Myocardial Ischaemia National Audit Project Research Articles

Association of prevalence of active transport to work and incidence of myocardial infarction: A nationwide ecological study.

There is a paucity of population-based geospatial data about the association between active transport and myocardial infarction. We investigated the association between active transport to work and incidence of myocardial infarction. This ecological study of 325 local authorities in England included 43,077,039 employed individuals aged 25-74 years (UK Census, 2011), and 117,521 individuals with myocardial infarction (Myocardial Ischaemia National Audit Project, 2011-2013). Bayesian negative binomial regression models were used to investigate the association of active transport to work and incidence of myocardial infarction adjusting for local levels of deprivation, obesity, smoking, diabetes and physical activity. In 2011, the prevalence of active transportation to work for people in employment in England aged 25-74 years was 11.4% (4,531,182 active transporters; 8.6% walking and 2.8% cycling). Active transport in 2011 was associated with a reduced incidence of myocardial infarction in 2012 amongst men cycling to work (incidence rate ratio (95% credible interval) 0.983 (0.967-0.999); and women walking to work (0.983 (0.967-0.999)) after full adjustments. However, the prevalence of active transport for men and women was not significantly associated with the combined incidence of myocardial infarction between 2011-2013 after adjusting for physical activity, smoking and diabetes. In England, the prevalence of active transportation was associated with a reduced incidence of myocardial infarction for women walking and men cycling to work in corresponding local geographic areas. The overall association of active transport with myocardial infarction was, however, explained by local area levels of smoking, diabetes and physical activity.

The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study

BackgroundThe degree to which elevated mortality associated with weekend or night-time hospital admissions reflects poorer quality of care (‘off-hours effect’) is a contentious issue. We examined if off-hours admissions for...

Use and impact of the prehospital 12-lead ECG in the primary PCI era (PHECG2): protocol for a mixed-method study

IntroductionUse of the prehospital 12-lead ECG (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found that although PHECG use...

A nationwide causal mediation analysis of survival following ST-elevation myocardial infarction

ObjectiveInternational studies report a decline in mortality following ST-elevation myocardial infarction (STEMI). The extent to which the observed improvements in STEMI survival are explained by temporal changes in patient characteristics...

The Myocardial Ischaemia National Audit Project (MINAP).

The Myocardial Ischaemia National Audit Project (MINAP) collects data from admissions in England, Wales, and Northern Ireland with Type 1 myocardial infarction (T1 MI). The project aims to improve clinical care through the audit process and to provide powerful high-resolution data for research. MINAP collects data spanning 130 data fields covering the course of patient care, from the moment the patient calls for professional help through to hospital discharge and rehabilitation. Data are entered by clinicians and clerical staff within hospitals, and pseudonymized records are uploaded centrally to the National Institute for Cardiovascular Outcomes Research (NICOR), hosted by Barts Health NHS Trust, London, UK. Two hundred and six hospitals submit over 92000 new cases to MINAP annually. Approximately 1.5 million patient records are currently held in the database. Patient demographics, medical history, clinical assessment, investigations, treatments, drug therapy prior to admission, during hospital stay, and at discharge are collected. Data completeness of three key data fields (age, admission blood pressure, and heart rate) is over 91%. Vital status following hospital discharge is obtained via linkage to data from the United Kingdom Office for National Statistics. An annual report is compiled using these data, with individual hospital summary data included. Datasets are available to researchers by application to NICOR. MINAP is the largest single healthcare system heart attack registry, and includes data from hospitalizations with T1 MI in England, Wales, and Northern Ireland. It includes high-resolution data across the patient pathway and is a powerful tool for quality improvement and research.

Feasibility of data linkage in the PARAMEDIC trial: a cluster randomised trial of mechanical chest compression in out-of-hospital cardiac arrest

ObjectivesThere is considerable interest in reducing the cost of clinical trials. Linkage of trial data to administrative datasets and disease-specific registries may improve trial efficiency, but it has not been...

Temporal Trends in Identification, Management, and Clinical Outcomes After Out-of-Hospital Cardiac Arrest: Insights From the Myocardial Ischaemia National Audit Project Database.

