Reperfusion strategy and in-hospital outcomes for ST elevation myocardial infarction in secondary and tertiary hospitals in predominantly rural central China: a multicentre, prospective and observational study

Age shock index and age-modified shock index are valuable bedside prognostic tools for postdischarge mortality in ST-elevation myocardial infarction patients

BACKGROUND

The incidence of mortality is considerable after ST-elevation myocardial infarction (STEMI) hospitalization; risk assessment is needed to guide postdischarge management. Age shock index (SI) and age modified shock index (MSI) were described as useful prognosis instruments; nevertheless, their predictive effect on short and long-term postdischarge mortality has not yet been sufficiently confirmed.

METHODS

This analysis included 3389 prospective patients enrolled from 2016 to 2018. Endpoints were postdischarge mortality within 30 days and from 30 days to 1 year. Hazard ratios (HRs) were evaluated by Cox proportional-hazards regression. Predictive performances were assessed by area under the curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) and compared with TIMI risk score and GRACE score.

RESULTS

The AUCs were 0.753, 0.746 for age SI and 0.755, 0.755 for age MSI for short- and long-term postdischarge mortality. No significant AUC differences and NRI were observed compared with the classic scores; decreased IDI was observed especially for long-term postdischarge mortality. Multivariate analysis revealed significantly higher short- and long-term postdischarge mortality for patients with high age SI (HR: 5.44 (2.73-10.85), 5.34(3.18-8.96)), high age MSI (HR: 4.17(1.78-9.79), 5.75(3.20-10.31)) compared to counterparts with low indices. DCA observed comparable clinical usefulness for predicting short-term postdischarge mortality. Furthermore, age SI and age MSI were not significantly associated with postdischarge prognosis for patients who received fibrinolysis.

CONCLUSIONS

Age SI and age MSI were valuable instruments to identify high postdischarge mortality with comparable predictive ability compared with the classic scores, especially for events within 30 days after hospitalization.

Age and gender mediated the association between anemia and 30-day outcomes in patients with ST-segment elevated myocardial infarction

Background

The higher prevalence of anemia in females and elderly may be attributed to its association with worsened outcomes in ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the precise effects of age and gender on the association between anemia and 30-day outcomes.

Method

We identified 4350 STEMI patients and divided into anemia and non-anemia. Effects were analyzed as categories using Cox proportional-hazards regression and as continuous using restricted cubic splines. Propensity score matching (PSM) and mediation analysis were applied to identify intermediate effects.

Results

Anemic patients were older, more likely to be female, and experienced doubled all-cause death (7.3 % versus 15.0 %), main adverse cardiovascular and cerebrovascular events (MACCE, 11.1 % versus 20.2 %), heart failure (HF, 5.1 % versus 8.6 %), and bleeding events (2.7 % versus 5.4 %). After adjustment, the association between anemia and all-cause death (Hazard ratio (HR) 1.15, 95 % confidence interval (95 %CI) 0.93-1.14), MACCE (HR 1.14, 95 %CI 0.95-1.36) and HF (HR 1.19, 95 %CI 0.92-1.55) were insignificant, the effects persisted nullified across age classes (P-interaction > 0.05) and PSM (P > 0.05). Ulteriorly, age mediated 77.6 %, 66.2 %, 48.0 %, gender mediated 38.1 %, 15.0 %, 3.2 %, age and gender together mediated 99.8 % 72.9 %, 48.1 % of the relationship. Anemia was independently associated with bleeding events (HR 2.02, 95 %CI 1.42-2.88), the effects consisted significant regardless of PSM (P < 0.05), age, and gender classes (P-interaction > 0.05), and no mediating role of age and gender were observed.

Conclusions

In STEMI patients, age and gender largely mediated the relationship between anemia and all-cause death, MACCE, and HF, anemia was independently associated with bleeding complications.

