The incidence, treatment strategies and outcomes of acute coronary syndromes in the “reperfusion network” of different hospital types in the Czech Republic: Results of the Czech evaluation of acute coronary syndromes in hospitalized patients (CZECH) registry

doi:10.1016/j.ijcard.2007.02.036

International Journal of Cardiology

Volume 119, Issue 2, 10 July 2007, Pages 212-219

https://doi.org/10.1016/j.ijcard.2007.02.036 Get rights and content

Abstract

Aims

To analyze the incidence, treatment strategies and outcomes of acute coronary syndromes (ACS) in Czech population.

Methods and results

ACS diagnosis was confirmed in 1345 of 1921 (70%) consecutively admitted patients with suspected ACS. ACS incidence was 3248 cases/million/year and the annual incidence of confirmed myocardial infarction was 1960 per million. In-hospital mortality was 5.1% (10.0% with Q-MI, 4.4% with non-Q-MI, and 0.9% with UAP). Coronary angiography was performed in 92% of STEMI (followed by primary PCI in 83%, by CABG in 3%, by conservative therapy in 6%). Thrombolysis was used in only 1% of patients. Reperfusion therapy was thus used in 87% of all STEMI patients. Discharge medication included aspirin in 95%, a statin in 76%, a beta-blocker in 78%, an ACE inhibitor in 50%, clopidogrel in 60%, and ticlopidine in 4% of patients.

Conclusions

In-hospital mortality of ACS in the Czech network of PCI and non-PCI hospitals is low. Nationwide application of primary PCI strategy for STEMI is feasible and increases the overall use of reperfusion therapy.

Introduction

Acute coronary syndromes (ACS) represent one of the major causes for hospital admission and death in European countries. Eastern Europe has a higher prevalence of coronary artery disease compared with other European regions. The Czech Republic has witnessed major political and economic changes over the last 15 years, resulting in marked improvement in the availability of modern diagnostic and treatment methods. A typical example is interventional cardiology: the 5571 coronary angiograms and 2105 percutaneous coronary interventions (PCI) per million population (unpublished data from the national PCI registry) in 2005 place the Czech Republic among the 10 European countries with the highest use of these procedures. At the beginning of economic and political transition (1992), the number of PCI procedures in the country was mere 58 per million population (thus, the figure increased 36 times over the last 13 years). Furthermore, currently the number of primary PCI procedures performed for STEMI (657 per million population in 2005) may be even the highest in Europe (precise data from other countries are not available). One of the reasons for this marked increase was the success of two national randomized trials in acute myocardial infarction — the PRAGUE and PRAGUE-2 trials [1], [2] and a smaller VINO trial [3]. The Czech Society of Cardiology implemented new guidelines for the treatment of acute myocardial infarction shortly after the results of the PRAGUE-2 and VINO trials were published in 2002 [4]. In 2005, the Czech Society of Cardiology decided to assess how these guidelines were being implemented in real life daily practice in the country. A 1-month registry of acute coronary syndromes was prepared and its results are presented below. The aim of this registry was also to analyze the incidence of acute coronary syndromes in the Czech population and their outcomes with a special focus on PCI, and to assess the efficiency of the Czech hospital network in acute coronary care.

Section snippets

Participating hospitals

The registry had two arms. A “Regional Registry” included all existing hospitals (n = 17) in two Czech regions (politically and geographically defined regions with a total population of 1,052,830). One regional hospital thus serves an average 75,233 inhabitants. The distance to the nearest PCI center varied between 11 and 90 km (average 47 km). Both regions are rural areas, each with a single (recently opened) non-university PCI center. Thus, 15 of these 17 hospitals are small community hospitals

Diagnosis

The admission diagnosis was specified above. The discharge diagnoses are shown in Fig. 3. Interestingly, ACS was confirmed at discharge in 42% of patients admitted as acute heart failure without chest pain.

