1. Associate Professor, Honorary Consultant Cardiologist
Association of Clinical Factors and Therapeutic Strategies With Improvements in Survival Following NSTEMI,
Chris P Gale
Associate Professor, Honorary Consultant Cardiologist
University of Leeds
@UoLCardioEpi
Hall M et al. JAMA Sep 13;316(10):

2. Declarations
None regarding this presentation

3. Decline in death following ACS
STEMI
NSTEMI
JAMA. 2007;297(17): doi: /jama

4. Increased use of guideline-indicated treatments for ACS
STEMI
NSTEMI
Fox KAA et al. JAMA.2007;297(17):

5. Changing characteristics of patients with ACS
Population demographics
Older
More co-morbid
Higher sensitivity troponin assays
Lower clinical (ischaemic) risk
NSTEMI: the vulnerable population 10 8 6 4 2
Mortality rate (%) 30 60 90
120
150
180
Days
NSTEMI
STEMI UA
Fox KAA, et al. Br Med J 2006;333:1091–1094.

6. Objectives
To determine whether changes in characteristics of patients with NSTEMI are associated with improvements in outcomes

7. Methods Design Setting Participants
Observational cohort using a national clinical registry, MINAP
Setting
All hospitals in England and Wales, 1st January June 30th 2013
Participants
patients with NSTEMI

8. Statistical analyses
Roystin-Parmar flexible survival models to determine the extent to which pharmacological therapies and an invasive coronary strategy (coronary angiography, PCI, CABG) explained the association between baseline risk (GRACE risk score; co-morbidities) and 6-months survival.
Checking selection bias. Instrumental variables analysis with hospital rates of coronary angiography to approximate a random assignment of patients to regional treatments groups that differed in their likelihood of receiving an invasive coronary strategy.
Mediation analyses to determine the extend to which survival trend where explained by pharmacological therapies or use of an invasive coronary strategy

9. Results The median age 72.7 (IQR 61.7 to 81.2) years 63.1% were male
At 180 days from hospital discharge, there were 37,236 (9.6%) deaths

10. Increase in (some) co-morbidities
Characteristics
Difference (95% CI)
Diabetes
20.6
24.5
3.9 ( )
Hypertension
47.3
55.5
8.2 ( )
Chronic renal failure
4.0
7.7
3.7 ( )
Previous PCI
5.7
12.3
6.6 ( )
Age
72.8
72.0
0.8 ( )
Peripheral vascular disease
5.8
5.0
-0.8 ( )

11. Decrease in higher and increase in lower GRACE risk score, 2003-2013
Proportion of patients with intermediate to high GRACE risk declined (87.6% vs. 82%, P=0.01

12. Temporal improvements in use of guideline-indicated treatments
Coronary angiography
PCI
CABG

13. Decline in 6-month mortality, greatest for highest risk
Unadjusted relative temporal
improvement in 6-month survival
of 3.2% per year
Significant reduction in 180-day all cause mortality from 10.8% (95%CI 10.5 to 10.9) in 2003/4 to 7.6% (95%CI 7.4 to 7.8%) in 2012/13.

14. Invasive coronary strategy explained temporal survival improvements
Temporal improvements in
survival remain even after
additive adjustment for
clinical risk, demographics,
co-morbidities and
pharmacological therapies
Invasive coronary strategy
reversed the direction of the
temporal survival effects

15. Invasive coronary strategy explained majority of temporal effects
Mediation analysis
Invasive coronary strategy explained majority of temporal effects
Instrumental variable analysis
Invasive coronary strategy associated with 46.1% relative decrease in mortality

16. Discussion
The use of an invasive coronary strategy significantly accounted for the reduction in mortality over and above that of reducing baseline risk, increasing co-morbidity, and increasing use of pharmacological therapies
Doesn’t mean that pharmacological therapies are not associated with improved outcomes

17. Explanation? Greatest gains occur in those at highest risk
Improved diagnostics

18. Acknowledgements c.p.gale@leeds.ac.uk @UoLCardioEpi Co-authors:
M Hall, TB Donda, A Yan, SG Goodman, H Bueno, DP Chew, D Brieger, A Timmis, D Batin, JE Deanfield, H Hemingway, KAA Fox
MINAP + NHS hospitals & staff
University of Leeds
National Institute for Cardiovascular Outcomes Research
University College London, Farr Institute
British Heart Foundation
National Institute for Health Research
@UoLCardioEpi
Hall M et al. JAMA Sep 13;316(10):