Gender differences in the decrease of in-hospital mortality in patients with acute myocardial infarction during the last 20 years in Switzerland

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Temporal trends in mortality and provision of intensive care in younger women and men with acute myocardial infarction or stroke

BACKGROUND

Timely management of acute myocardial infarction (AMI) and acute stroke has undergone impressive progress during the last decade. However, it is currently unknown whether both sexes have profited equally from improved strategies. We sought to analyze sex-specific temporal trends in intensive care unit (ICU) admission and mortality in younger patients presenting with AMI or stroke in Switzerland.

METHODS

Retrospective analysis of temporal trends in 16,954 younger patients aged 18 to ≤ 52 years with AMI or acute stroke admitted to Swiss ICUs between 01/2008 and 12/2019.

RESULTS

Over a period of 12 years, ICU admissions for AMI decreased more in women than in men (- 6.4% in women versus - 4.5% in men, p < 0.001), while ICU mortality for AMI significantly increased in women (OR 1.2 [1.10-1.30], p = 0.032), but remained unchanged in men (OR 0.99 [0.94-1.03], p = 0.71). In stroke patients, ICU admission rates increased between 3.6 and 4.1% per year in both sexes, while ICU mortality tended to decrease only in women (OR 0.91 [0.85-0.95, p = 0.057], but remained essentially unaltered in men (OR 0.99 [0.94-1.03], p = 0.75). Interventions aimed at restoring tissue perfusion were more often performed in men with AMI, while no sex difference was noted in neurovascular interventions.

CONCLUSION

Sex and gender disparities in disease management and outcomes persist in the era of modern interventional neurology and cardiology with opposite trends observed in younger stroke and AMI patients admitted to intensive care. Although our study has several limitations, our data suggest that management and selection criteria for ICU admission, particularly in younger women with AMI, should be carefully reassessed.

Creatinine clearance is key to solving the enigma of sex difference in in-hospital mortality after STEMI: Propensity score matching and mediation analysis

BACKGROUND

The precise impact of sex difference on in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients are unclear, and the studies are no longer consistent. Therefore, we sought to evaluate the impact of sex differences in a cohort of STEMI patients.

METHODS

We analyzed the data of 2647 STEMI patients enrolled in the Kermanshah STEMI Cohort from July 2017 to May 2020. To accurately clarify the relationship between sex and hospital mortality, propensity score matching (PSM) and causal mediation analysis was applied to the selected confounder and identified intermediate variables, respectively.

RESULTS

Before matching, the two groups differed on almost every baseline variable and in-hospital death. After matching with 30 selected variables, 574 male and female matched pairs were significantly different only for five baseline variables and women were no longer at greater risk of in-hospital mortality (10.63% vs. 9.76%, p = 0.626). Among the suspected mediating variables, creatinine clearance (CLCR) alone accounts for 74% (0.665/0.895) of the total effect equal to 0.895(95% CI: 0.464-1.332). In this milieu, the relationship between sex and in-hospital death was no longer significant and reversed -0.233(95% CI: -0.623-0.068), which shows the full mediating role of CLCR.

CONCLUSION

Our research could help address sex disparities in STEMI mortality and provide a consequence. Moreover, CLCR alone can fully explain this relationship, which can highlight the importance of CLCR in predicting the short-term outcomes of STEMI patients and provide a useful indicator for clinicians.

Sex Differences in Characteristics, Treatments, and Outcomes Among Patients Hospitalized for Non-ST-Segment-Elevation Myocardial Infarction in China: 2006 to 2015

BACKGROUND

Sex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.

METHODS

We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.

RESULTS

Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.

CONCLUSIONS

Sex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique identifier: NCT01624883.

Variation in regional implantation patterns of cardiac implantable electronic device in Switzerland

Introduction

There is a substantial geographical variation in the rates of pacemaker (PM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) device implantation across European countries. We assessed the extent of regional variation and potential determinants of such variation.

