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Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK.

https://arctichealth.org/en/permalink/ahliterature105169
Source
Lancet. 2014 Apr 12;383(9925):1305-12
Publication Type
Article
Date
Apr-12-2014
Author
Sheng-Chia Chung
Rolf Gedeborg
Owen Nicholas
Stefan James
Anders Jeppsson
Charles Wolfe
Peter Heuschmann
Lars Wallentin
John Deanfield
Adam Timmis
Tomas Jernberg
Harry Hemingway
Author Affiliation
Farr Institute of Health Informatics Research at UCL Partners, University College London, London, UK.
Source
Lancet. 2014 Apr 12;383(9925):1305-12
Date
Apr-12-2014
Language
English
Publication Type
Article
Keywords
Aged
Female
Great Britain - epidemiology
Humans
Male
Myocardial Infarction - mortality - therapy
Registries
Risk factors
Survival Analysis
Sweden - epidemiology
Abstract
International research for acute myocardial infarction lacks comparisons of whole health systems. We assessed time trends for care and outcomes in Sweden and the UK.
We used data from national registries on consecutive patients registered between 2004 and 2010 in all hospitals providing care for acute coronary syndrome in Sweden and the UK. The primary outcome was all-cause mortality 30 days after admission. We compared effectiveness of treatment by indirect casemix standardisation. This study is registered with ClinicalTrials.gov, number NCT01359033.
We assessed data for 119,786 patients in Sweden and 391,077 in the UK. 30-day mortality was 7·6% (95% CI 7·4-7·7) in Sweden and 10·5% (10·4-10·6) in the UK. Mortality was higher in the UK in clinically relevant subgroups defined by troponin concentration, ST-segment elevation, age, sex, heart rate, systolic blood pressure, diabetes mellitus status, and smoking status. In Sweden, compared with the UK, there was earlier and more extensive uptake of primary percutaneous coronary intervention (59% vs 22%) and more frequent use of ß blockers at discharge (89% vs 78%). After casemix standardisation the 30-day mortality ratio for UK versus Sweden was 1·37 (95% CI 1·30-1·45), which corresponds to 11,263 (95% CI 9620-12,827) excess deaths, but did decline over time (from 1·47, 95% CI 1·38-1·58 in 2004 to 1·20, 1·12-1·29 in 2010; p=0·01).
We found clinically important differences between countries in acute myocardial infarction care and outcomes. International comparisons research might help to improve health systems and prevent deaths.
Seventh Framework Programme for Research, National Institute for Health Research, Wellcome Trust (UK), Swedish Association of Local Authorities and Regions, Swedish Heart-Lung Foundation.
Notes
Comment In: Lancet. 2014 Apr 12;383(9925):1274-624461716
Comment In: Lancet. 2014 Apr 19;383(9926):136024759236
Comment In: Lancet. 2014 Jul 26;384(9940):303-425066152
Comment In: Lancet. 2014 Jul 26;384(9940):30425066153
Comment In: Lancet. 2014 Jul 26;384(9940):304-525066154
Comment In: Lancet. 2014 Jul 26;384(9940):30525066156
Comment In: Lancet. 2014 Jul 26;384(9940):305-625066155
Comment In: Nat Rev Cardiol. 2014 Mar;11(3):12624514022
PubMed ID
24461715 View in PubMed
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[Acute myocardial infarction. Cases from the Gjøvik County Hospital]

https://arctichealth.org/en/permalink/ahliterature55805
Source
Tidsskr Nor Laegeforen. 1983 Mar 10;103(7):667-70
Publication Type
Article
Date
Mar-10-1983
Author
P. Smith
O. Breder
Source
Tidsskr Nor Laegeforen. 1983 Mar 10;103(7):667-70
Date
Mar-10-1983
Language
Norwegian
Publication Type
Article
Keywords
Adult
Aged
Female
Hospitals, County
Humans
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Norway
Resuscitation
PubMed ID
6868043 View in PubMed
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Acute myocardial infarction: does pre-hospital treatment increase survival?