There is wide variation in survival rates from out-of-hospital cardiac arrest (OHCA) and overall survival remains poor. There is an expert consensus that early reperfusion therapy in ST-elevation reduces mortality. The management of patients without ST-elevation, however, is controversial. The Myocardial Ischaemia National Audit Project database is a national registry of all hospital admissions in England and Wales treated as an acute coronary syndrome (ACS). We examined temporal trends, over a 5-year period, of OHCAs identified by Myocardial Ischaemia National Audit Project, admitted to hospital and treated as ACS, the interventional management of these patients and clinical outcomes. Four hundred ten thousand four hundred sixty-two patients were admitted to hospital in England and Wales with ACS. Of these, 9421 presented with OHCA (2.30%). There was an increase in OHCA cases as a proportion of ACS between 2009 and 2013 (1.79% in 2009 versus 2.74% in 2013; Ptrend<0.001). The rate of coronary angiography+percutaneous coronary intervention increased in ACS patients presenting with OHCA (54.9% in 2009 [876/1595] versus 66.3% in 2013 [884/1334]; Ptrend<0.001). Cox proportional hazards model with time-varying exposure to coronary angiography demonstrated a significant reduction in mortality in both the ST-elevation (hazard ratio, 0.30; 95% confidence interval, 0.28-0.32; P<0.05) and non-ST-elevation cohort (hazard ratio, 0.44; 95% confidence interval, 0.42-0.46; P<0.001). Predictors of favorable outcome were synonymous with the selection criteria for patients undergoing coronary angiography±percutaneous coronary intervention. This observational study showed that selection for coronary angiography±percutaneous coronary intervention was associated with reduced mortality in OHCA patients diagnosed with ACS. These data support the need for a randomized controlled trial.

Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort.

BackgroundThere is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.Methods and findingsThis national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0–40.0], 38.2 [27.7–26.8], and 26.6 [25.2–26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3–2.5) and 1.5-fold (95% CI 1.4–1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.ConclusionsMultimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.Trial registrationClinicalTrials.gov NCT03037255.

Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study

Background Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA. Objectives To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS. Data source Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015. Participants Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital. Main outcome measures Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality. Methods We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome. Results Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI. Limitations This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias. Conclusions In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital. Future work There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Patient, health service factors and variation in mortality following resuscitated out-of-hospital cardiac arrest in acute coronary syndrome: Analysis of the Myocardial Ischaemia National Audit Project

AimsTo determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS). MethodsIn this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality. ResultsWe included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation.After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients. ConclusionThere was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients.

A user-friendly risk-score for predicting in-hospital cardiac arrest among patients admitted with suspected non ST-elevation acute coronary syndrome – The SAFER-score

AimTo develop a simple risk-score model for predicting in-hospital cardiac arrest (CA) among patients hospitalized with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). MethodsUsing the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified patients (n=242 303) admitted with suspected NSTE-ACS between 2008 and 2014. Logistic regression was used to assess the association between 26 candidate variables and in-hospital CA. A risk-score model was developed and validated using a temporal cohort (n=126 073) comprising patients from SWEDEHEART between 2005 and 2007 and an external cohort (n=276 109) comprising patients from the Myocardial Ischaemia National Audit Project (MINAP) between 2008 and 2013. ResultsThe incidence of in-hospital CA for NSTE-ACS and non-ACS was lower in the SWEDEHEART-derivation cohort than in MINAP (1.3% and 0.5% vs. 2.3% and 2.3%). A seven point, five variable risk score (age ≥60 years (1 point), ST-T abnormalities (2 points), Killip Class >1 (1 point), heart rate <50 or ≥100bpm (1 point), and systolic blood pressure <100mmHg (2 points) was developed. Model discrimination was good in the derivation cohort (c-statistic 0.72) and temporal validation cohort (c-statistic 0.74), and calibration was reasonable with a tendency towards overestimation of risk with a higher sum of score points. External validation showed moderate discrimination (c-statistic 0.65) and calibration showed a general underestimation of predicted risk. ConclusionsA simple points score containing five variables readily available on admission predicts in-hospital CA for patients with suspected NSTE-ACS.

