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Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej
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Original paper

The progress in outcomes of the management of patients with non-ST-segment elevation myocardial infarction between 2005 and 2014 in Poland – a propensity score matching analysis from the PL-ACS registry

Łukasz Piątek
1, 2
,
Agnieszka Janion-Sadowska
2
,
Karolina Piątek
2
,
Łukasz Zandecki
1, 2
,
Jacek Kurzawski
2
,
Mariusz Gąsior
3
,
Marcin Sadowski
1, 4

1.
The Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
2.
2nd Department of Cardiology, Świętokrzyskie Cardiology Centre, Kielce, Poland
3.
3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Silesian Center for Heart Disease, Zabrze, Poland
4.
Department of Interventional Cardiology, Świętokrzyskie Cardiology Centre, Kielce, Poland
Adv Interv Cardiol 2020; 16, 1 (59): 41–48
Online publish date: 2020/04/03
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Summary

Dynamic changes both in clinical profile and treatment strategy of non ST-segment elevation myocardial infarction (NSTEMI) patients have been observed recently. The exact impact of them on prognosis in a wide national population remains unclear. NSTEMI patients from the Polish Registry of Acute Coronary Syndromes (PL-ACS) were included to the analysis. In-hospital mortality decreased by fifty percent (in women from 6.6% to 3.3%; p < 0.001 and in men from 4.9% to 2.5%; p < 0.001, respectively). Similarly, 12-month mortality decreased up to one third (in women from 21.6% to 15.1%; p < 0.001 and in men from 17.8% to 12.8%; p < 0.001, respectively). Invasive strategy appeared to be the strongest factor decreasing mortality. Into in-hospital observation it reduces triple mortality risk whereas in 12-month follow up twice. Using propensity score matching analysis the impact of the treatment improvements on relative risk reduction was estimated on over 60%.

Introduction

In the last decade a non-ST-segment elevation myocardial infarction (NSTEMI) has become the most common MI type in Poland which is consistent with previous observations from the majority of Western European countries [1]. Simultaneously, dynamic changes in the clinical profile and the treatment strategy have been noticed, however their contribution to outcomes in a wide national population remains unclear [25].

Aim

Using the data from the Polish Registry of Acute Coronary Syndromes (PL-ACS) we analyzed the trends in clinical characteristics, treatment strategy and outcomes in almost two hundred thousand NSTEMI cases registered between 2005 and 2014.

Material and methods

The study population was drawn from 463 hospitals in Poland providing care for patients with MI. It consists of patients admitted with a diagnosis of NSTEMI according to the guidelines of European Society of Cardiology (ESC) [68]. The study covers last 10-year period from 2005 to 2014. Contribution to the study was voluntary, nevertheless it comprises a half of all estimated cases of NSTEMI in Poland in that time. The study complies with the Declaration of Helsinki and was approved by the PL-ACS Registry committee.

Data was collected from the PL-ACS Registry questionnaires that include variables on demographic factors (gender, age), risk factors (smoking, arterial hypertension, hypercholesterolemia, diabetes mellitus and obesity), previous coronary incidences and procedures (MI, percutaneous coronary intervention (PCI), coronary artery by-pass grafting (CABG)), clinical presentation on admission (Killip class, heart rate, systolic blood pressure), electrocardiographic abnormalities (left ventricular ejection fraction (EF) – echocardiographic assessment on admission), coronary angiography (CA), coronary intervention details and in-hospital and post-discharge treatment. In-hospital complications (including bleeding, stroke and re-infarction (ST-elevation in at least two contiguous leads in association with ischemic symptoms)) as well as in-hospital mortality together with 12-month follow-up were evaluated. Propensity score matching (PSM) was used to compensate for the nonrandomized design of the study to control for imbalances in patients characteristics.

Statistical analysis

Females and males were analyzed separately. To assess age impact on outcomes the analysis was conducted in consecutive decades of life. Changes over time were investigated as comparison between subgroup in marginal 3-year intervals (2005–2007 and 2012–2014).

Categorical data are presented as numbers and percentages while continuous data as arithmetic mean ± standard deviation (SD). Differences in categorical variables were tested by χ2 test with Pearson modification whereas in continuous variables with Student t-test. A two-sided p-value ≤ 0.05 was considered significant. A logistic regression was used to identify variables that independently contributed to mortality. Propensity scores were calculated using a multiple regression model that included all covariates presented in Table I. Matching was performed using a nearest neighbor algorithm. In-hospital and 12-month mortality were evaluated of the studied groups as well as propensity score-matched subgroups were evaluated. Finally, the impact of the change in the treatment strategy changes was estimated by comparison the relative risk reduction (RRR) in the PSM groups with the RRR in the entire study group.

