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Observational Study
. 2017 Nov 1;38(41):3056-3065.
doi: 10.1093/eurheartj/ehx515.

Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995-2014

Karolina Szummer  1   2 , Lars Wallentin  3 , Lars Lindhagen  3 , Joakim Alfredsson  4   5 , David Erlinge  6   7 , Claes Held  3 , Stefan James  3 , Thomas Kellerth  8 , Bertil Lindahl  3 , Annica Ravn-Fischer  9 , Erik Rydberg  6   7 , Troels Yndigegn  6   7 , Tomas Jernberg  10
Affiliations
Observational Study

Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995-2014

Karolina Szummer et al. Eur Heart J. .

Abstract

Aims: Impact of changes of treatments on outcomes in ST-elevation myocardial infarction (STEMI) patients in real-life health care has not been documented.

Methods and results: All STEMI cases (n = 105.674) registered in the nation-wide SWEDEHEART registry between 1995 and 2014 were included and followed for fatal and non-fatal outcomes for up to 20 years. Most changes in treatment and outcomes occurred from 1994 to 2008. Evidence-based treatments increased: reperfusion from 66.2 to 81.7%; primary percutaneous coronary intervention: 4.5 to 78.0%; dual antiplatelet therapy from 0 to 89.6%; statin: 14.1 to 93.6%; beta-blocker: 78.2 to 91.0%, and angiotensin-converting-enzyme/angiotensin-2-receptor inhibitors: 40.8 to 85.2% (P-value for-trend <0.001 for all). One-year mortality decreased from 22.1 to 14.1%. Standardized incidence ratio compared with the general population decreased from 5.54 to 3.74 (P < 0.001). Cardiovascular (CV) death decreased from 20.1 to 11.1%, myocardial infarction (MI) from 11.5 to 5.8%; stroke from 2.9 to 2.1%; heart failure from 7.1 to 6.2%. After standardization for differences in demography and baseline characteristics, the change of 1-year CV-death or MI corresponded to a linear trend of 0.915 (95% confidence interval: 0.906-0.923) per 2-year period which no longer was significant, 0.997 (0.984-1.009), after adjustment for changes in treatment. The changes in treatment and outcomes were most pronounced from 1994 to 2008.

Conclusion: Gradual implementation of new and established evidence-based treatments in STEMI patients during the last 20 years has been associated with prolonged survival and lower risk of recurrent ischaemic events, although a plateauing is seen since around 2008.

Keywords: Myocardial infarction; Outcomes; Registry; Time-trends.

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Figures

Figure 1
Figure 1
Key treatments 1995–2014. STEMI, ST-elevation myocardial infarction.
Figure 2
Figure 2
Kaplan–Meier curves for long-term outcomes in patients included from 1995–96 (dark red) to 2013–14 (dark green).
Figure 3
Figure 3
Odds and hazard ratios for the association between 2 years change in time-period and outcome (cardiovascular death or MI)—unadjusted and after stepwise adjustment for differences in demography, baseline characteristics, and treatments over time. CV, cardiovascular; PCI, percutaneous coronary intervention; MI, myocardial infarction.
Central illustration
Central illustration
In-hospital and 1-year outcomes. (A) Absolute rates for in-hospital (1995–2012) and 1-year outcomes (1995–2012) in each 2-year block. (B) Standardized death and MI rates for in-hospital and 1-year outcomes. MI, myocardial infarction; STEMI, ST-elevation myocardial infarction.
See this image and copyright information in PMC

Comment in

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