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ACS Registries

An article from the e-journal of the ESC Council for Cardiology Practice

The data in registries of acute coronary syndromes largely vary due to many factors: regional differences, type of patients enrolled, type of hospitals participating, treatment strategies used, etc. To provide reliable and comparable results, a registry should fullfill the following criteria: 1. To cover all hospitals (invasive and non-invasive) in a given region (to enroll 100% patients in that region during a given period). Unfortunately, most registries are based on voluntary participation of only selected (and usually better !) hospitals and thus cannot provide the true picture. 2. To enroll the most difficult patients: elderly (>80 years), Killip III-IV class or resuscitated (i.e. patients, who in many hospitals are admitted to resuscitation units and not to cardiology units). 3. To match the mortality data with an independent national database of death certificates.Registries, fulfilling these criteria, usually provide significantly higher mortality data – but they represent the real life situation.

Acute Coronary Syndromes (ACS)


Acute coronary syndrome (ACS) is the major cause for hospital admission and mortality. The frequency, management and outcomes of acute coronary syndromes vary in different registries. The key factor predicting the outcome is age. The specific type of acute coronary syndrome (unstable angina vs. non-STEMI vs. STEMI) included in each given registry must always be kept in mind when analysing the outcome of any given registry. Some registries mix all MIs  (STEMI and non-STEMI) or even report all three forms of ACS together; some registries enroll patients with suspected ACS, while other ones only enroll patients with confirmed ACS, etc.

Incidence of acute coronary syndromes.

Only a few registries report the true incidence of acute coronary syndromes (i.e., cover completely a defined geographic region with a known total population). A carefully done regional acute MI registry in Denmark (1) revealed 727 hospitalised patients with confirmed MI (mean age 73 years) during a two-year follow-up in a region with 139,000 inhabitants: 58% were non-ST-elevation MI, 37% ST-elevation MI, and 5% bundle branch block type MI’s. The calculated annual incidence of hospitalised MI cases is thus 2,612 per million.
A change in diagnostic criteria for acute MI increased the hospitalisation rate for acute MI in Denmark from 2,560 to 3,091/mil. pop. (2). Early mortality decreased from 26% in 1994 to 17.5% in 2002.

In the recently published CZECH registry (3), the annual incidence of hospitalised patients with confirmed MI was 1,960/mil. pop., i.e., substantially less than in Denmark. The CZECH registry was the first registry reporting the incidence of confirmed acute coronary syndromes (all three forms): 3,248 patients/mil. pop.

Treatment strategies for acute coronary syndromes.

The CZECH registry (3) confirmed that widespread use of the network system for primary PCI as the default reperfusion strategy dramatically increased the overall availability of reperfusion therapy: 87% STEMI patients enrolled in the CZECH registry were treated by reperfusion (primary PCI in 83%, CABG in 3% and thrombolysis in only 1% of cases).

Reperfusion therapy was used in 54% of ST elevation infarctions in Denmark (1), while 25% ST-elevation MI patients were admitted within 12 hours of symptom onset, but were not treated by reperfusion. The remaining 21% of ST-elevation MI patients arrived late (after 12 hours). An early invasive strategy (CAG) was performed in 48% of non-ST-elevation MI patients. Patients with ST-elevations receiving any reperfusion therapy died in 10.5%, while no reperfusion therapy was associated with 34% mortality. Patients with non-ST-elevation MI?s undergoing  early CAG died in 10% whereas those who did not died in 49.5% of cases!

In the Euro Heart Survey (4), CAG was undertaken in 56% of STEMI and 52% of NSTE-ACS. PCI was performed in 72% of STEMI patients undergoing CAG, the figure being 49% in NSTE-ACS patients undergoing CAG.

In the GRACE registry (5, 6, 7), CAG was performed in 55% of STEMI (followed by PCI in 73%), 53% of NSTEMI (followed by PCI in 53%), and in 42% of UAP patients (followed by PCI in 43%). Reperfusion therapy was used in 62% of STEMI patients (with primary PCI in 15%, rescue PCI after failed thrombolysis in 3%, and thrombolysis in only 44%). The primary PCI-to-thrombolysis ratio was thus 28 : 72. In the Italian BLITZ survey (8), the ratio of primary PCI to thrombolysis was 23 : 77.