Table I

Baseline characteristics of NSTEMI patients after propensity score matching

ParameterWomenMen
2005–20072012–2014P-value2005–20072012–2014P-value
17346 (100%)17346 (100%)26059 (100%)26059 (100%)
Risk factors:
 Hypertension13489 (77.8)13541 (78.1)0.50118399 (70.6)18565 (71.2)0.109
 Diabetes6106 (35.2)6094 (35.1)0.8936387 (24.5)6497 (24.9)0.264
 Hypercholesterolemia7472 (43.1)7496 (43.2)0.79511080 (42.5)11165 (42.8)0.452
 Smoking2015 (11.6)2102 (12.1)0.1498098 (31.1)7997 (30.7)0.338
 Obesity4310 (24.8)4338 (25.0)0.7294242 (16.3)4369 (16.8)0.134
 Prior MI3247 (18.7)3069 (17.7)0.0135954 (22.8)5570 (22.1)0.054
 Prior PCI731 (4.2)876 (5.1)< 0.0011666 (6.4)1987 (7.6)< 0.001
 Prior CABG693 (4.0)690 (4.0)0.9341634 (6.3)1650 (6.3)0.773
Clinical characteristics on admission:
 SBP < 100 mm Hg651 (3.8)652 (3.8)0.448892 (3.6)904 (3.5)0.406
 SBP 100–160 mm Hg12232 (74.4)12863 (75.0)0.23419417 (79.1)20505 (79.3)0.566
 SBP > 160 mm Hg3559 (21.6)3645 (21.2)0.3664247 (17.3)4455 (17.2)0.834
 HR > 100/min2162 (13.1)2113 (12.3)0.0292747 (11.2)2779 (10.8)0.169
 Killip class 4377 (2.2)344 (2.0)0.298564 (2.2)519 (2.0)0.251
 Killip class 3939 (5.4)834 (4.9)0.0251083 (4.2)1008 (3.9)0.179
 Killip class 22826 (16.3)2602 (15.2)0.0073477 (13.3)3305 (12.9)0.106
 ECG: sinus rythm14209 (86.1)14678 (85.8)0.42721751 (88.2)22682 (88.1)0.904
 ECG: atrial fibrilation1690 (10.2)1659 (9.7)0.0971950 (7.9)1963 (7.6)0.195
 ECG: pacemaker207 (1.3)213 (1.2)0.940295 (1.2)285 (1.1)0.352
 ECG: ST-segment depression7704 (44.4)7675 (44.2)0.75410542 (40.5)10675 (41.0)0.236
 ECG: T-wave inversion3409 (19.7)3384 (19.5)0.7354877 (18.7)4836 (18.6)0.645
 ECG: other ST-T abnormal.5120 (29.5)5044 (29.1)0.3708557 (32.8)8383 (32.2)0.104
 ECG: normal1623 (9.4)1285 (7.4)< 0.0012790 (10.7)2198 (8.4)< 0.001
 LVEF > 50%4010 (44.0)6077 (43.9)0.9685802 (39.1)8262 (38.9)0.749
 LVEF 35–50%4174 (45.8)6385 (46.2)0.5507116 (47.9)10168 (47.9)0.940
 LVEF < 35%939 (10.3)1372 (9.9)0.3551923 (13.0)2794 (13.2)0.566
 Time pain to admission 0–2 h1919 (13.1)1890 (12.4)0.0713169 (14.3)3205 (13.9)0.190
 Time pain to admission 2–12 h7038 (48.2)7361 (48.4)0.65210594 (47.9)11149 (48.3)0.339
 Time pain to admission > 12 h5650 (38.7)5944 (39.1)0.4388376 (37.8)8728 (37.8)0.964
 Time pain to admission > 24 h3705 (25.4)3905 (25.7)0.5085585 (25.205764 (25.0)0.531
 Prehospital cardiac arrest190 (1.1)164 (0.9)0.173365 (1.4)335 (1.3)0.269

[i] CABG – coronary artery by-pass graft, ECG – electrocardiogram, HR – heart rate, LVEF – left ventricle ejection fraction, MI – myocardial infarction, PCI – percutaneous coronary intervention, SBP – systolic blood pressure.

