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Acute myocardial infarction (AMI), commonly referred to as a heart attack, is a life-threatening condition that occurs when blood flow to a part of the heart is blocked, resulting in damage to the heart muscle. According to the World Health Organization (WHO), it is one of the leading causes of death worldwide, with an estimated 8.9 million deaths in 2019, which represents 16% of the total deaths in the world. Early diagnosis and appropriate management of AMI are crucial for reducing morbidity and mortality. Since the 1960’s, extraordinary progress has been made in its diagnosis and treatment, impressively reducing the in-hospital mortality of these patients from 26.7 to 7.2% in the latest reports of in-hospital mortality of AMI. In addition, each tool applied for the prevention and treatment of coronary disease has modified the mortality rates of the different types of coronary syndrome by changing the population that suffers from them. Nevertheless, some tools for risk stratification in patients with AMI still remain.
*Address all correspondence to: lucasferrero19@gmail.com
1. Introduction
Coronary heart disease and its main complication, acute myocardial infarction (AMI), are major causes of morbidity and mortality worldwide. Its pathophysiology has been known for more than a century, but the bases of its treatment were established only a few decades ago. Despite advancements in the treatment and management of AMI, it remains a leading cause of mortality and morbidity globally [1].
In-hospital mortality, which refers to deaths that occur during hospitalization, is an important measure of the quality of care provided to AMI patients. Understanding the factors associated with in-hospital mortality is crucial for improving outcomes for AMI patients. This chapter aims to provide a comprehensive overview of the current knowledge on in-hospital mortality from AMI, including the risk factors, prognostic markers, diagnosis, and management, which have undergone great changes and advances in the last 60 years.
The epidemiology of in-hospital mortality from acute myocardial infarction is important to understand the burden of this disease on healthcare systems and patients.
Acute myocardial infarction is a common cause of hospitalization and death worldwide. The incidence of AMI varies by country and region, with the higher rates reported in developed countries. According to a study by the World Health Organization, approximately 100 million people worldwide suffer from AMI each year, and around 9 million die from this disease, which in 2019 represented 16% of the total deaths in the world [1].
Over the past few decades, there have been significant changes in the epidemiology of AMI. While the incidence of AMI should have declined due to improvements in the healthcare system and the development of new treatments for atherosclerosis factors, the worldwide incidence of AMI is expected to rise due to aging populations and an increase in risk factors such as obesity, diabetes, and hypertension, which will be discussed in the following paragraphs. The Global Burden of Disease (GBD) Study 2019 is an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time. It shows that the prevalence of total cardiovascular disease (CVD) nearly doubled from 1990 (271 million) to 2019 (523 million), and the number of CVD deaths steadily increased from 12.1 million in 1990, reaching 18.6 million in 2019 [2].
With the advent of new drugs and procedures, the cost of treatment for a person suffering from AMI has multiplied in the recent years. Because of this, a disparity in the quality of care has been created among populations with socioeconomic differences, both between countries and within each country. These healthcare disparities begin to be an important discussion in the preparation of the different medical care guidelines. Both non-governmental institutions such as the WHO and those responsible for the health of each government should advocate for the right of every person to receive the best possible treatment in order to achieve equality in the population.
The risk factors for cardiovascular disease are diverse and multifactorial. Some risk factors are modifiable, while others are non-modifiable. Identifying these risk factors is crucial for developing effective prevention and management strategies for patients suffering from AMI.
Non-modifiable risk factors include age (the elderly are at greater risk), gender (men have a higher incidence of AMI up to age 60), family history, and genetics. Inside this category, the greatest change to consider in the last decades is the aging of the world population, which occurs mainly in the developed countries [3].
Modifiable risk factors are those that can be modified or controlled through lifestyle changes or medical interventions. These risk factors include smoking, physical inactivity, an unhealthy diet, hypertension, diabetes, obesity, dyslipidemia, and psychosocial factors such as stress, anxiety, and depression. Over the last five decades, there have been significant changes in the presence of these risk factors among the world’s populations. Besides the decline in the prevalence of smoking in many countries, all other cardiovascular risk factors have increased in most countries of the world, both developed and developing [4]. According to the GBD Study 2019, here are some estimates of the global prevalence of some major cardiovascular risk factors in 2019 [5]:
Tobacco use: 1.3 billion people (16.8% of the population).
