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

Li J, Xi Li X, Wang Q, et al., for the China PEACE Collaborative Group
The Lancet, Early Online Publication, 24 June 2014

Background

Along with economic growth, China has faced a more than doubling of mortality due to ischaemic heart disease over the past two decades, to over 1 million deaths per year [1,2]. The World Bank estimates this trend to accelerate [3].
The Chinese medical care system has developed rapidly, by improving access through reducing financial barriers and increasing numbers of hospitals and physicians [4,5].
No nationally representative studies have characterised the clinical profiles, management and outcomes of patients with acute myocardial infarction (MI), especially ST-segment elevation MI that accounts for over 80% of MIs, in China, despite its high incidence. This lack of data on contemporary burden of disease, quality of care and treatment outcomes form barriers to implementation of interventions to improve care and outcomes.
The China Patient-centered Evaluative Assessment of Cardiac Events Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study) aimed to assess trends in STEMI management and outcomes in China over the past decade in a retrospective analysis of hospital records. Data were obtained from a sample of 162 hospitals in both rural and urban regions, yielding 31601 hospital admissions for acute MI. The study sample finally consisted of 13815 patients admitted to hospital for STEMI.

Main results

• Hospital admissions for STEMI per 100.000 people increased during the study period from 3.7 in 2001 to 8.1 in 2006, to 15.8 in 2011 (P(trend)<0.0001).
• Median time between symptom onset and hospital admission did not change between 2001 and 2011. As compared to 2001, in 2011 patients were less likely to present with hypotension, tachycardia, ejection fraction of 0.40 or low estimated glomerular filtration rate.
• Among patients classified as ideal candidates for reperfusion therapy, the weighted rate of primary percutaneous coronary intervention (PCI) increased over the study period from 10.2% to 27.6% (P(trend)<0.0001).
  Use of fibrinolytic therapy decreased over this period (45.0% to 27.4% , P(trend)<0.0001).
  The overall use of reperfusion therapy, betablockers, ACE inhibitors, or ARBs did not change during the study period. All other recommended therapies were increasingly used in ideal patients over the course of the study period. Use of traditional Chinese medicine also increased.
• More patients underwent cardiac catheterisation, non-primary PCI or received drug-eluting stents. The use of diagnostic tests, such as troponin measurement and echocardiography increased.
• Median hospital length of stay was 13 days (IQR: 7-18) in 2001, 11 days (IQR: 6-16) in 2006 and 11 days (IQR: 7-14) in 2011 (P(trend)<0.0001).
• In a multilevel logistical regression, risk of in-hospital mortality adjusted  for patient demographics and clinical characteristics, did not significantly decrease over time. Risk of in-hospital death, adjusted by mini-GRACE risk score, was 1.06 (95%CI: 0.80-1.40) in 2006 and 0.76 (0.56-1.01) in 2011. Major bleeding was seen in 6 out of 1933 patients in 2001 (weighted rate: 0.3%, 95%CI: 0.1-0.6), 34 out of 3581 patients in 2006 (1.1%, 95%CI: 0.8-1.4) and 62 of 6472 patients in 2011 (0.9%, 95%CI: 0.7-1.1)(P(trend)=0.16).

Conclusion

The China PEACE Retrospective AMI Study shows that between 2001 and 2011 hospital admissions for STEMI have become increasingly common, that patients are more likely to have comorbidities. Over the same period, the intensity of testing and treatment has increased. Quality of care has improved for certain treatments, but gaps between recommended care and practice persist. In-hospital mortality has not significantly improved over the study period. These findings should inform policy makers and health professionals to develop strategies for medical resource allocation, system improvement and disease management.

Find this article online

References

1 Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990–2010: fi ndings from the Global Burden of Disease Study 2010. Lancet 2013; 381: 1987–2015.
2 Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Q Dec 1971; 49: 509–38.
3 The World Bank. Toward a healthy and harmonious life in China: stemming the rising tide of non-communicable diseases. http://www.worldbank.org/content/dam/Worldbank/document/NCD_
report_en.pdf (accessed Nov 27, 2013).
4 Chen Z. Launch of the health-care reform plan in China. Lancet 2009; 373: 1322–24.
5 Ministry of Health of People’s Republic of China. China public health statistical yearbook 2012. Beijing: Peking Union Medical College Publishing House, 2012.