Incidence of acute coronary syndromes

The calculated annual incidence of confirmed ACS (either Q-wave, non-Q-wave myocardial infarction or unstable angina pectoris) was 3248 patients per million population. The annual incidence of hospitalized confirmed acute myocardial infarction (i.e., any type of infarction, without unstable

Discussion

The frequency, management and outcomes of acute coronary syndromes vary in different registries (Table 2). The key factor predicting the outcome is age. The specific type of the acute coronary syndrome (unstable angina vs. non-STEMI vs. STEMI) included in each given registry must always be kept in mind when analyzing the outcomes of any given registry. Some registries mix all MIs (STEMI and non-STEMI) or even report together all three forms of ACS; some registries enroll patients with suspected

Acknowledgements

The registry organizer was the Czech Society of Cardiology. Data collection was kindly supported by Sanofi-Aventis Czech Republic. Manuscript preparation was supported by the Charles University project MSM0021620817. All six authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India
2017, Indian Heart Journal
Outcomes of patients hospitalized for suspected acute coronary syndrome, in whom the diagnosis was not confirmed: Results from the CZECH-1 and CZECH-2 registries
2015, Cor et Vasa
Citation Excerpt :
Because of the challenge of determining an appropriate diagnosis and the poor clinical outcome of mistakenly discharged patients with myocardial infarction (MI), a high proportion of patients are admitted with possible ACS that subsequently is not confirmed [1,2]. Two large registries of patients with an initial diagnosis of ACS admitted to regional community hospitals or cardiocentres were created in 2005 and 2012 in the Czech Republic [3,4]. In both registries, ACS diagnosis was excluded during hospitalization in 30% of patients.
Suspicion of acute coronary syndrome (ACS) is one of the most common reasons for hospital admission. However, ACS is not confirmed in a high proportion of these patients during hospitalization. Very few details exist about these patients.
To evaluate the clinical characteristics and outcomes of hospitalized patients with a suspicion for ACS that has not been confirmed and compare these results with patients with confirmed ACS.
Data were used from the CZECH-1 and CZECH-2 registries, collected in November 2005 and October–November 2012. Both registries contain data from all consecutive patients who have been hospitalized with an initial diagnosis of ACS. ACS was not confirmed during hospitalization in 578 of 1921 patients (30.1%) in the CZECH-1 registry and in 372 of 1221 (30.5%) in the CZECH-2 registry. In both registries, higher proportions of females (52 vs. 36%; p < 0.001 and 46 vs. 33%; p < 0.01, respectively) were observed between patients with unconfirmed ACS compared to those with confirmed ACS. A history of myocardial infarction was known in 25% of the patients with unconfirmed ACS in both registries. On admission, atrial fibrillation or other non-sinus rhythm on ECG was present in 17% of patients with unconfirmed ACS, bundle branch block in 18%, ST depression in 8%, and ST elevation in 3.6%. Coronary angiography was performed on 36% of these patients in CZECH-1 and 27% of patients in CZECH-2 (p < 0.01). In-hospital mortality of the ACS unconfirmed patients was 1.2% in the CZECH-1 registry and 2.1% in the CZECH-2 registry (p = NS). 30-day and 1-year mortality in patients with unconfirmed ACS in the CZECH-2 registry were significantly lower compared to patients with confirmed ACS (3.5 vs. 6.6%; p < 0.05 and 6.5 vs. 13%; p < 0.05, respectively). Musculoskeletal pain and acute heart failure were the most common discharge diagnosis in patients with unconfirmed ACS.
Hospitalized patients in whom the suspicion of ACS had not been confirmed were more often female and a high proportion had abnormal ECG on admission. In-hospital mortality was very low, and the 1-year mortality was significantly lower compared to patients with confirmed ACS.
Why some patients with acute coronary syndrome hospitalized in a university tertiary centre do not undergo coronary angiography? Results from the AHEAD-ACS registry
2014, Cor et Vasa
To evaluate in-hospital and long-term mortality of patients with acute coronary syndromes (ACS) not having selective coronary angiography (CAG) during hospitalization and to analyze the reasons for conservative approach.
A single-centre retrospective study using registry data. Over the period from January 2005 to April 2009, a total of 193 ACS patients did not have in-hospital CAG. Fifty-five (28.5%) patients had recent CAG (within the last 12 months) or the procedure was planned after discharge (invasive group “I”). In 138 (71.5%) patients, CAG was not considered at all (conservative approach, group “C”). These subgroups were compared in terms of in-hospital parameters and long-term mortality.
ST-segment elevation myocardial infarction (STEMI) was diagnosed in 50 (25.9%) patients. The most frequent reasons for not performing CAG included serious comorbidities affecting the prognosis (22%) and pharmacological stabilization in very old individuals with non-STEMI (21%). One in ten (11%) patients died before the CAG was performed, the same proportion of patients refused to have CAG or had a long ischaemia time (STEMI subgroup). A temporary contraindication to CAG was found in 8%, a recent CAG finding not suitable for revascularization in 8%, while a limiting neurological disease was present in 6% of patients. In-hospital mortality was 30.1%, being higher in Group C (34.1% vs. 20.0%; p = 0.049), 6-year mortality was as high as 78.8%, also with higher rates in Group C (86.2% vs. 60.2%; p < 0.001). Patients receiving conservative therapy were older, with a higher proportion of limiting comorbidities that contraindicated CAG, and had a more serious course of hospitalization.