Results

A total of 197,192 patients (including 77,550 women, 39.3%) hospitalized in Poland due to NSTEMI between 2005 and 2014 were enrolled. All patients from two marginal 3-year periods (i.e. 2005–2007 and 2012–2014) were incorporated to the final analysis (Table II). Two matched cohorts of 17,346 women as well as two matched cohorts of 26,059 men were created as a result of the propensity score matching (Table I).

Table II

Baseline characteristics of NSTEMI patients

ParameterWomenMen
2005–20072012–2014P-value2005–20072012–2014P-value
23189 (100%)25542 (100%)33148 (100%)41125 (100%)
Risk factors:
 Hypertension17908 (77.2)20568 (80.5)< 0.00122792 (68.8)31219 (75.9)< 0.001
 Diabetes8180 (35.3)9623 (37.3)< 0.0017865 (23.7)11999 (29.2)< 0.001
 Hypercholesterolemia10182 (43.9)11264 (44.1)0.67114446 (43.6)18067 (43.9)0.337
 Smoking2403 (10.4)3340 (13.1)< 0.00110595 (32.0)10989 (26.7)< 0.001
 Obesity5879 (25.4)6391 (25.0)0.4005143 (15.5)7807 (19.0)< 0.001
 Prior MI5899 (25.4)5681 (22.2)< 0.00110097 (30.5)10728 (26.1)< 0.001
 Prior PCI736 (3.2)4301 (16.8)< 0.0011680 (5.1)8534 (20.8)< 0.001
 Prior CABG1321 (5.7)1092 (4.3)< 0.0012764 (8.3)2755 (6.7)< 0.001
Clinical characteristics on admission:
 SBP < 100 mm Hg1034 (4.7)813 (3.4)< 0.0011407 (4.5)1201 (2.9)< 0.001
 SBP 100–160 mm Hg15744 (71.1)19698 (77.8)< 0.00124468 (77.8)33140 (81.1)< 0.001
 SBP > 160 mm Hg5367 (24.2)4795 (18.9)< 0.0015588 (17.8)6505 (15.9)< 0.001
 HR > 100/min3713 (16.7)2501 (9.9)< 0.0014402 (13.9)3470 (8.5)< 0.001
 Killip class 4662 (2.9)388 (1.5)< 0.001919 (2.8)659 (1.6)< 0.001
 Killip class 31932 (8.3)995 (4.0)< 0.0012052 (6.2)1231 (3.0)< 0.001
 Killip class 24349 (18.8)3265 (13.0)< 0.0015109 (15.4)4462 (11.0)< 0.001
 ECG: sinus rythm18667 (83.6)22072 (87.6)< 0.00127506 (86.9)36102 (88.9)< 0.001
 ECG: atrial fibrilation2728 (12.2)2062 (8.2)< 0.0012764 (8.7)2822 (6.9)< 0.001
 ECG: pacemaker292 (1.3)293 (1.2)0.145419 (1.3)472 (1.2)0.051
 ECG: ST-segment depression11124 (48.8)10361 (40.6)< 0.00114564 (43.9)15200 (37.0)< 0.001
 ECG: T-wave inversion6778 (29.2)3795 (14.9)< 0.0018798 (26.5)5559 (13.5)< 0.001
 ECG: other ST-T abnormal.5957 (14.9)7725 (30.0)< 0.0019802 (21.1)13542 (32.8)< 0.001
 ECG: normal1648 (7.1)3703 (14.5)< 0.0012817 (8.5)6857 (16.7)< 0.001
 LVEF > 50%5077 (42.0)8890 (43.3)0.0197015 (37.3)12851 (38.2)0.043
 LVEF 35–50%5647 (46.7)9662 (47.1)0.5059062 (48.2)16331 (48.6)0.437
 LVEF < 35%1370 (11.3)1973 (9.6)< 0.0012706 (14.4)4421 (13.2)< 0.001
 Time pain to admission 0–2 h3322 (16.7)2247 (10.1)< 0.0014966 (17.5)4097 (11.3)< 0.001
 Time pain to admission 2–12 h9227 (46.7)10882 (48.7)< 0.00113123 (46.2)17726 (49.0)< 0.001
 Time pain to admission > 12 h7227 (36.5)9205 (41.2)< 0.00110342 (36.4)14374 (39.7)< 0.001
 Time pain to admission > 24 h4850 (24.5)5818 (26.0)< 0.0017115 (25.0)9157 (25.3)< 0.001
 Prehospital cardiac arrest360 (1.6)204 (0.8)< 0.001712 (2.1)389 (0.9)< 0.001

[i] CABG – coronary artery by-pass graft, ECG – electrocardiogram, HR – heart rate, LVEF – left ventricle ejection fraction, MI – myocardial infarction, PCI – percutaneous coronary intervention, SBP – systolic blood pressure.

