improving survivorship following acute myocardial

Improving survivorship following acute myocardial infarction:

High resolution insights from national health records data

Chris P Gale

Professor of Cardiovascular Medicine,

Honorary Consultant Cardiologist,

Head of Clinical and Population Sciences,

University of Leeds, UK

c.p.gale@leeds.ac.uk @cpgale3

Increasing incidence of CVD

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High Income Middle Income Total

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1000000

2000000

3000000

4000000

5000000

6000000

1990 1995 2000 2005 2010 2015

Nn

um

ber

of

new

cas

es

High Income Middle Income Total

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

1990 1995 2000 2005 2010 2015

Nn

um

ber

of

new

cas

es

High Income Middle Income Total

Men, CVD incidence

Women, CVD incidence

Diabetes, prevalence

Atlas Writing Group. Eur Heart J. 2018;39(7):508-579

Increasing incidence of NSTEMI

Yeh RW. N Engl J Med 2010;362:2155-2165

Decline in mortality following AMI

Gale CP. Eur Heart J. 2012;33:630–639

MINAP data sites, 2003 – 2013

Fundamental questions

• What is associated with the decline in early deaths from AMI?

• What are the opportunities to improve AMI survivorship?

• What does the future hold for improving AMI survivorship?

STEMI

National diffusion of PPCI service for STEMI

Hall M, Heart 2016, Jan 5 pii: heartjnl-2015-308616

NSTEMI

Temporal improvements in NSTEMI care

Hall M. JAMA. 2016 Sep 13;316(10):1073-82

Invasive coronary strategy explains NSTEMI temporal survival improvements

Hall M. JAMA. 2016 Sep 13;316(10):1073-82

Improved survival following AMI in Sweden compared with the UK

Chung SC. Lancet. 2014 Apr 12;383(9925):1305-12

Hospital variation in 30-day mortality in Sweden and the UK

Chung SC. BMJ 2015;351:bmj.h3913

Regional inequalities in 30-day mortality

Gale CP. Heart. 2011 Dec;97(23):1926-31

Gap between evidence and practice

Dondo T. BMJ Open 2016;6(7):e011600

Reduced survival among NSTEMI who do not receive eligible care

TR 0.44, 95% CI 0.41–0.45

Dondo T, EHJ Acute Cardiovasc Care, 2017 Aug;6(5):412-420

#measure2improve because #datasaveslives

Bebb O. EHJ 2017;38(13):974-982 Schiele F. Circ CVQO 2017;10(6)

Test and implement

Chew D. AHJ 201;170(5):995-104 e1

@UKGRIS

Multimorbidity and survival

Diabetes

Stroke

COPD or asthma

Heart failure

Renal failure

PVD

No long-term

condition

Hall M. Plos Medicine. 2018 Mar 6;15(3):e1002501

Creating ‘room’ to improve AMI survivorship

Dondo TB. JACC. 2017 Jun 6;69(22):2710-2720 Neal B. N Engl J Med 2017; 377:644-657

Fundamental answers

• What is associated with the decline in early deaths from AMI?• STEMI – National PPCI service• NSTEMI – The use of an invasive coronary strategy

• What are the opportunities to improve AMI survivorship?• Preventing missed opportunities for guideline-indicated care

• What does the future hold for improving AMI survivorship?• Improving guideline adherence, UKGRIS• Testing generic therapies to remove the redundant, REDUCE

trials• Repurposing therapies to new populations, SGLT2i

@cpgale3 c.p.gale@leeds.ac.uk