ESC 2017: Further decreasing mortality after STEMI will be difficult

NSTEMI patietnts tend to be older and have more comorbidity than STEMI patients. This may explain why mortality has plateaued in this popualtion

According to results from the FAST-MI programme, six-month mortality after ST-segment elevation myocardial infarction (STEMI) and after non-STEMI (NSTEMI) considerably decreased between 1995 and 2015.

Nicolas Danchin (Department of Cardiology, Hospital Europeen Georges Pompidou, AP-HP, Paris, France), who presented the results at the European Society of Cardiology (ESC) congress (26–30 August, Barcelona, Spain), told Cardiovascular News why he believes we may soon reach a point when mortality after STEMI cannot be reduced any further.

Prior to your study, what data were available for the changes in mortality following STEMI/NSTEMI over the last 20 years?

Results from several registries up to 2010—mainly in STEMI patients—had already been published and had shown a reduction in mortality. However, more recent data (ie, from 2010 onwards) were lacking.

Why do you think that six-month mortality, for both STEMI and NSTEMI patients, has decreased over the last 20 years?

The answer probably differs for STEMI and NSTEMI. With STEMI, changes in patient population (patients now present at a younger age than they did 20 years ago), improved organisation of care (such as referral to larger centres, and shorter times to reperfusion), increased use of reperfusion therapy (particularly primary percutaneous coronary intervention), and improved use of secondary prevention medications may have all contributed to the decrease in mortality. With NSTEMI, most of the improvement in mortality seems to be related to increased use of invasive approaches and recommended medications.

In your study, mortality continued to decline for STEMI patients after 2010 but it reached a plateau in NSTEMI patients. Why do you think this was?

The answer is all but obvious. One of the possible explanations is that the NSTEMI population is older by five years, with more comorbidity, and that improved cardiac management may not be sufficient in an elderly population. Management of ischaemic heart disease has made tremendous progress, while management of comorbidity may lag behind.

What research is needed to further reduce mortality after STEMI/NSTEMI?

From the epidemiologic standpoint, mortality of both STEMI and NSTEMI has become very low. Improving outcomes will need to address two key issues:

  • Primary prevention of acute myocardial infarction and more importantly, primary prevention of sudden cardiac death; out of hospital sudden death clearly represents the main cause of mortality in acute myocardial infarction
  • Stopping the evolution of coronary artery disease, which may require other strategies than risk factor modification, lipid control and other conventional medications of secondary prevention. New fields will have to be explored; for example, the recent results of the CANTOS (Canakinumab anti-inflammatory thrombosis outcomes) trial [also presented at the ESC congress] certainly show that controlling the disease process may need addressing new mechanisms, such as inflammation.

Do you think we will reach a point where it will not be possible to further decrease mortality?

We are more or less there. During the ESC congress, data from the SWEDEHEART registry that outlined 20-year trends in care and mortality of STEMI patients were presented. Interestingly, according to these results, there has been little change in mortality in the past 10 years in Sweden;  it is probable that it will now become very difficult to further decrease mortality.