Methods

We conducted a population-based analysis using discharge data for PM/ICD/CRT implantations from all Swiss acute care hospitals during 2013–2016. We derived hospital service areas (HSA) by analyzing patient flows. We calculated age- and sex-standardized rates and quantified variation using the extremal quotient (EQ) and the systemic component of variation (SCV). We estimated the reduction in variance of crude implantation rates across HSAs using multilevel regression models, with incremental adjustment for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and the density of cardiologists on the HSA level.

Results

We analyzed implantations of 8129 PM, 1461 ICD, and 1411 CRT from 25 Swiss HSAs. The mean age- and sex-standardized implantation rate was 29 (range 8–57) per 100,000 persons for PM, 5 (1–9) for ICD, and 5 (2–8) for CRT. There was a very high variation in PM (EQ 7.0; SCV 12.6) and ICD (EQ 7.2; SCV 11.3) and a high variation in CRT implantation rates (EQ 3.9; SCV 7.1) across HSAs. Adjustments for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and density of cardiologists explained 94% of the variance in ICD and 87.5% of the variance in CRT implantation rates, but only 36.3% of the variance in PM implantation rates. Women had substantially lower PM/ICD/CRT implantation rates than men.

Conclusion

Switzerland has a very high regional variation in PM/ICD implantation and a high variation in CRT implantation rates. Women had substantially lower implantation rates than men. A large share of the variation in PM procedure rates remained unexplained which might reflect variations in physicians’ preferences and practices.

Gender differences in the provision of intensive care: a Bayesian approach

Purpose

It is currently unclear whether management and outcomes of critically ill patients differ between men and women. We sought to assess the influence of age, sex and diagnoses on the probability of intensive care provision in critically ill cardio- and neurovascular patients in a large nationwide cohort in Switzerland.

Methods

Retrospective analysis of 450,948 adult patients with neuro- and cardiovascular disease admitted to all hospitals in Switzerland between 01/2012 and 12/2016 using Bayesian modeling.

Results

For all diagnoses and populations, median ages at admission were consistently higher for women than for men [75 (64;82) years in women vs. 68 (58;77) years in men, p < 0.001]. Overall, women had a lower likelihood to be admitted to an intensive care unit (ICU) than men, despite being more severely ill [odds ratio (OR) 0.78 (0.76–0.79)]. ICU admission probability was lowest in women aged > 65 years (OR women:men 0.94 (0.89–0.99), p < 0.001). Women < 45 years had a similar ICU admission probability as men in the same age category [OR women:men 1.03 (0.94–1.13)], in spite of more severe illness. The odds to die were significantly higher in women than in men per unit increase in Simplified Acute Physiology Score (SAPS) II (OR 1.008 [1.004–1.012]).

Conclusion

In the care of the critically ill, our study suggests that women are less likely to receive ICU treatment regardless of disease severity. Underuse of ICU care was most prominent in younger women < 45 years. Although our study has several limitations that are imposed by the limited data available from the registries, our findings suggest that current ICU triage algorithms could benefit from careful reassessment. Further, and ideally prospective, studies are needed to confirm our findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06393-3.

Temporal trends in cardiovascular risk factors' prevalence in patients with myocardial infarction

INTRODUCTION AND OBJECTIVES

Little is known about changes in cardiovascular risk factors (CVRF) profile over time in patients presenting with acute myocardial infarction (AMI).

METHODS

We assessed changes in age and CVRF profile in consecutive AMI patients enrolled in the Swiss nationwide AMIS Plus registry between 1 January 1997 and 31 December 2018.

RESULTS

A total of 57 995 AMI patients were included in the analysis. Mean age at presentation was 71.5 ± 11.3 years for women and 63.9 ± 12.8 years for men and did not change over time. Overall, the mean (standard deviation) number of CVRF increased from 1.76 (1.07) in 1997/98 to 2.26 (1.10) in 2017/18 in men (P_trend  < .001), while the corresponding rates in females were 1.83 (1.11) and 2.24 (1.08) (P_trend  < .001). In terms of active smoking, no significant trend was detected for males, while there was a significant increase in females (P < .001). As a result, the gap in smoking rates between men and women presenting with AMI decreased from 19.9% (45.3% vs 25.4%) in 1997/98 to 7.9% (41.2% vs 33.3%) in 2017/18. Reassuring was the stability in terms of diabetes prevalence for both genders. Obesity was more prevalent over time in men, while the prevalence of hypertension and dyslipidemia increased in both genders.