59 Are type 2 myocardial infarctions clouding the minap databases mortality data?

BackgroundThe Myocardial Ischemia National Audit Project (MINAP) is a national clinical registry of the management of Myocardial Infarctions (MIs) and Acute Coronary Syndromes. It was established in 1998 to allow...

71 Up-titration of secondary prevention following acute coronary syndrome (acs)

IntroductionOptimum doses of secondary prevention cardiac medicines need to be achieved post-ACS to derive evidence-based benefits, including reductions in mortality, hospital readmission and improved symptom control. High intensity statin therapy...

β-Blockers and Mortality After Acute Myocardial Infarction in Patients Without Heart Failure or Ventricular Dysfunction

BackgroundFor acute myocardial infarction (AMI) without heart failure (HF), it is unclear if β-blockers are associated with reduced mortality. ObjectivesThe goal of this study was to determine the association between β-blocker use and mortality in patients with AMI without HF or left ventricular systolic dysfunction (LVSD). MethodsThis cohort study used national English and Welsh registry data from the Myocardial Ischaemia National Audit Project. A total of 179,810 survivors of hospitalization with AMI without HF or LVSD, between January 1, 2007, and June 30, 2013 (final follow-up: December 31, 2013), were assessed. Survival-time inverse probability weighting propensity scores and instrumental variable analyses were used to investigate the association between the use of β-blockers and 1-year mortality. ResultsOf 91,895 patients with ST-segment elevation myocardial infarction and 87,915 patients with non–ST-segment elevation myocardial infarction, 88,542 (96.4%) and 81,933 (93.2%) received β-blockers, respectively. For the entire cohort, with >163,772 person-years of observation, there were 9,373 deaths (5.2%). Unadjusted 1-year mortality was lower for patients who received β-blockers compared with those who did not (4.9% vs. 11.2%; p < 0.001). However, after weighting and adjustment, there was no significant difference in mortality between those with and without β-blocker use (average treatment effect [ATE] coefficient: 0.07; 95% confidence interval [CI]: −0.60 to 0.75; p = 0.827). Findings were similar for ST-segment elevation myocardial infarction (ATE coefficient: 0.30; 95% CI: −0.98 to 1.58; p = 0.637) and non–ST-segment elevation myocardial infarction (ATE coefficient: −0.07; 95% CI: −0.68 to 0.54; p = 0.819). ConclusionsAmong survivors of hospitalization with AMI who did not have HF or LVSD as recorded in the hospital, the use of β-blockers was not associated with a lower risk of death at any time point up to 1 year. (β-Blocker Use and Mortality in Hospital Survivors of Acute Myocardial Infarction Without Heart Failure; NCT02786654)

Methods for enhancing the reproducibility of clinical epidemiology research in linked electronic health records: results and lessons learned from the CALIBER platform

ABSTRACTObjectivesElectronic health records (EHR) across primary, secondary, and tertiary care are increasingly being linked for research at a population level. The increasing volume, variety, velocity, and veracity of big biomedical data makes research reproducibility challenging. Research reproducibility and replicability is essential for the external validity and generalizability of scientific findings and the lack of standardized approaches and tools and relative opaqueness of data manipulation methods is detrimental to their integrity. The objective of this study was to explore, evaluate and propose methods, tools and approaches for addressing some of the challenges associated with reproducibility when using linked national electronic health records for research.&#x0D; ApproachWe systematically searched literature and internet resources for well-established and appropriate methods, tools, and approaches used in related scientific disciplines. The identified techniques were systematically evaluated in terms of their capacity to facilitate reproducible research in routinely collected health data across the life course of a research project: from protocol creation and raw data curation to data transformation and statistical analysis though to finding dissemination and impact. Most importantly, the identified techniques were tested and applied in a contemporary database of linked electronic health records. CALIBER is a research data platform of linked national electronic health records from primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics), acute coronary syndrome disease registry (Myocardial Ischaemia National Audit Project) and cause-specific mortality (Office for National Statistics) for roughly 2 million adults.&#x0D; ResultsFirstly, we present the review of methods and approaches which we identified through our search. Secondly, we propose a set of recommendations for applying them within the context of research projects making use of linked routinely collected health data. Focal interests included: a) documentation of data (attributes, relationships, and interpretation), b) data processing (source code, instructions, and parameters), c) results (visualizations, figures), and any supplementary material. Thirdly, we present approaches around a) raw data curation using international metadata standards, b) study protocol encoding, c) provenance and sharing of data transformation and statistical analysis operations, d) public and private data retention, and e) computable EHR-driven phenotypes.&#x0D; ConclusionThe complexity and size of routinely collected health data is increasing through linkages across distributed data sources. The scientific community benefits from findings which can be replicated. This study presents a number of methods, tools and approaches across the project life course for ensuring that their research studies are reproducible and replicable from the wider scientific community.