https://arctichealth.org/en/permalink/ahliterature52222
Source
Eur J Emerg Med. 2002 Sep;9(3):210-6
Publication Type
Article
Date
Sep-2002
Author
J. Koefoed-Nielsen
E F Christensen
H. Melchiorsen
A. Foldspang
Author Affiliation
Department of Anaesthesiology, University Hospital of Aarhus, Denmark.
Source
Eur J Emerg Med. 2002 Sep;9(3):210-6
Date
Sep-2002
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Ambulances
Angioplasty, Transluminal, Percutaneous Coronary
Denmark
Emergency Medical Services - statistics & numerical data
Female
Humans
Logistic Models
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Registries
Research Support, Non-U.S. Gov't
Urban Population
Abstract
The aim of this study was to assess the impact of a mobile emergency care unit (MECU) staffed with an anaesthetist, in terms of increased survival among patients with acute myocardial infarction (MI). The setting was an urban area with 330 000 inhabitants. This was a quasi-experimental before-and-after-study including consecutive emergency calls during September to November 1996 (Period 1, without the MECU) and September to November 1997 (Period 2, including the MECU). Fifty-four ambulance patients had their MI diagnosis confirmed at hospital during Period 1, and another 54 in Period 2. The 28-day mortality was collected from relevant registers. Twenty-four (44%) of Period 2 patients were transported by the MECU. MECU patients had lower systolic blood pressure (SBP) than other patients, both before and after hospital admission. Nitroglycerine treatment was relatively frequent in MECU patients, and cardioversion, anaesthesia and intubation was applied exclusively in these patients. After arrival at hospital, MECU patients had thrombolysis relatively often (46% versus 23% in other Period 2 patients) but percutaneous transluminal coronary angioplasty (PTCA) relatively infrequently (21% vs 30%). The total mortality was significantly lower in Period 2 than in Period 1 patients (11% vs 21%,
PubMed ID
12394616 View in PubMed
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Administrative Data Feedback for Effective Cardiac Treatment: AFFECT, a cluster randomized trial.

https://arctichealth.org/en/permalink/ahliterature173735
Source
JAMA. 2005 Jul 20;294(3):309-17
Publication Type
Article
Date
Jul-20-2005
Author
Christine A Beck
Hugues Richard
Jack V Tu
Louise Pilote
Author Affiliation
Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada.
Source
JAMA. 2005 Jul 20;294(3):309-17
Date
Jul-20-2005
Language
English
Publication Type
Article
Keywords
Adrenergic beta-Antagonists - therapeutic use
Benchmarking
Cluster analysis
Hospitals - standards
Humans
Medical Record Linkage
Myocardial Infarction - mortality - therapy
Outcome and Process Assessment (Health Care)
Quality Indicators, Health Care
Quebec
Abstract
Hospital report cards are increasingly being implemented for quality improvement despite lack of strong evidence to support their use.
To determine whether hospital report cards constructed using linked hospital and prescription administrative databases are effective for improving quality of care for acute myocardial infarction (AMI).
The Administrative Data Feedback for Effective Cardiac Treatment (AFFECT) study, a cluster randomized trial.
Patients with AMI who were admitted to 76 acute care hospitals in Quebec that treated at least 30 AMI patients per year between April 1, 1999, and March 31, 2003.
Hospitals were randomly assigned to receive rapid (immediate; n = 38 hospitals and 2533 patients) or delayed (14 months; n = 38 hospitals and 3142 patients) confidential feedback on quality indicators constructed using administrative data.
Quality indicators pertaining to processes of care and outcomes of patients admitted between 4 and 10 months after randomization. The primary indicator was the proportion of elderly survivors of AMI at each study hospital who filled a prescription for a beta-blocker within 30 days after discharge.
At follow-up, adjusted prescription rates within 30 days after discharge were similar in the early vs late groups (for beta-blockers, odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82-1.37; for angiotensin-converting enzyme inhibitors, OR, 1.17; 95% CI, 0.90-1.52; for lipid-lowering drugs, OR, 1.14; 95% CI, 0.86-1.50; and for aspirin, OR, 1.05; 95% CI, 0.84-1.33). In addition, adjusted mortality was similar in both groups, as were length of in-hospital stay, physician visits after discharge, waiting times for invasive cardiac procedures, and readmissions for cardiac complications.
Feedback based on one-time, confidential report cards constructed using administrative data is not an effective strategy for quality improvement regarding care of patients with AMI. A need exists for further studies to rigorously evaluate the effectiveness of more intensive report card interventions.
Notes
Comment In: ACP J Club. 2005 Nov-Dec;143(3):7916262236
Comment In: JAMA. 2005 Jul 20;294(3):369-7116030283
PubMed ID
16030275 View in PubMed
Less detail