In the last decade the mean age of males increased from 65.8 ±11.8 to 66.7 ±11.3 years (p < 0.001), whereas the mean age of females slightly decreased from 72.3 ±10.8 to 72.1 ±11.0 years (p = 0.018). The frequency of major coronary artery disease risk factors like diabetes, arterial hypertension, obesity (in men only), smoking (in women only) increased. In the later years of the study the rate of prior PCI increased significantly. Additionally, there were substantial differences in Killip class, blood pressure, heart rate, ECG and echocardiography (Table II). Differences in the baseline clinical characteristics were equalized by the propensity score matching model (Table I).

During the last decade the frequency of invasive procedures increased remarkably in general population (coronary angiography from 35.8% to 90.7%; p < 0.05 and percutaneous coronary intervention from 25.7% to 63.6%; p < 0.05) as well as in PSM subgroups (Table III). In addition there were also modifications in medical treatment scheme. The usage of P2Y12 – inhibitors (especially clopidogrel) raised substantially from 56% in 2005–2007 to 93%; p < 0.05 in 2012–2014 (Table III).

Table III

Management of NSTEMI patients (after propensity score matching)

ParameterWomenMen
2005–20072012–2014P-value2005–20072012–2014P-value
17346 (100%)17346 (100%)26059 (100%)26059 (100%)
Treatment strategy:
 Hospitalisation on cardiology depart.12000 (69.2)15420 (88.9)< 0.00119222 (73.8)23982 (92.0)< 0.001
 Conservative treatment11787 (68.0)2255 (13.0)< 0.00115032 (57.7)2315 (8.9)< 0.001
 Coronary angiography5542 (32.0)15090 (87.0)< 0.00110998 (42.3)23744 (91.1)< 0.001
 Percutaneous coronary intervention3838 (22.1)10021 (57.8)< 0.0018015 (30.8)16861 (64.7)< 0.001
 Second PCI (non-IRA) during indx hosp.612 (3.6)2268 (13.1)< 0.0011149 (4.4)2849 (10.9)< 0.001
 PCI with stent implantation3357 (87.5)9083 (90.5)< 0.0017719 (88.9)15434 (91.3)< 0.001
 PCI with BMS implantation3192 (83.2)4115 (41.0)< 0.0016808 (85.0)6618 (39.1)< 0.001
 PCI with DES implantation165 (4.3)4968 (49.5)< 0.001311 (3.9)8816 (52.2)< 0.001
 Intra aortic ballon pump52 (0.3)88 (0.5)0.023105 (0.4)143 (0.5)0.016
Medical treatment during hospitalisation:
 Acetlosalycic acid15974 (92.1)14271 (82.3)< 0.00124244 (93.0)21671 (83.2)< 0.001
 P2Y12B inhibitor9041 (52.1)16096 (92.8)< 0.00115581 (59.8)24281 (93.2)< 0.001
 Clopidogrel7019 (40.5)16040 (92.5)< 0.00112625 (48.4)24243 (93.0)< 0.001
 GPIIb/IIIa inhibitor371 (2.1)1318 (7.6)< 0.001880 (3.4)2619 (10.1)< 0.001
 Heparin12949 (74.7)8919 (51.5)< 0.00118988 (72.9)13152 (50.5)< 0.001
 Beta-adrenolytic13705 (79.0)11607 (66.9)< 0.00120499 (78.7)17790 (68.3)< 0.001
 Calcium channel blocker1664 (9.8)2228 (12.8)< 0.0012032 (7.8)2878 (11.0)< 0.001
 Statin13633 (78.6)12311 (71.0)< 0.00121050 (80.8)19224 (73.8)< 0.001
 ACEI/ARB13616 (78.8)10529 (60.7)< 0.00120166 (77.4)16286 (62.6)< 0.001
 Nitrate9366 (54.0)2496 (14.4)< 0.00113015 (49.9)3448 (13.2)< 0.001
 Diuretics6903 (39.8)5100 (29.4)< 0.0018082 (31.0)6326 (24.3)< 0.001

[i] ACEI/ARB – angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, BMS – bare metal stent, DES – drug eluting stent, IRA – infarct-related artery.

