Outcome of patients admitted with acute coronary syndrome on palliative treatment: insights from the nationwide AMIS Plus Registry 1997-2014.
OBJECTIVE
Compliance with guidelines is increasingly used to benchmark the quality of hospital care, however, very little is known on patients admitted with acute coronary syndromes (ACS) and treated palliatively. This study aimed to evaluate the baseline characteristics and outcomes of these patients.


METHODS
Prospective cohort study.


METHODS
Eighty-two Swiss hospitals enrolled patients from 1997 to 2014.


METHODS
All patients with ACS enrolled in the AMIS Plus registry (n=45,091) were analysed according to three treatment groups: palliative treatment, defined as use of aspirin and analgesics only and no reperfusion; conservative treatment, defined as any treatment including antithrombotics or anticoagulants, heparins, P2Y12 inhibitors, GPIIb/IIIa but no pharmacological or mechanical reperfusion; and reperfusion treatment (thrombolysis and/or percutaneous coronary intervention during initial hospitalisation). The primary outcome measure was in-hospital mortality and the secondary measure was 1-year mortality.


RESULTS
Of the patients, 1485 (3.3%) were palliatively treated, 11,119 (24.7%) were conservatively treated and 32,487 (72.0%) underwent reperfusion therapy. In 1997, 6% of all patients were treated palliatively and this continuously decreased to 2% in 2013. Baseline characteristics of palliative patients differed in comparison with conservatively treated and reperfusion patients in age, gender and comorbidities (all p<0.001). These patients had more in-hospital complications such as postadmission onset of cardiogenic shock (15.6% vs 5.2%; p<0.001), stroke (1.8% vs 0.8%; p=0.001) and a higher in-hospital mortality (25.8% vs 5.6%; p<0.001).The subgroup of patients followed 1 year after discharge (n=8316) had a higher rate of reinfarction (9.2% vs 3.4%; p=0.003) and mortality (14.0% vs 3.5%; p<0.001).


CONCLUSIONS
Patients with ACS treated palliatively were older, sicker, with more heart failure at admission and very high in-hospital mortality. While refraining from more active therapy may often constitute the most humane and appropriate approach, we think it is important to also evaluate these patients and include them in registries and outcome evaluations.


BACKGROUND
ClinicalTrials.gov Identifier: NCT01 305 785.
AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland Department of Cardiology, Clinic St. Anna, Lucerne and University Hospital Zurich, Zurich, Switzerland.
Paul
P
Erne
AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Dragana
D
Radovanovic
Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Burkhardt
B
Seifert
Cardiology Centre, Klinik Im Park, Zurich, Switzerland.
Osmund
O
Bertel
Cardiovascular Department, Hôpital de La Tour, Geneva, Switzerland.
Philip
P
Urban
D054058:Acute Coronary Syndrome / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D000925:Anticoagulants / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D006333:Heart Failure / Q000209:etiology / Q000401:mortality*; D006493:Heparin / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology; D010166:Palliative Care / Q000379:methods*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000627:therapeutic use; D015995:Prevalence; D058921:Purinergic P2Y Receptor Antagonists / Q000627:therapeutic use; D012042:Registries; D012770:Shock, Cardiogenic / Q000453:epidemiology / Q000209:etiology; D013557:Switzerland / Q000453:epidemiology; D015912:Thrombolytic Therapy; D016896:Treatment Outcome
D000925:Anticoagulants; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D058921:Purinergic P2Y Receptor Antagonists; D006493:Heparin