Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome. A prospective cohort study in patients with non ST-elevation acute coronary syndromes

Impact of the admitting ward on care quality and outcomes in non-ST-segment elevation myocardial infarction: insights from a national registry

AIMS

Little is known about the association between the type of admission ward and quality of care and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS AND RESULTS

We analysed data from 337 155 NSTEMI admissions between 2010 and 2017 in the UK Myocardial Ischaemia National Audit Project (MINAP) database. The cohort was dichotomised according to receipt of care either on a medical (n = 142,876) or cardiac ward, inclusive of acute cardiac wards and cardiac care unit (n = 194,279) on admission to hospital. Patients admitted to a cardiac ward were younger (median age 70 y vs. 75 y, P < 0.001), and less likely to be female (33% vs. 40%, P < 0.001). Independent factors associated with admission to a cardiac ward included ischaemic ECG changes (OR: 1.20, 95% CI: 1.18-1.23) and prior percutaneous coronary intervention (PCI) (OR: 1.19, 95% CI: 1.16-1.22). Patients admitted to a cardiac ward were more likely to receive optimal pharmacotherapy with statin (85% vs. 81%, P < 0.001) and dual antiplatelet therapy (DAPT) (91% vs. 88%, P < 0.001) on discharge, undergo invasive coronary angiography (78% vs. 59%, P < 0.001), and receive revascularisation in the form of PCI (52% vs. 36%, P < 0.001). Following multivariable logistic regression, the odds of inhospital all-cause mortality (OR: 0.75, 95% CI: 0.70-0.81) and major adverse cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.78-0.91) were lower in patients admitted to a cardiac ward.

CONCLUSION

Patients with NSTEMI admitted to a cardiac ward on admission were more likely to receive guideline directed management and had better clinical outcomes.

Sex Differences in Characteristics and Outcomes among Low-Risk Non-ST-Elevation Acute Coronary Syndrome Patients during Long Term Follow-Up

Previous heterogenous studies show conflicting data about sex-based outcomes of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients. This study evaluated 300 NSTE-ACS patients undergoing a coronary angiography between September 2012 and May 2015 that were managed with all-treatment strategies. The sample was stratified by sex and analyzed for the baseline characteristics and outcomes. The main outcome included major adverse cardiovascular and cerebrovascular events (MACCE), which were a composite of cardiac death, nonfatal myocardial infarction, ischemic stroke or urgent coronary revascularization. The female patients were older (median of 69.0 vs. 63.0 years, p = 0.008) and had lower values of BMI (median of 26.3 vs. 28.2 kg/m², p < 0.001) and eGFR (76.44 ± 22.43 vs. 94.04 ± 27.91 mL/min, p < 0.001). There was no significant difference in the treatment strategies, angiographic characteristics and discharge therapy between the groups (p > 0.05). The female patients had significantly higher unadjusted rates of ischemic stroke (4.2% vs. 0.5%, p = 0.023), cardiac mortality (11.3%, vs. 3.9%, p = 0.022) and MACCE (33.8%, vs. 19.5%, p = 0.014); female sex was a significant predictor of MACCE in the univariate analysis (HR 1.86, 95%CI 1.12–3.09, p = 0.014); and the cumulative incidence of MACCE was higher in female patients (p = 0.014). After the adjustment, the predictive effect of female sex became non-significant (HR 1.60, 95%CI 0.94–2.73, p = 0.083), while there was no difference in the cumulative incidence of MACCE among the propensity score matched cohort (p = 0.177). Female NSTE-ACS patients have worse long-term outcomes compared to their male counterparts. However, the differences disappear after adjustment and propensity score matching. Continuing efforts and health measures are required to alleviate any sex-based differences in the NSTE-ACS population.

Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome

BACKGROUND

Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated.

OBJECTIVES

To assess long-term mortality and explore its association with the baseline variables in women and men.

METHODS

We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months.

RESULTS

At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05-1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78-1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76-0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender.

CONCLUSION

For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.

Sex differences in survival after myocardial infarction in Sweden, 1987-2010

Objective

In this nationwide study, we investigated age-specific and sex-specific trends in sex differences in survival after acute myocardial infarction (AMI), including deaths from coronary heart disease (CHD) that occurred outside hospital.

Methods

Observational study in Sweden of 28-day and 1-year mortality among 658 110 persons (35.7% women) aged 35–84 years with a first-time CHD event 1987–2010 with data retrieved from the national Swedish death and hospital registries.

Results

Age-adjusted 28-day case fatality decreased from 23.5% to 8.5% over the period (p<0.05). In hospitalised cases, short-term survival in women aged 35–54 years compared with men of the same age was poorer, not changing appreciably over time (HRs for women relative to men 1.63 (95% CI 1.28 to 2.08) at age 35–54 years and 1.28 (95% CI 1.12 to 1.46) at age 55–64 years in 2005–2010), but after adjustment for comorbidities, differences between men and women were no longer significant (HR 1.25 (95% CI 0.97 to 1.61) and 1.05 (95% CI 0.91 to 1.20)). When CHD deaths outside hospital were included, women had better prognosis regardless of age and period. In patients surviving the first 28 days, age-adjusted 1-year case fatality decreased from 15.3% to 7.7% (p<0.05) for both men and women. After adjustment for comorbidities, no significant sex differences persisted below the age of 75 years in the last period. Female 28-day survivors 75–84 years old had a consistently better prognosis than older men.