The Euro Heart Survey (9) showed that 4.5% of patients hospitalized with ACS in Europe underwent CABG during the same hospital stay. Their in-hospital mortality was 3.7%.
 Reperfusion therapy is used in 60-70% of STEMI patients in Canada, with a vast majority of procedures being thrombolysis, and only few primary PCIs (10).

There were 17,926 high-risk NSTE ACS patients in the CRUSADE registry (11, 12) enrolled in 248 US hospitals with catheterization and revascularization facilities. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001).

In-hospital CAG was performed in the UK registry (13) in only 10% of patients and only 29% of CAG patients underwent PCI.

In the Israeli registry (14), 69% of patients had CAG during their hospital stay and 58% of these underwent PCI. Discharge medication included aspirin in 89%, ticlopidine/clopidogrel in 48%, ACE inhibitors in 60%, beta-blockers in 75% and statins in 67% of patients.

In the Canadian registry (15), CAG was performed in 39.6% of patients and PCI in 41% of the CAG group.

The large US registry (16) analyzed 255,256 patients with acute myocardial infarction enrolled in the NRMI-2,3,4 in the US between 1994 and 2002: 20% had ST depression (mean age, 71 years) and 80% had ST elevation or bundle branch block (mean age, 66 years) on their admission ECG. Females made up 40% of the entire registry population, and individuals with 25%. CAG at any time during hospital stay was performed in 62% of STEMI patients. Primary PCI was performed in 22% of STEMI patients, and the ratio of primary PCI to thrombolysis was 37 : 63.

The recently published Euro Heart Survey on Acute Coronary Syndromes II (17) described the characteristics, treatment, and outcome of 6385 patients diagnosed with ACS in 190 medical centres in 32 countries. ACS with ST-elevation was the initial diagnosis in 47% of patients and non-ST-elevation in 48%. This survey showed greater use of recommended medications and coronary interventions. Among patients with ST-elevation, the use of primary reperfusion was 64% (primary PCI : thrombolysis ratio 59:41).

Outcomes of acute coronary syndromes. 

The in-hospital mortality of myocardial infarctions in the Danish registry (1) was 14%, with one-year mortality of 28%. The strength of this Danish registry is independent and objective assessment of one-year mortality obtained from the “Civil Registration System“ in Denmark. The one-year mortality is thus higher than in other registries or trials: being 20.5% for ST-elevations (mean age was 69 years), 30.5% for non-ST-elevations (mean age 75 years) and as high as 54.8% for bundle branch block infarctions (mean age 80 years).

In a Swiss registry (18), in-hospital mortality varied between 2.4% and 11.8% (depending on the subgroup considered). Killip III and IV classes on admission were associated with mortality increased by factors 3.6 and 6, respectively. The Euro Heart Survey (4) enrolled 10,484 patients in 25 countries based on the discharge diagnosis of confirmed ACS. The admission diagnoses were STEMI in 42% and NSTE-ACS in 58%. The discharge diagnoses were Q-MI in 33%, non-Q MI in 25%, and UAP in 42%. In-hospital mortality was 7% for STEMI and 2.8% for NSTE-ACS. In the GRACE registry (5, 6, 7), the mean age of patients with STEMI was 64 years, with NSTEMI 68 years, and with UAP 66 years. In-hospital mortality was 4.5% (all ACS patients) and 7% for STEMI, 5% for NSTEMI, and 3% for UAP. Death rates between discharge and 6 months were 4.8% (STEMI), 6.2% (NSTEMI), and 3.6% (UAP).B

The BLITZ survey, performed in 2001 (8), enrolled 1,959 patients (mean age, 67 years) with acute MI admitted to 296 Italian coronary care units. Two thirds of cases were STEMI and one third NSTEMI. In-hospital mortality was 7.4% and 30-day mortality 9.4% for the entire cohort and 7.5% / 9.5% for STEMI, and 5.2% / 7.1% for NSTEMI. The second BLITZ survey (19) enrolled 1,888 NSTE-ACS patients (half had NSTEMI and half had UAP with negative myocardial necrosis markers) in 275 Italian hospitals over a 3-week period. The 30-day mortality was 2.4%. There was no significant difference between invasive (2.0% mortality) and non-invasive (2.9% mortality) hospitals. The only
independent predictors of outcome were age and Killip class.

