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Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

BMJ 2019; 365 doi: (Published 04 June 2019) Cite this as: BMJ 2019;365:l1927

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Re: Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

In the study by Valley TS et al (1), 109 375 patients aged 65 years and older with ST elevation myocardial infarction (STEMI) were admitted to hospitals in the United States of America. These hospitals in the top quarter of intensive care use (ICU) admission rates admitted 85% or more of STEMI patients to an ICU and the study used 30 day mortality as the main outcome index. The authors found that ICU care for STEMI is associated with improved mortality among those patients who could be treated in an ICU unit, and they concluded that ICU care may be underused for some patients with STEMI (1). These novel findings throw light on our daily medical practice. However, whether this potentially beneficial strategy pattern matches all is questionable.

To date, whether STEMI patients should be cared for in an ICU or a coronary care unit (CCU) is still unknown. The European Society of Cardiology recommended admitting patients with STEMI to an intensive care unit (ICU); moreover, patients with successful reperfusion therapy and an uncomplicated clinical course shpuld be kept in the CCU or intermediate CCU for a minimum of 24h whenever possible (2). Previous American guidelines suggested that it is not necessary for STEMI patients at low risk to accept ICU level care (3) though the updated version did not specifically mention this (4). The study by Valley TS et al [1] provided new data supporting intensive care for STEMI patients aged 65 years and olded in ICU besides the fact that over 75% STEMI patients have been treated and cared in ICU.

To date, in most developing countries, the first key issue is still to increase the reperfusion rate in STEMI patients especially primary percutaneous coronary intervention (pPCI) or fibrinolysis (5), not to mention in underdeveloped countries like Kenya with only 5% STEMI patients eligible for reperfusion therapy received reperfusion (6). As the largest developing country, in China, the total PCI cases were 228380 in 2009 and 915256 in 2018 respectively, though pPCI in STEMI dramatically decreased the death rate and major adverse cardiac events; the number of pPCI cases in STEMI patients was 15613 in 2009 and 83268 in 2018 and the rate of pPCI of all STEMI patients receiving PCI was 29.76% in 2009 and 45.94% in 2018, which is still lower than in most developed countries.

Globally, owing to a lack of convincing data from randomized control trials, whether patients with STEMI benefit from ICU care has been uncertain and guidelines do not offer consistent recommendations about whether to admit STEMI patients to an ICU (2,4,7). Neither the existing literature nor this paper (1) precisely identifies why ICU care might be particularly beneficial to these patients. Furthermore, one major limitation is that this study treated ICU and CCU as the same. However, much difference exists between the two units in most countries. This would have an impact on these patients’ care and should be carefully evaluated. This study’s cohort consisted of US Medicare beneficiaries and may not generalize to STEMI patients younger than 65 or to non-US STEMI patients, especially in most developing and underdeveloped countries, where both social development and public health all need vast financial investment, and there is a long way to go to increase life expectancy. How to reasonably distribute ICU resources for these very sick and fragile patients does matter for most countries in this diversified era.

In China, although STEMI is still one of the main cause of motality among patients with ischemic heart disease, there has been great progress in the treatment of these high risk patients, to a large extent attributed to the project of Chest Pain Center Construction promoted by both government regulators and medical academic associations. Even so, there exist many medical limitations in most countries. For example, a single nurse often takes care of more than two patients in ICU units, and ICU admission rates of STEMI patients is lower than in the US. Given the relatively lack of medical resources in most countries, STEMI patients who might benefit from ICU care should be identified through randomized clinical trials and the results must be subjected to strict health-economy analysis.

Obviously, critically ill STEMI patients with complications needing specific interventions or operations like coronary artery bypass grafting, mechanical ventilation, renal replacement therapy, mechanical cardiac support or targeted temperature management should be routinely admitted to ICU. Furthermore, psychotherapy for STEMI patients in ICU units should attract more attention. Besides pPCI and fibrinolysis as the preferred standard reperfusion strategies in most countries, chest pain center construction, cardiac catheterization availability, together with new antithrombotic therapy agents and evidence-based therapy and prevention are all effective measures we should take to further decrease the mortality from STEMI (8-10). Encouragingly, there has been progress in the training of doctors, nurses and medical communications between China and other countries based on the continuing ONE BELT, ONE ROAD project raised by China and accepted by more and more countries.

Thank you for considering our views.

Dr. Zhu Yanrong

MD phD Chen Zhong

Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital East, Shanghai, P.R.China
July 23, 2019

Competing interests: no competing interests.

1. Valley TS, Iwashyna TJ, Cooke CR, et al. Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study. BMJ 2019;365:l1927. doi: 10.1136/bmj.l1927.
2. Ibanez B, James S, Agewall S, et al, ESC Scientifc Document Group.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.
3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44:E1-211.
4. Puymirat E, Simon T, Cayla G, et al. Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation 2017;136:1908-19.
5. Zubaid M, Rashed W, Alsheikh-Ali AA, et al. Disparity in ST-segment Elevation Myocardial Infarction Practices and Outcomes in Arabian Gulf Countries (Gulf COAST Registry). Heart Views 2017;18:41-46. doi: 10.4103/HEARTVIEWS.HEARTVIEWS_113_16.
6. Bahiru E, Temu T, Gitura B, et al. Presentation, management and outcomes of acute coronary syndrome: a registry study from Kenyatta National Hospital in Nairobi, Kenya. Cardiovasc J Afr 2018;29:225-30. doi: 10.5830/CVJA-2018-017.
7. China Society of Cardiology of Chinese Medical Association, Editorial Board of Chinese Journal of Cardiology; China Society of Cardiology of Chinese Medical Association Editorial Board of Chinese Journal of Cardiology. Guideline on the diagnosis and therapy of ST-segment elevation myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi 2015;43:380-93. [Article in Chinese]
8. Downing NS, Wang Y, Dharmarajan K, et al. Quality of Care in Chinese Hospitals: Processes and Outcomes After ST-segment Elevation Myocardial Infarction. J Am Heart Assoc 2017;6. pii: e005040. doi: 10.1161/JAHA.116.005040.
9. Jneid H, Addison D, Bhatt DL, et al.2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2017;70:2048-90. doi: 10.1016/j.jacc.2017.06.032.
10. Hao Y, Liu J, Liu J, et al. Sex Differences in In-Hospital Management and Outcomes of Patients With Acute Coronary Syndrome. Circulation 2019;139:1776-85. doi: 10.1161/CIRCULATIONAHA.118.037655.

Competing interests: No competing interests

23 July 2019
Chen Zhong
Chief Physician
Yanrong Zhu
Shanghai Jiao Tong University Affiliated Sixth People’s Hospital East, P.R.China
NO.222, Huanhu Xisan Road, Shanghai 201306, P.R.China.