1. Has acute myocardial infarction mortality hit rock bottom
Has acute myocardial infarction mortality hit rock bottom? Changes in patient characteristics, management, and 6-month outcomes over a period of 20 years in the FAST-MI programme
N. Danchin, E. Puymirat, F. Schiele, T. Simon, on behalf of the USIK, USIC 2000 and FAST-MI investigators

2. Consu lting/Royalties/Owner/ Stockholder of a healthcare company (Amgen AstraZeneca, Bayer, BMS, Boehringer -lngelheim Daiichi Sankyo, Eli-Lilly MSD Novo- ordisk, Pfizer, Sanofi)
Research contracts (Amgen AstraZeneca, Bayer BMS, Boehringer -Ingelheim Daiichi Sankyo Eli-Lilly MSD Pfizer Sanofi)

3. Study sponsors USIK 1995: Roussel USIC 2000: Aventis – FAST-MI 2005:
Pfizer, Servier
FAST-MI 2010: AstraZeneca, Daiichi-Sankyo, Eli-Lilly, GSK,
MSD, Novartis, Sanofi
FAT-MI 2015: Amgen, AstraZeneca, Bayer, BMS, Boehringer
-Ingelheim, Daiichi-Sankyo, Eli-Lilly, MSD, Pfizer, Sanofi

4. Background
Early mortality in patients admitted for STEMI or NSTEMI has declined in the past 2 decades, and improved outcomes have been attributed to increased use of revascularisation but also to changes in patient characteristics and overall management.
Few studies have compared trends in outcomes for STEMI and NSTEMI patients and little information beyond the early s is available.

5. Aim
To assess 6-month mortality in consecutive patients admitted to ICCUs for STEMI or NSTEMI and recruited in 5 one-month nationwide surveys in France, carried out 5 years apart since 1995

6. The French AMI registry programme
5 Nationwide French registries conducted 5 years apart since 1995, including consecutive adult patients with acute STEMI or NSTEMI, with symptom onset ≤ 48 hours, admitted alive to a coronary care unit (CCU) or an intensive care unit (ICU) within 48 hours of symptom onset, over a 1-month period (possible extension for up to one additional month).
AMI criteria: 1) cardiac markers elevation with 2) compatible symptoms, or ST-T changes.
No unstable angina. Exclusion of iatrogenic AMIs or MI diagnosis subsequently disproved.
All type of institutions: academic teaching hospitals, community and regional hospitals, private clinics (for profit and not-for-profit), army hospitals.
Compliance with GCP, patient consent and compliance with French law, including the law on data protection.

7. French AMI registries USIK 1995 USIC 2000 FAST-MI 2005 FAST-MI 2010
2152
patients 312 centres
1536 STEMI
616 NSTEMI
2320
patients 369 centres
1844 STEMI
476 NSTEMI
3059
patients 223 centres
3079
patients 213 centres
3813
patients 204 centres
1611 STEMI
1716 STEMI
1872 STEMI
1448 NSTEMI
1363 NSTEMI
1941 NSTEMI

8. STEMI patients: baseline characteristics
USIK 1995a USIC 2000a FAST-MI 2005 FAST-MI 2010 FAST-MI P (n=1536) (n=1844) (n=1611) (n=1716) (n=1872) value
Demography
Age
Female, n (%)
66.2±14.0
64.5±14.6
64.0±14.7
63.3±14.5
63.5±13.8
<0.001
431 (28)
499 (27)
458 (28)
423 (25)
469 (25)
0.04
Cardiovascular history and comorbidities, n (%)
Myocardial Infarction
Heart failure
Peripheral artery disease
225 (15)
276 (15)
180 (11)
187 (11)
231 (12)
98 (6)
84 (5)
56 (3.5)
41 (2)
54 (3)
148 (10)
145 (8)
85 (5)
83 (5)
84 (4.5)
% aged 60 years or less among STEMI patients 60 50 40 30 20 10
50.7
46.2 49
48.2
40.5
29.4
Men Women
23.4
25.5
17.5
13.7
1995
2000
2005
2010
2015

9. Patient behaviour: STEMI
Time from symptom onset to first call
2000
2005
2010
2015
Median
120 90 74
25th; 75th percentiles
41; 360
30; 295
30; 240
30; 300
Direct call to EMS (SAMU) 60 50 40 30 20 10
41.3
23.2
2000
2005
2010
2015

10. Reperfusion treatment in STEMI90 80 70 60 50 40 30 20 10
PPCI 76
% of STEMI patients 67
Thrombolysis
No reperfusion 51 47 41 38 30 31 29 23 19 18 14 12 6
1995
PCI after lysis: 15%
2005
84%
2010
87%
2000
2015
60%
87%

11. STEMI: medications used in first 48 hours
100 80 60 40
Beta-blockers
[VALU100 81
Statins
90 [VALU
100 80 60 40 20
ACE-i or ARBs 73 72 E] 78 E]
[VALU E] 65 80 60 40 65 46 48 53 41 20
Antiplatelet agents
P2Y12 inhibitors
Anticoagulants 97
100 92 95 96
100 80 60 40 20
100 80 60 40 20 88 85
Clopidogrel
100 80 60 40 20 96
UFH
LMWH
Prasugrel Ticagrelor 59 79
67 61 62 61 55 45 33
27 24 27 19
13.5
0 0
6.5
0 0 0
0 0
0 0 4
2005
2010
2015