Age-related differences in the management and outcome of patients with acute coronary syndromes.

https://arctichealth.org/en/permalink/ahliterature170984
Source
Am Heart J. 2006 Feb;151(2):352-9
Publication Type
Article
Date
Feb-2006
Author
Raymond T Yan
Andrew T Yan
Mary Tan
Chi-Ming Chow
David H Fitchett
Frank L Ervin
James Y M Cha
Anatoly Langer
Shaun G Goodman
Author Affiliation
Division of Cardiology, Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Source
Am Heart J. 2006 Feb;151(2):352-9
Date
Feb-2006
Language
English
Publication Type
Article
Keywords
Age Factors
Aged
Angina, Unstable - mortality - therapy
Canada
Comorbidity
Epidemiologic Methods
Evidence-Based Medicine - statistics & numerical data
Female
Fibrinolytic Agents - administration & dosage
Hospital Mortality
Humans
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Myocardial Revascularization - methods - utilization
Registries
Syndrome
Thrombolytic Therapy - utilization
Treatment Outcome
Abstract
Age-related differences in patients with an acute coronary syndrome (ACS) have not been well characterized in prior observational studies that often included only certain age groups or subjects with myocardial infarction (MI).
We stratified 4627 patients admitted with an ACS across 9 provinces between 1999 and 2001 enrolled in the Canadian ACS Registry into 3 age groups ( or = 75 years) to evaluate differences in clinical characteristics, management, and 1-year outcome.
Older patients more frequently had previous angina, MI, or heart failure and were less likely to have positive cardiac markers, ST elevation, and Q-wave MI or to receive thrombolytics, beta-blockers, and cholesterol-lowering and antiplatelet agents in hospital, at discharge, and at 1 year. In multivariable analyses controlling for patient factors, every decade increase in age was independently associated with reduced use of coronary angiography (odds ratio [OR] 0.79, 95% CI 0.74-0.84, P
PubMed ID
16442898 View in PubMed
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Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature134962
Source
JAMA. 2011 Apr 27;305(16):1677-84
Publication Type
Article
Date
Apr-27-2011
Author
Tomas Jernberg
Per Johanson
Claes Held
Bodil Svennblad
Johan Lindbäck
Lars Wallentin
Author Affiliation
Department of Medicine, Section of Cardiology, Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. tomas.jernberg@karolinska.se
Source
JAMA. 2011 Apr 27;305(16):1677-84
Date
Apr-27-2011
Language
English
Publication Type
Article
Keywords
Aged
Coronary Artery Bypass - utilization
Diffusion of Innovation
Drug Therapy - utilization
Evidence-Based Medicine
Female
Guideline Adherence - statistics & numerical data
Humans
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Myocardial Revascularization - utilization
Practice Guidelines as Topic
Registries - statistics & numerical data
Sweden - epidemiology
Treatment Outcome
Abstract
Only limited information is available on the speed of implementation of new evidence-based and guideline-recommended treatments and its association with survival in real life health care of patients with ST-elevation myocardial infarction (STEMI).
To describe the adoption of new treatments and the related chances of short- and long-term survival in consecutive patients with STEMI in a single country over a 12-year period.
The Register of Information and Knowledge about Swedish Heart Intensive Care Admission (RIKS-HIA) records baseline characteristics, treatments, and outcome of consecutive patients with acute coronary syndrome admitted to almost all hospitals in Sweden. This study includes 61,238 patients with a first-time diagnosis of STEMI between 1996 and 2007.
Estimated and crude proportions of patients treated with different medications and invasive procedures and mortality over time.
Of evidence-based treatments, reperfusion increased from 66% (95%, confidence interval [CI], 52%-79%) to 79% (95% CI, 69%-89%; P
Notes
Comment In: JAMA. 2011 Apr 27;305(16):1710-121521855
Comment In: JAMA. 2011 Aug 17;306(7):706-7; author reply 707-821846849
PubMed ID
21521849 View in PubMed
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Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature143168
Source
JAMA. 2010 Jun 2;303(21):2148-55
Publication Type
Article
Date
Jun-2-2010
Author
Laurie Lambert
Kevin Brown
Eli Segal
James Brophy
Josep Rodes-Cabau
Peter Bogaty
Author Affiliation
Cardiology Evaluation Unit, Agence d'évaluation des technologies et des modes d'interventions en santé, Montreal, Québec, Canada. laurie.lambert@aetmis.gouv.qc.ca
Source
JAMA. 2010 Jun 2;303(21):2148-55
Date
Jun-2-2010
Language
English
Publication Type
Article
Keywords
Aged
Angioplasty, Balloon
Female
Fibrinolysis
Guideline Adherence
Heart Failure - mortality
Humans
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Myocardial Reperfusion
Patient Readmission - statistics & numerical data
Quebec
Retrospective Studies
Time Factors
Treatment Outcome
Abstract
Guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients.
To obtain a complete interregional portrait of contemporary STEMI care and to investigate timeliness of reperfusion and outcomes.
Systematic evaluation of STEMI care for 6 months during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute myocardial infarction in the province of Quebec, Canada (population, 7.8 million).
Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive heart failure at 1 year by linkage to Quebec's medicoadministrative databases.
Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinolysis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely (>30 minutes) in 54% and PPCI was untimely (>90 minutes) in 68%. Death or readmission for acute myocardial infarction or heart failure at 1 year occurred in 13.5% of fibrinolysis patients and 13.6% of PPCI patients. When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6% vs 3.3%; odds ratio [OR], 2.14; 95% confidence interval [CI], 1.21-3.93) and a statistically nonsignificant increase in risk of death at 1 year (9.3% vs 5.2%; OR, 1.61; 95% CI, 1.00-2.66) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction at 1 year (15.0% vs 9.2%; OR, 1.57; 95% CI, 1.08-2.30). At the regional level, after adjustment, each 10% increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality (OR, 0.80; 95% CI, 0.65-0.98).
Among patients in Quebec with STEMI, reperfusion delivered outside guideline-recommend delays was associated with significantly increased 30-day mortality, a statistically nonsignificant increase in 1-year mortality, and significantly increased risk of the composite of mortality or readmission for acute myocardial infarction or heart failure at 1 year.
Notes
Comment In: JAMA. 2010 Jun 2;303(21):2188-920516422
PubMed ID
20516415 View in PubMed
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Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals.

