Myocardial Ischaemia National Audit Project Research Articles

20 A Minap-Like e-registry for the First Time in NHS Scotland? A Proof-of-Concept Report from the Pilot Project

Background The Myocardial Ischaemia National Audit Project (MINAP) provides data on national standards of care for patients with myocardial infarction (MI) in England and Wales but not in Scotland. In the West of Scotland (WoS), electronic patient records are being implemented in place of paper records. We aimed to record-link hospital patient episodes using the new e-systems in order to develop a secondary care e-registry for hospitalised patients with an acute coronary syndrome (ACS), including suspected STEMI, NSTEMI or unstable angina (UA). Methods The systems are (1) Trakcare Patient Admin System with extracts data based on ICD-10 diagnosis codes, (2) SCI-Gateway e-referrals for invasive cardiovascular procedures, (3) a hospital-level integrated patient record including cardiac catheter laboratory data (CATHI), (4) the WoS NHS Safe Haven for healthcare data including hospitalisation and mortality. We implemented a pilot study with data extraction for 1 Oct – 31 Dec 2013 for all admissions with an ICD-10 diagnosis of angina (I200-I209), MI (I210-I229), Other Ischaemic Heart Disease (IHD) (I240-I249), and heart failure (I50). The project involved identification of the NHS referral pathways, case e-record linkage, and quality assurance. Results The regional ACS network involves 7 acute hospitals in WoS (population 2.2 million) including the Golden Jubilee National Hospital, a regional hub for invasive cardiology. During the 3-month pilot, 930 unique patients had 1090 admissions involving 969 distinct spells (i.e. index admission and early out-patient re-admission for angiography). Of these spells, the final diagnosis was IHD in 775 (80%) patients, including 164 (16.9%) with STEMI, 287 (29.6%) with NSTEMI, 26 (2.7%) with unstable angina, 249 (25.7%) with stable angina, 5 with other IHD (0.5%), 43 (4.4%) with ‘other chest pain’ and 194 with a non-IHD final diagnosis (20%) (e.g. pericarditis). The pathways were mapped in 100% of the patients including 25.8% admitted directly to the invasive centre, 5.6% via local A&E to the invasive centre, 22.3% via the local hospital followed by in-patient transfer to the invasive centre, 8.9% discharged from the local hospital then readmitted to the invasive centre for planned early out-patient angiography, 4.6% within the local hospital only (no transfer), and 32.8% directly admitted on an elective basis to the invasive centre (non-acute). The mean duration of stay was similar for patients with a diagnosis of STEMI (5.2 days) or NSTEMI (4.6 days), but less for patients with UA (2.2 days) and more for other IHD diagnosis (9.1 days). Data on health outcomes will be presented at the conference. Conclusions For the first time, the pilot e-Registry has generated MINAP-like data in NHS Scotland. Information on admissions with or without a final ACS diagnosis is collected. NHS Scotland has emerging potential to contribute to MINAP.

Simultaneous computerised activation of the primary percutaneous coronary intervention pathway reduces out-of-hours door-to-balloon time but not mortality

BackgroundIn 2009 activation of out of hours (OOH) primary percutaneous coronary intervention (PPCI) in our institution changed from separate telephone calls to a simultaneous computerised alert. We assessed the impact of this protocol change on door-to-balloon (DTB) time, in hospital and 1year mortality. MethodsRetrospective survey of our Myocardial Ischaemia National Audit Project (MINAP) database. OOH patients were categorised — pre- (Group 1) and post- (Group 2) introduction of the computerised alert protocol. ResultsOOH PPCI was performed for 793 patients (mean age 61, 73.4% male) — 295 in Group 1 and 498 in Group 2. Median DTB times were 92min (interquartile range [IQR] 75–111) for Group 1 and 76min (IQR 64–97) for Group 2 (p<0.0001). Forty-eight percent achieved DTB in ≤90min in Group 1 compared to 70% in Group 2 (p<0.0001). Computerised alert was associated with a shorter DTB time on multivariate analysis (beta coefficient −0.09, p=0.03 for linear regression and OR 2.8, 95% CI 1.6–5.0, p<0.0001 for logistic regression). In hospital mortality was 4.1% in Group 1 and 5% in Group 2 (p=0.60). All-cause mortality at 1year was 6.1% in Group 1 and 9.9% in Group 2 (p=0.09). ConclusionsSimultaneous computerised activation for OOH PPCI reduced DTB times, increased the number of patients achieving target DTB times but did not affect mortality.

