Trends in acute myocardial infarction management: use of the national registry of myocardial infarction in quality improvement
Section snippets
Reperfusion therapy in eligible AMI patients
There is overwhelming evidence that fibrinolytic therapy reduces morbidity and mortality in AMI patients, and the use of reperfusion therapy in the emergency department—or primary percutaneous transluminal coronary angioplasty (PTCA) as an effective alternative—has been strongly recommended and encouraged as the standard of care by the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Management of Patients with AMI.1 Nevertheless, a minority of eligible
Medications received within 24 hours of AMI diagnosis
Numerous clinical trials have demonstrated the benefits of adjunctive therapies for AMI patients with no contraindications. Aspirin, β blockers, heparin, and angiotensin-converting enzyme (ACE) inhibitors are a routine aspect of AMI care in many institutions regardless of whether patients receive initial reperfusion therapy. According to the 1999 December quarterly NRMI 3 report, nearly 85% of all patients received aspirin within 24 hours of AMI diagnosis, and approximately 77% received either
Procedures performed before discharge
In NRMI hospitals nationwide, the utilization of echocardiography is 50% nationwide. Some 30% of patients undergo coronary angiography during hospitalization, in addition to those patients having a primary PTCA. The rate of PTCA nationally among all AMI patients, excluding primary PTCA is 12%, with >80% of these patients receiving a mean 1.3 stents. Only 3% of patients in this population receive intravenous glycoprotein IIb/IIIa receptor inhibitors at time points extending beyond 24 hours.
Risk stratification
It is noteworthy that stress testing has decreased markedly as a means of risk stratification. The nationwide utilization rate of this procedure in NRMI hospitals is 9%. Other considerations for risk stratification include age, blood pressure, pulse, previous AMI, new anterior wall AMI, which typically involves more cardiac muscle than an inferior wall AMI, and patients presenting with heart failure or with hypotension and tachycardia, groups all at increased risk of mortality.
The measurement
Utilization of medications at discharge
The most important discharge medications with regard to the long-term management of this AMI patient population are aspirin, ACE inhibitors, β blockers, and lipid-lowering agents. ACE inhibitors are indicated in all anterior AMIs and in patients with left ventricular ejection fractions ≤40%. According to recent NRMI 3 data, approximately 31% of patients nationally are being discharged on lipid-lowering therapy regardless of whether they have initially received reperfusion therapy, although the
Gender differences in the utilization of reperfusion therapy
Coronary artery disease is the leading cause of death in women. Furthermore, studies have shown a higher mortality rate in women with AMI than in men. Formerly, it was believed that women presented at an older age, when their risk of death was increased. However, a recent study by Vaccarino et al,4 based on NRMI 2 data of 384,878 patients, showed that younger women (<50 years of age) have the highest mortality rate. In many cases, the mortality rate for young women is double that of men in the
Clinical events
The NRMI also tracks clinical events at discharge according to whether patients receive reperfusion therapy at admission and according to the type of reperfusion therapy they receive. Nationwide, 51% of all NRMI 3 patients were free of adverse clinical events at discharge in the 1999 December quarterly report. Of those receiving no initial reperfusion therapy, 50% were free of adverse events, whereas 52% and 55% of those receiving intravenous thrombolysis or alternative initial reperfusion
Length of hospital stay
It is estimated that the total direct and indirect cost of coronary heart disease in the United States in 1999 will be $99.8 billion.6 Approximately $50 billion of that amount represents costs associated with hospitalization and nursing-home care. The median length of hospital stay for all NRMI 3 patients nationwide was 4.2 days. For those receiving no initial reperfusion therapy, it was 4.6 days. For those patients who received intravenous thrombolysis as initial reperfusion therapy, the
The Joint Commission on Accreditation of Healthcare Organizations ORYX initiative
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed its ORYX initiative to integrate performance measures into the accreditation process for healthcare providers. Each provider must select approved measurement systems by which it will be evaluated. The NRMI is included on the list of accepted systems, and 3 NRMI measures have been accepted for accreditation purposes in connection with ORYX. They include: (1) aspirin use in the first 24 hours; (2) door-to-drug
Conclusion
The NRMI database can be used to improve patient care throughout the healthcare system, to establish treatment priorities and standards of care, and to improve the implementation of action plans in individual hospitals. In particular, the data from NRMI 3 are valuable in identifying eligible untreated patients, initiating rapid treatment strategies, evaluating the use of medications and procedures, monitoring outcome data, and ensuring compatibility with current guidelines for the care of AMI
References (6)
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J Am Coll Cardiol
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Use of reperfusion therapy for acute myocardial infarction in the United Statesdata from the National Registry of Myocardial Infarction 2 for acute myocardial infarction
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Cited by (70)
Relationship of female sex to outcomes after myocardial infarction with persistent total occlusion of the infarct artery: Analysis of the Occluded Artery Trial (OAT)
2012, American Heart JournalCitation Excerpt :Comparison with the concurrent OAT registry and screening log demonstrated that a similarly low proportion of women screened were fully eligible for the trial and confirmed lower use of early reperfusion therapy in women screened for OAT. The proportion of female patients with MI who were entered into the screening log at OAT sites during the enrollment period was just 30%, lower than the proportion of patients with MI who are female in large US registries, about 39%.14,15 The rate of use of angiography in patients with MI at OAT sites was lower for women than for men during the enrollment period, and the entry criteria for OAT did include angiographic parameters.
Predictors of pre-hospital delay among patients with acute myocardial infarction
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