12. NSTEMI patients: baseline characteristics
USIK 1995a USIC 2000a FAST-MI FAST-MI 2010 FAST-MI 2015 P for Trend (n=616) (n=476) (n=1448) (n=1363) (n=1941)
Demography
Age (years) mean ± SD
Female, n (%)
68.5±14.2
68.9±13.5
70.2±13.3
68.6±13.6
68.1±13.5
<0.001
188 (30.5)
130 (27)
510 (35)
406 (30)
581 (30)
0.75
Risk factors, n (%)
Hypertension
303 (50)
272 (57)
962 (66)
847 (62)
1220 (63)
Hypercholesterolemia
221 (37)
225 (48)
749 (52)
653 (48)
979 (54)
Diabetes mellitus
122 (20)
123 (26)
422 (29)
370 (27)
522 (27)
0.001
Current smoking
157 (26)
103 (22)
322 (22)
334 (24.5)
566 (29)
Obesity (BMI ≥30)
77 (13)
93 (22.5)
268 (21)
306 (24)
468 (25)
Cardiovascular history and comorbidities, n (%)
Myocardial Infarction
169 (27)
135 (28)
345 (24)
311 (23)
469 (24)
0.055
PCI -
77 (16)
260 (18)
314 (23)
462 (24)
CABG
48 (10)
132 (9)
116 (8.5)
124 (6)
0.006
Heart failure
100 (16)
65 (14)
117 (8)
105 (8)
148 (8)
PAD
73 (12)
70 (15)
197 (14)
161 (12)
190 (10)
0.003

13. Invasive strategies in NSTEMI90 80 70 60 50 40 30 20 10 90 95 67 60
CAG 78
% of NSTEMI patients 71
PCI ≤ 72 hrs 65 55
PCI 51 44 39 25
9 12.5
1995
2000
2005
2010
2015

14. NSTEMI: medications used in first 48 hours
100 80 60 40
Beta-blockers
100
Statins 85
100 80 60 40 20
ACE-i or ARBs 77 71 78 64 66 80 60 40 71 60 61 57 51 43 42 37 20
Antiplatelet agents
P2Y12 inhibitors
Anticoagulants 98 98
100 80 60 40 20 89 94 94
100 80 60 40 20 90
Clopidogrel 82
100 80 60 40 20 95
UFH
LMWH
Prasugrel Ticagrelor51.5 63 66 60
5550 41 48 41 38 34 13
17.5 5
0 0
0 0 0
0 0
0 0 1 1
2005
2010
2015

15. Six-month mortality Adjusted HR (95%CI) (reference 1995) 2000:
2005
2010
2015
STEMI
NSTEMI
17.2
17.2
6.3
5.3
Adjusted HR
(95%CI) (reference 1995)
2000:
0.76 ( )
0.92 ( )
2005:
0.56 ( )
0.66 ( )
2010:
0.45 ( )
0.40 ( )
2015:
0.32 ( )
0.40 ( )
Figure 1

16. Crude and standardised 6-month mortality20 16 12 8 4
A: STEMI
Crude
9.7
9.1
6.9
6.8
2015
1995
2000
2005
2010 20 15
Crude
B: NSTEMI 10 5
12.2
10.5
2010
2015
1995
2000
2005

17. STEMI patients: 6-month mortality by reperfusion therapy30
23.4 25
16.9
16.4
15.1 20 15
10.8
8.9
7.4
6.7 10
5.0
4.8 5
1995
2000
2005
2010
2015
No reperfusion: Reperfusion: All STEMI
Reference
1.00
Adjusted HR ( )
0.85 ( )
0.76 ( )
Adjusted HR ( )
0.60 ( )
0.56 ( )
Adjusted HR ( )
0.41 ( )
0.45 ( )
Adjusted HR ( )
0.36 ( )
0.32 ( )
No reperfusion
Reperfusion
Figure 2

18. NSTEMI patients: 6-month mortality by use of early PCI30 25
No PCI ≤ 72h PCI ≤ 72h 20 15
[VALUE]
[VALUE]
16.1 10 5
1995
2000
2005
3.2
2010
2015
No PCI ≤72 hours:
Reference
Adjusted HR ( )
Adjusted HR ( )
Adjusted HR ( )
Adjusted HR ( )
PCI ≤72 hours:
1.00
0.28 ( )
0.19 ( )
0.09 ( )
0.11 ( )
All NSTEMI:
0.92 ( )
0.66 ( )
0.40 ( )
0.40 ( )
Figure 2

19. Final thoughts
From 1995 to 2015, 6-month mortality of both STEMI and NSTEMI patients has considerably decreased, together with major increases in use of procedures over time. Use of recommended secondary prevention medications has also increased until 2010 but levels down since then.
In STEMI patients, mortality has continued to decrease after 2010, to reach an all-time low in In NSTEMI patients, despite recent changes in antithrombotic medications at the acute stage, mortality has remained similar in 2015, compared with 2010.
Prolonged follow-up will determine whether improvement in survival will persist or materialise in both types of patients.

20. Acknowledgements
FAST-MI is a registry of the French Society of Cardiology
Supported by:
Funding of FAST-MI 2015:
Amgen, AstraZeneca, Bayer, BMS/Pfizer, Boehringer-Ingelheim, Daïchi-Sankyo/Eli-Lilly, MSD, Sanofi
We are indebted to:
The patients who accepted to participate in the surveys
All clinicians involved in the studies
All the devoted personnel involved at the Société Française de Cardiologie, and URCEST, AP-HP, Hôpital St Antoine .

21. Circulation. 2017;136:00–00. DOI: 10.1161/CIRCULATIONAHA.117.
030798

22. Barcelona
Aug,