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Implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years

The SWEDEHEART ( Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies ) registry routinely collects information on patients hospitalized in the coronary care unit or with suspected acute coronary syndromes in all Swedish hospitals.

The Registry included 205,693 cases with a diagnosis of non-ST segment elevation myocardial infarction ( NSTEMI ) from 1995-2014. Data from 1995-2001 mainly relied on elevations in creatine kinase-myocardial band ( CK-MB ) for the diagnosis of NSTEMI, while from 2001-2014, the diagnosis was based on the more contemporary criteria using troponin levels with either symptoms or electrocardiography.

Researchers have examined outcomes, specifically all-cause mortality, cardiovascular mortality, myocardial infarction, hospitalization for heart failure, and stroke over the 20-year study period divided into 2-year blocks, described differences in in-hospital therapies and discharge medications, and assessed the effect of time over the outcomes.

A dramatic decrease in in-hospital mortality ( from 12.4%-3.7% ), cardiovascular mortality ( 11.7%-3.2% ), and myocardial infarction ( 2.7%-0.6% ) over time, was seen.

This improvement in outcomes is despite no significant change in the median age at presentation ( 74 years ), the number of smokers ( 19% ), and an increase in the proportion of patients with diabetes mellitus, hypertension, and previous revascularization.

Concurrently, researchers noted an increase in the number of cases undergoing coronary angiography ( 1.9%-73.2% ), percutaneous coronary intervention ( 4.8%-52.3% ), and bypass grafting ( 1.7%-5.8% ), in addition to major increases in Class I-recommended medication prescriptions.

Their analyses suggest that the decrease in in-hospital outcomes was only partially attributed to the more frequent use of an early invasive strategy, while the reduction in 1-year outcomes is mostly explained by increasing implementation of an early invasive treatment strategy and guideline-based optimization of medical therapy.

In this nationwide, registry-based study, cardiovascular outcomes and mortality in patients with NSTEMI improved dramatically over a 20-year period, largely due to the increasing implementation of an early invasive strategy and use of guideline-based medical therapy. ( Xagena )

Source: European Heart Journal, 2018