all-cause mortality. Of the 55,619,430 population of England, 34,116,257 individuals contributing to 145,912,852 hospitalisations were included (mean age 41.7 years (standard deviation SD 26.1); n = 14,747,198 (44.2%) male). There were 433,361 individuals with MI (mean age 67.4 years SD 14.4); n = 283,742 (65.5%) male). Following MI, all-cause mortality was the most frequent event (adjusted cumulative incidence at 9 years 37.8% (95% confidence interval CI 37.6,37.9), followed by heart failure (29.6%; 95% CI 29.4,29.7), renal failure (27.2%; 95% CI 27.0,27.4), atrial fibrillation (22.3%; 95% CI 22.2,22.5), severe bleeding (19.0%; 95% CI 18.8,19.1), diabetes (17.0%; 95% CI 16.9,17.1), cancer (13.5%; 95% CI 13.3,13.6), cerebrovascular disease (12.5%; 95% CI 12.4,12.7), depression (8.9%; 95% CI 8.7,9.0), dementia (7.8%; 95% CI 7.7,7.9), subsequent MI (7.1%; 95% CI 7.0,7.2), and peripheral arterial disease (6.5%; 95% CI 6.4,6.6). Compared with a risk-set matched population of 2,001,310 individuals, first hospitalisation of all non-fatal health outcomes were increased after MI, except for dementia (adjusted hazard ratio aHR 1.01; 95% CI 0.99,1.02; p = 0.468) and cancer (aHR 0.56; 95% CI 0.56,0.57; p < 0.001). The study includes data from secondary care only—as such diagnoses made outside of secondary care may have been missed leading to the potential underestimation of the total burden of disease following MI. Conclusions In this study, up to a third of patients with MI developed heart failure or renal failure, 7% had another MI, and 38% died within 9 years (compared with 35% deaths among matched individuals). The incidence of all health outcomes, except dementia and cancer, was higher than expected during the normal life course without MI following adjustment for age, sex, year, and socioeconomic deprivation. Efforts targeted to prevent or limit the accrual of chronic, multisystem disease states following MI are needed and should be guided by the demographic-specific risk charts derived in this study.