The most common reasons for not performing CAG in ACS patients included advanced age, serious and often extra-cardiac comorbidities, and a complicated hospitalization course. The short- and long-term mortality rates in these patients are high.
Trends in epidemiology and the treatment of acute coronary syndromes in the Czech Republic: Comparison of the CZECH-1 and CZECH-2 registries
2014, Cor et Vasa
The clinical spectrum of acute coronary syndrome (ACS) has changed due to a progressively ageing population over the last two decades.
We analysed the changes in the epidemiological and treatment strategies between two large registries that were performed in 2005 and 2012 in well-defined populations of the Czech Republic.
The CZECH-1 and CZECH-2 registries enrolled all consecutive hospitalized patients with an initial diagnosis of ACS during a 1 or 2-month period, respectively. Thirty-six and 32 hospitals participated in the CZECH-1 and CZECH-2 registries, respectively. A total of 1921 patients were enrolled in the CZECH-1 registry and 1221 patients participated in the CZECH-2 registry. Patients enrolled in the CZECH-2 registry were older than those in CZECH-1 (68 ± 12 vs. 66 ± 12 years; p < 0.001). ACS was not confirmed during hospitalization in 30.5 and 30.1% (p > 0.05) of the patients in the CZECH-1 and CZECH-2 registries, respectively. Urgent angiography in patients with ST segment elevation myocardial infarction (STEMI) was performed in 92 and 94% of the patients (p > 0.05), respectively; of these, 87 and 89% subsequently underwent primary PCI. There were no signifiant differences in in-hospital (4.2 vs. 4.4%, p=0.805) or in the mortality of patients with a final diagnosis of Q-myocardial (10.3 vs. 10.7%; p = 0.870) or non-Q-myocardial infarction (4.7 vs. 3.8%; p = 0.497) between the two registries. The estimated incidence of confirmed ACS and STEMI in a representative population from both registries was 3248 and 661 cases/million individuals/year in the CZECH-1 registry and 2149 and 652 cases/million individuals/year in the CZECH-2 registry. The fall in ACS incidence was almost exclusively due to a significant decrease in the incidence of unstable angina as the final diagnosis. At discharge, the patients with confirmed ACS were administered the following medications: aspirin (95 vs. 94%; p > 0.05), clopidogrel (60 vs. 76.4%; p < 0.001), beta-blockers (78 vs. 78%; p > 0.05), angiotensin-converting enzyme (ACE) inhibitors (50 vs. 78%; p = <0.001) and statins (75 vs. 90%; p < 0.001) in the CZECH-1 and CZECH-2 registries, respectively.
In the Czech Republic, the age of the patients hospitalized with ACS increased between 2005 and 2012. Invasive reperfusion strategy for patients with STEMI was very high in both registries. The overall outcome in patients with confirmed ACS did not change between 2005 and 2012. The estimated incidence of ACS decreased due to the fall in unstable angina pectoris.
Dual antiplatelet therapy in patients with acute coronary syndrome treated by surgical revascularization
2014, Cor et Vasa
Twelve months dual antiplatelet therapy (DAPT) based on a combination of acetylsalicylic acid and purine receptor P2Y12 inhibitor is a standard for all patients with acute coronary syndrome (unstable angina pectoris, NSTEMI and STEMI). Previous sub-analysis of CURE and ACUITY studies suggested that DAPT could bring benefit even for patients treated by surgical revascularization. Sub-analysis of PLATO trial conducted on 1261 patients, who underwent surgical revascularization within 12 months, demonstrated a reduction of cardiovascular and total mortality within a group of patients treated by ticagrelor and acetylsalicylic acid compared to patients treated by clopidogrel and acetylsalicylic acid.
The incidence and outcomes of acute coronary syndromes in a central European country: Results of the CZECH-2 registry
2014, International Journal of Cardiology
Citation Excerpt :
In our registry, ACS was excluded in 30% of admitted patients. ACS was not confirmed in a similar proportion of patients in the CZECH-1 registry [15]. Based on our analysis, the main initial diagnosis in patients with subsequently excluded ACS was chest pain with nonspecific ST-T changes on the first ECG and no relation was observed in terms of referring modalities (emergency service/GPs/specialist/patients themselves).
The incidence and treatment strategies of acute coronary syndrome (ACS) vary by region. Additionally, the clinical spectrum of ACS is changing and outcomes are improving.
We assessed the incidence, treatment strategies, and outcomes of ACS for a well-defined population within a well-established network of percutaneous coronary intervention (PCI) centers and non-PCI centers.
The CZECH-2 registry included 1221 consecutive patients (mean age: 68 ± 13 years; 63.4% males) admitted for suspected ACS to 32 hospitals (including 4 PCI centers) within four Czech counties (total population: 2,370,841 inhabitants) during a 2-month period.
The estimated incidence of confirmed ACS was 2149 cases/million/year. In 374 (31%) patients, ACS was ruled out during the hospital stay. Coronary angiography (CAG) was performed in 60% of the patients overall and PCI was performed in 59% of the confirmed ACS patients. Killip classifications II–IV on admission were more common in patients with final diagnosis of non ST-elevation myocardial infarction (NSTEMI) than ST-elevation myocardial infarction (STEMI) (37.1% vs. 22.8%; p < 0.001). The 30-day mortality rate was 5.7% for the whole study group, 7.3% for STEMI patients, 8.4% for NSTEMI patients, and 1.6% for patients with unstable angina pectoris (UAP), respectively.
Almost one-third of the patients admitted for suspected ACS had a different final diagnosis. Among those with confirmed ACS, the use of CAG, PCI, CABG, and effective medications is rational. Outcome in NSTEMI patients was equivalent to those in STEMI patients, mainly due to the high-risk population in this group.

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^☆: This registry was organized by the Czech Society of Cardiology and was supported by an unrestricted grant from Sanofi-Aventis Czech Republic. Partial support for the preparation of the manuscript was also provided by the Charles University Research Project MSM0021620817. All authors contributed to the design of this registry, to the data analysis and preparation of the manuscript. The first author (P. Widimsky) was drafting the manuscript and coordinating its finalization. There is no other potential conflict of interest besides the abovementioned partial funding of this registry by Sanofi-Aventis CR. The registry was approved by the local ethical committees of all participating hospitals.

¹: The full list of investigators is in the Appendix.

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The incidence, treatment strategies and outcomes of acute coronary syndromes in the “reperfusion network” of different hospital types in the Czech Republic: Results of the Czech evaluation of acute coronary syndromes in hospitalized patients (CZECH) registry☆

Abstract

Aims

Methods and results

Conclusions

Introduction

Section snippets

Participating hospitals

Diagnosis

Incidence of acute coronary syndromes

Discussion

Acknowledgements

Am J Cardiol

Am J Cardiol

Int J Cardiol

Am J Cardiol

Am J Cardiol

Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study

Eur Heart J

Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial-PRAGUE-2

Eur Heart J.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study

Eur Heart J

z pověření ČKS: Doporučení pro diagnostiku a léčbu akutního infarktu myokardu (Q-typ/s elevacemi ST/s raménkovým blokem)

Cor Vasa

Mortality rates in patients with ST-elevation vs. non-ST-elevation acute myocardial infarction: observations from an unselected cohort

Eur Heart J

Changes in hospitalization rate and mortality after acute myocardial infarction in Denmark after diagnostic criteria and methods changed

Eur Heart J