Closing the mortality gap after a myocardial infarction in people with and without chronic obstructive pulmonary disease

ObjectivePatients with chronic obstructive pulmonary disease (COPD) have increased mortality following myocardial infarction (MI) compared with patients without COPD. We investigated the extent to which differences in recognition and management...

Long-Term Exposure to Air Pollution and Mortality or Readmission among Acute Coronary Syndrome Survivors in the Greater London Area

Background Long-term exposure to air pollution has been linked to increased mortality and morbidity risk. We used the Myocardial Ischaemia National Audit Project (MINAP) data of patients admitted t...

Mortality and missed opportunities along the pathway of care for ST-elevation myocardial infarction: a national cohort study.

To examine the association between cumulative missed opportunities for care (CMOC) and mortality in patients with ST-elevation myocardial infarction (STEMI). A cohort study of 112,286 STEMI patients discharged from hospital alive between January 2007 and December 2010, using data from the Myocardial Ischaemia National Audit Project (MINAP). A CMOC score was calculated for each patient and included: pre-hospital ECG, acute use of aspirin, timely reperfusion, prescription at hospital discharge of aspirin, thienopyridine inhibitor, ACE-inhibitor (or equivalent), HMG-CoA reductase inhibitor and β-blocker, and referral for cardiac rehabilitation. Mixed-effects logistic regression models evaluated the effect of CMOC on risk-adjusted 30-day and 1-year mortality (RAMR). 44.5% of patients were ineligible for ≥1 care component. Of patients eligible for all nine components, 50.6% missed ≥1 opportunity. Pre-hospital ECG and timely reperfusion were most frequently missed, predicting further missed care at discharge (pre-hospital ECG incident rate ratio [95% CI]: 1.64 [1.58-1.70]; timely reperfusion 9.94 [9.51-10.40]). Patients ineligible for care had higher RAMR than those eligible for care (30-days: 1.7% vs. 1.1%; 1-year: 8.6% vs. 5.2%), whilst those with no missed care had lower mortality than patients with ≥4 CMOC (30-days: 0.5% vs. 5.4%, adjusted OR (aOR) per CMOC group 1.22, 95% CI: 1.05-1.42; 1-year: 3.2% vs. 22.8%, aOR 1.23, 1.13-1.34). Opportunities for care in STEMI are commonly missed and significantly associated with early and later mortality. Thus, outcomes after STEMI may be improved by greater attention to missed opportunities to eligible care.

Antipsychotic drugs and risks of myocardial infarction: a self-controlled case series study.

AimAntipsychotics increase the risk of stroke. Their effect on myocardial infarction remains uncertain because people prescribed and not prescribed antipsychotic drugs differ in their underlying vascular risk making between-person comparisons difficult to interpret. The aim of our study was to investigate this association using the self-controlled case series design that eliminates between-person confounding effects.Methods and resultsAll the patients with a first recorded myocardial infarction and prescription for an antipsychotic identified in the Clinical Practice Research Datalink linked to the Myocardial Ischaemia National Audit Project were selected for the self-controlled case series. The incidence ratio of myocardial infarction during risk periods following the initiation of antipsychotic use relative to unexposed periods was estimated within individuals. A classical case–control study was undertaken for comparative purposes comparing antipsychotic exposure among cases and matched controls. We identified 1546 exposed cases for the self-controlled case series and found evidence of an association during the first 30 days after the first prescription of an antipsychotic, for first-generation agents [incidence rate ratio (IRR) 2.82, 95% confidence interval (CI) 2.0–3.99] and second-generation agents (IRR: 2.5, 95% CI: 1.18–5.32). Similar results were found for the case–control study for new users of first- (OR: 3.19, 95% CI: 1.9–5.37) and second-generation agents (OR: 2.55, 95% CI: 0.93–7.01) within 30 days of their myocardial infarction.ConclusionWe found an increased risk of myocardial infarction in the period following the initiation of antipsychotics that was not attributable to differences between people prescribed and not prescribed antipsychotics.

Prognostic value of troponins in acute coronary syndrome depends upon patient age

ObjectiveThis study aims to determine whether the prognostic significance of troponins in acute coronary syndrome in predicting mortality varies by age, and if so, to what extent when other prognostic...

Inpatient coronary angiography and revascularisation following non-ST-elevation acute coronary syndrome in patients with renal impairment: a cohort study using the Myocardial Ischaemia National Audit Project.

