Managed Care after Acute Myocardial Infarction (MC-AMI) – a Poland’s nationwide program of comprehensive post-MI care - improves prognosis in 12-month follow-up. Preliminary experience from a single high-volume center☆
Introduction
Cardiovascular diseases (CVD) are a leading cause of mortality in Western societies. Despite advances in the medical and interventional treatment of the acute phase of myocardial infarction (MI), the post-MI complications, including heart failure and sudden cardiac death remain a challenge and the major concerns of clinical cardiology.
In Poland, the network of approximately 160 interventional cardiology centers provides primary percutaneous coronary intervention (pPCI) service on the 24/7 basis with 735 pPCI/million inhabitants, thus providing low in-hospital mortality in the acute phase of MI. The post-discharge mortality in AMI patients is, however, still high - 10% after 1 year and almost 20% after 3 years [1]. European Society of Cardiology (ESC) registries show that 1-year mortality rate reached 4–12% and is highly variable across Europe. This is similar to data reported from the USA, and European countries [[2], [3], [4]]. The studies suggest that efforts should focus on a post-MI care and the secondary prevention of CVD [5,6].
The analysis of the post-discharge period shows a particularly high risk of complications and death within the first several months after MI. The causes comprise the lack of adequate lifestyle intervention, poor adherence to medical treatment, insufficient control of risk factors and the lack of balanced physical activity, which derives mostly from low access to cardiac rehabilitation (CR) programs, as well as poor and imbalanced access to outpatient cardiology care [7,8]. Other factors include comorbidities, incomplete coronary revascularization and underutilization of implantable cardioverters-defibrillators (ICDs) in eligible post-MI patients for primary prevention of sudden cardiac death (SCD) [[9], [10], [11]]. Despite clear ESC recommendations for secondary CVD prevention, the real-world data show that there is still much to do with regard to post-MI care and the coordination of all the key parts of it [12,13].
Considering the complexity of determinants of high post-MI mortality rate, Polish Cardiac Society, National Health Fund and Ministry of Health of Poland have introduced the program of coordinated care for patients with MI [14]. The Managed post-AMI Care Program (MC-AMI; in Polish KOS-zawal) includes diagnostic procedures and interventional therapy in acute phase of MI, immediate or staged complete revascularization, cardiac rehabilitation, primary prevention of SCD with implantation of ICD or cardiac resynchronization therapy (CRT) in eligible subjects and, 12-month scheduled outpatient cardiology care follow-up [15]. Although these are all the parts of the regular state-of-the-art care for MI survivors, we hypothesize that strict follow-up and coordination of all crucial parts of post-MI care may significantly improve the prognosis without any additional intervention.
Section snippets
Objectives/aims
The primary aim of the analysis was to assess the relation between participation in MC-AMI and the incidence of major cardiovascular and cerebrovascular events (MACCE), defined as a composite of death, recurrent myocardial infarction, ischemic stroke, and hospitalization for heart failure (HF) in one-year follow-up.
The secondary aim was to compare the utilization of crucial post MI care components: revascularization, cardiac rehabilitation, outpatient care and the prevention of SCD in MC-AMI
Patients and methods
We present a retrospective analysis from a single high-volume tertiary cardiology care center, where MC-AMI – a program of coordinated, supervised post MI care - was introduced. A study group consisted of all consecutive subjects diagnosed with AMI from November 1, 2017 to August 31, 2018 who consented to participate in MC-AMI. All patients with AMI, aged ≫18 years old who gave the informed consent for participation in MC-AMI, were included in the unmatched study group. Patients were followed
Results
We primarily analyzed 1782 patients with AMI: 719 in MC-AMI group and 1063 in the control group (Table 1). After 1:1 propensity score matching, we selected a group of 1058 well-balanced pairs (529 in MC-AMI group and 529 in control) (baseline characteristics after PSM shown in Table 3, supplementary data).
Relation between MC-AMI participation and primary endpoint (MACCE)
MC-AMI was related with MACCE reduction by 40% in a 12-month observation. Number needed to treat to avoid one MACCE was 14.7 patients.
In 12-month follow-up the incidence of MACCE was significantly lower in MC-AMI group than in the control group (16.82% vs 10.00% p ≪ 0.001). Differences in the incidence of MI, hospitalization for HF and all-cause mortality showed only a trend in favor of MC-AMI group (Table 2, Fig. 1). The incidence of stroke was significantly lower in study vs. control group
Discussion
Over past few years a number or articles assessed the effect of cardiac rehabilitation, complete revascularization or scheduled outpatient care as separate interventions on clinical endpoints [16,17]. There are, however, no studies assessing the effect of multi-module programs consisting of all crucial aspects of post MI care on hard clinical endpoints. This retrospective study performed in a population of MI patients in one high volume center was designed to assess the effect of MC-AMI on
Limitations
The observation is a retrospective cohort study performed in tertiary and high-volume, but still one single center. Moreover, as a retrospective analysis, it provides statistical association rather than causal relationships between intervention and the clinical effect. Finally, despite very encouraging results of 12-month observation (with a median follow-up time 8 months), a longer follow-up will be necessary to prove a long-term benefit of the program.
Conclusions
Participation in MC-AMI improves prognosis by increasing the rate of patients undergoing cardiac rehabilitation, complete revascularization, and ICD implantation. The strategy reduces major cardiovascular and cerebrovascular events by 40% in 12-month follow-up. Moreover, participation in MC-AMI is inversely related to mortality rate, recurrent MI and hospitalization for heart failure during 12 months.
Declaration of Competing Interest
None.
References (30)
Improving quality of care of acute myocardial infarction: more focus needed on long-term optimal medical treatment and secondary prevention
Rev. Esp. Cardiol. (Engl Ed).
(2012)- et al.
Predicting in-hospital mortality in patients with acute myocardial infarction
J. Am. Coll. Cardiol.
(2016) - et al.
Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective
J. Am. Coll. Cardiol.
(2001) - et al.
Complete or culprit-only revascularization for patients with multivessel coronary artery disease undergoing percutaneous coronary intervention: a pairwise and network meta-analysis of randomized trials
J. Am. Coll. Cardiol. Intv.
(2017) - et al.
Incidence, treatment, in-hospital mortality and one-year outcomes of acute myocardial infarction in Poland in 2009–2012-nationwide AMI-PL database
Kardiol. Pol.
(2015) - et al.
25 years trends in first hospitalization for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study
BMJ
(2012) - et al.
Long-term survival and recurrence after acute myocardial infarction in England, 2004 to 2010
Circ. Cardiovasc. Qual. Outcomes
(2012) - et al.
German nationwide data on current trends and management of acute myocardial infarction: discrepancies between trials and real-life
Eur. Heart J.
(2014) - et al.
Cardiovascular disease in Europe: epidemiological update 2016
Eur. Heart J.
(2016) - et al.
Trends in hospital treatments, including revascularisation, following acute myocardial infarction, 2003–2010: a multilevel and relative survival analysis for the National Institute for Cardiovascular Outcomes Research (NICOR)
Heart
(2014)
EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries
Eur. J. Prev. Cardiol.
2016 European guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation
Eur. Heart J.
Reasonable incomplete revascularisation after percutaneous coronary intervention: the SYNTAX Revascularisation Index
EuroIntervention
Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes: the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial
Circulation
Implantable cardioverter-defibrillator use among Medicare patients with low ejection fraction after acute myocardial infarction
JAMA
Cited by (0)
- ☆
All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.