Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction

Marlous Hall, Owen J. Bebb, Tatandashe B. Dondo, Andrew T. Yan, Shaun G. Goodman, Hector Bueno, Derek P. Chew, David Brieger, Philip D. Batin, Michel E. Farkouh, Harry Hemingway, Adam Timmis, Keith A.A. Fox, Chris P. Gale

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Aims: To investigate whether improved survival from non-ST-elevation myocardial infarction (NSTEMI), according to GRACE risk score, was associated with guideline-indicated treatments and diagnostics, and persisted after hospital discharge. Methods and results: National cohort study (n = 389 507 patients, n = 232 hospitals, MINAP registry), 2003-2013. The primary outcome was adjusted all-cause survival estimated using flexible parametric survival modelling with time-varying covariates. Optimal care was defined as the receipt of all eligible treatments and was inversely related to risk status (defined by the GRACE risk score): 25.6% in low, 18.6% in intermediate, and 11.5% in high-risk NSTEMI. At 30 days, the use of optimal care was associated with improved survival among high [adjusted hazard ratio (aHR) -0.66 95% confidence interval (CI) 0.53-0.86, difference in absolute mortality rate (AMR) per 100 patients (AMR/100-0.19 95% CI -0.29 to -0.08)], and intermediate (aHR = 0.74, 95% CI 0.62-0.92; AMR/100 = -0.15, 95% CI -0.23 to -0.08) risk NSTEMI. At the end of follow-up (8.4 years, median 2.3 years), the significant association between the use of all eligible guideline-indicated treatments and improved survival remained only for high-risk NSTEMI (aHR = 0.66, 95% CI 0.50-0.96; AMR/100 = -0.03, 95% CI -0.06 to -0.01). For low-risk NSTEMI, there was no association between the use of optimal care and improved survival at 30 days (aHR = 0.92, 95% CI 0.69-1.38) and at 8.4 years (aHR = 0.71, 95% CI 0.39-3.74). Conclusion: Optimal use of guideline-indicated care for NSTEMI was associated with greater survival gains with increasing GRACE risk, but its use decreased with increasing GRACE risk.
LanguageEnglish
Pages3798-3806
Number of pages9
JournalEuropean heart journal
Volume39
Issue number42
DOIs
Publication statusPublished - 7 Nov 2018

Keywords

  • GRACE risk score
  • Mortality
  • Non-ST-elevation myocardial infarction
  • Quality of care

Cite this

Hall, M., Bebb, O. J., Dondo, T. B., Yan, A. T., Goodman, S. G., Bueno, H., ... Gale, C. P. (2018). Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction. European heart journal, 39(42), 3798-3806. https://doi.org/10.1093/eurheartj/ehy517
Hall, Marlous ; Bebb, Owen J. ; Dondo, Tatandashe B. ; Yan, Andrew T. ; Goodman, Shaun G. ; Bueno, Hector ; Chew, Derek P. ; Brieger, David ; Batin, Philip D. ; Farkouh, Michel E. ; Hemingway, Harry ; Timmis, Adam ; Fox, Keith A.A. ; Gale, Chris P. / Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction. In: European heart journal. 2018 ; Vol. 39, No. 42. pp. 3798-3806.
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abstract = "Aims: To investigate whether improved survival from non-ST-elevation myocardial infarction (NSTEMI), according to GRACE risk score, was associated with guideline-indicated treatments and diagnostics, and persisted after hospital discharge. Methods and results: National cohort study (n = 389 507 patients, n = 232 hospitals, MINAP registry), 2003-2013. The primary outcome was adjusted all-cause survival estimated using flexible parametric survival modelling with time-varying covariates. Optimal care was defined as the receipt of all eligible treatments and was inversely related to risk status (defined by the GRACE risk score): 25.6{\%} in low, 18.6{\%} in intermediate, and 11.5{\%} in high-risk NSTEMI. At 30 days, the use of optimal care was associated with improved survival among high [adjusted hazard ratio (aHR) -0.66 95{\%} confidence interval (CI) 0.53-0.86, difference in absolute mortality rate (AMR) per 100 patients (AMR/100-0.19 95{\%} CI -0.29 to -0.08)], and intermediate (aHR = 0.74, 95{\%} CI 0.62-0.92; AMR/100 = -0.15, 95{\%} CI -0.23 to -0.08) risk NSTEMI. At the end of follow-up (8.4 years, median 2.3 years), the significant association between the use of all eligible guideline-indicated treatments and improved survival remained only for high-risk NSTEMI (aHR = 0.66, 95{\%} CI 0.50-0.96; AMR/100 = -0.03, 95{\%} CI -0.06 to -0.01). For low-risk NSTEMI, there was no association between the use of optimal care and improved survival at 30 days (aHR = 0.92, 95{\%} CI 0.69-1.38) and at 8.4 years (aHR = 0.71, 95{\%} CI 0.39-3.74). Conclusion: Optimal use of guideline-indicated care for NSTEMI was associated with greater survival gains with increasing GRACE risk, but its use decreased with increasing GRACE risk.",
keywords = "GRACE risk score, Mortality, Non-ST-elevation myocardial infarction, Quality of care",
author = "Marlous Hall and Bebb, {Owen J.} and Dondo, {Tatandashe B.} and Yan, {Andrew T.} and Goodman, {Shaun G.} and Hector Bueno and Chew, {Derek P.} and David Brieger and Batin, {Philip D.} and Farkouh, {Michel E.} and Harry Hemingway and Adam Timmis and Fox, {Keith A.A.} and Gale, {Chris P.}",
year = "2018",
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doi = "10.1093/eurheartj/ehy517",
language = "English",
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Hall, M, Bebb, OJ, Dondo, TB, Yan, AT, Goodman, SG, Bueno, H, Chew, DP, Brieger, D, Batin, PD, Farkouh, ME, Hemingway, H, Timmis, A, Fox, KAA & Gale, CP 2018, 'Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction', European heart journal, vol. 39, no. 42, pp. 3798-3806. https://doi.org/10.1093/eurheartj/ehy517

Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction. / Hall, Marlous; Bebb, Owen J.; Dondo, Tatandashe B.; Yan, Andrew T.; Goodman, Shaun G.; Bueno, Hector; Chew, Derek P.; Brieger, David; Batin, Philip D.; Farkouh, Michel E.; Hemingway, Harry; Timmis, Adam; Fox, Keith A.A.; Gale, Chris P.

In: European heart journal, Vol. 39, No. 42, 07.11.2018, p. 3798-3806.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction

AU - Hall, Marlous

AU - Bebb, Owen J.

AU - Dondo, Tatandashe B.

AU - Yan, Andrew T.

AU - Goodman, Shaun G.

AU - Bueno, Hector

AU - Chew, Derek P.

AU - Brieger, David

AU - Batin, Philip D.

AU - Farkouh, Michel E.

AU - Hemingway, Harry

AU - Timmis, Adam

AU - Fox, Keith A.A.

AU - Gale, Chris P.

PY - 2018/11/7

Y1 - 2018/11/7

N2 - Aims: To investigate whether improved survival from non-ST-elevation myocardial infarction (NSTEMI), according to GRACE risk score, was associated with guideline-indicated treatments and diagnostics, and persisted after hospital discharge. Methods and results: National cohort study (n = 389 507 patients, n = 232 hospitals, MINAP registry), 2003-2013. The primary outcome was adjusted all-cause survival estimated using flexible parametric survival modelling with time-varying covariates. Optimal care was defined as the receipt of all eligible treatments and was inversely related to risk status (defined by the GRACE risk score): 25.6% in low, 18.6% in intermediate, and 11.5% in high-risk NSTEMI. At 30 days, the use of optimal care was associated with improved survival among high [adjusted hazard ratio (aHR) -0.66 95% confidence interval (CI) 0.53-0.86, difference in absolute mortality rate (AMR) per 100 patients (AMR/100-0.19 95% CI -0.29 to -0.08)], and intermediate (aHR = 0.74, 95% CI 0.62-0.92; AMR/100 = -0.15, 95% CI -0.23 to -0.08) risk NSTEMI. At the end of follow-up (8.4 years, median 2.3 years), the significant association between the use of all eligible guideline-indicated treatments and improved survival remained only for high-risk NSTEMI (aHR = 0.66, 95% CI 0.50-0.96; AMR/100 = -0.03, 95% CI -0.06 to -0.01). For low-risk NSTEMI, there was no association between the use of optimal care and improved survival at 30 days (aHR = 0.92, 95% CI 0.69-1.38) and at 8.4 years (aHR = 0.71, 95% CI 0.39-3.74). Conclusion: Optimal use of guideline-indicated care for NSTEMI was associated with greater survival gains with increasing GRACE risk, but its use decreased with increasing GRACE risk.

AB - Aims: To investigate whether improved survival from non-ST-elevation myocardial infarction (NSTEMI), according to GRACE risk score, was associated with guideline-indicated treatments and diagnostics, and persisted after hospital discharge. Methods and results: National cohort study (n = 389 507 patients, n = 232 hospitals, MINAP registry), 2003-2013. The primary outcome was adjusted all-cause survival estimated using flexible parametric survival modelling with time-varying covariates. Optimal care was defined as the receipt of all eligible treatments and was inversely related to risk status (defined by the GRACE risk score): 25.6% in low, 18.6% in intermediate, and 11.5% in high-risk NSTEMI. At 30 days, the use of optimal care was associated with improved survival among high [adjusted hazard ratio (aHR) -0.66 95% confidence interval (CI) 0.53-0.86, difference in absolute mortality rate (AMR) per 100 patients (AMR/100-0.19 95% CI -0.29 to -0.08)], and intermediate (aHR = 0.74, 95% CI 0.62-0.92; AMR/100 = -0.15, 95% CI -0.23 to -0.08) risk NSTEMI. At the end of follow-up (8.4 years, median 2.3 years), the significant association between the use of all eligible guideline-indicated treatments and improved survival remained only for high-risk NSTEMI (aHR = 0.66, 95% CI 0.50-0.96; AMR/100 = -0.03, 95% CI -0.06 to -0.01). For low-risk NSTEMI, there was no association between the use of optimal care and improved survival at 30 days (aHR = 0.92, 95% CI 0.69-1.38) and at 8.4 years (aHR = 0.71, 95% CI 0.39-3.74). Conclusion: Optimal use of guideline-indicated care for NSTEMI was associated with greater survival gains with increasing GRACE risk, but its use decreased with increasing GRACE risk.

KW - GRACE risk score

KW - Mortality

KW - Non-ST-elevation myocardial infarction

KW - Quality of care

U2 - 10.1093/eurheartj/ehy517

DO - 10.1093/eurheartj/ehy517

M3 - Article

VL - 39

SP - 3798

EP - 3806

JO - European heart journal

T2 - European heart journal

JF - European heart journal

SN - 0195-668X

IS - 42

ER -