title: Age-dependent inequalities in improvements in mortality occur early after acute myocardial infarction in 478,242 patients in the Myocardial Ischaemia National Audit Project (MINAP) registry.
abstract: BACKGROUND
  Mortality rates after acute myocardial infarction (AMI) have declined, but there is uncertainty regarding the extent of improvements in early mortality in the elderly.
  
  
  METHODS
  Mixed-effects regression analysis of 30-day mortality using data from 478,242 patients with AMI at 215 hospitals in England and Wales stratified by STEMI/NSTEMI, sex, and age group. A hospital opportunity-based composite score (OBCS) for aspirin, ACE-inhibitor, statin, β blocker, and referral for cardiac rehabilitation was used as measure of quality of hospital care.
  
  
  RESULTS
  30-day mortality rates (95% CI) fell from 10.7% (10.6 to 10.9%) in 2004/5 to 8.4% (8.3 to 8.6%) in 2008/9. The median (IQR) hospital OBCSs increased over time, 2004/5: 87.3 (7.2), 2006/7: 88.9 (6.3), 2008/9: 90.3 (6.1), P<0.001, and were similar between age groups (18 to <65 years, 65 to 79 years, and ≥ 80 years) for STEMI: 89.4 (6.5) vs. 89.4 (6.6), vs. 89.2 (6.5) and NSTEMI: 88.6 (7.3) vs. 88.8 (7.0) vs. 88.9 (7.0), respectively For males, all age groups except patients <65 years demonstrated a significant decrease in adjusted mortality. For females, only patients ≥ 80 years demonstrated a significant reduction in adjusted mortality. A 1% increase in hospital OBCS was associated with a 1% decrease in 30-day mortality (95% CI: 0.99 to 0.99, P<0.001).
  
  
  CONCLUSIONS
  In England and Wales, for patients with AMI there are age and sex-dependent differences in improvements in 30-day mortality. Whereas young males with AMI have reached an acceptable performance plateau, all other groups are either improving or, more importantly, are yet to demonstrate this.
authors.affiliation: Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK; Department of Cardiology, York Teaching Hospital NHS Foundation Trust, York, UK. Electronic address: c.p.gale@leeds.ac.uk.
authors.forename: C P
authors.initials: CP
authors.lastname: Gale
authors.forename: B A
authors.initials: BA
authors.lastname: Cattle
authors.forename: P D
authors.initials: PD
authors.lastname: Baxter
authors.forename: D C
authors.initials: DC
authors.lastname: Greenwood
authors.forename: A D
authors.initials: AD
authors.lastname: Simms
authors.forename: J
authors.initials: J
authors.lastname: Deanfield
authors.forename: K A A
authors.initials: KA
authors.lastname: Fox
authors.forename: A S
authors.initials: AS
authors.lastname: Hall
authors.forename: R M
authors.initials: RM
authors.lastname: West
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D004739:England / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000639:trends*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality; D017202:Myocardial Ischemia / Q000175:diagnosis* / Q000401:mortality*; D011446:Prospective Studies; D012042:Registries; D012737:Sex Factors; D013997:Time Factors; D014852:Wales / Q000453:epidemiology; D055815:Young Adult