BackgroundInternational guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.MethodsWe performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010.FindingsOf 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m2 was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m2, patients with an eGFR between 45–59 ml/minute/1.73 m2 were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55–0.81); those with an eGFR<30/minute/1.73 m2 had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29–0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57–0.77), with no evidence of modification by renal function (p interaction = 0.744).InterpretationEarly revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.

Short-term effects of air pollution on a range of cardiovascular events in England and Wales: case-crossover analysis of the MINAP database, hospital admissions and mortality

ObjectiveTo inform potential pathophysiological mechanisms of air pollution effects on cardiovascular disease (CVD), we investigated short-term associations between ambient air pollution and a range of cardiovascular events from three national...

Resuscitated cardiac arrest and prognosis following myocardial infarction

ObjectivesTo determine whether resuscitated cardiac arrest (CA) complicating ST elevation myocardial infarction (STEMI) impacts outcome, particularly in patients surviving to discharge.BackgroundResuscitated CA complicating STEMI is associated with increased inpatient mortality....

Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project

ObjectiveTo describe patterns of prehospital ECG (PHECG) use and determine its association with processes and outcomes of care in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI.MethodsPopulation-based linked cohort study...

P2. Incidence and Severity of Myocardial Infarction in Subjects Receiving Anti-Tumour Necrosis Factor Drugs for Rheumatoid Arthritis: Results from Linking the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis and Myocardial Ischaemia National Audit Project

P2. Incidence and Severity of Myocardial Infarction in Subjects Receiving Anti-Tumour Necrosis Factor Drugs for Rheumatoid Arthritis: Results from Linking the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis and Myocardial Ischaemia National Audit Project

39. Non-Differential Reporting of Myocardial Infarction to a National Observational Drug Safety Study Using Linked Data: Linkage of the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis and the Myocardial Ischaemia National Audit Project

39. Non-Differential Reporting of Myocardial Infarction to a National Observational Drug Safety Study Using Linked Data: Linkage of the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis and the Myocardial Ischaemia National Audit Project

The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP)

Older people increasingly constitute a large proportion of the acute coronary syndrome (ACS) population. We examined the relationship of age with receipt of more intensive management and secondary prevention medicine. Then, the comparative association of intensive management (reperfusion/angiography) over a conservative strategy on time to death was investigated by age. Using data from 155 818 patients in the national registry for ACS in England and Wales [the Myocardial Ischaemia National Audit Project (MINAP)], we found that older patients were incrementally less likely to receive secondary prevention medicines and intensive management for both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In STEMI patients ≥85 years, 55% received reperfusion compared with 84% in those aged 18 to <65 [odds ratio 0.22 (95% CI 0.21, 0.24)]. Not receiving intensive management was associated with worse survival [mean follow-up 2.29 years (SD 1.42)] in all age groups (adjusted for sex, cardiovascular risk factors, co-morbidities, healthcare factors, and case severity), but there was an incremental reduction in survival benefit from intensive management with increasing age. In STEMI patients aged 18-64, 65-74, 75-84, and ≥85, adjusted hazard ratios (HRs) for all-cause mortality comparing conservative treatment to intensive management were 1.98 (1.78, 2.19), 1.65 (1.51, 1.80), 1.62 (1.52, 1.72), and 1.36 (1.27, 1.47), respectively. In NSTEMI patients, the respective HRs were 4.37 (4.00, 4.78), 3.76 (3.54, 3.99), 2.79 (2.67, 2.91), and 1.90 (1.77, 2.04). We found an incremental reduction in the use of evidence-based therapies with increasing age using a national ACS registry cohort. While survival benefit from more intensive management reduced with older age, better survival was associated with intensive management at all ages highlighting the requirement to improve standard of care in older patients with ACS.

Age-dependent improvements in survival after hospitalisation with acute myocardial infarction: an analysis of the Myocardial Ischemia National Audit Project (MINAP)

