The quality of care and long-term mortality of patients with ST-elevation myocardial infarction and cardiac devices: a nationwide cohort study

There is a growing population with cardiac devices (pacemakers, implantable cardioverter defibrillators and cardiac resynchronisation therapy), but whether this influences quality of care and long-term mortality after ST-elevation myocardial infarction (STEMI) is unknown.

Patients in England and Wales between January 2005 and March 2019 with a primary diagnosis of STEMI were included from the Myocardial Ischaemia National Audit Project, Hospital Episode Statistics and Office for National Statistics mortality linkage up to July 2021. Primary outcomes were all-cause mortality over the study period, secondary outcomes were odds of undergoing reperfusion within guideline mandated timeframes. Multivariate cox-models compared all-cause mortality over specified time-periods and logistic regression models illustrated odds of undergoing prompt reperfusion.

322,890 patients with STEMI were included, 2,118 (0.7%) had a cardiac device at STEMI admission. Patients with cardiac devices were older (78 years old vs. 66 years old) and more often female (32% vs. 29%) (P<0.001). After multivariate adjustment, patients with cardiac devices were less likely to have a "door to balloon time" of under 60 minutes (aOR 0.61 95% CI 0.54-0.70) (P<0.001). Patients with cardiac devices had an increased risk of all-cause mortality at five-years (aHR 1.16 95% CI 1.09-1.24) (P<0.001). Excluding patients dying within 30 days of admission, patients with cardiac devices still had a higher risk of death at five-years (aHR 1.25 95% CI 1.16-1.34) (all P<0.001).

Patients with cardiac devices were less likely to undergo revascularisation for STEMI within guideline mandated timeframes. They remain at elevated risk of all-cause mortality up to five-years compared to STEMI patients without cardiac devices.

Unadjusted Kaplan-Meier plot