Guideline Adherence After ST-Segment Elevation Versus Non-ST-Segment Elevation Myocardial Infarction
ABSTRACT Background- Clinical guidelines recommend similar medical therapy for patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation MI (NSTEMI). Methods and Results- Using the Get with the Guidelines-Coronary Artery Disease registry (GWTG-CAD), we analyzed data including 72 352 patients (48 966, NSTEMI; 23 386, STEMI) from 237 US sites between May 1, 2006 and March 21, 2010. Performance and quality measures were compared between NSTEMI and STEMI patients. NSTEMI patients were older and had a higher rate of medical comorbidities compared with STEMI patients, including prior coronary artery disease (38.5% versus 24.7%; P<0.0001), heart failure (17.5% versus 6.2%; P<0.0001), hypertension (70.8% versus 59.1%; P<0.0001) and diabetes mellitus (34.9 versus 23.3%; P<0.0001). Adjusting for confounding variables, STEMI patients were more likely to receive aspirin within 24 hours 98.5% versus 97.1% (adjusted odds ratio [AOR], 1.63; 95% confidence interval [CI], 1.32-2.02), be discharged on aspirin 98.5% versus 97.3% (AOR, 1.33; 95% CI, 1.19-1.49), β-blockers 98.2% versus 96.9% (AOR, 1.48; 95% CI, 1.35-1.63), or lipid-lowering medication for low-density lipoprotein level >100 mg/dL 96.8% versus 91.0% (AOR, 1.85; 95% CI, 1.61-2.13). STEMI patients were also more likely to receive β-blockers within 24 hours of hospital arrival 93.9% versus 90.8% (AOR, 1.57; 95% CI, 1.37-1.79) and the following discharge medications: angiotensin-converting enzyme inhibitors or angiotensin receptor blocking agents 85.3% versus 77.4% (AOR, 1.62; 95% CI, 1.51-1.75), clopidogrel 85.6% versus 67.0% (AOR, 2.42; 95% CI, 2.23-2.61) or lipid-lowering medications 94.8% versus 88.0% (AOR, 1.71; 95% CI, 1.56-1.86). Conclusions- Among hospitals participating in GWTG-CAD, adherence with guideline-based medical therapy was high for patients with both STEMI and NSTEMI. Yet, there is still room for further improvement, particularly in the care of NSTEMI patients.
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ABSTRACT: The Center for Medicare and Medicaid Services (CMS) publicly reports "core process of care measures" along with 30-day mortality rates for patients with acute myocardial infarction; the American College of Cardiology/American Heart Association has a similar but expanded set of performance measures. We sought to determine whether hospital-level adherence with these process performance measures was associated with risk-adjusted in-hospital mortality among 96,340 ST-segment elevation myocardial infarction (STEMI) and 145,832 non-STEMI (NSTEMI) patients in the National Cardiovascular Data Registry® ACTION Registry-Get With the Guidelines™ admitted from January 2007 to March 2011 from 372 US sites. Hospitals were grouped based on risk-adjusted in-hospital mortality: low (20%), middle (60%), and high mortality (20%). The mean (SD) mortality from low to high hospital mortality groups for STEMI was 4.9% (0.9%), 5.8% (0.3%), and 7.0% (0.5%); and that for NSTEMI was 3.3% (0.2%), 4.0% (0.2%), and 4.9% (0.3%). Adherence to individual process measures was high, with composite measure adherences exceeding 88%. Composite adherence for both CMS and American College of Cardiology/American Heart Association performance measures was inversely associated with risk-adjusted hospital mortality. However, the association was low for STEMI hospitals and not significant for NSTEMI hospitals. Variation tended to be higher for CMS measures for higher-mortality hospitals. Although process performance was associated with hospital mortality, the association was low for STEMI and nonsignificant for NSTEMI hospitals, thus supporting the need to measure complementary metrics of acute myocardial infarction quality of care. Copyright © 2014 Elsevier Inc. All rights reserved.American Heart Journal 11/2014; 168(5):766-75. DOI:10.1016/j.ahj.2014.07.005 · 4.56 Impact Factor
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ABSTRACT: Background-The American Heart Association Get With the Guidelines (GWTG) program has improved care quality of acute myocardial infarction (AMI) with important implications for other countries in the world. This study evaluated the incidence and care of AMI in Taiwan and assessed the compliance of GWTG in Taiwan. Methods and Results-We used the Taiwan National Health Insurance Research Database (1999-2008) to identify hospitalized patients >= 18 years of age presenting with AMI. The temporal trends of annual incidence and care quality of AMI were evaluated. The age-adjusted incidence of AMI (/ 100 000 person-years) increased from 28.0 in 1999 to 44.4 in 2008 (P<0.001). The use of guideline-based medications for AMI was evaluated. The use of dual antiplatelet therapy (DAPT) increased from 65% in 2004 to 83.9% in 2008 (P<0.001). Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) was used in 72.6% in 2004 and 71.7% in 2008 (P=NS) and beta-blocker was used in 60% in 2004 and 59.7% in 2008 (P=NS). Statin use increased from 32.1% to 50.1% from 2004 to 2008 (P<0.001). The in-hospital mortality decreased from 15.9% in 1999 to 12.3% in 2008 (P<0.0001). Multivariable analysis showed that DAPT, ACE inhibitor/ARB, beta-blocker, and statin use during hospitalization were all associated with reduced in-hospital mortality in our AMI patients. Conclusions-AMI incidence was increasing, but the guideline-based medications for AMI were underutilized in Taiwan. Quality improvement programs, such as GWTG, should be promoted to improve AMI care and outcomes in Taiwan.Journal of the American Heart Association 06/2014; 3(4). DOI:10.1161/JAHA.114.001066 · 2.88 Impact Factor
The American Journal of Cardiology 03/2015; 115(5 Suppl). DOI:10.1016/j.amjcard.2015.01.005 · 3.43 Impact Factor