Long-term survival after acute myocardial infarction

Transcription

1 Log-Term Survival ad Recurrece After Acute Myocardial Ifarctio i Eglad, 2004 to 2010 Kate Smolia, PhD; F. Lucy Wright, PhD; Mike Rayer, PhD; Michael J. Goldacre, FFPH, FRCP Backgroud There are limited populatio-based atioal data o progosis i survivors of acute myocardial ifarctio (AMI), particularly o log-term survival ad the risk of recurrece. Methods ad Results Record likage of hospital ad mortality data idetified idividuals i Eglad who were admitted to hospital with a mai diagosis of AMI betwee 2004 ad 2010 ad who survived for at least 30 days. Seve years after a AMI, the risk of death from ay cause i survivors of first or recurret AMI was, respectively, 2 ad 3 times higher tha that i the Eglish geeral populatio of equivalet age. For all survivors of a first AMI, the risk of a secod AMI was highest durig the first year ad the cumulative risk icreased more gradually thereafter. For me, 1- ad 7-year cumulative risks were 5.6% (95% cofidece iterval [CI], ) ad 13.9% (95% CI, ); for wome, they were 7.2% (95% CI, ) ad 16.2% (95% CI, ). Older age, higher deprivatio, o revascularizatio procedures, ad presece of comorbidities were associated with higher recurrece risk. Coclusios Survivors of both first ad recurret AMI remaied at a sigificatly higher risk of death compared with the geeral populatio for at least 7 years after the evet. For survivors of first AMI, the ifluece of predisposig factors for secod AMI lesseed with time after the iitial evet. The results reiforce the importace of acute cliical care ad secodary prevetio i improvig log-term progosis of hospitalized AMI patiets. (Circ Cardiovasc Qual Outcomes. 2012;5: ) Key Words: myocardial ifarctio survival progosis epidemiology Log-term survival after acute myocardial ifarctio (AMI) has improved over the last 3 decades i developed coutries. 1 8 Studies have reported improvig survival after both first ad recurret AMIs. 9,10 These improvemets have bee attributed to the icreasigly widespread use of revascularizatio procedures, effective acute treatmet, ad logterm secodary prevetio. 1,2,4,6 We have recetly published o short-term survival withi 30 days after AMI i Eglad durig the 2000s 11,12 ad have show substatial improvemets over time i short-term survival. 12 As short-term survival from AMI improves, the study of log-term progosis becomes ever more importat. This iformatio is of iterest to cliicias, public health professioals, ad decisio-makers because it ca be used to support cliical ad fudig decisios. However, much of the existig data o outcomes after AMI come from cliical trials, which have limited represetativeess ad geeralizability. Populatio-based studies provide a more accurate evidece base for assessmet of risk. Yet, oly a few such studies have examied log-term progosis i uselected patiet populatios, measured as log-term survival ad as risk of recurrece. 4,10,13 17 Of those that have, most used a combied ed poit of recurret AMI or death from ay cause but did ot aalyze risks of recurret evet ad death separately. 10,17 Oe possible meas for obtaiig iformatio o progosis is the aalysis of routiely collected atioal hospital admissio ad death certificate data. Sice 1998, it has bee possible to do perso-based likage of routie atioal hospital ad mortality data for Eglad. Usig a liked dataset of these patiet-level records, we provide a accout of logterm AMI progosis i Eglad. Specifically, we report o 7-year survival i 30-day survivors, distiguishig survivors of first ad recurret AMI, ad o the risk of a secod AMI i survivors of first AMI. We also compare log-term mortality rates of 30-day AMI survivors with those of the geeral populatio. Methods Data Sources Data were obtaied from 2 datasets, Hospital Episode Statistics (HES) ad mortality statistics, which were liked together by the Oxford Record Likage Study team. 18 The record matchig ad likage methods used ecrypted versios of each perso s Natioal Health Service (NHS) umber (uique to the idividual), HESID (a Received December 28, 2011; accepted May 31, From the Departmet of Public Health (K.S., M.R., M.J.G.), ad Cacer Epidemiology Uit (F.L.W.), Uiversity of Oxford, Uited Kigdom. The olie-oly Data Supplemet is available with this article at Correspodece to Michael Goldacre, FFPH, FRCP, Uit of Health-Care Epidemiology, Departmet of Public Health, Rosemary Rue Buildig, Old Road Campus, Roosevelt Drive, Headigto, Oxford, UK OX3 7LF. michael.goldacre@dph.ox.ac.uk 2012 America Heart Associatio, Ic. Circ Cardiovasc Qual Outcomes is available at DOI: /CIRCOUTCOMES