In that time the risk of in-hospital complications (re-infarction, stroke and cardiovascular death) decreased considerably. On the contrary, the risk of major bleeding incidences was higher in the later years of the study (Table IV). In the whole population in-hospital mortality decreased by fifty percent (from 5.6% in 2005–2007 to 2.8% in 2012–2014; p < 0.001, in women from 6.6% to 3.3%; p < 0.001 and in men from 4.9% to 2.5%; p < 0.001, respectively). Similarly, there was more than 30% decrease in the 12-month mortality (from 19.4% in 2005–2007 to 13.7% in 2012–2014; p < 0.001, in women from 21.6% to 15.1%; p < 0.001 and in men from 17.8% to 12.8%; p < 0.001, respectively). Also in the PSM model the outcomes improved considerably – in hospital mortality rates decreased by thirty percent whereas 12-month mortality decreased by 18% (Table IV).

Table IV

Outcomes of NSTEMI patients (after propensity score matching)

ParameterWomenMen
2005–20072012–2014P-value2005–20072012–2014P-value
17346 (100%)17346 (100%)26059 (100%)26059 (100%)
Myocardial reinfarction812 (4.7)59 (0.3)< 0.0011100 (4.3)82 (0.3)< 0.001
Stroke101 (0.6)54 (0.3)< 0.00178 (0.3)44 (0.2)< 0.001
Bleeding145 (0.8)270 (1.6)< 0.001137 (0.5)270 (1.0)< 0.001
Cardiovascular mortality in hospital964 (5.6)630 (3.6)< 0.0011051 (4.0)717 (2.8)< 0.001
Other cause of mortality in hospital54 (0.3)49 (0.3)0.62268 (0.3)66 (0.3)0.863
In-hospital mortality1018 (5.9)679 (3.9)< 0.0011119 (4.3)783 (3.0)< 0.001
30-day mortality1535 (8.8)1303 (7.5)< 0.0011825 (7.0)1534 (5.9)< 0.001
6-month mortality2760 (15.9)2204 (12.7)< 0.0013322 (12.7)2749 (10.6)< 0.001
12-month mortality3474 (20.0)2812 (16.2)< 0.0014293 (16.5)3544 (13.6)< 0.001

In the multivariable analysis the invasive strategy appeared to be the strongest factor decreasing mortality. It tripled the in-hospital and doubled the 12-month mortality rate reduction (Table V).

Table V

Multivariate analysis of factors of in-hospital as well as 12-month mortality.

ParameterIn-hospital mortality12-month mortality
RR (95% CI)P-valueOR (95% CI)P-value
Gender – female (vs. male)1.02 (0.97–1.08)0.44850.94 (0.92–0.97)< 0.0001
Age (on each decade)1.63 (1.59–1.68)< 0.00011.57 (1.55–1.59)< 0.0001
Hypertension0.73 (0.69–0.78)< 0.00010.85 (0.83–0.88)< 0.0001
Diabetes1.09 (1.03–1.15)0.00211.29 (1.26–1.32)< 0.0001
Hypercholesterolaemia 0.73 (0.69–0.77)< 0.00010.81 (0.79–0.83)< 0.0001
Smoking1.02 (0.94–1.10)0.67761.06 (1.03–1.10)0.0005
Obesity1.18 (1.10–1.26)< 0.00010.99 (0.96–1.02)0.37
Previuos MI1.07 (1.01–1.14)0.02551.12 (1.09–1.15)< 0.0001
Previous PCI0.80 (0.73–0.88)< 0.00010.90 (0.87–0.94)< 0.0001
Previous CABG0.80 (0.71–0.91)0.00060.84 (0.80–0.88)< 0.0001
SBP < 100 mm Hg2.25 (2.08–2.45)< 0.00011.69 (1.62–1.77)< 0.0001
SBP > 160 mm Hg0.48 (0.43–0.52)< 0.00010.68 (0.66–0.71)< 0.0001
HR > 100 /min1.31 (1.23–1.40)< 0.00011.23 (1.19–1.27)< 0.0001
Killip 3 class3.67 (3.41–3.94)< 0.00011.98 (1.91–2.06)< 0.0001
Killip 4 class13.2 (12.0–14.4)< 0.00014.48 (4.26–4.71)< 0.0001
Other than sinus rythm on ECG1.19 (1.12–1.27)< 0.00011.14 (1.11–1.18)< 0.0001
ST-T abnormalities on ECG1.16 (1.07–1.27)0.00071.15 (1.11–1.19)< 0.0001
LVEF 35–50%1.10 (1.01–1.20)0.02401.52 (1.47–1.57)< 0.0001
LVEF < 35%2.31 (2.11–2.53)< 0.00012.67 (2.57–2.78)< 0.0001
Time to admission > 12 h1.09 (1.03–1.16)0.00301.03 (1.00–1.06)0.022
Prehospital cardiac arrest2.37 (2.09–2.69)< 0.00011.74 (1.63–1.85)< 0.0001
Invasive treatment0.31 (0.29–0.33)< 0.00010.51 (0.49–0.52)< 0.0001

