Abstract
BackgroundComorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities.MethodsWe used data of 693,388 AMI patients recorded in the Myocardial Ischaemia National Audit Project (MINAP), 2003–2013. We investigated the association between comorbidities and receipt of optimal care for AMI (receipt of all eligible guideline-indicated treatments), and the effect of receipt of optimal care for comorbid AMI patients on long-term survival using flexible parametric survival models.ResultsA total of 412,809 [59.5%] patients with AMI had at least one comorbidity, including hypertension (302,388 [48.7%]), diabetes (122,228 [19.4%]), chronic obstructive pulmonary disease (COPD, 89,221 [14.9%]), cerebrovascular disease (51,883 [8.6%]), chronic heart failure (33,813 [5.6%]), chronic renal failure (31,029 [5.0%]) and peripheral vascular disease (27,627 [4.6%]).Receipt of optimal care was associated with greatest survival benefit for patients without comorbidities (HR 0.53, 95% CI 0.51–0.56) followed by patients with hypertension (HR 0.60, 95% CI 0.58–0.62), diabetes (HR 0.83, 95% CI 0.80–0.87), peripheral vascular disease (HR 0.85, 95% CI 0.79–0.91), renal failure (HR 0.89, 95% CI 0.84–0.94) and COPD (HR 0.90, 95% CI 0.87–0.94). For patients with heart failure and cerebrovascular disease, optimal care for AMI was not associated with improved survival.ConclusionsOverall, guideline-indicated care was associated with improved long-term survival. However, this was not the case in AMI patients with concomitant heart failure or cerebrovascular disease. There is therefore a need for novel treatments to improve outcomes for AMI patients with pre-existing heart failure or cerebrovascular disease.
Highlights
Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI)
The magnitude and direction of the estimates were upheld in sensitivity analyses comparing the imputed data with a complete case analysis, with the exception of AMI with cerebrovascular disease and patients with two or more comorbidities (Additional file 1: Table S9, S11; Figure S2, S3). In this nationwide study of nearly 700,000 people hospitalised with AMI, we have shown that the co-existence of diabetes mellitus, chronic obstructive pulmonary disease (COPD) or asthma, chronic heart failure and cerebrovascular disease is common and is inversely associated with receipt of optimal guideline-recommended care for AMI
We showed that patients with heart failure, cerebrovascular disease, diabetes mellitus and COPD or asthma were less likely to receive guideline-recommended care
Summary
Comorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. It is necessary to identify comorbidity states where receipt of treatment is suboptimal, or where AMI treatment has little impact on prognosis in order to guide research into novel therapies, thereby optimising patient-centred care delivery. Whilst there is good evidence to suggest that comorbidity adversely influences treatment pathways for a number of specific diseases including diabetes, cancer and chronic obstructive pulmonary disease (COPD) [3, 9,10,11,12], there is a paucity of information about the impact of comorbidity on treatment delivery and treatment efficacy for AMI. To our knowledge, there is no evidence to date concerning the efficacy of AMI treatments on clinical outcomes for patients with AMI and comorbidity
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