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

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Highlights

  • MC-AMI is a care model including revascularization, rehabilitation and prevention of SCD after MI.

  • Managed Care in Acute Myocardial Infarction reduces MACCE by 40% in 12-month follow-up.

  • Strict and complex approach after MI warrants better results within the same healthcare resources.

Abstract

Background

Despite progress in the treatment of acute myocardial infarction (AMI), long-term prognosis in MI survivors remains a challenge. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is the first program of a comprehensive, supervised care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD. Our aim was to assess the relation between participation in MC-AMI and major adverse cardiovascular and cerebrovascular events (MACCE) in 12-month follow-up.

Methods and results

In this single-center, retrospective analysis we compared 719 patients participating in MC-AMI and compared them to 1130 subjects in the control group. After propensity score matching, two groups of 529 subjects each were compared.

MC-AMI was related with MACCE reduction by 40% in a 12-month observation. Participants of MC-AMI had a higher adherence to cardiac rehabilitation (98 vs. 14%), higher rate of scheduled revascularisation (coronary artery bypass grafting: 9.8% vs. 4.9%, p ≪ 0.001; elective percutaneous coronary intervention: 3.0% vs 2.1%, p ≪ 0.05) and ICD implantation (2.8% vs. 0.6%, p ≪ 0.05) compared to control.

Multivariable Cox regression analysis revealed MC-AMI to be inversely associated with the occurrence of MACCE (HR = 0.500, 95% Cl 0.349–0.718, p ≪ 0.001). Besides, older age, diabetes mellitus, hyperlipidemia, prior PAD, previous UA, and lower LVEF were significantly associated with the primary endpoint.

Conclusions

MC-AMI is the first program of comprehensive care for AMI patients. MC-AMI improves prognosis by increasing the rate of patients undergoing CR, complete revascularization and ICD implantation, thus reducing MACCE.

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.

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    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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