Unhealthy diet: 2.5 billion people (32.4% of the population).
Obesity: 672 million people (8.7% of the population).
Physical inactivity: 1.6 billion people (20.6% of the population).
Harmful use of alcohol: 2 billion people (25.9% of the population).
Diabetes: 463 million people (6% of the population).
These numbers may vary depending on how each risk factor is defined and measured.
Throughout the history of medicine and in each pathology that afflicts the human being, researchers have made an effort to predict the outcome, and for this, specific data are sought to guide us in this effort. Generally, the marker that prevails and is standardized in the largest number of medical centers is usually the easiest to determine. Risk stratification in patients suffering from AMI is a fundamental part of treatment decision-making, since drugs and procedures are not free of complications. Among the dozens of prognostic markers of in-hospital mortality, there are two that remain among the most reliable and used within the coronary unit: the ventricular ejection fraction measurement and the Killip and Kimball classification. This is mainly due to the ease of their determination and the fact that they represent the impact of myocardial ischemia and necrosis on cardiac function as a pump.
4.1 Ejection fraction
Ejection fraction (EF) refers to the percentage of blood that is ejected from the left ventricle with each heartbeat. It is a measure of the heart’s pumping ability and is commonly assessed using echocardiography or other imaging techniques. The normal range for FE is 50–70%.
The use of ejection fraction as a marker for prognosis in cardiovascular disease has a long history. The concept of EF was first introduced in the early twentieth century by Frank and Starling. Then, in the 1950s and 1960s, advances in imaging technology, such as the advent of echocardiography, allowed for non-invasive measurement of EF in patients with cardiovascular disease. Researchers quickly recognized the potential of EF as a prognostic marker, and numerous studies were conducted in the following decades to investigate the relationship between EF and outcomes in patients with various forms of heart disease. The importance of fractional ejection in the prognosis of AMI lies in its ability to predict the risk of adverse outcomes, including heart failure, recurrent myocardial infarction, and death. Patients with a low EF are at higher risk and may benefit from more aggressive management strategies, such as early revascularization, aggressive medical therapy, and closer monitoring. On the other hand, patients with a preserved EF may have a lower risk of complications and may be managed with less aggressive strategies [6].
In addition to its prognostic value, EF is also an important parameter for assessing the response to treatment in patients with AMI. An improvement in EF following revascularization or other interventions is associated with a better prognosis and may guide ongoing management decisions.
4.2 Killip and Kimball classification
One of the first advances in the treatment of AMI was the creation of the coronary unit proposed by the researchers Killip and Kimball in 1967, who also introduced the classification that bears their names and clinically divides patients with acute myocardial infarction according to the degree of heart failure on hospital admission (Table 1) [7].
Group
Definition
A
Patient without clinical signs of heart failure.
B
Patient who presented rales on lung auscultation, R3 on cardiac auscultation, or jugular venous distention on hospital admission.
C
Patient admitted with acute pulmonary edema.
D
Patient admitted with cardiogenic shock (SBP < 90 mmHg and signs of peripheral hypoperfusion).
Table 1.
Killip and Kimball classification.
The Killip and Kimball (KK) classification was revalidated by multiple trials over the years [7, 8, 9, 10, 11, 12], which remains current despite multiple advances in the treatment of patients with AMI. This validity is not common in areas of medicine with such radical and important changes as emergency cardiology.
Although the correlation between greater heart failure and greater mortality was maintained, the overall and group mortality of patients with AMI has decreased considerably, as it can be seen in Table 2 and Figure 1.
Comparison of mortality rates according to the KK classification.
Figure 1.
Comparison of mortality rates according to the KK classification.
In addition to what can be observed in the decrease in mortality rates, the incidence of presentation of the different groups of KK has evolved since their initial presentation.