Presentation, management and mortality after a first MI in people with and without asthma: A study using UK MINAP data.

Asthma has been associated with a higher incidence of myocardial infarction (MI), higher prevalence of MI risk factors and higher burden of cardiovascular diseases. However, detailed associations between the presentation and initial management at the time of MI and post-MI outcomes in people with asthma compared to the general population have not been studied. A total of 300,161 people were identified with a first MI over the period 2003–2013 in the Myocardial Ischaemia National Audit Project database, of whom 8922 (3%) had asthma. Logistic regression was used to compare presentation, in-hospital care, in-hospital and 180-day post-discharge all-cause mortality in people with and without asthma adjusting for demographics and comorbidities, diagnosis on arrival and secondary prevention. People with asthma were more likely to have a delay in their MI diagnosis following an STEMI (ST-elevation myocardial infarction; odds ratio (OR) 1.38, confidence interval CI 1.06–1.79) but not an nSTEMI (non-ST-elevation myocardial infarction; OR 1.04, CI 0.92–1.17) compared to people without asthma and a delay in reperfusion (OR 1.19, CI 1.09–1.30) following an STEMI. They were much less likely to be discharged on a beta blocker following an STEMI or nSTEMI (OR 0.24, CI 0.21–0.28 and OR 0.27, CI 0.24–0.30, respectively). There was no difference in in-hospital or 180-day mortality (OR 0.98, CI 0.59–1.62 and OR 0.99, CI 0.72–1.36) following an STEMI or nSTEMI (OR 0.89, CI 0.47–1.68 and OR 1.05, CI 0.85–1.28). Although people with asthma were more likely to have a delay in diagnosis following an STEMI but not an nSTEMI compared to the general population, were more likely to have a delay in reperfusion therapy and were much less likely to receive beta blockers following an STEMI or nSTEMI, there was no difference in the prescriptions of other secondary prevention medications. None of the differences in presentation or management were associated with an increase in all-cause in-hospital or 180-day mortality in people with asthma compared to the general population.

Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register.

AimsTo investigate the application of the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QI) for acute myocardial infarction for the study of hospital performance and 30-day mortality.Methods and resultsNational cohort study (n = 118,075 patients, n = 211 hospitals, MINAP registry), 2012-13. Overall, 16 of the 20 QIs could be calculated. Eleven QIs had a significant inverse association with GRACE risk adjusted 30-day mortality (all P < 0.005). The association with the greatest magnitude was high attainment of the composite opportunity-based QI (80-100%) vs. zero attainment (odds ratio 0.04, 95% confidence interval 0.04-0.05, P < 0.001), increasing attainment from low (0.42, 0.37- 0.49, P < 0.001) to intermediate (0.15, 0.13-0.16, P < 0.001) was significantly associated with a reduced risk of 30-day mortality. A 1% increase in attainment of this QI was associated with a 3% reduction in 30-day mortality (0.97, 0.97-0.97, P < 0.001). The QI with the widest hospital variation was ′fondaparinux received among NSTEMI′ (interquartile range 84.7%) and least variation ′centre organisation′ (0.0%), with seven QIs depicting minimal variation (<11%). GRACE risk score adjusted 30-day mortality varied by hospital (median 6.7%, interquartile range 5.4-7.9%).ConclusionsEleven QIs were significantly inversely associated with 30-day mortality. Increasing patient attainment of the composite quality indicator was the most powerful predictor; a 1% increase in attainment represented a 3% decrease in 30-day standardised mortality. The ESC QIs for acute myocardial infarction are applicable in a large health system and have the potential to improve care and reduce unwarranted variation in death from acute myocardial infarction.

