Trends in evidence-based treatment and mortality for ST elevation myocardial infarction in Malaysia from 2006 to 2013: time for real change

Abstract

BACKGROUNDThe administration of evidence-based pharmacotherapy and timely primary percutaneous coronary intervention have been shown to improve outcome in ST elevation myocardial infarction (STEMI). However, implementation remains a challenge due to the limitations in facilities, expertise and funding.OBJECTIVESTo investigate adherence to guideline-based management and mortality of STEMI patients in Malaysia.DESIGNRetrospective analysis.SETTINGSSTEMI patients from 18 participating hospital across Malaysia included in the National Cardiovascular Database-Acute coronary syndrome (NCVD-ACS) registry year 2006 to 2013.PATIENTS AND METHODSPatients were categorized into four subgroups based on the year of admission (2006 to 2007, 2008 to 2009, 2010 to 2011 and 2012 to 2013). Baseline characteristics and clinical presentation, in-hospital pharmacotherapy, invasive revascularization and in-hospital/30-day mortality were analysed and compared between the subgroups.MAIN OUTCOME MEASURE(S)Rate of in-hospital catheterization/percutaneous coronary intervention.RESULTSThe registry contained data on 19 483 patients. Intravenous thrombolysis was the main reperfusion therapy. Although the overall rate of in-hospital catheterisation/PCI more than doubled over the study period, while the use of primary PCI only slowly increased from 7.6% in 2006/2007 to 13.6% in 2012/2013. The use of evidence-based oral therapies increased steadily over the years except for ACE-inhibitors and angiotensin-receptor blockers. The adjusted risk ratios (RR) for in-hospital mortality for the four sub-groups have not shown any significant improvement. The 30-day adjusted risk ratios however showed a significant albeit gradual risk reduction (RR 0.773 95% CI 0.679–0.881, P<.001).CONCLUSIONAdherence to evidence-based treatment in STEMI in Malaysia is still poor especially in terms of the rate of primary PCI. Although there is a general trend toward reduced 30-day mortality, the reduction was only slight over the study period. Drastic effort is needed to improve adherence and clinical outcomes.LIMITATIONRetrospective registry data with inter-hospital variation.

Trends and variations in the prescribing of secondary preventative cardiovascular therapies for non-ST elevation myocardial infarction (NSTEMI) in Malaysia

“…Improvement in prescribing rate is similarly observed in other countries [ 7 , 25 , 26 ] and is believed to contribute to improvement in NSTEMI outcomes [ 27 , 28 ]. Similar trend has been described for STEMI patients [ 18 ]. This may be due to increased adherence to clinical guidelines especially in hospitals who participated in NCVD registry.…”

“…Similar trend has been described for STEMI patients [18]. This may be due to increased adherence to clinical guidelines especially in hospitals who participated in NCVD registry.…”

“…However, little information is available on the prevalence of STEMI and NSTEMI [ 17 ]. An increase in the prescribing of evidence-based pharmacotherapies has been described for STEMI [ 18 ] while less is known on NSTEMI. In acute interventions of AMI, women [ 19 ] and elderly patients [ 20 ] were less likely to receive optimal management compared to men and younger patients while no significant variations across ethnicities were observed [ 21 ].…”

Gender differences in mortality among ST elevation myocardial infarction patients in Malaysia from 2006 to 2013

“…11 That the percentage of females affected with STEMI was much lower than males is supported by other studies where STEMI is more prevalent among males as compared to females. 9,12,13 However, females had a significantly higher mortality rate as compared to male patients in our study, which is compatible with other findings indicating that females have had higher mortality rates than males annually since 1984 with the cause of death mostly from myocardial infarction and sudden death. 14,15 Females are more resilient to developing CAD, but once they have CAD, they are more likely to experience the worse consequences.…”

“…This network plays an important role in referring acute STEMI patients between government hospitals, teaching university hospitals and the National Heart Institute right to PCI capable centres. 13 In conclusion, gender differences existed in the baseline characteristics, associated risk factors, clinical presentation and outcomes among STEMI patients. Female patients were older and more likely to have hypertension and diabetes mellitus, yet less likely to smoke than male patients.…”