Trends in Short- and Long-Term ST-Segment-Elevation Myocardial Infarction Prognosis Over 3 Decades: A Mediterranean Population-Based ST-Segment-Elevation Myocardial Infarction Registry

Abstract

Background Coronary artery disease remains a major cause of death despite better outcomes of ST-segment-elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti-STEMI registry of in-hospital, 28-day, and 1-year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28-day and 1-year STEMI mortality and in-hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28-day all-cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P<0.001), with a 40% reduction after multivariable adjustment (hazard ratio [HR], 0.6; 95% CI, 0.46-0.80; P<0.001). One-year all-cause mortality declined from period 1 to period 5 (11.7% versus 9.0%; P=0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60-0.98; P=0.036). A significant temporal reduction was observed for in-hospital complications including postinfarct angina (-78%), ventricular tachycardia (-57%), right ventricular dysfunction (-48%), atrioventricular block (-45%), pericarditis (-63%), and free wall rupture (-53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions In-hospital STEMI complications and 28-day and 1-year mortality rates have dropped markedly in the past 30 years. Reducing ischemia-driven primary ventricular fibrillation remains a major challenge.

Keywords: STEMI complications; STEMI mortality; ST‐segment–elevation myocardial infarction; prognosis.

Figure 1. Map of the University and community hospitals.

Geographical distribution of the Ruti‐STEMI population‐based registry, in northern Barcelona metro area.

Figure 2. Trends in STEMI in‐hospital complications among periods.

Angina (top left); atrial fibrillation (top middle); pericarditis (top right); right ventricular (RV) dysfunction (middle left); atrioventricular block (middle right); primary ventricular fibrillation (VF; bottom). Shaded regions represents 95% CI. AV indicates atrioventricular; and STEMI, ST‐segment–elevation myocardial infarction.

Figure 3. Trends in changes in 28‐day case fatality related to infarct location between periods.

Inferior wall AMI (blue), anterior wall AMI (green), all STEMI (red). AMI indicates acute myocardial infarction; and STEMI, ST‐segment–elevation myocardial infarction.

Figure 4. Kaplan–Meier curves among periods.

A, 28‐day case fatalities and (B) 1‐year all‐cause mortality among patients with STEMI during the 5 periods: period 1 (dark blue), period 2 (brown), period 3 (green), period 4 (orange) and period 5 (light blue). STEMI indicates ST‐segment–elevation myocardial infarction.

Figure 5. Twenty‐eight‐day case fatality among periods depending on maximum Killip class during hospital admission.

A, Killip I; B, Killip II; C, Killip III; D, Killip IV. Period 1 (dark blue), period 2 (brown), period 3 (green), period 4 (orange) and period 5 (light blue).

Figure 6. Early acute‐phase mortality relative to maximum Killip–Kimball class during intensive cardiac care unit admission.

Period 1 (dark blue), period 2 (red), period 3 (green), period 4 (violet) and period 5 (light blue).

Figure 7. Trends in STEMI outcomes among 3 decades in a Mediterranean population‐based registry.

Most in‐hospital STEMI (ST‐segment–elevation myocardial infarction) complications have been reduced above 50%: angina, right ventricular dysfunction, pericarditis, atrioventricular block, ventricular tachycardia (VT), heart failure, and free‐wall (FW) rupture, although primary ventricular fibrillation (VF) remains without changes. Twenty‐eight‐day case fatality declined 40% and 1‐year mortality has been reduced 25% among the past 3 decades. K‐K indicates Killip–Kimball.