2 Smolia et al Survival After Myocardial Ifarctio i Eglad 533 atioal hospital umber uique to each idividual), date of birth, sex, ad postcode. Both datasets cover all of Eglad ad iclude iformatio o all hospital admissios ad deaths. The HES dataset provides iformatio o all patiets admitted to hospital ad whose care is fuded by the NHS. The mortality data are collected by the Office for Natioal Statistics (ONS) ad iclude all deaths that occur i Eglad, whether i hospital or outside. WHAT IS KNOWN Progosis after acute myocardial ifarctio (AMI) varies with age at the time of AMI, with a higher risk of death ad recurrece i older idividuals. Data o the magitude of this risk ad the time durig which it persists is scarce. There are limited populatio-based represetative atioal data o log-term outcomes, particularly survival ad risk of recurrece. WHAT THE STUDY ADDS This large populatio-based study of AMI i Eglad (populatio 52 millio) provides a comprehesive accout of 7-year progosis i 30-day AMI survivors by quatifyig the extet to which survivors of AMI have worse mortality rates tha the geeral populatio, ad reportig their risk of havig a secod AMI. The results show that AMI survivors remai at highrisk for at least 7 years after a AMI ad reiforce the importace of both cliical care ad secodary prevetio i improvig the log-term outcomes of hospitalized AMI patiets. Study Populatio Eglad (populatio 52 millio) is 1 of 4 costituet coutries of the Uited Kigdom (the others, excluded from this aalysis, are Scotlad, Wales, ad Norther Irelad). Residets of Eglad were icluded i the study if they experieced a AMI evet betwee Jauary 1, 2004, ad December 31, 2010, ad were still alive after 30 days. A AMI evet was defied as a emergecy hospital admissio with a mai discharge diagosis of AMI (Iteratioal Classificatio of Diseases [ICD-10] codes I21 or I22) ad a legth of stay of at least 1 day for someoe discharged alive (for first ad secod AMIs), or a death with AMI coded as the uderlyig cause of death o the death certificate without a correspodig hospital admissio (oly for secod AMIs). The 1-day criterio for hospital stay was applied to avoid coutig suspected AMIs i patiets who were discharged home whe AMI was ot cofirmed. Ay hospital or death records that occurred withi 30 days of the admissio date for a idetified AMI evet were cosidered to relate to the same AMI. For each perso, the first occurrece of a hospital admissio for AMI durig the study period was recorded as the idex evet. To classify each idex AMI as first or recurret, we used a 6-year cliical history (defied as a previous hospital record with AMI as primary or secodary diagosis) for 1998 to If the idex AMI evet occurred i idividuals with o cliical history of AMI durig the previous 6 years, it was categorized as a first AMI, as a proxy for true first AMI. Otherwise, the idex evet was categorized as a recurret AMI. Idividuals were followed util March 31, 2011, ad all therefore had a miimum follow-up period of 3 moths. Statistical Aalyses Survival time was calculated as the time from the date of admissio for the idex AMI to the date of death from ay cause, or cesored at the ed of the study period (March 31, 2011), whichever came first. Survival curves were estimated for age groups, for me ad wome, ad after first ad recurret AMI usig Kapla Meier methods. Comparisos of survival betwee groups were performed usig log-rak tests. Cox proportioal hazards models, yieldig hazard ratios (HRs), were used to examie the effect o survival of age, sex, previous AMI, deprivatio category, coroary revascularizatio procedures, ad comorbidities. The proportioal hazards assumptio was checked visually usig log-log plots of the survival fuctio ad Nelso- Aale plots of the cumulative hazard fuctio. Results are reported separately for me