10-Year Temporal Trends of In-Hospital Mortality and Emergency Percutaneous Coronary Intervention for Acute Myocardial Infarction

Abstract

Background: The mortality rate of acute myocardial infarction (AMI) has improved dramatically because of reperfusion therapy during the last 40 years; however, recent temporal trends for AMI have not been fully clarified in Japan.

Objectives: The purpose of this study was to elucidate the temporary trend in in-hospital mortality and treatment of AMI for the last decade in the Tokyo Metropolitan area.

Methods: We enrolled 30,553 patients from the Tokyo Cardiovascular Care Unit Network Registry, diagnosed with AMI from 2007 to 2016, as part of an ongoing, multicenter, cohort study. We analyzed the temporal trends in basic characteristics, treatment, and in-hospital mortality of AMI.

Results: The overall emergency percutaneous coronary intervention (PCI) rate significantly increased (P < 0.001). In particular, it remarkably increased in patients older than 80 years of age (58.3% to 70.3%, P < 0.001) and patients with Killip III or IV (Killip III, 46.9% to 65.7%; Killip IV, 65.2% to 76.6%, P < 0.001 for both). The crude and age-adjusted in-hospital mortality remained low (5.2% to 8.2% and 3.4% to 5.5%, respectively) and significantly decreased during the decade (P < 0.001). The in-hospital mortality remarkably decreased in patients older than 80 years of age (17.3% to 12.7%, P < 0.001) and in those with cardiogenic shock (38.5% to 27.3%, P < 0.001).

Conclusions: This large cohort study from Tokyo revealed that in-hospital mortality of AMI significantly decreased with the increase in emergency percutaneous coronary intervention rate over the decade, particularly for high-risk patients such as older patients and those with cardiogenic shock.

Keywords: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; CAG, coronary angiography; CCU, cardiovascular care unit; D2B, door to balloon; ECMO, extracorporeal membrane oxygenation; FMC, first medical contact; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; in-hospital mortality; older patients; percutaneous coronary intervention; sex; temporal trends.

Graphical abstract

Figure 1

Age and Killip Class Distribution of AMI Patients (A, B) The temporal trend of age distribution in male and female patients with acute myocardial infarction (AMI), respectively. (C, D) The temporal trend of Killip class distribution in males and females, respectively.

Figure 2

Temporal Trends of Emergency PCI, Emergency CAG, and CABG (A to C) The temporal trend of emergency percutaneous coronary intervention (PCI), emergency coronary angiography (CAG), and coronary artery bypass grafting (CABG), respectively. (D) The temporal trends of emergency PCI rates classified by 4 age groups. (E) The temporal trends of emergency PCI rates according to Killip classification. y.o. = years old.

Figure 3

Temporal Trends of In-Hospital Mortality (A) The temporal trends of crude and age-adjusted in-hospital mortality (A-1, all; A-2, male; A-3, female). The crude in-hospital mortality showed decreasing trends in the overall, male, and female (all; P < 0.001). The age-adjusted in-hospital mortality also showed decreasing trends in the overall (black), male (blue), and female (red) (all; P < 0.001). (B) The temporal trends of age-specific in-hospital mortality in all (B-1), male (B-2), and female (B-3). (C) The temporal trends of in-hospital mortality classified by Killip class in all (C-1), male (C-2), and female (C-3).

Figure 4

Temporal Trends of Time to Treatment in Patients With STEMI (A) The temporal trends of onset-to-first medical contact (FMC) (green line), FMC-to-door (yellow line), door to balloon (D2B) (red line), and FMC-to-balloon time (blue line) in all patients with ST-segment elevation myocardial infarction (STEMI). (B) The time course of treatment in all years. (C, D) The time to treatment and time course according to the Killip classification, respectively. (E to H) The association of in-hospital mortality with D2B and FMC-to-balloon times according to four Killip classes and 4 age groups.

Central Illustration

Temporal Trends in In-Hospital Mortality and Emergency Percutaneous Coronary Intervention Rate The crude and age-adjusted in-hospital mortality of acute myocardial infarction (AMI) tended to decrease during the last decade in both sexes. The in-hospital mortality of AMI to high-risk patients such as older and Killip IV significantly decreased over time with the increase of emergency percutaneous coronary intervention (PCI) rate.