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Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study

Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study
Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study

AIMS: Early and accurate diagnosis of acute myocardial infarction is central to successful treatment and improved outcomes. We aimed to investigate the impact of the initial hospital diagnosis on mortality for patients with acute myocardial infarction.

METHODS AND RESULTS: Cohort study using data from the Myocardial Ischaemia National Audit Project of patients discharged with a final diagnosis of ST-elevation myocardial infarction (STEMI, n=221,635) and non-STEMI (NSTEMI, n=342,777) between 1 April 2004 and 31 March 2013 in all acute hospitals ( n = 243) in England and Wales. Overall, 168,534 (29.9%) patients had an initial diagnosis which was not the same as their final diagnosis. After multivariable adjustment, for STEMI a change from an initial diagnosis of NSTEMI (time ratio 0.97, 95% confidence interval 0.92-1.01) and chest pain of uncertain cause (0.98, 0.89-1.07) was not associated with a significant reduction in time to death, whereas for other initial diagnoses the time to death was significantly reduced by 21% (0.78, 0.74-0.83). For NSTEMI, after multivariable adjustment, a change from an initial diagnosis of STEMI was associated with a reduction in time to death of 10% (time ratio 0.90, 95% confidence interval 0.83-0.97), but not for chest pain of uncertain cause (0.99, 0.96-1.02). Patients with NSTEMI who had other initial diagnoses had a significant 14% reduction in their time to death (time ratio 0.86, 95% confidence interval 0.84-0.88). STEMI and NSTEMI with other initial diagnoses had low rates of pre-hospital electrocardiograph (24.3% and 21.5%), aspirin on hospitalisation (61.6% and 48.5%), care by a cardiologist (60.0% and 51.5%), invasive coronary procedures (38.8 % and 29.2%), cardiac rehabilitation (68.9% and 62.6%) and guideline indicated medications at time of discharge from hospital. Had the 3.3% of patients with STEMI and 17.9% of NSTEMI who were admitted with other initial diagnoses received an initial diagnosis of STEMI and NSTEMI, then 33 and 218 deaths per year might have been prevented, respectively.

CONCLUSION: Nearly one in three patients with acute myocardial infarction had other diagnoses at first medical contact, who less frequently received guideline indicated care and had significantly higher mortality rates. There is substantial potential, greater for NSTEMI than STEMI, to improve outcomes through earlier and more accurate diagnosis of acute myocardial infarction.

acute myocardial infarction, MINAP, mortality, NSTEMI, STEMI
139-148
Wu, Jianhua
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Gale, Chris P.
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Hall, Marlous
99c3916e-5cfe-4e5f-a388-4727140accb5
Dondo, Tatendashe B.
d62bfcb2-ae5b-418a-b44f-dd4098660398
Metcalfe, Elizabeth
a9f45cf8-eeac-4edc-ba82-8f13e222f121
Oliver, Ged
695f5f9f-4c6e-43fd-b8a5-f9c74545d227
Batin, Phil D.
6ce74ad3-eb1d-4b5c-a62f-a750518c6659
Hemingway, Harry
e7c49321-f006-48e0-854e-fe8221cc634e
Timmis, Adam
afa86b24-5997-4e05-a891-ccaa20c90f20
West, Robert M.
924e4166-bd25-4993-9a24-7f7fef6d3714
Wu, Jianhua
d1e83015-b7d2-4404-847e-c6f73e281759
Gale, Chris P.
96b5706c-fd86-4b41-9568-3d917ef2c805
Hall, Marlous
99c3916e-5cfe-4e5f-a388-4727140accb5
Dondo, Tatendashe B.
d62bfcb2-ae5b-418a-b44f-dd4098660398
Metcalfe, Elizabeth
a9f45cf8-eeac-4edc-ba82-8f13e222f121
Oliver, Ged
695f5f9f-4c6e-43fd-b8a5-f9c74545d227
Batin, Phil D.
6ce74ad3-eb1d-4b5c-a62f-a750518c6659
Hemingway, Harry
e7c49321-f006-48e0-854e-fe8221cc634e
Timmis, Adam
afa86b24-5997-4e05-a891-ccaa20c90f20
West, Robert M.
924e4166-bd25-4993-9a24-7f7fef6d3714

