Article

Quality of care by classification of myocardial infarction - Treatment patterns for ST-segment elevation vs non-ST-segment elevation myocardial infarction

Duke University, Durham, North Carolina, United States
Archives of Internal Medicine (Impact Factor: 13.25). 08/2005; 165(14):1630-6. DOI: 10.1001/archinte.165.14.1630
Source: PubMed

ABSTRACT Practice guidelines for acute ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) recommend similar therapies and interventions, but differences in patterns of care between MI categories have not been well described in contemporary practice.
In-hospital treatments with similar recommendations from practice guidelines were compared with outcomes in 185 968 eligible patients (without listed contraindications) with STEMI (n = 53 417; 29%) vs NSTEMI (n = 132 551; 71%) from 1247 US hospitals participating in the National Registry of Myocardial Infarction 4 between July 1, 2000, and June 30, 2002. Hierarchical logistic regression modeling was used to determine adjusted differences in treatment patterns in MI categories.
Unadjusted in-hospital mortality rates were high for NSTEMI (12.5%) and STEMI (14.3%), and the use of guideline-recommended medications and interventions was suboptimal in both categories of patients with MI. The adjusted likelihood of receiving early (within 24 hours of presentation) aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors was higher in patients with STEMI. Similar patterns of care were noted at hospital discharge: the adjusted likelihood of receiving aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, lipid-lowering agents, smoking cessation counseling, and cardiac rehabilitation referral was higher in patients with STEMI.
Evidence-based medications and lifestyle modification interventions were used less frequently in patients with NSTEMI. Quality improvement interventions designed to narrow the gaps in care between NSTEMI and STEMI and to improve adherence to guidelines for both categories of patients with MI may reduce the high mortality rates associated with acute MI in contemporary practice.

Full-text

Available from: Charles V Pollack, Aug 14, 2014
0 Followers
 · 
87 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization. All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points. The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality. In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.
    02/2014; 4(1):13-20. DOI:10.3978/j.issn.2223-3652.2014.02.02
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study is to compare the short-term and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI). A total of 266 STEMI patients and 140 NSTE-ACS patients received PCI. Patients were followed up by telephone or at medical record or case statistics center and were followed up for 4 years. Descriptive statistics and multivariate survival analyses were employed to compare the mortality in STEMI and NSTE-ACS. All statistical analyses were performed by SPSS19.0 software package. NSTE-ACS patients had significantly higher clinical and angiographic risk profiles at baseline. During the 4-year follow-up, all-cause mortality in STEMI was significantly higher than that in NSTE-ACS after coronary stent placement (HR 1.496, 95% CI 1.019-2.197). In a landmark analysis no difference was seen in all-cause mortality for both STEMI and NSTE-ACS between 6 month and 4 years of follow-up (HR 1.173, 95% CI 0.758-1.813). Patients with STEMI have a worse long-term prognosis compared to patients with NSTE-ACS after PCI, due to higher short-term mortality. However, NSTE-ACS patients have a worse long-term survival after 6 months.
    International Journal of Clinical and Experimental Medicine 01/2014; 7(12):5588-92. · 1.42 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The association between high-sensitivity C-reactive protein and recurrent major adverse cardiovascular events (MACE) in patients with ST-elevation myocardial infarction who undergo primary percutaneous coronary intervention remains controversial.
    Arquivos Brasileiros de Cardiologia 07/2014; 103(1):69-75. DOI:10.5935/abc.20140086 · 1.12 Impact Factor