ad wome ad for differet age groups because of a strog iteractio betwee sex ad age (likelihood ratio test, P<0.001). Age-stadardized mortality ratios (SMRs) were used to compare mortality rates for AMI survivors with mortality rates of the geeral Eglish populatio (for the latter, rates published by the ONS were used). SMRs were calculated usig the idirect method of stadardizatio ad the age- ad sex-specific rates i the Eglish atioal populatio as the stadard. Age stratificatio was i 5-year age groups. Average values for 2004 to 2010 for the Eglish mortality rates for each 5-year age group ad sex combiatio were used as the referece rates. For the aalysis of risk of a secod AMI, that is, recurrece risk, oly survivors whose idex evet was their first AMI were icluded. The recurrece risk was calculated usig cumulative icidece methods for survival data, developed by Fie ad Gray 19 for situatios where idividuals ca experiece a competig evet istead of the evet of iterest durig the follow-up period. I this study, the evet of iterest was a secod AMI ad the competig evet was death from causes other tha AMI. Secod AMIs were classified as fatal or ofatal evets. Fatal secod AMIs were defied as hospitalizatios for AMI that eded i death withi 30 days of the date of evet, irrespective of the cause or place of death, or a death with AMI coded as the uderlyig cause of death o the death certificate without a correspodig hospital admissio. Comorbidities ad coroary revascularizatio procedures were studied as progostic factors. A comorbidity was defied as a coditio listed as a secodary diagosis alogside the primary discharge diagosis of AMI i the idex admissio or i ay subsequet admissio withi 30 days of AMI occurrece. Comorbidities were divided ito the followig 5 groups (ICD-10 codes): (1) cacer (C00-C97); (2) diabetes (E10-E14); (3) respiratory disease (J00-J99); (4) real disease (N17-N19); ad (5) selected cardiovascular diseases (CVD), icludig: cerebrovascular disease (G45, I60-69), hypertesio (I10-I15), other CHD (I20, I23-I25), arrhythmia (I28-I29), heart failure (I50), ad peripheral vascular disease (I70-I74). A coroary revascularizatio procedure was defied as either of the followig procedures listed i ay operative field i ay hospital record withi 30 days of AMI date: coroary artery bypass graft (CABG) (Eglish Office of Populatio Ceses ad Surveys (OPCS-4) codes K40-46) ad percutaeous traslumial coroary agioplasty (PTCA) (OPCS- 4 codes K49-50 ad K75). The Idex of Multiple Deprivatio (IMD 2004) 20 score for the idividual s area of residece was used as a proxy measure of socioecoomic status. This is a stadard composite score, coverig several domais of social ad ecoomic deprivatio, widely used i research i the Uited Kigdom. The IMD scores of the idividuals i the 7-year study cohort were grouped ito deprivatio quitiles. Differeces i the distributios of baselie variables were examied usig t tests of statistical sigificace for cotiuous variables ad c 2 tests for categorical variables. Sigificace was accepted at the P<0.05 level; all tests were 2-tailed. All aalyses were performed usig STATA versio 11 (Stata Corporatio, College Statio, TX). Results Survivor Cohort Betwee Jauary 1, 2004, ad December 31, 2010, i Eglad, idividuals were admitted to hospital for

3 534 Circ Cardiovasc Qual Outcomes July 2012 Table 1. Characteristics of AMI 30-Day Survivors by Type of AMI, Eglad, 2004 to 2010 Characteristic Total Me First AMI Died* AMI. Of these, (86%) patiets survived for at least 30 days ad were icluded as the study cohort. Table 1 shows the characteristics of the survivor cohort by first ad recurret idex AMI. The mea age at admissio was higher for the survivors of recurret AMI tha for survivors of first AMI (74 versus 69 years, P<0.001). Aroud a quarter of all patiets with a first AMI ad a half of all those with a recurret AMI died durig the study period. The prevalece of comorbidities was sigificatly higher i wome tha me (P<0.001 for each comorbidity) ad i survivors of recurret AMI compared with survivors of first AMI (P<0.001 for each comorbidity). Media follow-up time was 2.8 years. Log-Term Survival After AMI Figure 1 shows 7-year Kapla Meier survival curves by