Trends in acute myocardial infarction management: use of the national registry of myocardial infarction in quality improvement

https://doi.org/10.1016/S0002-9149(00)00752-9Get rights and content

Abstract

Cardiovascular disease, including acute myocardial infarction (AMI), is the leading cause of death in the United States and was the primary disease category among hospital discharges in 1996. Efforts to improve hospital care of patients with AMI should be measured and assessed routinely for appropriateness of care and improvement of medical staff performance. The National Registry of Myocardial Infarction (NRMI), an observational Phase IV study, has enrolled >1 million AMI patients since 1990, and is now in its third phase. NRMI 3 collects patient data and facilitates the measurement of improvement in care and outcomes, while allowing participating institutions to benchmark their performance against national, state, and like-hospital data. Three measures from NRMI 3 are accepted for the Joint Commission on Accreditation of Healthcare Organizations’ ORYX initiative: (1) aspirin use within 24 hours of AMI diagnosis; (2) door-to-drug time for fibrinolysis; and (3) no initial reperfusion strategy given to eligible patients.

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)

There are more references available in the full text version of this article.

Cited by (70)

  • Achieving Quality in Cardiovascular Imaging II. Proceedings From the Second American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging

    2009, JACC: Cardiovascular Imaging
    Citation Excerpt :

    Develop standardized data elements to evaluate appropriateness of indications for cardiovascular imaging. Multicenter registries have proved instrumental for evaluating and improving quality of care for acute coronary syndromes (34–36) and cardiovascular procedures such as cardiac surgery and cardiac catheterization (37,38). An analogous approach using registries for cardiovascular imaging holds great promise for improving safety and quality.

  • Impact of Delay in Door-to-Needle Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction

    2007, American Journal of Cardiology
    Citation Excerpt :

    We used the NRMI, a voluntary acute myocardial infarction (AMI) registry sponsored by Genentech, Inc. (South San Francisco, California), to define a cohort of patients with STEMI who received acute fibrinolytic reperfusion therapy. NRMI criteria13,14 included a diagnosis of AMI according to the International Classification of Diseases, Ninth Revision, Clinical Modification (code 410. X1) and any of total creatine kinase or creatine kinase-MB ≥2 times the upper limit of the normal range or increases in alternative cardiac markers; electrocardiographic evidence of AMI; or nuclear medicine testing, echocardiographic, or autopsy evidence of AMI.

View all citing articles on Scopus
View full text