title: Excess mortality and guideline-indicated care following non-ST-elevation myocardial infarction.
abstract: BACKGROUND
  Adherence to guideline-indicated care for the treatment of non-ST-elevation myocardial infarction (NSTEMI) is associated with improved outcomes. We investigated the extent and consequences of non-adherence to guideline-indicated care across a national health system.
  
  
  METHODS
  A cohort study ( ClinicalTrials.gov identifier: NCT02436187) was conducted using data from the Myocardial Ischaemia National Audit Project ( n = 389,057 NSTEMI, n = 247 hospitals, England and Wales, 2003-2013). Accelerated failure time models were used to quantify the impact of non-adherence on survival according to dates of guideline publication.
  
  
  RESULTS
  Over a period of 1,079,044 person-years (median 2.2 years of follow-up), 113,586 (29.2%) NSTEMI patients died. Of those eligible to receive care, 337,881 (86.9%) did not receive one or more guideline-indicated intervention; the most frequently missed were dietary advice ( n = 254,869, 68.1%), smoking cessation advice ( n = 245,357, 87.9%), P2Y12 inhibitors ( n = 192,906, 66.3%) and coronary angiography ( n = 161,853, 43.4%). Missed interventions with the strongest impact on reduced survival were coronary angiography (time ratio: 0.18, 95% confidence interval (CI): 0.17-0.18), cardiac rehabilitation (time ratio: 0.49, 95% CI: 0.48-0.50), smoking cessation advice (time ratio: 0.53, 95% CI: 0.51-0.57) and statins (time ratio: 0.56, 95% CI: 0.55-0.58). If all eligible patients in the study had received optimal care at the time of guideline publication, then 32,765 (28.9%) deaths (95% CI: 30,531-33,509) may have been prevented.
  
  
  CONCLUSIONS
  The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality. Greater attention to the provision of guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.
authors.affiliation: 1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: Tatendashe B
authors.initials: TB
authors.lastname: Dondo
authors.affiliation: 1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: Marlous
authors.initials: M
authors.lastname: Hall
authors.affiliation: 2 The National Institute for Health Biomedical Research Unit, Barts Health, UK.
authors.forename: Adam D
authors.initials: AD
authors.lastname: Timmis
authors.affiliation: 1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Gilthorpe
authors.affiliation: 1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: Oras A
authors.initials: OA
authors.lastname: Alabas
authors.affiliation: 3 Department of Cardiology, The Mid Yorkshire Hospitals NHS Trust, UK.
authors.forename: Phillip D
authors.initials: PD
authors.lastname: Batin
authors.affiliation: 4 National Institute for Cardiovascular Outcomes Research, University College London, UK.
authors.forename: John E
authors.initials: JE
authors.lastname: Deanfield
authors.affiliation: 5 The Farr Institute, University College London, UK.
authors.forename: Harry
authors.initials: H
authors.lastname: Hemingway
authors.affiliation: 1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.|6 York Teaching Hospital NHS Foundation Trust, UK.
authors.forename: Chris P
authors.initials: CP
authors.lastname: Gale
mesh_terms: D000368:Aged; D000072038:Cardiac Rehabilitation / Q000592:standards*; D002423:Cause of Death / Q000639:trends; D017023:Coronary Angiography; D004562:Electrocardiography; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D009313:National Health Programs / Q000592:standards*; D000072658:Non-ST Elevated Myocardial Infarction / Q000175:diagnosis / Q000401:mortality* / Q000534:rehabilitation; D017410:Practice Guidelines as Topic; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D006113:United Kingdom / Q000453:epidemiology; D014852:Wales / Q000453:epidemiology
keywords: MINAP; NSTEMI; National Health Service; electronic health records; evidence-based medicine; excess mortality