sex ad age group for first ad recurret AMI, respectively. For each type of AMI, similar survival patters were observed for me ad wome withi the same age groups. Kapla Meier Wome Died* Total Recurret AMI Me Died* Total Age, y Mea Media Age group, y Deprivatio Least deprived, Most deprived, Operatio CABG PTCA Comorbidity Cacer Cardiovascular disease Diabetes Respiratory disease Real disease AMI idicates acute myocardial ifarctio. *Died durig the study period; media follow up was 2.8 years. CABG, coroary artery bypass graft withi 30 days of admissio. PTCA, percutaeous traslumial coroary agioplasty withi 30 days of admissio. Wome Died* survival probability estimates based o the survival curves idicated that survivors of a first AMI fared better tha survivors of a recurret AMI (P<0.001): overall, 7-year survival estimates for patiets with a first AMI were almost twice as high as for those with a recurret AMI. For me, 69% (95% CI, 68 69) were still alive 7 years after a first AMI ad 42% (95% CI, 41 43) after a recurret AMI. For wome, the correspodig figures were 53% (95% CI, 53 53) ad 26% (95% CI, 25 28). The associatios betwee the followig progostic factors for mortality were examied i AMI survivors: age, sex, prior AMI, deprivatio level, revascularizatio procedures, ad comorbidities. Results are preseted i the Data Supplemet Tables available olie. Importatly, fidigs idicate that after adjustig for prior AMI, deprivatio, revascularizatio procedures, ad comorbidities, wome faced a slightly higher risk of dyig tha me i idividuals uder 55 years, whereas me faced a higher risk of dyig tha wome i idividuals

4 Smolia et al Survival After Myocardial Ifarctio i Eglad 535 Figure 1. Seve-year survival i 30-day survivors of acute myocardial ifarctio (AMI) by type of AMI, sex, ad age group, 2004 to 2010, Eglad. 75 years ad older; there was o differece betwee me ad wome aged 55 to 74 years. Stadardized Mortality Ratios Stadardized mortality ratios (SMRs) were used to compare log-term mortality rates amog 30-day AMI survivors with the geeral populatio. The SMR at 4 moths after a first idex AMI peaked at 370 (95% CI, ) i me ad 420 (95% CI, ) i wome (Figure 2). SMRs declied with time ad stabilized at 3 years at about 200 for both sexes, without ay oteworthy chages i the followig 4 years. At 7 years, the risk of all-cause mortality i male ad female survivors of first AMI was about twice the risk of all-cause mortality i the Eglish geeral populatio. The age-specific SMRs i the 7th year after a first AMI were highest amog youger idividuals aged 55 to 64 years ad decreased with older age, approachig the mortality rate of the geeral populatio for those aged 85 years or more (Figure 3). For survivors of a recurret idex AMI, the SMR at 4 moths was 614 (95% CI, ) i me ad 597 (95% CI, 557 to 640) i wome (Figure 2). The SMR for both sexes had almost halved by the ed of 2 years. I the followig 5 years, it stabilized for me at aroud 300, but there was o clear patter for wome (probably because of the low umber of cases). There were also o clear patters i the differeces betwee me ad wome. By 7 years, the risk of all-cause mortality i both male ad female survivors of recurret AMI was about 3 times higher tha the risk of dyig i the Eglish geeral populatio. The age-specific SMRs i the 7th year after a recurret AMI exhibited similar patters as for first AMIs; however, amog those idividuals aged 85 years or more, the mortality rate was about twice as high as the rate i the geeral populatio (Figure 3). Risk of a Secod AMI The idex AMI evet was a first-ever AMI for (96%) of all 30-day AMI survivors. Amog these idividuals, (11%) experieced a secod AMI evet durig the study period, of which (33%) were fatal. A further (18%) people died from a cause other tha AMI durig the study period. Figure 4 shows cumulative icidece plots for risk of a secod AMI (fatal or ofatal) over 7 years by sex ad age. The recurrece risk was greatest i the first year after the idex first AMI, accoutig for just less tha half the cumulative 7-year risk. The risk cotiued to icrease i subsequet years, but more gradually. For me, the risk of ay secod AMI (fatal or ofatal) was 5.6% (95% CI, ) at 1 year, 11.1% (95% CI, ) at 4 years, ad 13.9% (95% CI, ) at 7 years. The correspodig figures for wome were 7.2% (95% CI, ), 13.4% (95% CI, ), ad 16.2% (95% CI, ), respectively. The risk of a secod AMI icreased

