Elsevier

American Heart Journal

Volume 156, Issue 6, December 2008, Pages 1026-1034
American Heart Journal

Special Articles: NRMI 1990-2006
Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

https://doi.org/10.1016/j.ahj.2008.07.030Get rights and content

Background

Although ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (AMI) have been the focus of intense clinical investigation, limited information exists on characteristics and hospital mortality of patients not enrolled in clinical trials. Previous large databases have reported declining mortality of patients with STEMI but have not noted substantial mortality change among those with NSTEMI.

Methods

The National Registry of Myocardial Infarction enrolled 2,515,106 patients at 2,157 US hospitals from 1990 to 2006. Of these, we evaluated 1,950,561 with diagnoses reflecting acute myocardial ischemia on admission.

Results

From 1990 to 2006, the proportion of NSTEMI increased from 14.2% to 59.1% (P < .0001), whereas the proportion of STEMI decreased. Mean age increased (from 64.1 to 66.4 years, P < .0001) as did the proportion of females (from 32.4% to 37.0%, P < .0001). Patients were less likely to report prior angina, prior AMI, or family history of coronary artery disease but more likely to report history of diabetes, hypertension, current smoking, heart failure, prior revascularization, stroke, and hyperlipidemia. From 1994 to 2006, hospital mortality fell among all patients (10.4% to 6.3%), STEMI (11.5% to 8.0%), and NSTEMI (7.1% to 5.2%), (all P < .0001). After adjustment for baseline covariates, hospital mortality fell among all patients by 23.6% (odds ratio [OR] 0.764, 95% CI 0.744-0.785), STEMI by 24.2% (OR 0.758, 0.732-0.784), and NSTEMI by 22.6% (OR 0.774, 0.741-0.809), all P < .001.

Conclusions

This large, observational database from 1990 to 2006 shows increasing prevalence of NSTEMI and, despite higher risk profile on presentation, falling risk-adjusted hospital mortality in patients with either STEMI or NSTEMI.

Section snippets

Data source

The NRMI was an industry-sponsored, voluntary, prospective observational study. No experimental intervention was required for registry participation; only routine and actual patient management was documented. Details of the NRMI data collection process have been published previously.5 Registry coordinators at participating hospitals used a standardized manual of instructions and definitions to collect data on consecutive patients with AMI. A centralized data center instituted systematic range

Patient population and participating hospitals

From 1990 to 2006, 2,515,106 patients were enrolled in NRMI 1 to 5 at 2,157 unique hospitals. Of these patients, 1,950,561 had evidence of myocardial ischemia on admission and constituted our study population. Over time, the proportion of hospitals with capabilities for revascularization increased as did the proportion of hospitals with smaller bed size (Table I). To account for this variability, subsequent data have been adjusted or “weighted” for hospital facility type (invasive capabilities)

Discussion

The principal findings of this analysis of temporal trends from 1990 to 2006 in a large, contemporary registry of AMI are that the prevalence of patients with NSTEMI has risen in proportion to that of patients with STEMI and that patients are presenting with higher risk for adverse outcome from AMI. However, despite the increasing risk profile, unadjusted hospital mortality among patients not transferred out of the registry hospitals fell by >39% from 1994 to 2006, and mortality adjusted for

References (37)

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Genentech Inc (San Francisco, CA) provided financial support to the study.

l

See Appendix A for author disclosure statements.

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