The large CRUSADE registry (11, 12) enrolled 56,352 patients with NSTE-ACS in 310 US hospitals, with in-hospital mortality being 4.2%. The Euro Heart Survey (20) expressed mortality risk per age group as compared to patients below 55 years: the odds ratios of in-hospital mortality due to any type of ACS were 1.9 (age 55-64), 3.7 (age 65-74), 6.2 (age 75-84) and 14.5 (age 85 or higher). The UK registry (13) enrolled 1,046 NSTE-ACS patients (mean age, 66 years) in 56 UK hospitals. The overall 6-month mortality was 7.3%. In an Israeli CCU registry (14), 970 NSTE-ACS patients (mean age, 65 years) were included with 30-day mortality of 2.9%. A Canadian registry enrolled 5,312 patients (mean age, 66 years) with suspected ACS in 51 hospitals (15). The diagnosis of ACS was confirmed in 4,627 patients 87%). The overall in-hospital mortality was 2.4% for the entire cohort and 4.9% (Q-MI), 2.5% (NQMI), 0.4% (UAP) for each specific type of ACS. One-year mortality of hospital survivors was 6.5% (Q-MI), 10% (NQMI), and 5.4% (UAP). The US in-hospital mortality (16) was the same for ST-elevations (15.5%) as for ST-depressions (15.8%).
Practical implications.

Conclusions

The data in registries of acute coronary syndromes largely vary due to many factors: regional differences, type of patients enrolled, type of hospitals participating, treatment strategies used, etc. To provide reliable and comparable results, a registry should fulfill the following criteria:
1. To cover all hospitals (invasive and non-invasive) in a given region (to enroll 100% patients in that region during a given period). Unfortunately, most registries are based on voluntary participation of only selected (and usually better !) hospitals and thus cannot provide the true picture.
2. To enroll the most difficult patients: elderly (>80 years), Killip III-IV class or resuscitated (i.e. patients, who in many hospitals are admitted to resuscitation units and not to cardiology units).
3. To match the mortality data with an independent national database of death certificates.
Registries, fulfilling these criteria, usually provide significantly higher mortality data – but they represent the real life situation.
 

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

References


1. Terkelsen CJ, Lassen JF, Norgaard BL, Gerdes JC, Jensen T, Gotzsche LB, Nielsen TT, Andersen HR. Mortality rates in patients with ST-elevation vs. non-ST-elevation acute myocardial infarction: observations from an unselected cohort. Eur Heart J 2005; 26: 18-26.

2. Abildstrom SZ, Rasmussen S, Madsen M. Changes in hospitalization rate and mortality after acute myocardial infarction in Denmark after diagnostic criteria and methods changed. Eur Heart J 2005; 26: 990-995.

3. Petr Widimsky, Michal Zelizko, Petr Jansky, Frantisek Tousek, Frantisek Holm and Michael Aschermann on behalf of the CZECH investigators: The incidence, treatment strategies and outcomes of acute coronary syndromes in the “reperfusion network” of different hospital types in the Czech Republic: Results of the CZech Evaluation of acute Coronary syndromes in Hospitalized patients (CZECH) Registry. Intern J Cardiol 2007; 119: 212-9.

4. Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, Fioretti PM, Simoons ML, Battler A on behalf of the Euro Heart Survey investigators. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin – the Euro Heart Survey of Acute Coronary Syndromes. Eur Heart J 2002; 23: 1190-1201.

5. Fox KAA, Goodman SG, Klein W on behalf of the GRACE investigators. Management of acute coronary syndromes. Variation in practice and outcome. Findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2002; 23: 1177-89.

6. Steg PG, Goldberg RJ, Gore JM, Fox KAA, Eagle KA, Flather MD, Sadiq I, Kasper R, Rushton-Mellor SK, Anderson FA for the GRACE Investigators. Baseline characteristics, management practices and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 2002; 90: 358-63.

7. Goldberg RJ, Currie K, White K, Brieger D, Steg PG, Goodman SG, Dabbous O, Fox KAA, Gore JM. Six-months outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (GRACE). Am J Cardiol 2004; 93: 288-93.