Relationship between exposure to tumour necrosis factor inhibitor therapy and incidence and severity of myocardial infarction in patients with rheumatoid arthritis

ObjectivesPatients with rheumatoid arthritis (RA) are at increased risk of myocardial infarction (MI) compared with subjects without RA, with the increased risk driven potentially by inflammation. Tumour necrosis factor inhibitors...

Relationship Between Anemia and Mortality Outcomes in a National Acute Coronary Syndrome Cohort: Insights From the UK Myocardial Ischemia National Audit Project Registry.

BackgroundWe aim to determine the prevalence of anemia in acute coronary syndrome (ACS) patients and compare their clinical characteristics, management, and clinical outcomes to those without anemia in an unselected national ACS cohort.Methods and ResultsThe Myocardial Ischemia National Audit Project (MINAP) registry collects data on all adults admitted to hospital trusts in England and Wales with diagnosis of an ACS. We conducted a retrospective cohort study by analyzing patients in this registry between January 2006 and December 2010 and followed them up until August 2011. Multiple logistic regressions were used to determine factors associated with anemia and the adjusted odds of 30‐day mortality with 1 g/dL incremental hemoglobin increase and the 30‐day and 1‐year mortality for anemic compared to nonanemic groups. Analyses were adjusted for covariates. Our analysis of 422 855 patients with ACS showed that 27.7% of patients presenting with ACS are anemic and that these patients are older, have a greater prevalence of renal disease, peripheral vascular disease, diabetes mellitus, and previous acute myocardial infarction, and are less likely to receive evidence‐based therapies shown to improve clinical outcomes. Finally, our analysis suggests that anemia is independently associated with 30‐day (OR 1.28, 95% CI 1.22‐1.35) and 1‐year mortality (OR 1.31, 95% CI 1.27‐1.35), and we observed a reverse J‐shaped relationship between hemoglobin levels and mortality outcomes.ConclusionsThe prevalence of anemia in a contemporary national ACS cohort is clinically significant. Patients with anemia are older and multimorbid and less likely to receive evidence‐based therapies shown to improve clinical outcomes, with the presence of anemia independently associated with mortality outcomes.

Effect of age on the prognostic value of left ventricular function in patients with acute coronary syndrome: A prospective registry study

This study aims to study the prognostic impact of left ventricular function on mortality and examine the effect of age on the prognostic value of left ventricular function. We examined the myocardial ischaemia national audit project registry (2006-2010) data with a mean follow-up of 2.1 years. Left ventricular function was categorised into good (ejection fraction ⩾50%), moderate (ejection fraction 30-49%) and poor (ejection fraction <30%) categories. Cox proportional hazards models were constructed to examine the prognostic significance of left ventricular function in different age groups (<65, 65-74, 75-84 and ⩾85 years) on all-cause mortality adjusting for baseline variables. Out of 424,848 patients, left ventricular function data were available for 123,609. Multiple imputations were used to impute missing values of left ventricular function and the final sample for analyses was drawn from 414,305. After controlling for confounders, 339,887 participants were included in the regression models. For any age group, mortality was higher with a worsening degree of left ventricular impairment. Increased age reduced the adverse prognosis associated with reduced left ventricular function (hazard ratios of death comparing poor left ventricular function to good left ventricular function were 2.11, 95% confidence interval 1.88-2.37 for age <65 years and 1.28, 95% confidence interval 1.20-1.36 for age ⩾85 years). Older patients had a high mortality risk even in those with good left ventricular function. Hazard ratios of mortality for ⩾85 compared to <65 years (hazard ratio = 1.00) within good, moderate and poor ejection fraction groups were 5.89, 4.86 and 3.43, respectively. In patients with acute coronary syndrome, clinicians should interpret the prognostic value of left ventricular function taking into account the patient's age.