recent studies report an age-dependent decline in mortality after acute myocardial infarction (AMI). to investigate age-dependent improvements in survival after hospitalisation with AMI. population-based cohort study using data from the Myocardial Ischaemia National Audit Project. a total of 583,466 patients with AMI admitted to 247 hospitals between 1 January 2003 and 31 December 2010. six-month relative survival (RS) was calculated from the ratio of observed to expected survival using an age-, sex- and biennial year-matched population from the Office for National Statistics. Risk-adjusted mortality rates (RMAR) were estimated using shared frailty regression. Data were stratified by age group, AMI phenotype [(ST-elevation myocardial infarction, (STEMI) and non-STEMI, (NSTEMI)] and period of admission to hospital. for STEMI, there was an increase in RS for patients aged 65-80 years (84.8 versus 89.2%) and those over 80 years (68.0 versus 71.8%), but not for patients aged 18 to <65 years (96.4 versus 96.9%). For NSTEMI patients aged 18 to <65 years RS was higher, but stable (95.5 versus 96.8%) and improved for patients aged 65-80 years (83.2 versus 88.5%) and patients aged >80 years (68.3% versus 75.5%). Likewise, RMAR improved for patients aged ≥65 years, were stable and higher for patients <65 years. there were significant improvements in survival after hospitalisation with AMI in the older but not younger patients. The scope for further reductions in mortality is likely to be much greater for older than younger patients with AMI.

Effect of β blockers on mortality after myocardial infarction in adults with COPD: population based cohort study of UK electronic healthcare records

Objectives To investigate whether the use and timing of prescription of β blockers in patients with chronic obstructive pulmonary disease (COPD) having a first myocardial infarction was associated with survival...

An evaluation of composite indicators of hospital acute myocardial infarction care: A study of 136,392 patients from the Myocardial Ischaemia National Audit Project

BackgroundHospital acute myocardial infarction (AMI) care is increasingly evaluated using composite quality scores. We investigated the influence of three aggregation methods for an AMI indicator on mortality and hospital rank. Methods and resultsWe studied 136,392 patients discharged alive from 199 hospitals with AMI recorded in the Myocardial Ischaemia National Audit Project, between 01/01/2008 and 31/12/2009. A composite of prescription of aspirin, thienopyridine inhibitor, β-blocker, angiotensin converting enzyme inhibitor, HMG CoA reductase enzyme inhibitor and enrolment in cardiac rehabilitation at discharge was aggregated as opportunity based (OBCS), weighted opportunity-based (WOBCS) and all-or-nothing (ANCS) scores. We quantified adjusted 30-day, 6-month and 1-year mortality rates and hospital performance rank. Median (IQR) scores were OBCS: 95.0% (3.5), WOBCS: 94.7% (0.8) and ANCS: 80.9% (11.8). The three methods affected the proportion of hospitals outside 99.8% credible limits of the national median (OBCS: 52.2%, WOBCS: 64.3% and ANCS: 37.7%) and hospital rank. Each 1% increase in composite score was significantly associated with a 1 to 3% and a 4% reduction in 6-month and 1-year mortality, respectively. However, the ANCS had fewer cases and no significant association with 30-day mortality. ConclusionsA hospital composite score, incorporating 6 aspects of AMI care, was significantly inversely associated with mortality. However, composite aggregation method influenced hospital rank, number of cases available for analysis and size of the association with all-cause mortality, with the ANCS performing least well. The use and choice of composite scores in hospital AMI quality improvement requires careful evaluation.

The effect of older age on receipt and outcomes of care in patients with acute coronary syndromes: a cohort study of 68,025 patients from the national acute coronary syndrome register of England/Wales

Purpose: To determine the effect of older age on receipt of care and mortality in STEMI patients from the national register of England and Wales. Methods: We analysed 68,025 patients between 2006 and 2010 using the Myocardial Ischaemia National Audit Project (MINAP) with one-year all-cause mortality follow-up. Results: Older patients were incrementally less likely to receive secondary prevention and primary reperfusion (angioplasty or thrombolysis)- OR (95% CI) for receiving reperfusion in patients over the 85 compared to those under 65 was 0.24 (0.23,0.25), OR for receiving statin was 0.31 (0.29,0.32). Reperfusion reduced mortality compared to medical treatment in all age groups, with a trend towards a reduced benefit for older patients. View this table: Impact of reperfusion on time to death ![Figure][1] Odds ratio for receipt of each treatment Conclusions: Older patients were less likely to receive treatment in ACS. There was less benefit from primary reperfusion with older age. [1]: pending:yes

Composite quality scores for care of acute myocardial infarction patients at discharge from hospital: a study of 136,392 patients from the Myocardial Ischaemia National Audit Project (MINAP)

Composite quality scores for care of acute myocardial infarction patients at discharge from hospital: a study of 136,392 patients from the Myocardial Ischaemia National Audit Project (MINAP)

Completeness and diagnostic validity of recording acute myocardial infarction events in primary care, hospital care, disease registry, and national mortality records: cohort study

Objective To determine the completeness and diagnostic validity of myocardial infarction recording across four national health record sources in primary care, hospital care, a disease registry, and mortality register. Design...