5 536 Circ Cardiovasc Qual Outcomes July 2012 Figure 2. Age-stadardized mortality ratios over 7 years i 30-day survivors of acute myocardial ifarctio (AMI), by sex ad type of AMI, 2004 to 2010, Eglad. with older age i both sexes. The cumulative icidece plots by age ad sex for risk of a secod ofatal AMI were similar to the plots for ay secod AMI, but the risks were lower (data ot show). Progostic Factors for a Secod AMI Table 2 shows HRs for the risk of a secod AMI for me ad wome, after adjustig for age, deprivatio, procedures, ad comorbidities. The risk of a secod AMI icreased with older age ad greater deprivatio: the HRs were 3.21 (95% CI, ) i me ad 2.98 (95% CI, ) i wome, whe comparig the age group of 85 years ad older with the age group of 30 to 54 years; ad 1.38 (95% CI ) i me ad 1.24 (95% CI, ) i wome, whe comparig the most deprived group with the least deprived group. Havig a PTCA or CABG procedure was associated with a lower risk of a secod AMI. Geerally, the presece of comorbidities was associated with a icreased risk of a secod AMI. Similar patters were observed for the risk of a ofatal secod AMI (data ot show). Table 3 shows adjusted HRs for the risk of a secod AMI by age. Geerally, there were o large differeces i the risk betwee me ad wome, with me havig oly slightly higher risk of recurrece after adjustig for the other factors. However, i those aged 85 years ad older, me had about a 30% higher risk tha wome after adjustmet. The effect of deprivatio o recurrece risk decreased with icreasigly older age. The effect of comorbidities varied by age group, Figure 3. Age-stadardized mortality ratios i 30-day survivors of acute myocardial ifarctio (AMI), i the 7th year after the AMI, by sex, age, ad type of AMI, 2004 to 2010, Eglad. but geerally also atteuated with icreasig age. Diabetes cotiued to be a risk factor for a secod AMI at all ages. The stregth of the associatio betwee havig a revascularizatio procedure ad loger survival icreased with older age. However, very few patiets aged over 85 years had udergoe CABG ad its effect could ot be determied i this age group. Similar patters were observed for the risk of a ofatal secod AMI (data ot show). Discussio This study provides a comprehesive accout of 7-year progosis i 30-day AMI survivors i Eglad betwee 2004 ad It exteds curret kowledge of AMI epidemiology by reportig log-term survival, quatifyig the extet to which AMI survivors have a worse progosis tha the geeral populatio, ad reportig their risk of havig a secod AMI. Aroud 1 i 7 me ad 1 i 6 wome who survived their first AMI experieced a secod AMI withi 7 years, with the recurrece risk icreasig with older age. By 7 years, all-cause mortality i survivors of first ad recurret AMI remaied, respectively, 2 ad 3 times higher tha that of the Eglish geeral populatio of equivalet age. Log-Term Survival Overall, we showed that 30-day survivors of AMI cotiue to be a high-risk group of patiets, with about oe-quarter of survivors

6 Smolia et al Survival After Myocardial Ifarctio i Eglad 537 Table 2. Factors Ifluecig the Risk of a Fatal or Nofatal Secod AMI Amog 30-Day Survivors of First AMI by Sex, 2004 to 2010, Eglad Figure 4. Risk of a secod acute myocardial ifarctio (AMI) over 7 years amog 30-day survivors of first AMI by sex, age, ad year sice first AMI, 2004 to 2010, Eglad. Risk of a secod AMI i %=cumulative icidece 100. of first idex AMI ad half of survivors of recurret idex AMI dyig withi 7 years of the evet. Importatly, survivors of both first ad recurret AMI had a sustaied worse progosis tha the geeral populatio. Studies from Caada ad Swede also foud a similarly higher mortality risk i AMI survivors compared with the geeral populatio (about 3 times as high at 1 year after the evet). 