Does the presence of transcatheter aortic valve replacement (TAVR) service impact acute myocardial infarction care? A binational analysis from MINAP and SWEDEHEART between 2015-2019

Transcatheter aortic valve replacement (TAVR) volume has significantly increased globally although whether this has impacted routine acute myocardial (AMI) care is unclear.

We used two national AMI registries, MINAP and SWEDEHEART, including patients admitted directly to England and Sweden hospitals between 2015-2019 with either PCI-alone, or TAVR services. Logistic regression models compared odds of receiving reperfusion for STEMI or invasive coronary angiography (ICA) within specified timeframes for NSTEMI. Secondary outcomes were adjusted thirty day mortality for STEMI and NSTEMI. Subgroup analyses compared outcomes according to TAVR centre volume, and included patients that underwent interhospital transfer to PCI centres.

150,479 AMI patients were included from England (46%), 58,060 (31%) from Sweden (% admitted directly to TAVR centres). For STEMI, odds of "door-to-balloon" time <60 minutes was lower in TAVR centres (England aOR: 0.82; 95% CIs 0.79-0.86, Sweden; 0.81 [0.79-0.86], both P<0.001. Odds of all-cause mortality at 30d for STEMI were lower (England 0.87; [0.78-0.96], P<0.001), Sweden: 0.85 [0.75-0.95], P=0.004) across both nations in TAVR centres. For NSTEMI, odds of undergoing ICA within 72hr (England 1.17; [1.12-1.22], P<0.001), Sweden; 1.55 [1.45-1.66], P<0.001) were significantly higher in TAVR centres. For NSTEMI, odds of undergoing ICA within 72hr were higher in low (1.37; [1.27-1.47], P<0.001) and moderate-volume TAVR centres (1.17; [1.10-1.25], P<0.001), in England, but in Sweden, highest in high-volume TAVR centres (2.32; [2.09-2.58], P<0.001).

The expansion of TAVR services has not impacted routine AMI care across England and Sweden between 2015-2019, and there is a signal that patients admitted to TAVR units have better survival for STEMI in both nations, and NSTEMI in Sweden. NSTEMI time to angiography varies by TAVR centre volume, with an early sign that the highest volume TAVR centres in England may struggle to maintain prompt NSTEMI angiography.For image description, please refer to the figure legend and surrounding text.