Impact of a Prior Cancer Diagnosis on Quality of Care and Survival Following Acute Myocardial Infarction: Retrospective Population-Based Cohort Study in England.

Background: An increasing proportion of patients with cancer experience acute myocardial infarction (AMI). We investigated differences in quality of AMI care and survival between patients with and without previous cancer diagnoses.
Methods: A retrospective cohort study using Virtual Cardio-Oncology Research Initiative data. Patients aged 40+ years hospitalized in England with AMI between January 2010 and March 2018 were assessed, ascertaining previous cancers diagnosed within 15 years. Multivariable regression was used to assess effects of cancer diagnosis, time, stage, and site on international quality indicators and mortality.
Results: Of 512 388 patients with AMI (mean age, 69.3 years; 33.5% women), 42 187 (8.2%) had previous cancers. Patients with cancer had significantly lower use of ACE (angiotensin-converting enzyme) inhibitors/angiotensin receptor blockers (mean percentage point decrease [mppd], 2.6% [95% CI, 1.8-3.4]) and lower overall composite care (mppd, 1.2% [95% CI, 0.9-1.6]). Poorer quality indicator attainment was observed in patients with cancer diagnosed in the last year (mppd, 1.4% [95% CI, 1.8-1.0]), with later stage disease (mppd, 2.5% [95% CI, 3.3-1.4]), and with lung cancer (mppd, 2.2% [95% CI, 3.0-1.3]). Twelve-month all-cause survival was 90.5% in noncancer controls and 86.3% in adjusted counterfactual controls. Differences in post-AMI survival were driven by cancer-related deaths. Modeling improving quality indicator attainment to noncancer patient levels showed modest 12-month survival benefits (lung cancer, 0.6%; other cancers, 0.3%).
Conclusions: Measures of quality of AMI care are poorer in patients with cancer, with lower use of secondary prevention medications. Findings are primarily driven by differences in age and comorbidities between cancer and noncancer populations and attenuated after adjustment. The largest impact was observed in recent cancer diagnoses (<1 year) and lung cancer. Further investigation will determine whether differences reflect appropriate management according to cancer prognosis or whether opportunities to improve AMI outcomes in patients with cancer exist.
Competing Interests: Disclosures Dr Teece, Dr Sweeting, B. Coles, Dr Oliver-Williams, Dr Welch, Dr Rutherford, Dr Lambert, D. Adlam, and M.D. Peake had financial support from the British Heart Foundation and Cancer Research UK for the submitted work. D. Adlam has received research funding and in kind support for unrelated research from AstraZeneca, Inc. He has received an educational grant from Abbott Vascular, Inc, to support a clinical research fellow for unrelated research. He has also conducted consultancy for General Electric Inc., to support research funds for unrelated research. B. Coles previously received funding from Novo Nordisk. J. Deanfield had financial support from the British Heart Foundation in the previous 3 years. Dr Sweeting is a full-time employee of AstraZeneca. C. Weston is the clinical lead of the Myocardial Ischaemia National Audit Project. Dr de Belder reports data safety and monitoring board membership of the UK GRIS (UK GRACE Risk Score Intervention Study) trial, is chair of the ARREST (a randomized trial of expedited transfer to a cardiac arrest center for non-ST elevation out-of-hospital cardiac arrest) trial Steering Committee, and is an executive member of the DAPA-MI (dapagliflozin effects on cardiovascular events in patients with an acute heart attack) trial. The other authors report no conflicts.