Prof. Filippo Crea,
Dr. Nicolas Danchin,
See the press release:Munich, Germany – August 27 2012: Data from four French nationwide registries of STEMI (ST-elevation myocardial infarction) patients initiated five years apart and covering more than 15 years show that mortality rate decreased by 68% over this period, from 13.7% to 4.4%. Around one quarter of this mortality reduction could be attributed to a change in patient characteristics...Read more
Presenter: Nicolas Danchin | see Discussant report
List of Authors: Prof. Nicolas Danchin / FranceCo-authors: Etienne Puymirat, MD/Philippe-Gabriel Steg, MD, PhD/Khalife Khelife, MD/Pascal Gueret, MD, PhD/Didier Blanchard, MD/Jean-Pierre Cambou, MD/Jean Ferrières, MD, PhD/Tabassome Simon, MD, PhD
Background & aimRegistries have shown a decline in mortality in patients with ST-elevation myocardial infarction (STEMI), which is often attributed to increased use of reperfusion therapy. We used the data from 4 nationwide French surveys conducted 5 years apart from 1995 to 2010 to assess the association between early mortality and patient profile, initial behavior, as well as organization of medical care.
MethodsUSIK 1995, USIC 2000, FAST-MI 2005 and FAST-MI 2010 all included patients with STEMI < 48 hours from symptom onset, over a one-month period of time in a large number of French cardiology centres (60 to 80% of all centres taking care of STEMI patients). In all, 6,704 patients participated (1995: 1,536; 2000: 1,841; 2005: 1,611; 2010: 1,716).
ResultsFrom 1995 to 2005, mean age declined from 66 ± 14 to 63 ± 15 years (P<0.001); there was an increase in obesity (14% to 21%; P<0.001), smoking (32% to 41%; P<0.001) and hypertension (44% to 47%; P=0.01). History of MI (15% to 11%), peripheral artery disease (10% to 5%) and stroke (6% to 4%) decreased. Median time from onset to first call decreased from 120 to 74 minutes (P<0.001), and use of MICU (SAMU) increased from 55% to 81.5% (P<0.001). Reperfusion therapy use increased from 49% to 80%, with a decrease in lysis (37.5% to 15%) and an increase in primary PCI (12% to 65%). Early use of antiplatelet agents (92 to 97%), LMWH (27% to 62%), beta-blockers (65% to 81%), ACE-I (48 to 60%), statins (10% to 90%), increased and UFH decreased (96% to 45%). All complications decreased (shock: 7.4 to 4.7%, recurrent MI: 2.6% to 1.0%, VF: 4.2% to 2.7%, AF: 12.5% to 5.6%). Thirty-day mortality decreased from 13.7% to 4.5%. Mortality decreased irrespective of use and type of reperfusion therapy: no reperfusion (18.9% to 10.4%), lysis (8.2% to 2.1%), PPCI (8.7% to 3.1%). Multivariate analysis confirmed that overall management was strongly related to mortality.
Conclusionthese results show that mortality in STEMI patients decreased in a spectacular way, resulting from increased use of reperfusion therapy but also from changing patients characteristics, changing behavior, and better overall organization of care.
What is new compared to the latest presentation of the trialA 15-year perspective based upon 4 nationwide surveys of AMI in France, showing that the major decrease in mortality in related to overall improved care and not only to increased use of reperfusion therapy.
Discussant: Filippo Crea | see Presenter abstract
The FAST-MI programme assessed changes in 30-day mortality of STEMI patients participating in four one-month surveys carried out 5 years apart, from 1995 to 2010, in France, in relation to changes in patient characteristics and early management. The FAST-MI is an excellent programme with several strengths including homogeneous distribution of enrolling centres across the whole country, high participation rate, patients enrolment using similar criteria over a period of 15 years and on-line data recording by dedicated research technicians; last but not least the programme has been sponsored by the French Society of Cardiology confirming the important role that scientific societies may have in promoting knowledge and improvement of patient care. Some minor weaknesses include potential biases related to the prevalent inclusion of large volume hospitals, lack of information on infarct size and microvascular obstruction, lack of assessment of EF at discharge lack of follow-up data on the recurrence of acute coronary events.
Two major points, which deserve attention, are: 1) the decreasing age at the time of STEMI; 2) the decreasing mortality rate regardless of the initial reperfusion strategy.
The cause of the decreasing age at the time of STEMI appears to be related to the increasing prevalence over time of risk factors, in particular obesity. The increasing prevalence of obesity observed in the past 10 years is alarming and has been observed, in particular, in Northern America and in Asia and, to a lesser extent in Europe with some differences among countries.
The causes of the decreasing mortality rate, regardless of the initial reperfusion strategy, are probably multiple. A first important cause is the progressive reduction of time from pain onset to first medical contact. A second cause is the increasing use of percutaneous coronary interventions (PCI), including not only primary, but also rescue PCI as well as PCI carried out after successful thrombolysis. Thus, the FAST-MI programme confirms in real life what has been demonstrated in large randomized trials, giving further support to what is recommended in current guidelines. A third cause potentially responsible for the decreasing mortality rate is represented by the increasing rate of early statin administration. This observation, again, confirms the findings of large randomized trials and might well be accounted for by pleiotropic statin effects associated to a reduction of arrhythmic and ischemic events.
In conclusion, the FAST-MI programme indicates that the battle against risk factors is not over and confirms the benefits of an invasive strategy and of early intensive statin treatment in real life.
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