Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; UK Small Area Health Statistics Unit, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
Lancet Public Health. 2017 Apr;2(4):e191-e201. doi: 10.1016/S2468-2667(17)30032-4. Epub 2017 Mar 1.
Little information is available on how primary and comorbid acute myocardial infarction contribute to the mortality burden of acute myocardial infarction, the share of these deaths that occur during or after a hospital admission, and the reasons for hospital admission of those who died from acute myocardial infarction. Our aim was to fill in these gaps in the knowledge about deaths and hospital admissions due to acute myocardial infarction.
We used individually linked national hospital admission and mortality data for England from 2006 to 2010 to identify all primary and comorbid diagnoses of acute myocardial infarction during hospital stay and their associated fatality rates (during or within 28 days of being in hospital). Data were obtained from the UK Small Area Health Statistics Unit and supplied by the Health and Social Care Information Centre (now NHS Digital) and the Office of National Statistics. We calculated event rates (reported as per 100 000 population for relevant age and sex groups) and case-fatality rate for primary acute myocardial infarction diagnosed during the first physician encounter or during subsequent encounters, and acute myocardial infarction diagnosed only as a comorbidity. We also calculated what proportion of deaths from acute myocardial infarction occurred in people who had been in hospital on or within the 28 days preceding death, and whether acute myocardial infarction was one of the recorded diagnoses in such admissions.
Acute myocardial infarction was diagnosed in the first physician encounter in 307 496 (69%) of 446 744 admissions with a diagnosis of acute myocardial infarction, in the second or later physician encounter in 52 374 (12%) admissions, and recorded only as a comorbidity in 86 874 (19%) admissions. Patients with comorbid diagnoses of acute myocardial infarction had two to three times the case-fatality rate of patients in whom acute myocardial infarction was a primary diagnosis. 135 950 deaths were recorded as being caused by acute myocardial infarction as the underlying cause of death, of which 66 490 (49%) occurred in patients who were in hospital on the day of death or in the 28 days preceding death. AMI was the primary diagnosis in 32 695 (49%) of these 66 490 patients (27 678 [42%] diagnosed in the first physician encounter and 5017 [8%] in a second or subsequent encounter), was a comorbid diagnosis in 12 118 (18%), and was not mentioned at all in the remaining 21 677 (33%). The most common causes of admission in people who did not have an acute myocardial infarction diagnosis but went on to die of acute myocardial infarction as the underlying cause of death were other circulatory conditions (7566 [35%] of 21 677 deaths), symptomatic diagnoses including non-specific chest pain, dyspnoea and syncope (1368 [6%] deaths), and respiratory disorders (2662 [12%] deaths), mainly pneumonia and chronic obstructive airways disease.
As many acute myocardial infarction deaths occurring within 28 days of being in hospital follow a non-acute myocardial infarction admission as follow an acute myocardial infarction admission. These people are often diagnosed with other circulatory disorders or symptoms of circulatory disturbance. Further investigation is needed to establish whether there are symptoms and information that can be used to predict the risk of a fatal acute myocardial infarction in such patients, which can contribute to reducing the mortality burden of acute myocardial infarction.
Wellcome Trust, Medical Research Council, Public Health England, National Institute for Health Research.
关于原发性和合并急性心肌梗死在急性心肌梗死的死亡率负担中所起的作用、这些死亡中有多少发生在住院期间或之后，以及因急性心肌梗死而死亡的人住院的原因，相关信息有限。我们的目的是填补关于急性心肌梗死死亡和住院的知识空白。
我们使用 2006 年至 2010 年英格兰国家医院入院和死亡率的个体链接数据，确定在住院期间所有原发性和合并急性心肌梗死的诊断及其相关死亡率（住院期间或住院后 28 天内）。数据来自英国小区域健康统计单位，由卫生和社会保健信息中心（现为 NHS Digital）和国家统计局提供。我们计算了首次就诊或随后就诊时诊断为原发性急性心肌梗死的事件发生率（按相关年龄和性别组每 100000 人报告）和病死率，以及仅诊断为合并症的急性心肌梗死的病死率。我们还计算了有多少急性心肌梗死死亡发生在死亡前 28 天内住院的患者中，以及此类入院记录中是否有急性心肌梗死作为记录诊断之一。
在 446744 例因急性心肌梗死入院的患者中，有 307496 例（69%）在首次就诊时诊断为急性心肌梗死，52374 例（12%）在第二次或以后的就诊时诊断，86874 例（19%）仅作为合并症记录。合并诊断为急性心肌梗死的患者的病死率是急性心肌梗死为原发性诊断的患者的两到三倍。记录了 135950 例因急性心肌梗死为根本死因的死亡，其中 66490 例（49%）发生在死亡当天或死亡前 28 天住院的患者中。在这 66490 例死亡中，AMI 是主要诊断（32695 例，占 49%），其中 27678 例（42%）在首次就诊时诊断，5017 例（8%）在第二次或以后的就诊时诊断，是合并诊断（12118 例，占 18%），其余 21677 例（33%）根本没有提及。在没有急性心肌梗死诊断但最终因急性心肌梗死为根本死因而死亡的患者中，最常见的入院原因是其他循环系统疾病（21677 例死亡中的 7566 例，占 35%）、包括非特异性胸痛、呼吸困难和晕厥在内的有症状诊断（1368 例死亡，占 6%）和呼吸障碍（2662 例死亡，占 12%），主要是肺炎和慢性阻塞性气道疾病。
发生在住院后 28 天内的许多急性心肌梗死死亡病例与急性心肌梗死入院病例一样，都是由非急性心肌梗死入院引起的。这些人通常被诊断为其他循环系统疾病或循环系统紊乱的症状。需要进一步调查，以确定是否有症状和信息可用于预测此类患者致命性急性心肌梗死的风险，这有助于降低急性心肌梗死的死亡率负担。
惠康信托基金会、医学研究理事会、英国公共卫生署、国民健康保险制度。
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