People with a mental disorder are less likely to receive guideline-informed MI care, with disparities greatest following NSTEMI and for people with schizophrenia, and no clear evidence that the COVID-19 pandemic affected these disparities.
Key Findings
Results
People with schizophrenia had markedly lower odds of receiving angiography following NSTEMI compared to those without mental disorders.
OR for angiography receipt for schizophrenia following NSTEMI was 0.25 (95% CI 0.20 to 0.31)
This was the most extreme disparity observed across all mental disorder and care standard combinations studied
The study population included 131,075 adults with NSTEMI identified from the Myocardial Ischaemia National Audit Project
Logistic regression was used to adjust for confounders
Results
Mental disorder disparities in receipt of guideline-informed care were more evident following NSTEMI than following STEMI.
Following NSTEMI, people with mental disorders had lower odds of angiography eligibility and receipt, cardiac ward admission, and cardiac rehabilitation referral
ORs ranged from 0.25 (0.20 to 0.31) for angiography receipt in schizophrenia to 0.92 (0.89 to 0.96) for cardiac ward admission in depression
The study included 131,075 adults with NSTEMI and 79,045 adults with STEMI
Prior diagnoses of mental disorder were ascertained from linked hospitalisation and primary care records
Results
People with depression had lower odds of cardiac ward admission following NSTEMI.
OR for cardiac ward admission for depression following NSTEMI was 0.92 (95% CI 0.89 to 0.96)
This represented the smallest but still statistically significant disparity observed among the mental disorder groups for NSTEMI outcomes
Depression was one of three mental disorders examined, alongside schizophrenia and bipolar disorder
Results
People with bipolar disorder were less likely to meet the 150-minute call-to-balloon target following STEMI.
OR for meeting the 150-minute call-to-balloon target for bipolar disorder following STEMI was 0.72 (95% CI 0.55 to 0.93)
The study population for STEMI included 79,045 adults
This was one of the few significant disparities identified specifically in the STEMI population
Results
People with schizophrenia were substantially less likely to receive cardiac rehabilitation referral or indicated secondary prevention medication following STEMI.
OR for rehabilitation referral following STEMI for schizophrenia was 0.38 (95% CI 0.23 to 0.61)
OR for indicated secondary prevention medication following STEMI for schizophrenia was 0.46 (95% CI 0.27 to 0.77)
These findings indicate large disparities even for the time-critical STEMI pathway
Results
There was no clear evidence that the COVID-19 pandemic affected the disparities in MI care received by people with mental disorders.
The study period spanned November 2019 to February 2023, encompassing the pre-pandemic and pandemic periods
Differences over time were investigated using logistic regression
The finding suggests that pre-existing mental disorder disparities in cardiac care were neither substantially worsened nor improved during the pandemic period
Methods
The study used a large population-based cohort design with linked electronic health records across England.
131,075 adults with NSTEMI and 79,045 adults with STEMI were identified from the Myocardial Ischaemia National Audit Project
Prior diagnoses of mental disorder were ascertained from linked hospitalisation and primary care records
The study period ran from November 2019 to February 2023
Three mental disorders were compared: schizophrenia, bipolar disorder, and depression, versus those without any of these disorders
What This Means
This research suggests that people living with mental health conditions such as schizophrenia, bipolar disorder, or depression receive substantially worse cardiac care after a heart attack compared to people without these conditions. Using records from over 210,000 heart attack patients in England between 2019 and 2023, the study found that people with schizophrenia were especially disadvantaged — for example, they were about 75% less likely to receive a key diagnostic procedure called angiography after a certain type of heart attack (NSTEMI), and about 62% less likely to be referred to cardiac rehabilitation after a different type (STEMI). Even people with depression, a much more common condition, were less likely to be admitted to a cardiac ward after a heart attack.
The gaps in care were most pronounced for non-ST-elevation myocardial infarction (NSTEMI), which is a type of heart attack that requires clinical judgment about which patients should receive further investigation, compared to ST-elevation myocardial infarction (STEMI), where treatment pathways are more standardized and time-critical. This suggests that when clinicians have more discretion in deciding who receives further care, people with mental health conditions are more likely to be overlooked or deprioritized.
Notably, the COVID-19 pandemic did not appear to make these disparities better or worse, meaning these inequalities were a persistent feature of care both before and during the pandemic. This research highlights a longstanding and significant gap in equitable cardiac care for people with mental health conditions and points to the need for targeted interventions to ensure this vulnerable group receives the same standard of heart attack treatment as everyone else.
Fleetwood K, Nolan J, Berry C, Cavers D, Mercer S, Padmanabhan S, et al.. (2026). Mental disorders, receipt of cardiac care following myocardial infarction and the impact of the COVID-19 pandemic: a cohort study.. BMJ open. https://doi.org/10.1136/bmjopen-2026-124463