Study of STEMI Care in China Exposes Crucial Treatment Gaps

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Over the past decade, the quality of care for patients with ST-segment elevation myocardial infarction (STEMI) living in China has increased, but lingering issues including underuse of beta-blockers and angiotensin-converting-enzyme (ACE) inhibitors and low rates of reperfusion in suitable candidates has precluded a significant decline in mortality, according to a study published online June 24, 2014, ahead of print in the Lancet.

Methods
For the China PEACE-Retrospective Acute Myocardial Infarction Study, Lixin Jiang, MD, PhD, of the National Center for Cardiovascular Diseases (Beijing, China), and colleagues used a random sampling strategy to identify 13,815 patients admitted for STEMI at 162 hospitals from varied economic and geographic regions of China in 2001, 2006, and 2011. In a retrospective analysis, they examined hospitalization rates, treatments, procedures, tests, and use of magnesium sulfate and traditional Chinese medicine.

 

Between 2001 and 2011, the age and sex of STEMI patients did not change nor did the median time between symptom onset and hospital admission or mini-GRACE scores. In contrast, the prevalence of risk factors for cardiovascular disease including smoking, hypertension, diabetes, and dyslipidemia increased. In 2011, patients were less likely than in 2001 to present with hypotension, tachycardia, ejection fraction ≤ 40%, or low estimated glomerular filtration rate. However, they were slightly more likely to present with cardiac arrest and cardiogenic shock.
Hospital admission for STEMI increased from 3.7 per 100,000 people in 2001 to 15.8 in 2011 (P < .0001 for trend). The percentage of patients classified as ideal candidates for reperfusion did not change over time, with just over half of qualified patients receiving the therapy in both 2001 (55.2%) and 2011 (55%). The rate of primary PCI increased from 10.2% in 2001 to 27.6% in 2011 (P < .0001 for trend). This was accompanied by a decrease in use of fibrinolysis (from 45.0% to 27.4%; P < .0001 for trend) over the same period.

Improvements, but Not in Mortality

Importantly, while the use of beta-blockers and ACE inhibitors or angiotensin receptor blockers (ARBs) did not change during the study period, an increase was seen in use of aspirin and clopidogrel within 24 hours. Additionally, use of magnesium sulfate, which has been shown to be ineffective as far back as 1995, decreased, but traditional Chinese medicine—broken down into 7 main categories—increased (table 1).

Table 1. Changes in Medication Usage: 2001-2011

 

 2001

 2011

P Value for Trend

Beta-Blockers

52.3%

57.7%

.74

ACE Inhibitors/ARBs

61.8%

66.2%

.45

Magnesium Sulfate

32.3%

16.4%

< .0001

Chinese Medicine

57.4%

69.2%

< .0001

Aspirin

79.3%

91.2%

< .0001

Clopidogrel

1.5%

80.7%

< .0001


The median hospital length of stay was 13 days in 2001 and remained relatively high at 11 days in 2011 (P < .0001 for trend). On multivariate analysis, the risk of in-hospital mortality did not decrease over the study period (OR 0.84; 95% CI 0.62-1.12; P = .06 for trend).

Care Gaps Persist

In an editorial accompanying the study, Ajay J. Kirtane, MD, SM, and Gregg W. Stone, MD, both of Columbia University Medical Center (New York, NY), say the study provides “remarkable insight” into STEMI care in China.

“Publication of these data is an important step towards improving health care in China, and should be cherished as an opportunity that could translate into saving hundreds of thousands of lives,” they write. “Addressing the identified gaps in widespread access to timely reperfusion and administration of adjunctive medical therapies alone is a proven paradigm with the greatest potential to improve cardiovascular survival, especially in rural areas that have a very low density of hospitals.”

Drs. Kirtane and Stone add that improvement in STEMI care in China will require expansion of acute cardiac care resources, in particular as average life expectancy increases. “Major emphasis must be placed on early patient presentation (requiring public education of acute myocardial infarction symptoms and prompt response), followed by rapid diagnosis and reperfusion therapy in all appropriate patients (ultimately with primary [PCI] or a pharmacoinvasive strategy). Equally important is establishment of high-quality continuity of care and efforts at secondary prevention after hospital discharge,” they write.

‘Throwback in Time’

In a telephone interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said the China PEACE study harkens back 20 years to the publication of the Cooperative Cardiovascular Project in the United States, which resulted in substantial investment in efforts to improve cardiovascular disease care and outcomes.
The picture is “comparable to what we had here many years ago, so in some sense it’s a throwback in time,” he explained. “But the jumps that can happen when you undertake improvements can happen very fast, so that doesn’t mean it will take China another 20 years to catch up.”

Dr. Brener said that while the data are of interest, he questioned the unusually high rate of DES use in the study, which topped out at 98.6% in 2011, much higher than in the United States or Europe.

In an email with TCTMD, Dr. Kirtane said that the prevalence of DES “has been something we've recognized for some time through academic collaborations [and] is another example of differences in practice. It also may reflect some element of differences in patient selection for reperfusion therapies.”

Dr. Brener added that the data from China PEACE will be useful when designing future global trials because “when we include China in these trials, we now have this information and know what to expect or not expect.”

Note: Drs. Kirtane and Stone are faculty members of the Cardiovascular Research Foundation, which owns and operates TCTMD.



Sources:
1. Li J, Li X, Wang Q, et al. ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data. Lancet. 2014;Epub ahead of print.

2. Kirtane AJ, Stone GW. STEMI care in China: a world opportunity. Lancet. 2014;Epub ahead of print.


Disclosures:

  • The study was funded by the National Health and Family Planning Commission of China.
  • Drs. Jiang and Brener report no relevant conflicts of interest.
  • Dr. Kirtane reports institutional research grants from Abbott Vascular, Abiomed, Boston Scientific, Eli Lilly, Medtronic, St. Jude Medical, and Vascular Dynamics.
  • Dr. Stone reports serving as a consultant for Abbott Vascular, Boston Scientific, and Medtronic.

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