One-year and 5-year transition risks between major bleeding, reinfarction and death following Acute Myocardial Infarction in England and Wales: A population-based cohort study

BACKGROUND: There is limited data on the long-term transition risks between major bleeding, reinfarction, and death following acute myocardial infarction (AMI). We examined 1-year and 5-year transition risks of major bleeding, reinfarction and mortality post-AMI. METHODS: We analysed national registry data of AMI patients across England and Wales between 2005-2021. Multistate modelling was used to estimate the transition-specific adjusted incidence rates (IRs) across the three outcomes using a six-state model with nine transitions. FINDINGS: Out of 837,384 patients included, 19.8% had bleeding, 8.1% reinfarction, and 20.6% death as their first event post- AMI admission. Of those with bleeding, 39.4% died while 49.9% of those with reinfarction died. Overall, females had higher rates of transitioning to any of the five states than males. A reference female patient with median age (76.3 years), at 1-year had an IR of 6.7 (95% CI 6.5-6.9) x100PY for AMI admission → bleeding transition, 0.2 (95% CI 0.2-0.2) x100PY for AMI admission → reinfarction, 43.5 (95% CI 41.9-45.2) x100PY for AMI admission → death, 22.2 (95% CI 20.9-23.5) x100PY for bleeding → death, and 41.9 (95% CI 38.1-46.0) x100PY for reinfarction → death. At 5-year, the IRs decreased to 2.1 (95% CI 2.0-2.2) x100PY, 0.04 (95% CI 0.04-0.05) x100PY, 17.5 (95% CI 16.9-18.2) x100PY, 9.7 (95% CI 9.2-10.3) x100PY, and 17.6 (95% CI 16.0-19.4) x100PY respectively.A reference male patient with median age (67.1 years) at 1-year had an IR of 5.2 (95% CI 5.0-5.4) x100PY for AMI admission → bleeding transition, 0.2 (95% CI 0.2-0.2) x100PY for AMI admission→ reinfarction, 23.7 (95% CI 22.8-24.6) x100PY for AMI admission → death, 14.5 (95% CI 13.6-15.4) x100PY for bleeding → death, and 25.9 (95% CI 23.8-28.3) x100PY for reinfarction → death. Similarly, 5-year IRs decreased to 1.6 (95% CI 1.6-1.7) x100PY, 0.04 (95% CI 0.04-0.04) x100PY, 9.5 (95% CI 9.2-9.9) x100PY, 6.3 (95% CI 5.9-6.8) x100PY, and 10.9 (95% CI 10.0-11.9) x100PY respectively. Also, those with diabetes and white patients had higher transition rates than those without diabetes and black patients. CONCLUSION: In this national AMI cohort, 5-year direct death and bleeding events were more frequent than reinfarction, and the highest mortality occurred in women after AMI admission and in men following reinfarction. These transition patterns quantify the substantial absolute risks patients face post-AMI and highlight important sex-specific differences in adverse outcomes.