https://arctichealth.org/en/permalink/ahliterature126185
Source
JAMA. 2012 Mar 14;307(10):1037-45
Publication Type
Article
Date
Mar-14-2012
Author
Therese A Stukel
Elliott S Fisher
David A Alter
Astrid Guttmann
Dennis T Ko
Kinwah Fung
Walter P Wodchis
Nancy N Baxter
Craig C Earle
Douglas S Lee
Author Affiliation
Institute for Clinical Evaluative Sciences, G106-2075 Bayview Ave, Toronto, ON M4N 3M5, Canada. stukel@ices.on.ca
Source
JAMA. 2012 Mar 14;307(10):1037-45
Date
Mar-14-2012
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Colonic Neoplasms - mortality - therapy
Economics, Hospital
Female
Health Expenditures - statistics & numerical data
Heart Failure - mortality - therapy
Hip Fractures - mortality - therapy
Hospital Costs - statistics & numerical data
Humans
Longitudinal Studies
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Ontario - epidemiology
Patient Readmission - statistics & numerical data
Quality of Health Care
Treatment Outcome
Young Adult
Abstract
The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.
The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services.
The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.
Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
Notes
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Comment In: JAMA. 2012 Mar 14;307(10):1082-322416105
PubMed ID
22416099 View in PubMed
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Bivalirudin for primary percutaneous coronary interventions: outcome assessment in the Ottawa STEMI registry.