Cardiogenic shock presentation (KK group D) is more frequent in patients with ST-segment elevation myocardial infarction (STEMI) compared to patients with non-ST-segment elevation myocardial infarction (NSTEMI), but the overall incidence is declining. The differences between the two AMI subtypes may be due to differences in their pathophysiology: Patients with STEMI have acute occlusion of a coronary artery with sudden ischemia and immediate impairment in function of the affected area of myocardium, which, of sufficient magnitude, can cause such a drop in ejection fraction to cause a drop in blood pressure and the installation of a state of cardiogenic shock, while patients with NSTEMI usually have a gradual progression of coronary obstruction, which allows the myocardium to adapt and not suddenly lose a large percentage of its contractile strength. The increasingly lower incidence of cardiogenic shock in patients with AMI is mainly due to the intention of rapid revascularization that international guidelines demand.
Groups B and C of the KK classification have a higher incidence among patients with NSTEMI, who usually have chronic myocardial ischemia before suffering the acute event, while group A (without heart failure) dominates the world of AMIs today in most of the world. Among the reasons that can be included, in addition to the advances in coronary reperfusion, is the greater and faster access to treatment for an increasing part of the world population [12].
The timely assessment and management of patients with AMI are critical to reducing morbidity and mortality. Risk stratification is an essential part of the evaluation of patients with AMI, as it helps identify those who are at a higher risk of complications and mortality. Several risk scores have been developed to predict the risk of adverse outcomes in patients with AMI, including the “Global Registry of Acute Coronary Events” (GRACE), “Thrombolysis in Myocardial Infarction” (TIMI), and “Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines” (CRUSADE) scores [13, 14, 15].
The GRACE risk score is a well-established tool that predicts the risk of death and major cardiovascular events in patients with AMI. The score is based on eight clinical variables, including age, heart rate, blood pressure, serum creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac enzymes. The score ranges from 1 to 372, with higher scores indicating a higher risk of adverse outcomes [13].
Similarly, the TIMI risk score is another widely used tool for risk stratification in patients with AMI. The score is based on seven clinical variables, including age, heart rate, systolic blood pressure, Killip class, ST-segment deviation, cardiac arrest at admission, and the presence of three or more risk factors for coronary artery disease. The score ranges from 0 to 7, with higher scores indicating a higher risk of adverse outcomes. Both scores have been validated in several large cohorts of patients with AMI and have been shown to be strong predictors of mortality and other adverse outcomes [14].
On the other hand, the CRUSADE risk score is a newer tool that was developed specifically for patients with non-ST-segment elevation acute coronary syndrome, which includes unstable angina and NSTEMI. The score is based on eight clinical variables, including age, heart rate, systolic blood pressure, serum creatinine, Killip class, cardiac arrest at admission, the presence of ST-segment deviation, and the use of glycoprotein IIb/IIIa inhibitors. The score ranges from 1 to 100, with higher scores indicating a higher risk of bleeding complications, and it is used as an antagonist to balance the risks and benefits of anticoagulant treatment in each patient [15].
Over the past century, the diagnostic criteria for AMI have changed multiple times, driven by advances in technology, changes in our understanding of the pathophysiology of the disease, and a growing recognition of the importance of an early and accurate diagnosis.
The diagnosis of AMI has been a challenge for clinicians throughout the history of medicine, with early descriptions of the disease dating back to ancient times. However, it was not until the twentieth century that significant progress was made in understanding the pathophysiology of AMI and developing effective diagnostic tools. The early diagnostic criteria for AMI were based on clinical presentation, ECG findings (such as ST-segment elevation or depression), and serum biomarkers such as glutamic-oxaloacetic transaminase (GOT), lactate dehydrogenase (LDH), and glutamic pyruvic transaminase (GPT). Then, these general biomarkers of damage were replaced with creatine kinase (CK) and its MB isoenzyme (CK-MB). However, these were also limited by their lack of specificity and sensitivity, as CK and CK-MB can be elevated in other conditions [16].
