Drivers of 1-year mortality decline after acute myocardial infarction in England and Wales: a 15-year national cohort study

Background One-year mortality following acute myocardial infarction (AMI) has declined over time, yet the reasons for this improvement remain unclear. Understanding the drivers of these changes is essential for informing clinical strategies and health policy. Methods We analysed 852 914 adult patients admitted with AMI across England and Wales between 2005 and 2019 using national registry data. We examined changes in 1-year all-cause mortality and quantified the contribution of clinical, treatment and demographic factors to this trend using decomposition analysis. Results Between 2005 and 2019, 1-year all-cause mortality declined from 22.8% (95% CI 22.4% to 23.2%) to 14.2% (95% CI 13.7% to 14.7%), an absolute reduction of 8.6 percentage points. Approximately 68.2% of this decline was explained by measured factors. The greatest contributor was increased use of evidence-based pharmacological therapies—including statins, beta blockers and ACE inhibitors—accounting for 27.7% of the reduction (95% CI 26.0% to 29.5%). Increased use of percutaneous coronary intervention (PCI) contributed 17.6% (95% CI 16.3% to 19.0%). Mortality improvements were observed in both ST-elevation myocardial infarction (STEMI) and non-STEMI populations. However, older adults and women continued to experience higher mortality rates throughout the study period. Conclusion One-year survival after AMI improved substantially over 15 years in England and Wales largely due to advances in pharmacotherapy and PCI. Nevertheless, about one-third of the mortality decline remains unexplained, underscoring the need to investigate other contributors such as postdischarge care and health system factors.