Acute MI Mortality Has Dropped to Very Low Levels in France

BARCELONA, Spain—A series of French surveys shows that 6-month mortality declined markedly for patients with STEMI or NSTEMI between 1995 and 2015, coinciding with a substantial increase in use of invasive procedures.

Mortality dropped steadily through the end of the study period for the STEMI group, but there appeared to be a leveling off after 2010 in the NSTEMI group, Nicolas Danchin, MD, PhD (Hôpital Européen Georges-Pompidou, Paris, France), reported last week at the European Society of Cardiology Congress 2017.

When asked after his presentation whether outcomes can continue to improve, Danchin said, “I think it will be difficult.” Referring to patients with NSTEMI specifically, he added that “it’s quite possible that we indeed have reached the nadir of the mortality in these patients, who are often rather elderly.”

The findings were published simultaneously online in Circulation.

Patient Management Changes and Outcomes Improve

Prior research has shown a dramatic reduction in early mortality after acute MI in the past 2 decades, but few studies have compared trends for STEMI and NSTEMI individually, Danchin said.

In the current study, he and his colleagues examined results from five nationwide surveys conducted in France every 5 years from 1995 to 2015 as part of the French acute MI registry program—USIK in 1995, USIC in 2000, and FAST-MI in 2005, 2010, and 2015. The investigators included patients with STEMI or NSTEMI who presented within 48 hours of symptom onset and were admitted alive to an intensive coronary care unit. The number of centers participating in each survey progressively declined due to a deliberate policy of shuttering smaller institutions, Danchin noted.

Over time, there was a notable decline in average age from 66.2 to 63.5 in the STEMI population, with increases in the percentage of patients 60 or younger for both men and women. Consequently, fewer patients had a history of MI, heart failure, or PAD at presentation.

Of note, the average time from STEMI symptom onset to the first call for help decreased between 2000 and 2010 (from 120 to 74 minutes), but then bumped back up to 90 minutes in 2015.

“I think there is reason to be concerned,” Danchin said, adding that one likely explanation is that many of the French media campaigns focused on the issue stopped after 2010.

Turning to patient management, there was an expected increase in the use of primary PCI from 12% in 1995 to 76% in 2015, which was accompanied by a decline in use of fibrinolytic therapy from 38% to 6%. In the NSTEMI group, early PCI (within 72 hours) was used in only 9% of patients in 1995, increasing to 60% in 2015.

From 1995 to 2010, there were steady rises in the proportions of patients with STEMI and NSTEMI who received beta-blockers, statins, and ACE inhibitors/angiotensin receptor blockers, although usage dropped off by 2015. The rate of antiplatelet therapy use increased progressively over time, with expected shifts in the types of agents used after prasugrel (Effient; Eli Lilly) and ticagrelor (Brilinta; AstraZeneca) were introduced.

From 1995 to 2015, there were substantial drops in 6-month mortality after both STEMI (from 17.2% to 5.3%) and NSTEMI (from 17.2% to 6.3%). There was little change between 2010 and 2015 for patients with NSTEMI, however.

In the STEMI group, mortality declined both in patients who did not receive reperfusion therapy (from 23.4% to 7.4%) and in those who underwent reperfusion (from 10.8% to 4.8%). Similarly, in the NSTEMI group, 6-month mortality fell regardless of whether patients received early PCI.

“Of course, prolonged follow-up will be needed to determine whether improvement will persist or materialize in both types of patients,” Danchin said.