[i] CABG – coronary artery by-pass graft, ECG – electrocardiogram, HR – heart rate, LVEF – left ventricle ejection fraction, MI – myocardial infarction, PCI – percutaneous coronary intervention, SBP – systolic blood pressure.

An estimated impact of the treatment improvements on relative risk reduction in in-hospital mortality amounted to 67.8% in women and 61.6% in men, respectively. Similarly changes of the management in the last decade accounted for 63.3% (in women) and 62.6% (in men) of the relative risk reduction in 12-month mortality (Figure 1).

Figure 1

Impact of the treatment improvements and clinical profile changes on mortality reduction in NSTEMI in 2005–2014

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Discussion

The major finding of our study is the confirmation of the progress in therapeutic strategies to outcomes of the management of patients with NSTEMI in the last decade. The propensity score analysis revealed the substantial input (over 60%) of modern treatment into the overall benefit of prognosis. Irrespective of the clinical profile changes the routine invasive approach as well as modern medical therapies resulted in a spectacular mortality rates reduction.

As in many previous reports significant changes in the clinical characteristics, management and treatment outcomes of NSTEMI patients were observed [35]. The prevalence of major coronary risk factors like diabetes, obesity, arterial hypertension and chronic kidney disease is still increasing. On the contrary, percentage of smoking habit significantly decreased recently. Additionally, in the years 2005–2014 numerous changes in the clinical profile (mean age, gender, comorbidities and Killip class on admission) that might have impact on prognosis were noted [913].

Recently, a significant progress in the medical therapy was achieved, as the vast majority of NSTEMI patients receive double antiplatelet therapy (including P2Y12-receptor blockers). Previously, a significant proportion of patients were administered ticlopidine that was gradually substituted by clopidogrel and later by ticagrelor according to the guidelines of European Society of Cardiology [68]. Nevertheless, due to financial issue, the implantation of the novel antiplatelets agents in a routine practice was delayed in Poland compared with other countries.

An invasive approach became a predominant treatment strategy in NSTEMI [7, 8, 14, 15]. Importantly, the CA or PCI rates in Poland are currently equal to those in the Western Europe and United States [3, 4, 5, 16]. A rapid growth in invasive strategy utilization in Poland was distinctively noticeable in 2005–2011 that was mainly related to the opening of new catheterization laboratories. These allowed to follow ECS guidelines of that time on management of acute coronary syndromes in patients presenting without persistent ST-segment elevation from 2002 [6] and 2007 [7].

Multivariable analysis confirmed the significant invasive strategy contribution to outcomes which appear to be continuously better than previously reported [4, 9, 15].

In the last decade a spectacular decrease in mortality rates was observed in Poland which is in line with the reports from France, Sweden, Denmark and Germany [3, 5, 17, 18]. In contrast to the numerous other retrospective studies we applied the propensity score matching method to our analysis. By virtue of PSM the independent impact of the treatment development on outcomes was revealed. Interestingly, that input in prognosis improvements seems to be higher than it could be expected before.

Our study have several limitations. PL-ACS is a voluntary, observational study, and not all hospitals participated in the data collecting. Our analysis has a retrospective nature and some potentially important parameters might not be included. That is a single country study, therefore some trends should be interpreted with caution. Finally, propensity score matching analysis is based on a simplified model, even after data adjustment, the results could be biased by potentially important parameters that were not included.

Conclusions

In Poland, the routine invasive strategy implementation contributed substantially to the outcomes of NSTEMI patients in the last 10 years. The impact of treatment advances on better prognosis was estimated at over sixty percent.

Conflict of interest

The authors declare no conflict of interest.

References

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