An early invasive management strategy is recommended for patients with non-ST-segment elevation myocardial infarction (NSTEMI) who do not have a contraindication to cardiac catheterization (CCC). However, the frequency of CCC reporting has not been delineated, and the relationship of CCC reporting to hospital-level guidelines adherence for NSTEMI has not been investigated.
We used the American College of Cardiology National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines database to evaluate variations in hospital-level reporting of CCC for 111,320 patients with NSTEMI admitted to 370 hospitals with revascularization capabilities in the United States from 2007 to 2010 and how these variations were associated with guideline adherence and in-hospital mortality. Hospitals were grouped into tertiles based on rates of reported CCCs. Treatment patterns and in-hospital mortality rates were evaluated across hospital tertiles separately for patients with and without a reported CCC.
A total of 18,290 (16.4%) of 111,320 patients with NSTEMI had a reported CCC, but hospital-level CCC reporting varied considerably (low tertile 0%-8.2%, intermediate tertile >8.2%-18.8%, and high tertile >18.8%-75.6%). Patients with a reported CCC had more comorbidities and high-risk features compared with patients without a CCC. The use of most guideline-recommended medications and in-hospital mortality rates were similar across hospital tertiles-both for patients with and without a reported CCC.
The reporting of CCC among patients with NSTEMI varies widely across US hospitals and does not appear to be related to guidelines adherence or in-hospital mortality rates. These findings suggest that it will be a challenge to standardize the reporting of CCC and thus use invasive management to assess the quality of NSTEMI care.
[Show abstract][Hide abstract] ABSTRACT: Although high-sensitivity cardiac troponin (hs-cTn) substantially improves the early detection of myocardial injury, it lacks specificity for acute myocardial infarction (MI). In suspected non-ST-elevation MI, invasive coronary angiography (ICA) remains necessary to distinguish between acute MI and noncoronary myocardial disease (eg, myocarditis), unnecessarily subjecting the latter to ICA and associated complications. This trial investigates whether implementing cardiovascular magnetic resonance (CMR) or computed tomography angiography (CTA) early in the diagnostic process may help to differentiate between coronary and noncoronary myocardial disease, thereby preventing unnecessary ICA.
In this prospective, single-center, randomized controlled clinical trial, 321 consecutive patients with acute chest pain, elevated hs-cTnT, and nondiagnostic electrocardiogram are randomized to 1 of 3 strategies: (1) CMR, or (2) CTA early in the diagnostic process, or (3) routine clinical management. In the 2 investigational arms of the study, results of CMR or CTA will guide further clinical management. It is expected that noncoronary myocardial disease is detected more frequently after early noninvasive imaging as compared with routine clinical management, and unnecessary ICA will be prevented. The primary end point is the total number of patients undergoing ICA during initial admission. Secondary end points are 30-day and 1-year clinical outcome (major adverse cardiac events and major procedure-related complications), time to final diagnosis, quality of life, and cost-effectiveness.
The CARMENTA trial investigates whether implementing CTA or CMR early in the diagnostic process in suspected non-ST-elevation MI based on elevated hs-cTnT can prevent unnecessary ICA as compared with routine clinical management, with no detrimental effect on clinical outcome.
American heart journal 12/2013; 166(6):968-975. DOI:10.1016/j.ahj.2013.09.012 · 4.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Age and gender associated risks for non-ST-elevation myocardial infarction (NSTEMI) at the population level are largely uncharacterized. Design: Nationwide, population (26,724,165 person-years) based eight-year registry-study in Finland. Methods: Gender- and age-associated frequency and incidence of NSTEMI were studied using a nationwide, population based registry of hospital admissions in patients aged ≥30 years during 2001-2008. Patients with NSTEMI as primary (88%), secondary (10%) or tertiary (2%) discharge diagnosis were included. Data was collected nationwide from all 22 hospitals with a coronary angiolaboratory. Results: The study period included 48,584 NSTEMI admissions of which 55.3% (95% confidence interval (CI) 54.6-56.0%) were of men and 44.7% (CI 44.1-45.3%) were of women, with age-adjusted relative risk of 1.86 (CI 1.60-2.16, p<0.0001) for male gender. Female patients were significantly older than males (77.8 SD 10.2 vs. 70.2 SD 11.9 years, p<0.0001). Standardized incidence rate of NSTEMI was 20.6 (CI 20.4-20.8)/10,000 person-years overall, 28.7 (CI 28.3-29.0)/10,000 in men and 15.0 (CI 14.7-15.2)/10,000 in women. Men had a 2.36-fold (CI 2.23-2.49; p<0.0001) age-adjusted relative risk for NSTEMI compared with women, with highest risk difference in population under 40 years of age (relative risk 4.48; CI 3.10-6.48, p<0.0001). Incidence increased with age by an estimated genderadjusted increase rate of 61% (CI 59-62%; p<0.0001) per five-year increase in age. Conclusions: Men have a 2.4-fold overall risk for NSTEMI compared with women, with highest relative risk in young adults. Incidence rate of non-ST-elevation myocardial infarction increases by an estimated 61% per five-year increase in age.
European Journal of Preventive Cardiology 06/2014; 22(8). DOI:10.1177/2047487314539434 · 3.32 Impact Factor
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