Docstoc

MINAP Painting the Picture

Document Sample
MINAP Painting the Picture Powered By Docstoc
					PCI for non-STEMI ACS
  How are we doing?
 A national perspective

  Glimpses of data from MINAP
        BCIS ACI 2010
          Clive Weston
        Swansea University

              c.f.m.weston@swansea.ac.uk
No conflict of interest to
        declare
For most patients with ACS - PPCI is irrelevant
30-day mortality rates are falling for STEMI
and NSTEMI, but nSTEMI has poorer outcome




 Unadjusted early mortality rates (with 95% CI) trend for
    STEMI and NSTEMI (MINAP 1/1/04 31/12/06)
     Courtesy of Dr Chris Gale. Division of Biostatistics, University of Leeds
  nSTEMI patients differ from STEMI patients
            (Older with more co-morbidity)
      Characteristics of STEMI and NSTEMI patients.
      MINAP 1st January 2004 to 31st December 2007.
                                               ST EMI         NST EMI
Number of patients                            110,840         165,207
Mean age (years) (SD)                          66 (14)         72 (13)
Male gender (%)                             76,842 (70%)   101,143 (62%)
Mean heart rate (bpm) (SD)                     79 (22)         85 (25)
Mean systolic blood pressur e (mmHg) (SD)     138 (30)        141 (30)
Diabetes (%)                                13,995 (13%)    33,676 (21%)
Current smoker (%)                          37,961 (38%)    34,076 (23%)
Chronic renal failure (%)                    2,071 (2%)      8,195 (5%)
Previous MI (%)                             17,085 (16%)    49,772 (31%)




                                   Courtesy of Dr Chris Gale.
                                   Division of Biostatistics, University of Leeds
Unadjusted 30-day mortality after nSTEMI is still
falling




                         Unpublished data - John Bikhead
  Patients with nSTEMI in MINAP are not
  becoming lower risk
            Year              ‘miniGRACE’ score*
             2003                          107

             2004                          108

             2005                          110

             2006                          111

             2007                          111

             2008                          111

             2009                          109
* Determined by age, admission HR, BP, cardiac arrest, Troponin elevation,
ST segment deviation
Those having angiography after nSTEMI
 have lower mortality: cause or effect?




                                    MINAP 2009
Are the right people getting in the
            lifeboats?
Rate of angiography after nSTEMI is increasing




                                         55.3%
                 Tipping point
    Rate of angiography after nSTEMI is linked
    to facilities available in admitting hospital




%
Younger patients are more likely to have
angiography (interventional hospitals Jul 05-Dec 06)

 Age group   Median age   Proportion of   Proportion of
                (yr)      group getting   angio getting
                          angiography     intervention

 < 65 yr      56.8 yr       84.3%           68.6%

 65-79 yr     73.5 yr       65.1%           61.7%

 80 yr +       85 yr        22.7%           51.3%

                                   Birkhead et al Heart 2009
Angiography is most likely performed in men, those
cared for by cardiologists and those in cardiac units




Adjusted Odds Ratio for angiography after nSTEMI
                                  Birkhead et al Heart 2009
Angiography is less likely to be performed when
there is co-morbidity




Adjusted OR for angiography after nSTEMI
                                 Birkhead et al Heart 2009
                             Adj HR    95% CI

No cardiac        Angio      0.57      0.37 to 0.88
Co-morbidity
                  PCI/CABG   0.45      0.30 to 0.69

Any cardiac co-   Angio      0.53      0.40 to 0.70
morbidity
                  PCI/CABG   0.33      0.24 to 0.45




                             HR       95% CI
No co-morbidity   Angio      0.43     0.25 to 0.74
                  PCI/CABG   0.35     0.20 t0 0.62
Single co-        Angio      0.42     0.28 to 0.64
morbidity
                  PCI/CABG   0.32     0.20 to 0.49
Multiple          Angio      0.68     0.49 to 0.95
Co-morbidity
                  PCI/CABG   0.43     0.29 to 0.62



     Angio and intervention is
     associated with lower 6mo
     mortality regardless of
     Co-morbidity
      Angiography and intervention is associated with
        lower 6 mo mortality in all three age bands
                              180 day          Adjusted       95% CI             p
                              mortality %        HR
< 65 y         No angio            7.6             1
               Angio               2.9           0.51        0.17 to 1.58       NS
               PCI/CABG            0.7           0.09        0.02 to 0.41      0.02


65 – 79 y      No angio           14.2             1
               Angio               7.2           0.46        0.33 to 0.66     <0.001
               PCI/CABG            5.3           0.24        0.24 to 0.48     <0.001


80 y +         No angio           20.5             1
               Angio              15.2           0.68        0.49 to 0.95     0.022
               PCI/CABG            9.9           0.45        0.30 to 0.67     <0.001

Adjusted Hazard ratio for death within 180 days using matched propensity analysis (n= 5074)

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:2/28/2012
language:
pages:16