Conclusions

The worse short-term outcomes in women <55 years of age hospitalised with AMI did not persist after adjustment for comorbidities. When CHD deaths outside hospital were included, women had consistently better short-term prognosis. In 28-day survivors, women did not fare worse than men when differences in comorbidities were considered.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND

Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described.

METHODS

We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728).

RESULTS

Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina.

CONCLUSIONS

There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

Sex-related differences in baseline characteristics, management and outcome in patients with acute coronary syndrome without ST-segment elevation

AIM

To detect sex-related differences in baseline characteristics, management and outcome in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

METHODS

Data from 812 consecutive patients admitted to our cardiology department for NSTE-ACS between 2001 and 2004 were obtained. Early invasive therapy was defined as revascularization during first hospital stay. A seven-year follow-up for the clinical endpoint of all-cause mortality could be obtained in 342 women and 440 men, respectively.

RESULTS

Compared with men, women were significantly older and more likely to suffer from renal insufficiency. The proportion treated with clopidogrel at admission was 43.6% for women and 52.7% for men, respectively (p=0.011). Significantly fewer women underwent an early invasive therapy compared with men (27.5% vs. 35.2%; p=0.021). Age and renal insufficiency were the strongest predictors for a conservative approach in both female and male patients. After adjustment for baseline characteristics there was no significant difference in treatment between women and men (odds ratio 0.89; 95% confidence interval 0.59-1.35; p=0.588). While in-hospital mortality was similar between the sexes, long-term mortality was significantly higher in women compared with men (8.2% vs. 7.0%; p=0.549 for in-hospital mortality and 54.8% vs. 39.3%; p<0.001 for seven-year mortality). However, after adjustment for baseline characteristics and treatment there was no significant difference in long-term mortality between women and men (hazard ratio 1.14; 95% confidence interval 0.89-1.47; p=0.307).

CONCLUSION

In these patients with NSTE-ACS women were less likely to undergo an early invasive therapy compared with men due to their higher age and the higher rate of renal insufficiency. After adjustment for age, comorbidities and treatment female sex was not associated with worse long-term outcome.

Likelihood of treatment in a coronary care unit for a first-time myocardial infarction in relation to sex, country of birth and socioeconomic position in Sweden

OBJECTIVE

To examine the relationship between sex, country of birth, level of education as an indicator of socioeconomic position, and the likelihood of treatment in a coronary care unit (CCU) for a first-time myocardial infarction.

DESIGN

Nationwide register based study.

SETTING

Sweden.

PATIENTS

199 906 patients (114 387 men and 85,519 women) of all ages who were admitted to hospital for first-time myocardial infarction between 2001 and 2009.

MAIN OUTCOME MEASURES

Admission to a coronary care unit due to myocardial infarction.

RESULTS

Despite the observed increasing access to coronary care units over time, the proportion of women treated in a coronary care unit was 13% less than for men. As compared with men, the multivariable adjusted odds ratio among women was 0.80 (95% confidence interval 0.77 to 0.82). This lower proportion of women treated in a CCU varied by age and year of diagnosis and country of birth. Overall, there was no evidence of a difference in likelihood of treatment in a coronary care unit between Sweden-born and foreign-born patients. As compared with patients with high education, the adjusted odds ratio among patients with a low level of education was 0.93 (95% confidence interval 0.89 to 0.96).

CONCLUSIONS

Foreign-born and Sweden-born first-time myocardial infarction patients had equal opportunity of being treated in a coronary care unit in Sweden; this is in contrast to the situation in many other countries with large immigrant populations. However, the apparent lower rate of coronary care unit admission after first-time myocardial infarction among women and patients with low socioeconomic position warrants further investigation.

Large differences between patients with acute myocardial infarction included in two Swedish health registers

BACKGROUND

Acute myocardial infarction (MI) is a leading cause for morbidity and mortality in Sweden. We aimed to compare patients with an acute MI included in the Register of information and knowledge about Swedish heart intensive care admissions (RIKS-HIA, now included in the register Swedeheart) and in the Swedish statistics of acute myocardial infarctions (S-AMI).

METHODS

Population based register study including RIKS-HIA, S-AMI, the National patient register and the Cause of death register. Odds ratios were determined by logistic regression analysis.

RESULTS

From 2001 to 2007, 114,311 cases in RIKS-HIA and 198,693 cases in S-AMI were included with a discharge diagnosis of an acute MI. Linkage was possible for 110,958 cases. These cases were younger, more often males, had fewer concomitant diseases and were more often treated with invasive coronary artery procedures than patients included in S-AMI only. There were substantial regional differences in proportions of patients reported to RIKS-HIA.

CONCLUSIONS

Approximately half of all patients with an acute MI were included in RIKS-HIA. They represented a relatively more healthy population than patients included in S-AMI only. S-AMI covered almost all patients with an acute MI but had limited information about the patients. Used in combination, these two registers can give better prerequisites for improved quality of care of all patients with acute coronary syndromes.