CONCLUSION

Among patients with AMI in Switzerland over two decades, age at presentation remained stable, while the mean number of CVRF increased in both men and women. Striking was the increase in the prevalence of smoking in women, leading to a reduction of the gender gap over time.

Temporal trends in in-hospital complications of acute coronary syndromes: Insights from the nationwide AMIS Plus registry

BACKGROUND

Acute coronary syndrome (ACS)-related morbidity and mortality remain substantial. Data on temporal trends in in-hospital complications of ACS patients are scarce. This study sought to investigate whether the incidence of in-hospital complications of ACS patients changed over time.

METHODS

Acute coronary syndrome patients prospectively enrolled in the National Registry of Acute Myocardial Infarction in Switzerland (AMIS Plus) between 2003 and 2018 and with available data on in-hospital complications were included in the analysis. Rates of in-hospital complications, including recurrent angina, recurrent myocardial infarction, cerebrovascular events, cardiogenic shock, bleeding, acute renal failure, sepsis/systemic inflammatory response syndrome (SIRS)/multiorgan dysfunction syndrome (MODS), AV block needing pacing and new-onset atrial fibrillation, were assessed for each 2-year period.

RESULTS

Among 47,845 ACS patients, in-hospital complications significantly decreased from 22.0% in 2003/2004 to 18.9% in 2017/2018 (p for trend <0.001). An initial decline in rates of in-hospital complications to 15.7% in 2009/2010 (p for trend <0.001) was followed by a constant increase thereafter (p for trend = 0.002). While rates of recurrent angina, recurrent myocardial infarction, and cardiogenic shock decreased over time, rates of bleeding events, acute renal failure, sepsis/SIRS/MODS, and new-onset atrial fibrillation increased. Rates of in-hospital complications were higher in women, mainly due to a constantly increased risk of bleeding and AV block needing pacing.

CONCLUSIONS

The decrease in ischemic complications was paralleled by a concomitant increase in non-ischemic events. These findings emphasize that advanced strategies targeting non-ischemic complications are warranted to further improve quality of care of ACS patients.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types

Advances in cardiovascular (CV) imaging, redefined electrocardiogram criteria, and high‐sensitivity CV biomarker assays have enabled more differentiated etiological classification of myocardial infarction (MI). Type 1 MI has a different underlying pathophysiology than type 2 through type 5 MI; type 1 MI is characterized primarily by intracoronary atherothrombosis and the other types by a variety of mechanisms, which can occur with or without an atherosclerotic component. In type 2 MI, there is evidence of myocardial oxygen supply‐demand imbalance unrelated to acute coronary atherothrombosis. Types 1 and 2 MI are spontaneous events, while type 4 and type 5 are procedure‐related; type 3 MI is identified only after death. Most type 1 and type 2 MI present as non‐ST‐elevation MI (NSTEMI), although both types can also present as ST‐elevation MI. Because of their different underlying etiologies, type 1 and type 2 NSTEMI have different presentation and prognosis and should be managed differently. In this article, we discuss the epidemiology, prognosis, and management of NSTEMI occurring in the setting of underlying type 1 or type 2 pathophysiology. Most NSTEMI (65%–90%) are type 1 MI. Patients with type 2 MI have multiple comorbidities and causes of in‐hospital mortality among these patients are not always CV‐related. It is important to distinguish between type 1 and type 2 NSTEMI early in the clinical course to allow for the use of the most appropriate treatments that will provide the greatest benefit for these patients.

Temporal trends in latecomer STEMI patients: insights from the AMIS Plus registry 1997-2017

INTRODUCTION AND OBJECTIVES

A substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients.

METHODS

All STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively).