https://arctichealth.org/en/permalink/ahliterature119003
Source
Circ Cardiovasc Interv. 2012 Dec;5(6):805-12
Publication Type
Article
Date
Dec-2012
Author
Benjamin Hibbert
Andrea MacDougall
Marino Labinaz
Edward R O'Brien
Derek Y F So
Alexander Dick
Christopher Glover
Michael Froeschl
Jean-Francois Marquis
George A Wells
Melissa Blondeau
Michel R Le May
Author Affiliation
Division of Cardiology, University of Ottawa Heart Institute, ON, Canada.
Source
Circ Cardiovasc Interv. 2012 Dec;5(6):805-12
Date
Dec-2012
Language
English
Publication Type
Article
Keywords
Aged
Anticoagulants - therapeutic use
Antithrombins - adverse effects - therapeutic use
Chi-Square Distribution
Drug Therapy, Combination
Female
Fibrinolytic Agents - adverse effects - therapeutic use
Hemorrhage - chemically induced - prevention & control
Heparin - therapeutic use
Hirudins - adverse effects
Hospital Mortality
Hospitals, University
Humans
Logistic Models
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Odds Ratio
Ontario
Peptide Fragments - adverse effects - therapeutic use
Percutaneous Coronary Intervention - adverse effects - mortality
Platelet Aggregation Inhibitors - therapeutic use
Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors
Propensity Score
Recombinant Proteins - adverse effects - therapeutic use
Recurrence
Registries
Risk factors
Stroke - etiology - prevention & control
Thrombosis - etiology - prevention & control
Time Factors
Treatment Outcome
Abstract
Data from randomized trials has demonstrated the superiority of bivalirudin to glycoprotein IIb/IIIa inhibitors plus heparin in patients undergoing primary percutaneous coronary intervention. Real-world performance of bivalirudin in primary percutaneous coronary intervention and the benefit of bivalirudin over heparin remain unknown in an era of routine dual antiplatelet therapy.
From July 2004 to December 2010, 2317 consecutive patients were indexed in the University of Ottawa Heart Institute ST-segment-elevation myocardial infarction registry. During this period 748 patients received bivalirudin, 699 patients received glycoprotein IIb/IIIa inhibitors, and 676 patients received unfractionated heparin alone. The primary outcome was the rate of noncoronary artery bypass graft related thrombolysis in myocardial infarction major bleeding. Bivalirudin significantly reduced the primary outcome compared with heparin plus glycoprotein IIb/IIIa inhibitors (2.7% versus 7.3%, adjusted OR 2.96, 95% CI: 1.61-5.45, P
Notes
Comment In: Circ Cardiovasc Interv. 2013 Apr;6(2):e2623591425
Comment In: Circ Cardiovasc Interv. 2013 Apr;6(2):e2723591426
PubMed ID
23149331 View in PubMed
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Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study.

https://arctichealth.org/en/permalink/ahliterature121881
Source
Circulation. 2012 Sep 4;126(10):1185-93
Publication Type
Article
Date
Sep-4-2012
Author
Morten Lamberts
Jonas Bjerring Olesen
Martin Huth Ruwald
Carolina Malta Hansen
Deniz Karasoy
Søren Lund Kristensen
Lars Køber
Christian Torp-Pedersen
Gunnar Hilmar Gislason
Morten Lock Hansen
Author Affiliation
Department of Cardiology, Post 635, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark. mortenlamberts@gmail.com
Source
Circulation. 2012 Sep 4;126(10):1185-93
Date
Sep-4-2012
Language
English
Publication Type
Article
Keywords
Acute Coronary Syndrome - drug therapy - mortality
Aged
Aged, 80 and over
Angioplasty, Balloon, Coronary
Aspirin - administration & dosage - adverse effects
Atrial Fibrillation - drug therapy - mortality
Cohort Studies
Comorbidity
Denmark - epidemiology
Drug Therapy, Combination - adverse effects
Female
Fibrinolytic Agents - administration & dosage - adverse effects
Hemorrhage - chemically induced - mortality - prevention & control
Humans
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Platelet Aggregation Inhibitors - administration & dosage - adverse effects
Registries - statistics & numerical data
Risk factors
Stroke - mortality
Ticlopidine - administration & dosage - adverse effects - analogs & derivatives
Vitamin K - antagonists & inhibitors
Abstract
Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment.
Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD ±10.3], males 60.9%) were identified by individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was determined according to antithrombotic treatment regimen: triple therapy (TT) with vitamin K antagonist (VKA)+aspirin+clopidogrel, VKA+antiplatelet, and dual antiplatelet therapy with aspirin+clopidogrel. We calculated crude incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKA+antiplatelet, and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90-360 days) bleeding risk with TT exposure in relation to VKA+antiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant difference in thromboembolic risk was observed for TT versus VKA+antiplatelet; hazard ratio, 1.15 (0.95;1.40).
High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.
Notes
Comment In: Circulation. 2013 Apr 30;127(17):e58523762910
Comment In: Circulation. 2012 Sep 4;126(10):1176-822869840
Comment In: Circulation. 2013 Apr 30;127(17):e58423630091
PubMed ID
22869839 View in PubMed
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