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: 17.33). 08/2005; 165(14):1630-6. DOI: 10.1001/archinte.165.14.1630
Source: PubMed


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.

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Available from: Charles V Pollack, Aug 14, 2014
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    • "The percentage of MI cases with ST-segment elevation varies in different registries/databases and depends heavily on the age of patients included and the type of surveillance used. Among the registries, about 29% of US in-hospital patients with MI are STEMI [7], whereas 47% of European patients with MI are STEMI [8]. "
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    ABSTRACT: Clinical studies have demonstrated the predictive values of changes in electrocardiographic (ECG) parameters for the preexisting myocardial ischemic infarction. However, a simple and early predictor for the subsequent development of myocardial infarction during the ischemic phase is of significant value for the identification of ischemic patients at high risk. The present study was undertaken by using non-human primate model of myocardial ischemic infarction to fulfill this gap. Twenty male Rhesus monkeys at age of 2-3 years old were subjected to left anterior descending artery ligation. This ligation was performed at varying position along the artery so that it produced varying sizes of myocardial infarction at the late stage. The ECG recording was undertaken before the surgical procedure, at 2 h after the ligation, and 8 weeks after the surgery for each animal. The correlation of the changes in the ECG waves in the early or the late stage with the myocardial infarction size was analyzed. The R wave depression and the QT shortening in the early ischemic stage were found to have an inverse correlation with the myocardial infarction size. At the late stage, the R wave depression, the QT prolongation, the QRS score, and the ST segment elevation were all closely correlated with the developed infarction size. The poor R wave progression was identified at both the early ischemic and the late infarction stages. Therefore, the present study using non-human primate model of myocardial ischemic infarction identified the decreases in the R wave and the QT interval as early predictors of myocardial infarction. Validation of these parameters in clinical studies would greatly help identifying patients with myocardial ischemia at high risk for the subsequent development of myocardial infarction.
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    • "Cardiovascular disease is the leading cause of death in the US.1 Acute coronary syndromes (ACS) are responsible for more than 1.3 million hospitalizations in the US annually.1 Registry data indicate that nearly 30% of these cases are due to ST-elevation myocardial infarctions (STEMI).2 In patients with STEMI, timely reperfusion is the primary goal, and this is often achieved through primary percutaneous coronary intervention (PCI).3 "
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    • "Other factors than patient characteristics and treatment strategy that may account for worse outcome in non-STEMI are the fact that identification of MI is often delayed due to lack of definitive ECG abnormalities and timing of cardiac troponin elevation [23,24]. In addition, almost half of patients with non-STEMI have other symptoms than chest pain when first seen, which may contribute to delayed diagnosis [25]. "
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