RESULTS

A total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y₁₂ inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55).

CONCLUSIONS

During the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.

Gender differences in treatment strategies among patients ≥80 years old with non-ST-segment elevation myocardial infarction

Background

This study aims to investigate the gender differences in treatment strategies among non-ST-segment elevation myocardial infarction (NSTEMI) patients ≥80 years old in China.

Methods

A total of 190 consecutive NSTEMI patients ≥80 years old in Fuwai Hospital were included from 2014 to 2017. These patients were grouped by gender, and sub-grouped by conservative treatment or invasive treatment. The clinical characteristics, medical history, discharge drug used, and prognosis were collected and compared between these two treatment strategies.

Results

There were significant differences between these two treatment strategies in terms of GRACE grade, history of myocardial infarction (MI), after coronary artery bypass grafting (CABG), III grade, renal dysfunction, anemia, and use of diuretic (P<0.05). In addition, the age, creatinine and Killip class of female patients, and the death and good prognosis of male patients were found to be significantly different between these two treatment strategies (P<0.05). The multivariate logistic regression analysis revealed that the death of males was significantly associated with treatment strategies in the multivariable logistic regression analysis (P<0.05). In addition, the Kaplan-Meier survival analyses revealed that the survival rates of invasive strategy were significantly higher, when compared to that of conservative strategy in males (P=0.001) and females (P=0.015).

Conclusions

There were gender differences in treatment strategies among NSTEMI patients ≥80 years old. The difference in treatment strategies in males was more pronounced than in females, in terms of long-term survival rate.

Emergency management of patients with ST-segment elevation myocardial infarction in Eastern Austria: a descriptive quality control study

Background

Myocardial infarction is a time-critical condition and its outcome is determined by appropriate emergency care. Thus we assessed the efficacy of a supra-regional ST-segment elevation myocardial infarction (STEMI) network in Easternern Austria.

Methods

The Eastern Austrian STEMI network serves a population of approx. 766.000 inhabitants within a region of 4186 km². Established in 2007, it now comprises 20 pre-hospital emergency medical service (EMS) units (10 of these physician-staffed), 4 hospitals and 3 cardiac intervention centres. Treatment guidelines were updated in 2012 and documentation within a web-based STEMI registry became mandatory. For this retrospective qualitative control study, data from February 2012–April 2015 was assessed.

Results

A total of 416 STEMI cases were documented, and 99% were identified by EMS within 6 (4.0–8.0) minutes after arrival. Median time loss between onset of pain and EMS call was 54 (20–135) minutes; response, pre-hospital and door-to-balloon times were 14 (10–20), 46 (37–59) and 45 (32–66) minutes, respectively. When general practitioners were involved, time between onset of pain and balloon inflation significantly increased from 180 (135–254) to 218 (155–348) minutes (p < .001). A pre-hospital time < 30 min was achieved in 25.8% of all patients during the day vs. 11.6% during the night (p < .001). Three hundred forty-five patients (83%) were subjected to primary percutaneous coronary intervention (PPCI), and 6.5% were thrombolysed by EMS. Pre-hospital complication rate was 18% (witnessed cardiac arrest 7%, threatening arrhythmias 6%, cardiogenic shock 5%). Twenty-four hours and hospital mortality rate were 1.2 and 2.8%, respectively.

Discussion

Optimal patient care and subsequently outcome of STEMI is strongly determined by a short patient-decision time to call EMS and by the first medical contact to balloon time (FMCBT). Supra-regional networks are key in order to increase the efficacy and efficiency of health care. The goal of 120 min FMCBT was achieved in 78% of our patients immediately managed by EMS, thus indicating room for improvement.

Conclusion

In conclusion, results from the Eastern Austrian STEMI network shed light on the necessity of increasing patient awareness in order to minimize any time loss derived by delayed EMS calls. Involvement of family physicians resulted in prolonged FMCBT. A stronger utilization of rescue helicopters could further improve the efficacy of this supra-regional network. Nevertheless PPCI rates, time intervals and outcome rates compare well with international benchmarks.