In the 1980s, the use of troponin as a biomarker for AMI diagnosis began to gain acceptance. Troponin is a cardiac-specific protein that is released into the bloodstream in response to myocardial injury. Unlike CK and CK-MB, troponin is highly specific for myocardial injury and is not affected by skeletal muscle injury. The introduction of troponin led to the development of the Universal Definition of Myocardial Infarction, a consensus document of The Joint European Society of Cardiology and The American College of Cardiology, which was first published in 2000 and has been revised several times since then. The Universal Definition established the use of troponin as the preferred biomarker for AMI diagnosis and defined a rise or fall in troponin levels as a key diagnostic criterion [17].
More recently, high-sensitivity troponin assays have become available, which allow for an even earlier and more accurate diagnosis of AMI. These assays can detect very small amounts of troponin in the bloodstream, allowing diagnosis within a few hours of symptom onset and, furthermore, the diagnosis of small infarcts that would not be recognized with the use of less sensitive markers [18].
This is how patients diagnosed with AMI have changed throughout history, mainly due to progress in the detection of increasingly sensitive and specific biomarkers. In summary, currently a large number of patients who decades ago were not considered to have AMI are diagnosed with this pathology and therefore treated in a better way.
The treatment of AMI has undergone significant evolution over the past few decades, with advances in medical technology and research leading to the improved outcomes for patients.
The treatment of AMI has undergone significant evolution over the past few decades, with advances in medical technology and research leading to the improved outcomes for patients. In the past, treatment for AMI was primarily focused on managing symptoms and reducing the risk of complications. However, with the introduction of new therapies and interventions, the goal of treatment has shifted to restoring blood flow to the affected area of the heart as quickly as possible. One of the most significant advancements in AMI treatment has been the widespread adoption of percutaneous coronary intervention (PCI), also known as angioplasty. This procedure involves inserting a catheter into the blocked coronary artery and inflating a small balloon to open the artery and restore blood flow. This is often accompanied by the placement of a stent, a small metal mesh tube that helps keep the artery open. The use of PCI has been shown to significantly reduce the risk of death and major complications in patients with AMI. In addition, advances in technology and techniques have made PCI safer and more effective, with faster procedural times and lower complication rates [19].
Another important development in AMI treatment is the use of pharmacological therapies to prevent and treat blood clots. Antiplatelet and anticoagulant medications, such as aspirin and heparin, can help prevent the formation of blood clots that can lead to a new or more severe AMI. Newer agents, such as P2Y12 inhibitors and direct oral anticoagulants, have also been developed and shown to be effective in reducing the risk of recurrent events [20].
In addition, cardiac rehabilitation programs have become an important component of AMI treatment, helping patients recover and reduce their risk of future cardiovascular events. These programs typically include exercise, dietary counseling, and lifestyle modifications and have been shown to improve quality of life and reduce the risk of death and hospitalization [21].
Overall, the evolution of AMI treatment has been marked by significant improvements in patient outcomes and quality of life. With continued research and development, it is likely that new and even more effective therapies will be developed to further improve the management of this serious condition.
There are two main types of AMI: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). STEMI is characterized by a complete blockage of a coronary artery, while NSTEMI involves a partial blockage. The incidence of these two types of AMI has changed differently over time [22].
In the past, the incidence of STEMI was higher than that of NSTEMI. However, over the past few decades, this trend has been reversed [23]. The increase in NSTEMI incidence can be attributed to a variety of factors. In particular, the use of high-sensitivity cardiac troponin assays has allowed for earlier detection of myocardial injury, leading to a more frequent diagnosis of NSTEMI. Additionally, the increasing prevalence of risk factors such as diabetes and obesity, associated with greater and longer survival of patients with atherosclerotic disease, may be contributing to the rise in NSTEMI incidence.
The treatment and prognosis are also different between STEMI and NSTEMI, and as such, it is important to examine mortality trends separately. For most of human history, the mortality rate associated with AMI was high, with STEMI having a significantly higher mortality rate compared to NSTEMI. However, the advances in medical technology and treatments mentioned above have led to significant improvements in outcomes for both types of AMI, with the mortality rates of these AMI subtypes equalizing and even reversing, according to some surveys.
