Poor long-term prognosis in patients admitted with strong suspicion of acute myocardial infarction but discharged with another diagnosis

B Lindahl, L Ljung, J Herlitz, J Alfredsson, D Erlinge, T Kellerth, E Omerovic, A Ravn-Fischer, D Sparv, T Yndigegn, P Svensson, O Östlund, T Jernberg, S K James, R Hofmann, DETO2X-SWEDEHEART Investigators, B Lindahl, L Ljung, J Herlitz, J Alfredsson, D Erlinge, T Kellerth, E Omerovic, A Ravn-Fischer, D Sparv, T Yndigegn, P Svensson, O Östlund, T Jernberg, S K James, R Hofmann, DETO2X-SWEDEHEART Investigators

Abstract

Background: Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well-described.

Objectives: To compare background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis.

Methods: The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end-point of this subgroup analysis was the incidence of all-cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow-up of 2.1 years (median; range: 1-3.7 years) irrespective of randomized treatment.

Results: 1619 (24%) received a non-MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non-MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end-point was 2.8% (45 of 1619) in non-MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end-points. However, for the long-term follow-up, the incidence of the composite end-point increased in the non-MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all-cause death, stroke and HF.

Conclusions: Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short-term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long-term prognosis.

Trial registration: ClinicalTrials.gov NCT01787110.

Keywords: acute myocardial infarction; cardiovascular clinical research; cardiovascular risk factors; chest pain; noncardiac chest pain; randomized clinical trial.

© 2021 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.

References

    1. Niska R, Bhuiya F, Xu J, National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;26:1-31.
    1. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119-77.
    1. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020;ehaa575. . Online ahead of print.
    1. Timmis A, Townsend N, Gale C, et al. European society of cardiology: cardiovascular disease statistics 2017. Eur Heart J. 2018;39:508-79.
    1. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87-165.
    1. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40:237-69.
    1. Mills NL, Omland T. Cardiac troponin to guide the use of noninvasive testing in patients ruled out for myocardial infarction. Circulation. 2019;139:1655-7.
    1. Nagele P. A simplified proposal to redefine acute myocardial infarction versus acute myocardial injury. Circulation. 2020;141:1431-3.
    1. Sandoval Y, Thygesen K, Jaffe AS. The universal definition of myocardial infarction: present and future. Circulation. 2020;141:1434-6.
    1. de Lemos JA, Newby LK, Mills NL. A proposal for modest revision of the definition of type 1 and type 2 myocardial infarction. Circulation. 2019;140:1773-5.
    1. Yndigegn T, Hofmann R, Jernberg T, Gale CP. Registry-based randomised clinical trial: efficient evaluation of generic pharmacotherapies in the contemporary era. Heart. 2018;104:1562-7.
    1. Jernberg T, Attebring MF, Hambraeus K, et al. The Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies (SWEDEHEART). Heart. 2010;96:1617-21.
    1. Hofmann R, James SK, Svensson L, et al. DETermination of the role of OXygen in suspected Acute Myocardial Infarction trial. Am Heart J. 2014;167:322-8.
    1. Hofmann R, James SK, Jernberg T, et al. Oxygen therapy in suspected acute myocardial infarction. New Engl J Med. 2017;377:1240-9.
    1. Hofmann R, Witt N, Lagerqvist B, et al. Oxygen therapy in ST-elevation myocardial infarction. Eur Heart J. 2018;39:2730-9.
    1. Jernberg T, Lindahl B, Alfredsson J, et al. Long-term effects of oxygen therapy on death or hospitalization for heart failure in patients with suspected acute myocardial infarction. Circulation. 2018;138:2754-62.
    1. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012;33:2551-67.
    1. Ludvigsson JF, Almqvist C, Bonamy AK, et al. Registers of the Swedish total population and their use in medical research. Eur J Epidemiol. 2016;31:125-36.
    1. Hofmann R, Svensson L, James SK. Oxygen therapy in suspected acute myocardial infarction. New Engl J Med. 2018;378:201-2.
    1. Ludvigsson JF, Andersson E, Ekbom A, et al. External review and validation of the Swedish national inpatient register. BMC Public Health. 2011;11:450.
    1. Shah AS, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet. 2015;386:2481-8.
    1. Neumann JT, Twerenbold R, Ojeda F, et al. Application of high-sensitivity troponin in suspected myocardial infarction. New Engl J Med. 2019;380:2529-40.
    1. Wahrenberg A, Magnusson PK, Discacciati A, et al. Family history of coronary artery disease is associated with acute coronary syndrome in 28,188 chest pain patients. Eur Heart J Acute Cardiovasc Care. 2020;9:741-7.
    1. Bandstein N, Ljung R, Johansson M, Holzmann MJ. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol. 2014;63:2569-78.
    1. Chapman AR, Shah ASV, Lee KK, et al. Long-term outcomes in patients with type 2 myocardial infarction and myocardial injury. Circulation. 2018;137:1236-45.
    1. Kadesjo E, Roos A, Siddiqui A, Desta L, Lundback M, Holzmann MJ. Acute versus chronic myocardial injury and long-term outcomes. Heart. 2019;105:1905-12.
    1. Sarkisian L, Saaby L, Poulsen TS, et al. Clinical characteristics and outcomes of patients with myocardial infarction, myocardial injury, and nonelevated troponins. Am J Med. 2016;129:446.e5-446.e21.
    1. Cediel G, Gonzalez-Del-Hoyo M, Carrasquer A, Sanchez R, Boque C, Bardaji A. Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury. Heart. 2017;103:616-22.
    1. Neumann JT, Sorensen NA, Rubsamen N, et al. Discrimination of patients with type 2 myocardial infarction. Eur Heart J. 2017;38:3514-20.
    1. Giannitsis E, Katus HA. Cardiac troponin level elevations not related to acute coronary syndromes. Nat Rev Cardiol. 2013;10:623-34.
    1. Thang ND, Karlson BW, Sundstrom BW, Karlsson T, Herlitz J. Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients. Int J Cardiol. 2015;185:308-12.
    1. DeFilippis AP, Chapman AR, Mills NL, de Lemos JA, Arbab-Zadeh A, Newby LK, et al. Assessment and treatment of patients with type 2 myocardial infarction and acute nonischemic myocardial injury. Circulation. 2019;140:1661-78.
    1. Eggers KM, Jernberg T, Lindahl B. Cardiac troponin elevation in patients without a specific diagnosis. J Am Coll Cardiol. 2019;73:1-9.
    1. Fabbri A, Ottani F, Marchesini G, Galvani M, Vandelli A. Predicting unfavorable outcome in subjects with diagnosis of chest pain of undifferentiated origin. Am J Emerg Med. 2012;30:61-7.
    1. Omstedt A, Hoijer J, Djarv T, Svensson P. Hypertension predicts major adverse cardiac events after discharge from the emergency department with unspecified chest pain. Eur Heart J Acute Cardiovasc Care. 2016;5:441-8.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir