Elsevier

The Lancet

Volume 385, Issue 9966, 31 January–6 February 2015, Pages 441-451
The Lancet

Articles
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

https://doi.org/10.1016/S0140-6736(14)60921-1Get rights and content

Summary

Background

Despite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011.

Methods

In a retrospective analysis of hospital records, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for STEMI in 3 years (2001, 2006, and 2011). In the first stage, we used a simple random-sampling procedure stratified by economic–geographical region to generate a list of participating hospitals. In the second stage we obtained case data for rates of STEMI, treatments, and baseline characteristics from patients attending each sampled hospital with a systematic sampling approach. We weighted our findings to estimate nationally representative rates and assess changes from 2001 to 2011. This study is registered with ClinicalTrials.gov, number NCT01624883.

Findings

We sampled 175 hospitals (162 participated in the study) and 18 631 acute myocardial infarction admissions, of which 13 815 were STEMI admissions. 12 264 patients were included in analysis of treatments, procedures, and tests, and 11 986 were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100 000 people increased (from 3·5 in 2001, to 7·9 in 2006, to 15·4 in 2011; ptrend<0·0001) and the prevalence of risk factors—including smoking, hypertension, diabetes, and dyslipidaemia—increased. We noted significant increases in use of aspirin within 24 h (79·7% [95% CI 77·9–81·5] in 2001 vs 91·2% [90·5–91·8] in 2011, ptrend<0·0001) and clopidogrel (1·5% [95% CI 1·0–2·1] in 2001 vs 82·1% [81·1–83·0] in 2011, ptrend<0·0001) in patients without documented contraindications. Despite an increase in the use of primary percutaneous coronary intervention (10·6% [95% CI 8·6–12·6] in 2001 vs 28·1% [26·6–29·7] in 2011, ptrend<0·0001), the proportion of patients who did not receive reperfusion did not significantly change (45·3% [95% CI 42·1–48·5] in 2001 vs 44·8% [43·1–46·5] in 2011, ptrend=0·69). The median length of hospital stay decreased from 12 days (IQR 7–18) in 2001 to 10 days (6–14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between 2001 and 2011 (odds ratio 0·82, 95% CI 0·62–1·10, ptrend=0·07).

Interpretation

During the past decade in China, hospital admissions for STEMI have risen; in these patients, comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some treatments, but important gaps persist and in-hospital mortality has not decreased. National efforts are needed to improve the care and outcomes for patients with STEMI in China.

Funding

National Health and Family Planning Commission of China.

Introduction

As China has grown economically, it has experienced an epidemiological transition, with mortality due to ischaemic heart disease more than doubling during the past two decades to more than 1 million deaths per year.1, 2 This trend is expected to accelerate, with the World Bank estimating that the number of individuals with myocardial infarction in China will increase to 23 million by 2030.3 Concurrent with this changing epidemiology, the Chinese medical care system has developed rapidly, implementing policies that have improved access by reducing financial barriers and increasing the numbers of hospitals and physicians.4, 5

Despite the importance of acute myocardial infarction in China—particularly ST-segment elevation myocardial infarction (STEMI), which accounts for more than 80% of such events in the country6, 7—no nationally representative studies have defined the clinical profiles, management, and outcomes of patients with this disorder during the past decade. The scarcity of contemporary national estimates and data for changes in burden of disease, quality of care (including use of recommended treatments and inappropriate use of non-evidence-based treatments), and treatment outcomes are important barriers to implementation of interventions to improve care and outcomes. In particular, little information is available about acute myocardial infarction in rural areas, where most of the Chinese population lives.8, 9, 10

In the China Patient-centered Evaluative Assessment of Cardiac Events Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study), we aimed to assess trends in STEMI management and outcomes in China during the past decade in a retrospective analysis of hospital records. We selected representative hospitals from 2011 to assess present practices and traced this cohort of hospitals backwards to 2006 and 2001 to describe temporal changes.

Section snippets

Study design

The design of the China PEACE-Retrospective AMI Study has been described previously.11 Briefly, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for acute myocardial infarction in 3 years (2001, 2006, and 2011). In the first stage, we assessed all non-military hospitals in China and excluded prison hospitals, specialised hospitals without a division for cardiovascular disease, and hospitals for traditional Chinese

Results

According to government documents, China had 6623 non-military hospitals in 2011 (figure 1). We excluded 23 prison hospitals, 687 specialised hospitals without divisions for cardiovascular disease, and 1692 hospitals for traditional Chinese medicine. The sampling framework comprised 2010 central hospitals in 2010 rural regions in three rural strata, and 833 highest-level hospitals in 287 urban regions in two urban strata.

We sampled 175 hospitals and invited them to participate in the study.

Discussion

In the China PEACE-Retrospective AMI Study we aimed to document changes in the clinical profiles, treatment patterns, quality of care, and in-hospital mortality of patients admitted to hospital for STEMI in China during the past decade. This study, funded by the Chinese Government, was designed to generate the knowledge to support future national initiatives to improve STEMI care and patient outcomes in China.

Our study of a nationally representative sample of patients between 2001 and 2011

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