STEMI and NSTEMI: Are They So Different?
STEMI and NSTEMI: Are They So Different?
Aims: The ESC/ACC redefined myocardial infarction as any amount of necrosis caused by ischaemia. The aim of this study was to describe the management and outcomes using 'real-world' data taking the new definition of acute myocardial infarction into account.
Methods and results: A total of 2151 consecutive patients (76.0% men) with a myocardial infarction were enrolled at 56 centres in France. The median delay to presentation was shorter in patients with ST-segment elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) (4 vs. 7 h, P < 0.0001). STEMI patients were more likely to receive fibrinolysis (28.9 vs. 0.7%, P < 0.0001) or undergo PCI (71.0 vs. 51.6%, P < 0.0001) but less likely to have bypass surgery (3.1 vs. 4.9%, P < 0.05). At discharge, patients with STEMI received more aggressive secondary prevention therapies than those with NSTEMI, which was not supported by differences in disease severity. A total of 1878 patients were followed-up for 1 year: 36.7% of STEMI and 41.5% of NSTEMI patients were rehospitalized (P = 0.05); 16% in both groups were revascularized. In-hospital mortality was similar (4.6 vs. 4.3%), and 1-year mortality was 9.0% in STEMI patients and 11.6% in NSTEMI patients (Log-Rank P = 0.09). Independent correlates of in-hospital mortality were untreated dyslipidaemia, advanced age, diabetes, and low blood pressure. The strongest predictors of 1-year mortality were heart failure and age. Similar predictors were found in STEMI and NSTEMI subgroups.
Conclusions: Despite different management, patients with STEMI and NSTEMI have similar prognoses and independent correlates of outcome. These findings support the new definition of myocardial infarction.
Despite advances in our understanding of the pathophysiology of coronary disease and improvements in its management and prevention, acute coronary syndromes remain a major cause of mortality and morbidity in industrialized countries and are becoming an increasingly important problem in developing countries.
In 2000, The Joint European Society of Cardiology/American College of Cardiology (ESC/ACC) Committee for the redefinition of myocardial infarction suggested that any amount of necrosis resulting from ischaemia should be diagnosed as a myocardial infarction. As a consequence of this new definition, patients who would previously have been considered to have unstable angina are being diagnosed with a myocardial infarction. Since then, higher levels of troponin have also been associated with more severe prognosis.
Recent guidelines for the management of patients with myocardial infarction have been published in response to improvements in clinical outcomes reported in major randomized clinical trials of new pharmacological or interventional treatments. Few studies have, however, reported on how these guidelines are being implemented in clinical practice, both in hospital and over the longer term, from a 'real-world' perspective. Most observational studies are limited to a follow-up of 6 months following discharge from hospital. In addition, the most recent registry data on acute myocardial infarction have enrolled patients with ST-segment elevation myocardial infarction (STEMI), whereas data from patients with non-STEMI (NSTEMI) are analysed separately with unstable angina patients.
The primary objective of the nationwide OPERA (Observatoire sur la Prise en charge hospitalière, l'Evolution à un an et les caRactéristiques de patients présentant un infArctus du myocarde avec ou sans onde Q) study was to describe the in-hospital management and cardiovascular outcomes at 1 year of patients with a myocardial infarction, using the new definition. The secondary objectives were to describe the management of patients in the year following the index admission, including smoking status and level of physical activity in patients with STEMI and NSTEMI. The aim of the present study was to describe patients' in-hospital and long-term management and their clinical outcomes and to identify independent predictors of death.
Abstract and Introduction
Abstract
Aims: The ESC/ACC redefined myocardial infarction as any amount of necrosis caused by ischaemia. The aim of this study was to describe the management and outcomes using 'real-world' data taking the new definition of acute myocardial infarction into account.
Methods and results: A total of 2151 consecutive patients (76.0% men) with a myocardial infarction were enrolled at 56 centres in France. The median delay to presentation was shorter in patients with ST-segment elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) (4 vs. 7 h, P < 0.0001). STEMI patients were more likely to receive fibrinolysis (28.9 vs. 0.7%, P < 0.0001) or undergo PCI (71.0 vs. 51.6%, P < 0.0001) but less likely to have bypass surgery (3.1 vs. 4.9%, P < 0.05). At discharge, patients with STEMI received more aggressive secondary prevention therapies than those with NSTEMI, which was not supported by differences in disease severity. A total of 1878 patients were followed-up for 1 year: 36.7% of STEMI and 41.5% of NSTEMI patients were rehospitalized (P = 0.05); 16% in both groups were revascularized. In-hospital mortality was similar (4.6 vs. 4.3%), and 1-year mortality was 9.0% in STEMI patients and 11.6% in NSTEMI patients (Log-Rank P = 0.09). Independent correlates of in-hospital mortality were untreated dyslipidaemia, advanced age, diabetes, and low blood pressure. The strongest predictors of 1-year mortality were heart failure and age. Similar predictors were found in STEMI and NSTEMI subgroups.
Conclusions: Despite different management, patients with STEMI and NSTEMI have similar prognoses and independent correlates of outcome. These findings support the new definition of myocardial infarction.
Introduction
Despite advances in our understanding of the pathophysiology of coronary disease and improvements in its management and prevention, acute coronary syndromes remain a major cause of mortality and morbidity in industrialized countries and are becoming an increasingly important problem in developing countries.
In 2000, The Joint European Society of Cardiology/American College of Cardiology (ESC/ACC) Committee for the redefinition of myocardial infarction suggested that any amount of necrosis resulting from ischaemia should be diagnosed as a myocardial infarction. As a consequence of this new definition, patients who would previously have been considered to have unstable angina are being diagnosed with a myocardial infarction. Since then, higher levels of troponin have also been associated with more severe prognosis.
Recent guidelines for the management of patients with myocardial infarction have been published in response to improvements in clinical outcomes reported in major randomized clinical trials of new pharmacological or interventional treatments. Few studies have, however, reported on how these guidelines are being implemented in clinical practice, both in hospital and over the longer term, from a 'real-world' perspective. Most observational studies are limited to a follow-up of 6 months following discharge from hospital. In addition, the most recent registry data on acute myocardial infarction have enrolled patients with ST-segment elevation myocardial infarction (STEMI), whereas data from patients with non-STEMI (NSTEMI) are analysed separately with unstable angina patients.
The primary objective of the nationwide OPERA (Observatoire sur la Prise en charge hospitalière, l'Evolution à un an et les caRactéristiques de patients présentant un infArctus du myocarde avec ou sans onde Q) study was to describe the in-hospital management and cardiovascular outcomes at 1 year of patients with a myocardial infarction, using the new definition. The secondary objectives were to describe the management of patients in the year following the index admission, including smoking status and level of physical activity in patients with STEMI and NSTEMI. The aim of the present study was to describe patients' in-hospital and long-term management and their clinical outcomes and to identify independent predictors of death.