4,21 We also report that the icreased risk of death is particularly high i the middle-aged AMI survivors. These results carry a importat message for cliicias: eve several years after the evet, AMI patiets cotiue to have a elevated risk of death ad may beefit from log-term secodary prevetio. Factor Age, y Me HR* (95% CI) Wome HR* (95% CI) Ref. Ref ( ) 1.10 ( ) ( ) 1.70 ( ) ( ) 2.51 ( ) ( ) 2.98 ( ) Deprivatio Least deprived, 1 Ref. Ref ( ) 1.05 ( ) ( ) 1.05 ( ) ( ) 1.13 ( ) Most deprived, ( ) 1.24 ( ) Procedure CABG 0.30 ( ) 0.38 ( ) PTCA 0.57 ( ) 0.60 ( ) Comorbidity Cacer 0.97 ( ) 0.78 ( ) Cardiovascular disease 1.36 ( ) 1.43 ( ) Diabetes 1.59 ( ) 1.66 ( ) Respiratory disease 1.18 ( ) 1.06 ( ) Real disease 1.19 ( ) 1.03 ( ) AMI idicates acute myocardial ifarctio; HR, hazard ratio; ad CI, cofidece iterval. *Adjusted for all other factors show. CABG, coroary artery bypass graft; referece group is those without CABG. PTCA, percutaeous traslumial coroary agioplasty; referece group is those without PTCA. We foud that log-term progosis for AMI survivors is worse i youger ad better i older wome tha me, a fidig similar to that i earlier reports from the Uited States, 22 Caada, 23 Norway, 7 ad Swede. 24 Others have foud o sex differeces i age-adjusted log-term mortality after AMI, 13,25 27 but age-specific rates for me ad wome were ot reported i these studies. Some of the higher mortality i youger wome ca be attributed to a higher prevalece of diabetes ad other comorbidities ad more i-hospital complicatios tha me. 22,24,25,28 30 Other possible explaatios iclude premature coroary heart disease, differet pathophysiological mechaisms, aatomic differeces, ad atypical symptom presetatio i wome. 22,28,31 33 Risk of a Secod AMI We foud that amog survivors of a first AMI who experieced a secod evet, about half of these secod AMIs occurred withi the first year. These results idicate that patiets who survived their first AMI are most proe to recurrece i the earlier period after the iitial ifarct, idicatig that the ifluece of predisposig factors for secod AMI lesses with time. Aother study recetly reported similar results: i Swede, a study of recurrece amog survivors of AMI betwee 1972 ad 2001 foud that the risk of a secod AMI decreased sharply withi the first

7 538 Circ Cardiovasc Qual Outcomes July 2012 Table 3. Factors Ifluecig Occurrece of a Fatal or Nofatal Secod AMI Amog 30-Day Survivors of First AMI by Age Group, 2003 to 2007, Eglad Factor Sex two years, reached its miimum at 5 years, ad the started to slowly icrease agai. 17 The greater recurrece risk durig the first few years immediately after the iitial evet is likely to be caused by ogoig disease processes. These fidigs idicate that patiets who have experieced a AMI will beefit from prompt iitiatio of evidece-based secodary prevetio. Progostic factors for a secod AMI were similar to those for death: older age, higher deprivatio, ad the presece of other diseases as comorbidities. The effect of deprivatio ad comorbidities decreased with age. Diabetes was cofirmed to be a strog risk factor for recurrece for both me ad wome ad for all age groups. 15,16,34 Because of the limited iformatio available i the dataset used for this study, the effect of the mai coroary risk factors (smokig status, high blood cholesterol levels, ad high blood pressure), which have bee show to affect AMI recurrece, 15 could ot be assessed. Other factors that may have iflueced recurrece, but could ot be ivestigated i this study, iclude ifarct severity, pharmaceutical treatmet, psychological factors, social eviromet, ad patiet compliace with drug therapy ad advice o physical activity, weight cotrol, ad healthy diet. Study Stregths ad Limitatios The stregths of this study iclude its large size, populatiolevel represetatio, complete atioal coverage, ad recet data. I additio, we report age-specific iformatio ad distiguish betwee first ad recurret evets. This study also demostrates the use of very large scale atioal record-likage Years Years Years Years 85+ Years HR* (95% CI) HR* (95% CI) HR* (95% CI) HR* (95% CI) HR* (95% CI) Wome Ref. Ref. Ref. Ref. Ref. Me 1.11 ( ) 1.11 ( ) 1.03 ( ) 1.11 ( ) 1.24 ( ) Deprivatio Least deprived, 1 Ref. Ref. Ref. Ref. Ref ( ) 1.15 ( ) 1.06 ( ) 1.07 ( ) 1.01 ( ) ( ) 1.34 ( ) 1.14 ( ) 1.12 ( ) 1.04 ( ) ( ) 1.51 ( ) 1.24 ( ) 1.16 ( ) 1.00 ( ) Most deprived, ( ) 1.76 ( ) 1.44 ( ) 1.22 ( ) 1.08 ( ) Procedure CABG 0.51 ( ) 0.40 ( ) 0.31 ( ) 0.25 ( ) - PTCA 0.88 ( ) 0.64 ( ) 0.53 ( ) 0.49 ( ) 0.58 ( ) Comorbidity Cacer 1.24 ( ) 1.25 ( ) 1.07 ( ) 0.86 ( ) 0.82 ( ) Cardiovascular disease 1.27 ( ) 1.32 ( ) 1.40 ( ) 1.41 ( ) 1.34 ( ) Diabetes 1.77 ( ) 2.17 ( ) 1.90 ( ) 1.46 ( ) 1.22 ( ) Respiratory disease 1.30 ( ) 1.30 ( ) 1.34 ( ) 1.11 ( ) 0.91 ( ) Real disease 2.35 ( ) 1.95 ( ) 1.46 ( ) 1.07 ( ) 0.92 ( ) AMI idicates acute myocardial ifarctio; HR, hazard ratio; ad CI, cofidece iterval. *Adjusted for all other factors show. CABG, coroary artery bypass graft; referece group is those without CABG. PTCA, percutaeous traslumial coroary agioplasty; referece group is those without PTCA. resources for the study of outcomes i cardiovascular (ad other) diseases. Methodologically, this is the first study, to the best of our kowledge, to use competig risk aalysis to estimate AMI recurrece a approach that has bee previously used i a umber of cacer studies ad recetly, for stroke recurrece. 35 The mai limitatio is the reliace o the accuracy ad validity of routiely collected data. However, a systematic review of studies comparig routie hospital discharge statistics with medical records coducted i Eglad, Wales, ad Scotlad reported, o average, high codig accuracy rates. 36 Liked Scottish Morbidity Record Database ad Patiet Episode Database for Wales, equivalets of the Eglish HES, were reported to have high accuracy rates for the diagosis of AMI. 16,37 Further limitatios iclude the absece of cliical iformatio, makig it impossible to adjust for coroary risk factors ad ifarct severity, or to report o the diagostic criteria used i makig the cliical diagosis of AMI. HES records do ot cotai iformatio o drug prescriptios ad thus treatmet effect could ot be examied. Iformatio o previous episodes of AMI was limited to 6 years of prior history ad, ievitably, a small proportio of evets that were classified as first were i fact recurret. It is also possible that some AMIs that were idetified as recurret (based o the 30-day cut-off to distiguish separate evets) might ot have bee ew evets ad were still related to the previous AMI. Some AMI hospital admissios with a legth of stay of 1 day or less ad live discharge or with oly a secodary

8 Smolia et al Survival After Myocardial Ifarctio i Eglad 539 diagosis of AMI excluded from this study could have bee true istaces of AMI. Silet AMIs that did ot lead to a hospital admissio or a death record could ot be captured by the available data ad thus would ot have bee icluded i the study. Some deaths coded with other CHD as the uderlyig cause of death could have bee cases of AMI, but, as this is ot kowable, they could ot be icluded. The itroductio of the ew diagostic criteria for AMI i 2000 could have iflueced our estimates. However, studies have show that this chage i criteria does ot affect hospitalized case fatality It is plausible that estimates of log-term survival are also ot affected to ay great extet. Ufortuately, we did ot have access to cliical iformatio ad therefore could ot adjust for the chage i diagostic criteria for AMI. Coclusios This study exteds ad updates curret iformatio o progosis after a AMI, specifically log-term survival ad the risk of a secod evet. Survivors of either a first or a recurret AMI remaied at a sigificatly higher risk of death compared with the geeral populatio over at least 7 years, particularly the middle-aged idividuals. A substatial proportio of 30-day survivors of first AMI experieced a secod AMI withi the subsequet 7 years. The ifluece of predisposig factors for a secod AMI lesseed with time after the iitial evet. The results highlight the fact that AMI survivors remai a highrisk group for recurret evets ad mortality ad reiforce the importace of both acute cliical care ad secodary prevetio i improvig the log-term progosis of hospitalized AMI patiets. Sources of Fudig Dr Smolia is fuded by the Rhodes Trust; Dr Wright is fuded by the Medical Research Coucil; Dr Rayer is fuded by the British Heart Foudatio; ad Dr Goldacre is partly fuded by the Natioal Istitute for Health Research (NIHR); the work to build the Eglish atioal liked dataset of HES ad ONS records is fuded by the NIHR. 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