8. DiChiara A, Chiarella F, Savonitto S, Lucci D, Bolognese L, DeServi S, Greco C, Boccanelli A, Zonzin P, Coccolini S, Maggioni AP on behalf of the BLITZ Investigators. Epidemiology of acute myocardial infarction in the Italian CCU network - the BLITZ study. Eur Heart J 2003; 24: 1616-29.

9. Solodky A, Behar S, Boyko V, Battler A, Hasdai D. The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: The Euro Heart Survey of acute coronary syndrome experience. Cardiology 2005; 103: 44-7.

10. Jackevicius CA, Alter D, Cox J, Daly P, Goodman S, Filate W, Newman A, Tu JV. Acute treatment of myocardial infarction in Canada 1999 – 2002. Can J Cardiol 2005; 21: 145-152.

11. Ryan JW, Peterson ED, Chen AY, Roe MT, Ohman EM, Cannon CP, Berger PB, Saucedo JF, DeLong ER, Normand SL, Pollack CV, Cohen DJ for the CRUSADE Investigators. Optimal timing of intervention in non-ST-segment elevation acute coronary syndromes – insights from the CRUSADE registry. Circulation 2005; 112: 3049-57.

12. Bhatt DL, Roe MT, Peterson ED, Li Y, Chen AY, Harrington RA, Greenbaum AB, Berger PB, Cannon CP, Cohen DJ, Gibson CM, Saucedo JF, Kleiman NS, Hochman JS, Boden WE, Brindis RG, Peacock WF, Smith SC Jr, Pollack CV Jr, Gibler WB, Ohman EM; CRUSADE Investigators. Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 2004; 292: 2096-104.

13. Collinson J, Flather MD, Fox KA, et al. Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: prospective registry of acute ischemic syndromes in the UK (PRAIS-UK). Eur Heart J 2000; 21: 1450-7.

14. Zahger D, Hod H, Gottlieb S, Leor J, Hasdai D, Sandach A, Hammerman H, Behar S. Influence of the new definition of acute myocardial infarction on coronary care unit admission, discharge diagnosis, management and outcome in patients with non-ST elevation acute coronary syndromes: a national survey. Int J Cardiol 2006; 106: 164-9.

15. Yan AT, Tan M, Fitchett D, Chow CM, Fowlis RA, McAvinue TG, Roe MT, Peterson ED, Tu JV, Langer A, Goodman SG for the Canadian Acute Coronary Syndromes Registry Investigators. One-year outcome of patients after acute coronary syndrome (from the Canadian Acute Coronary Syndromes Registry). Am J Cardiol 2004; 94: 25-9.

16. Pitta SR, Grzybowski M, Welch RD, Frederick PD, Wahl R, Zalenski RJ. ST-segment depression on the initial electrocardiogram in acute myocardial infarction – prognostic significance and its effect on short-term mortality: a report from the National Registry of Myocardial Infarction (NRMI-2, 3, 4). Am J Cardiol 2005; 95: 843-8.


17. Mandelzweig L, Battler A, Boyko V, Bueno H, Danchin N, Filippatos G, Gitt A, Hasdai D, Hasin Y, Marrugat J, Van de Werf F, Wallentin L, Behar S. The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J 2006; 27: 2285-93.

18. Urban P, Bernstein MS, Constanza MC for the AMIS Investigators. An internet-based registry of acute myocardial infarction in Switzerland. Kardiovasc Med 2000; 3: 430-40.
19. DiChiara A, Fresco C, Savonitto S, Greco C, Lucci D, Gonzini L, Mafrici A, Ottani F, Bolognese L, DeServi S, Boccanelli A, Maggioni AP, Chiarella F on behalf of the BLITZ-2 Investigators. Epidemiology non-ST elevation acute coronary syndromes in the Italian cardiology network: the BLITZ-2 study. Eur Heart J 2006; 27: 393-405.

20. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, Hasdai D. Age, clinical presentation and outcome of acute coronary syndromes in the Euro Heart Acute Coronary Syndrome Survey. Eur Heart J 2006; 27: 789-95.

 

VolumeNumber:

Vol5 N°40

Notes to editor


Prof. P. Widimsky
Prague, Czech Republic
Chairman of the ESC credentials Committee

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.