Validity of regional network systems on reperfusion therapy in diabetes mellitus and non-diabetes mellitus patients with ST-segment elevation myocardial infarction

Background

Patients with ST-segment elevation myocardial infarction (STEMI) with diabetes mellitus (DM) had higher mortality and poorer prognosis than those without DM. Previous studies had demonstrated the effectiveness of regional network systems (RNS) for reperfusion therapy in patients with STEMI. However, the differences in nursing care with RNS in subgroups of patients with DM with STEMI were unclear. Our study aimed to evaluate the validity of RNS in reperfusion therapy in patients with STEMI with or without DM.

Methods

We retrospectively enrolled patients with STEMI who received reperfusion therapy at the chest pain center of the 920th Hospital in Kunming City, Yunnan Province from 2019 to 2021. Personal information and hospitalization information for patients with STEMI were collected through the chest pain center registration system. Univariate and multivariate logistic regression were used to analyze factors associated with outcomes in patients with STEMI who received RNS. Wilcoxon rank-sum test and chi-squared test were used to analyze the differences in reperfusion therapy times and clinical outcomes between RNS and non-RNS in patients with STEMI with or without DM.

Results

This study enrolled 1,054 patients with STEMI, including 148 patients with DM and 906 patients without DM. Logistic regression analysis indicated that DM was associated with patients with STEMI who received RNS [OR 1.590 95% CI (1.034-2.446), P = 0.035]. RNS may decrease the reperfusion therapy time in patients with STEMI and patients without DM with STEMI, including the first medical contact (FMC) to door, FMC to wire and FMC to catheterization laboratory activity (all P < 0.05). However, we found no significant difference in reperfusion therapy times with and without RNS in patients with DM (all P > 0.05).

Conclusion

Regional network systems may decrease the reperfusion therapy time in patients without DM with STEMI, but no decrease was found in patients with DM with STEMI.

Sex Disparity in Characteristics, Management, and In-Hospital Outcomes of Patients with ST-Segment Elevated Myocardial Infarction: Insights from Henan STEMI Registry

Background. Women hospitalized with ST-elevation myocardial infarction (STEMI) experience higher risk of early mortality than men. We aimed to investigate the potential impact of risk factors, clinical characteristics, and management among gender-related risk differences. Method. We analyzed 5063 STEMI patients prospectively enrolled from 66 hospitals during 2016–2018 and compared sex differences in mortality, death, or treatment withdrawal and main adverse cardiovascular and cerebrovascular events (MACCE) using the generalized linear mixed model, following sequential adjustment for covariates. Results. Women were older and had a higher prevalence of hypertension (53.3% vs. 41.1%, $P<0.001$ ) and diabetes (24.5% vs. 15.2%, $P<0.001$ ). Eligible women were less likely to receive reperfusion therapy (56.1% vs. 62.4%, $P<0.001$ ); the onset to first medical contact (FMC) (255 vs. 190 minutes, $P<0.001$ ), onset to fibrinolysis (218 vs. 185 minutes, $P<0.001$ ), and onset to percutaneous coronary intervention (PCI) (307 vs. 243 minutes, $P<0.001$ ) were significantly delayed in women. The incidence of in-hospital death (6.8% vs. 3.0%, $P<0.001$ ), death or treatment withdrawal (14.5% vs. 5.6%, $P<0.001$ ), and MACCE (18.5% vs. 9.4%, $P<0.001$ ) were notably higher. The gender disparities persist in death (OR: 1.61, 95% CI: 1.12–2.33), death or treatment withdrawal (OR: 1.68, 95% CI: 1.26–2.24), and MACCE (OR: 1.37, 95% CI: 1.08–1.74) after adjustment for covariates. Among possible explanatory factors, age (−58.46%, −59.04%, −62.20%) and cardiovascular risk factors (−40.77%, −39.36%, −41.73%) accounted for most of the gender-associated risk differences. Conclusions. Women experienced worse in-hospital outcomes, and age and cardiovascular risk factors were major factors influencing sex-related differences. The sex disparity stressed the awareness and importance of quality improvement efforts against female patients in clinical practice.