According to an English study examining long-term trends in incidence and case fatality rates at the AMI hospital, by 2005, the odds of dying within 1 year after discharge were 50% lower among STEMI patients in comparison with those admitted in 1997, and a nonsignificant trend toward lower odds of dying within 1 year of hospitalization was noted among patients with NSTEMI [24].
In the English study previously mentioned, mortality from NSTEMI remained higher than STEMI. These can also be seen in the results of a small Argentine survey, represented in Table 3 and Figure 2 [12].
KK Group
STEMI In-Hospital death/total (mortality rate)
NSTEMI In-Hospital death/total (mortality rate)
All AMI In-Hospital death/total (mortality rate)
A
0/47 (0%)
4/65 (6%)
4/112 (3.5%)
B
0/11 (0%)
2/18 (11%)
2/29 (6.9%)
C
0/0
1/4 (25%)
1/4 (25%)
D
4/7 (57%)
0/0
4/7 (57.1%)
Total
4/65 (6.1%)
7/87 (8%)
11/152 (7.2%)
Table 3.
Comparison of mortality rates according to the KK classification and type of AMI.
Figure 2.
Comparison of mortality rates according to the KK classification and type of AMI.
The higher death rates in STEMI patients may have resulted from the fact that those patients were older, had a greater burden of cardiovascular comorbidities, and were more likely to have 3-vessel coronary disease or not revascularizable disease. This also may explain why doctors may have been less aggressive in managing NSTEMI patients due to concerns about adverse effects, culminating in the underutilization of effective cardiac medications and PCI as well as greater delays in the time to receipt of PCI in patients with NSTEMI.
In conclusion, in addition to showing an increase in the representation of NSTEMI among patients with AMI, the above allows us to assume that the differences in mortality in hospitalized patients with STEMI and NSTEMI are strongly related to the clinical characteristics of the patients and less to the presence (or absence) of ST segment elevation. Therefore, by modifying the populations (affected by progress in the treatment of risk factors, the diagnosis of AMI, and its treatment), the mortality of patients with AMI changed to the point where currently the mortality of NSTEMI is equal to or higher than STEMI.
As we have already established, the in-hospital mortality of patients with AMI has been decreasing over the last 50 years thanks to advances in the prevention, diagnosis, and treatment of these patients, but many challenges still arise. An example of adversity to overcome is the inequality between populations with higher incomes and the most deprived population, which are not only exposed to more environmental risk factors but also do not usually have access to the new treatments that scientific progress constantly provides, both in the treatment of these risk factors (such as atherosclerosis) and in the treatment of patients suffering from AMI [25].
Looking ahead, there are several promising areas of research that may further improve the outlook for AMI patients. These include the development of new medications and therapies that target specific mechanisms involved in the pathophysiology of AMI, as well as advances in precision medicine that can help tailor treatments to individual patients based on their genetic and clinical characteristics.
Overall, while significant progress has been made in the prevention and treatment of AMI, there is still much work to be done to reduce the morbidity and mortality associated with this condition, particularly in underserved populations. Continued investment in research, prevention efforts, and access to quality healthcare will be essential to improving the outlook for AMI patients in the future.
Years of research and scientific progress added knowledge and tools for its treatment, considerably lowering the mortality rates, but the Killip and Kimball classification and fraction ejection measurement continue to be a prognostic marker of in-hospital mortality, retaining their clinical importance decades after their first implementation. Its ability to predict the risk of adverse outcomes, guide risk stratification, and assess the response to treatment makes it a valuable tool for clinicians managing patients with this life-threatening condition. Understanding the importance of prognostic markers in the context of AMI can help clinicians make informed decisions and improve patient outcomes.
Continued efforts to improve prevention, early detection, and personalized management strategies for all patients with AMI are crucial in reducing mortality rates and addressing disparities in outcomes between AMI subtypes.
Conflict of interest
The authors declare no conflict of interest.
Thanks
I want to thank my family for accompanying me and being a pillar both in my professional career and in my personal life, and to my wife for her patience and permanent support.
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Written By
Lucas Ferrero
Submitted: 14 March 2023Reviewed: 14 March 2023Published: 23 November 2023
Open access peer-reviewed chapter
