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RIKS HIA: Survival benefits by 12 years registry supported improvement of acute cardiac care in the Sweden - the RIKS-HIA 12 years study

ESC Congress 2010

Acute Coronary Syndromes

Tomas Jernberg
Presenter | see Discussant report Play presentation webcast
Jernberg, Tomas
Open presentation slides

List of Authors:

Lars Wallentin, Bodil Svennblad, Johan Lindbäck, Tomas Jernberg


Introduction : Over the last 15 years a series of large scale prospective randomized trials have documented the efficacy and safety of several new treatments in patients with acute ST-elevation and non-ST-elevation myocardial infarction. European and National guidelines have been developed to support the implementation of the new treatments in clinical practice. However, only limited information is available concerning the impact of these new treatment strategies on long term survival in real life health care. We therefore evaluated the changes of treatments and the long term survival in the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) covering the acute care process and with complete long term follow up in all patients admitted to coronary care units in Sweden.

Material and methods: Consecutive patients admitted to a coronary care unit and entered in the nationwide Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA, register between 1996 and 2007 were available for analyses concerning treatments and at least one year follow-up. All patients with a first time discharge diagnosis of myocardial infarction in the registry were included in this analysis. Information was collected prospectively for more than 100 variables including baseline characteristics, electrocardiographic changes, biochemical markers, in-hospital course, acute interventions, and discharge-medications.

Statistics: Development of proportions of patients treated and changes in mortality over time were evaluated by comparing cohorts of patients admitted over 1 and 2 year periods both for the whole country and individual centres. Comparisons of mortality were also analyzed after adjustment for differences in baseline characteristics and, as a sensitivity analysis, only including patients without previous myocardial infarction. Long-term survival was presented as Kaplan-Meier 1-survival plots.

Results: During the 12 years 92205 patients with NSTEMI and 61237 with STEMI in the registry database fulfilled the inclusion criteria. There was a gradual increase in number of sites and patients from 46 sites with 15248 (8096 NSTEMI; 7152 STEMI) patients in1996-97 to 73 sites with 29176 (18809 NSTEMI; 10367 STEMI) patients in 2006-2007.

NSTEMI: In the NSTEMI population there was from 1996 to 2007 an increase in median age from 72 to 73 years, proportion women from 34 to 38%, hypertension 34 to 47%, smoking from 19% to 21% but decrease in the history of previous MI from 32 to 20%. Out of evidence based treatments known to influence outcomes in hospital use of heparin/lmw heparin was increasing from 36% to 85% and in hospital start of aspirin from 85% to 91%, clopidogrel 0 to 65%, beta-blockade 77% to 88%, ACE-inhibitors/ARB 33% to 62% and statins 23% to 78%. In hospital coronary angiography increased from 14% to 64% and revascularisation within 14 days from 6% to 45%.
From 1996 to 2007 the risk factor adjusted 30 day and 1 year mortality decreased from respectively 11.7% to 5.1% and 21.9% to 12.9%. The 12 year survival analyses indicated that the early mortality benefits were sustained over time providing an overall average gain of 1.70 years of life for the whole NSTEMI population.

STEMI: In the STEMI population there was over the same period a decrease in median age from 71 to 69 years, unchanged proportion women 34 %, increase in hypertension from 29 to 39% and smoking from 26 to 30% but decrease in the history of previous MI from 18 to 10%. Out of evidence based treatments known to influence outcomes reperfusion treatment increased from 67% to 78%, primary PCI 4% to 65%, in hospital use of lmw heparin 10% to 40% and in hospital start of aspirin from 84% to 94%, clopidogrel 0 to 84%, beta-blockade 81% to 90%, ACE-inhibitors/ARB 41% to 71% and statins 23% to 87%. In hospital coronary angiography increased from 12% to 85% and revascularisation within 14 days from 8% to 78%.
From 1996 to 2007 the risk factor adjusted 30 day and 1 year mortality decreased from respectively 12.9% to 6.3% and 19.0% to 11.2%. The 12 year survival analyses indicated that the early mortality benefits were sustained over time providing an overall average gain of 2.6 years of life for the whole STEMI population.

Conclusion: Registry supported implementation of new treatment strategies in acute myocardial infarction has contributed to more than halving of 30 day mortality and providing around 1.7-2.6 years gain in expected long-term life span for patients with myocardial infarction admitted for coronary in Sweden.

Discussant | see Presenter abstract Play presentation webcast
Price, Susanna
(United Kingdom)
Open presentation slides


The aims of this study were to use the RIKS-HIA registry to describe the adoption of new treatments & changes in short/long-term survival in Swedish patients admitted to the CCU with MI over a 12 year period (1995-2007). The authors conclude that implementation of new guidelines has contributed to a >50% reduction in 30-day mortality, an increase in long-term survival and increasing quality/equality of treatment.

RIKS-HIA fulfils most of the requirements for an effective registry; however, the dataset is incomplete, excluding patients with MI not admitted via the CCU & details regarding comprehensiveness (including follow-up) are not presented. Of note, over the preceding decade ten different relevant guidelines have been published by the ESC, including a change in the universal definition of MI to include the use of troponin biomarkers.

Over the study period the admission rate for STEMI in Sweden has remained constant, contrasting with results from other registries. However as in other studies, rates of NSTEMI have risen with the increase also preceding the “new” universal definition, suggesting additional/alternative factors may be implicated. The percentage of patients already treated with β-blockade, clopidogrel, statins & ACE inhibitors/ARBs increased over the study period. This may reflect a changing patient population and/or changing practice in response to guidelines, but may be implicated in the measured increase in NSTEMI as a result of disease modification.

Although rates of revascularisation have increased significantly in STEMI & NSTEMI groups, the use of coronary angiography, revascularisation, & IIbIIIa inhibitors remain significantly lower in the NSTEMI population. Similarly the pre-discharge prescription of aspirin, β-blockers, clopidogrel, statins & ACE inhibitors/ARBs has increased in both patient groups, but disappointingly remains lower in the NSTEMI population.

The main outcome measure reported was mortality (in-hospital, 30 day & 1 year). Short-term mortality fell significantly over the study period in both STEMI & NSTEMI groups; however the numbers were not risk-adjusted. The authors propose a 1.7-2.6year average gain in long-term survival, derived from cumulative rate of death curves. The data as presented rather demonstrates the 82% survival time has increased by 2.6years (STEMI) & the 72% survival time by 1.7years (NSTEMI). However, if the divergence of the cumulative rate of death curves continues, the increase in long-term survival is likely to be even greater. As with all registry data, causality (from increased compliance with guidelines) is unproven.

The authors conclude that implementation of guidelines has contributed to increasing quality/equality of treatment. Assessment of quality requires the application of performance measures & the specific evaluation of the relevant structural, process & outcome measures. Although guidelines should not generally be regarded as performance measures the study assessed several in-hospital process-of-care quality performance measures derived from ESC guidelines. Of note, although prescription of these measures increased throughout the study period, the validity of each is contentious, additionally depending upon administration & patient compliance. The only quality outcome-of-care measure was mortality, with none reported related to complications, readmission, reinfarction or functional status. The authors finally suggest that the implementation of guidelines has contributed to increasing equality of treatment, however, no measures of equality (or possibly more importantly equity) are provided. Further, it is possible that in this rapidly changing field in which patients with the highest healthcare needs are in the lowest socioeconomic group the “inverse equity” hypothesis might be particularly applicable.


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Clinical Trial Update II
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.