Wu, Jianhua, Gale, Chris P., Hall, Marlous, Dondo, Tatendashe B., Metcalfe, Elizabeth, Oliver, Ged, Batin, Phil D., Hemingway, Harry, Timmis, Adam and West, Robert M. (2018) Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study. European heart journal. Acute cardiovascular care, 7 (2), 139-148. (doi:10.1177/2048872616661693).

Record type: Editorial

Abstract

AIMS: Early and accurate diagnosis of acute myocardial infarction is central to successful treatment and improved outcomes. We aimed to investigate the impact of the initial hospital diagnosis on mortality for patients with acute myocardial infarction.

METHODS AND RESULTS: Cohort study using data from the Myocardial Ischaemia National Audit Project of patients discharged with a final diagnosis of ST-elevation myocardial infarction (STEMI, n=221,635) and non-STEMI (NSTEMI, n=342,777) between 1 April 2004 and 31 March 2013 in all acute hospitals ( n = 243) in England and Wales. Overall, 168,534 (29.9%) patients had an initial diagnosis which was not the same as their final diagnosis. After multivariable adjustment, for STEMI a change from an initial diagnosis of NSTEMI (time ratio 0.97, 95% confidence interval 0.92-1.01) and chest pain of uncertain cause (0.98, 0.89-1.07) was not associated with a significant reduction in time to death, whereas for other initial diagnoses the time to death was significantly reduced by 21% (0.78, 0.74-0.83). For NSTEMI, after multivariable adjustment, a change from an initial diagnosis of STEMI was associated with a reduction in time to death of 10% (time ratio 0.90, 95% confidence interval 0.83-0.97), but not for chest pain of uncertain cause (0.99, 0.96-1.02). Patients with NSTEMI who had other initial diagnoses had a significant 14% reduction in their time to death (time ratio 0.86, 95% confidence interval 0.84-0.88). STEMI and NSTEMI with other initial diagnoses had low rates of pre-hospital electrocardiograph (24.3% and 21.5%), aspirin on hospitalisation (61.6% and 48.5%), care by a cardiologist (60.0% and 51.5%), invasive coronary procedures (38.8 % and 29.2%), cardiac rehabilitation (68.9% and 62.6%) and guideline indicated medications at time of discharge from hospital. Had the 3.3% of patients with STEMI and 17.9% of NSTEMI who were admitted with other initial diagnoses received an initial diagnosis of STEMI and NSTEMI, then 33 and 218 deaths per year might have been prevented, respectively.

CONCLUSION: Nearly one in three patients with acute myocardial infarction had other diagnoses at first medical contact, who less frequently received guideline indicated care and had significantly higher mortality rates. There is substantial potential, greater for NSTEMI than STEMI, to improve outcomes through earlier and more accurate diagnosis of acute myocardial infarction.

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More information

Accepted/In Press date: 4 July 2016
e-pub ahead of print date: 26 August 2016
Published date: 1 March 2018
Keywords: acute myocardial infarction, MINAP, mortality, NSTEMI, STEMI

Identifiers

Local EPrints ID: 424586
URI: http://eprints.soton.ac.uk/id/eprint/424586
PURE UUID: 37ab91b6-890c-496f-a74a-fe22e74873a1

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Date deposited: 05 Oct 2018 11:38
Last modified: 25 Nov 2021 23:15

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Contributors

Author: Jianhua Wu
Author: Chris P. Gale
Author: Marlous Hall
Author: Tatendashe B. Dondo
Author: Elizabeth Metcalfe
Author: Ged Oliver
Author: Phil D. Batin
Author: Harry Hemingway
Author: Adam Timmis
Author: Robert M. West

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