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. 2020 Aug 24;18(1):231.
doi: 10.1186/s12916-020-01689-5.

Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study

Mohammad E Yadegarfar  1   2 , Chris P Gale  1   2   3 , Tatendashe B Dondo  1   2 , Chris G Wilkinson  1   2   4 , Martin R Cowie  5   6 , Marlous Hall  7   8
Affiliations

Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study

Mohammad E Yadegarfar et al. BMC Med. .

Abstract

Background: Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities.

Methods: We used data of 693,388 AMI patients recorded in the Myocardial Ischaemia National Audit Project (MINAP), 2003-2013. We investigated the association between comorbidities and receipt of optimal care for AMI (receipt of all eligible guideline-indicated treatments), and the effect of receipt of optimal care for comorbid AMI patients on long-term survival using flexible parametric survival models.

Results: A total of 412,809 [59.5%] patients with AMI had at least one comorbidity, including hypertension (302,388 [48.7%]), diabetes (122,228 [19.4%]), chronic obstructive pulmonary disease (COPD, 89,221 [14.9%]), cerebrovascular disease (51,883 [8.6%]), chronic heart failure (33,813 [5.6%]), chronic renal failure (31,029 [5.0%]) and peripheral vascular disease (27,627 [4.6%]). Receipt of optimal care was associated with greatest survival benefit for patients without comorbidities (HR 0.53, 95% CI 0.51-0.56) followed by patients with hypertension (HR 0.60, 95% CI 0.58-0.62), diabetes (HR 0.83, 95% CI 0.80-0.87), peripheral vascular disease (HR 0.85, 95% CI 0.79-0.91), renal failure (HR 0.89, 95% CI 0.84-0.94) and COPD (HR 0.90, 95% CI 0.87-0.94). For patients with heart failure and cerebrovascular disease, optimal care for AMI was not associated with improved survival.

Conclusions: Overall, guideline-indicated care was associated with improved long-term survival. However, this was not the case in AMI patients with concomitant heart failure or cerebrovascular disease. There is therefore a need for novel treatments to improve outcomes for AMI patients with pre-existing heart failure or cerebrovascular disease.

Keywords: Acute myocardial infarction; Comorbidity; Guideline care; Survival.

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Conflict of interest statement

MH has received research grants from the Wellcome Trust for the submitted work; CPG has received personal fees and non-financial support from AstraZeneca; research grants and personal fees from BMS; research grants, personal fees and non-financial support from Bayer; personal fees and non-financial support from Daiichy Sankyo; and personal fees and non-financial support from Vifor Pharma, outside the submitted work. CGW reports research grants from Bristol-Myer-Squibb, outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig. 1
Fig. 1
Derivation of the analytical cohort
Fig. 2
Fig. 2
Treatment receipt ratio (total treatments received out of total eligible) by comorbidity group including those without comorbidity and those with one or more comorbidity. AMI patients presenting with the specified condition may have any of the other 6 comorbidities
Fig. 3
Fig. 3
Association of comorbidities with receipt of optimal AMI care. Missing data multiply imputed. Patients with each of the chronic conditions may be subject to diagnosis of the 6 other chronic conditions. *Adjusted for GRACE risk, sex, year of diagnosis, smoking status, IMD score and all seven chronic conditions; multiple imputation by chained equations was used to produce 10 imputed datasets to minimise potential bias due to missing data. COPD, chronic obstructive pulmonary disease; IMD, index of multiple deprivation (continuous); Global Registry of Acute Coronary Events (GRACE) risk score; patients were classified as ineligible if a treatment was recorded in MINAP as contraindicated, not indicated, or not applicable; if the patient declined treatment; or if the patient was hospitalised prior to the guideline treatment recommendation
Fig. 4
Fig. 4
Association of receipt of optimal AMI care with long-term survival in the absence or presence of each comorbidity. Missing data multiply imputed. Patients with each of the chronic conditions may be subject to diagnosis of the 6 other chronic conditions. *Adjusted for GRACE risk, sex, year of diagnosis, smoking status, IMD score and all seven comorbidities; multiple imputation by chained equations was used to produce 10 imputed datasets to minimise potential bias due to missing data, and hazard ratios presented are pooled across all ten imputations. COPD, chronic obstructive pulmonary disease; IMD, index of multiple deprivation (continuous); Global Registry of Acute Coronary Events (GRACE) risk score
Fig. 5
Fig. 5
Survival graph of optimal AMI care vs suboptimal AMI care. *Adjusted for GRACE risk, sex, year of diagnosis, smoking status and IMD score
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