Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. Investigators in the National Registry of Myocardial Infarction

Disparity in the Process and Outcome of the Treatment for Acute Myocardial Infarction in Japan CAMPAIGN Study in the National Hospital Network

BACKGROUND

A nationwide survey of the process and outcome of treatment for acute myocardial infarction (AMI) has not been conducted in Japan.

METHODS AND RESULTS

In the present study 2,007 patients with AMI admitted to 22 national hospitals were registered between July 1999 and January 2002 for CAMPAIGN Study 1; an additional 206 and 238 cases were registered between October and December 2002 (CAMPAIGN 2) and between October and December 2003 (CAMPAIGN 3), respectively. In CAMPAIGN 1, the length of stay varied from 15 to 35 days among hospitals (mean: 24.8 days), and was mainly determined by the schedule of follow-up examinations rather than clinical course. Of the prescriptions at discharge, beta-blockers and angiotensin-converting enzyme inhibitors varied widely; the use of beta-blockers was very low (25%). Nitrates were frequently used (68%) although there is no evidence for secondary prevention. In CAMPAIGNs 2 and 3, the use of beta-blockers increased (36%, 47%) and that of nitrates decreased (24%, 21%).

CONCLUSION

CAMPAIGN Study 1 revealed considerable variation in the treatment of AMI during the acute phase among the hospitals. The use of beta-blocker and nitrates as discharge medication was inappropriate. CAMPAIGNs 2 and 3 showed some improvement in the problems revealed by CAMPAIGN 1.

Hospital therapy traditions influence long-term survival in patients with acute myocardial infarction

BACKGROUND

Differences in therapy and outcome among hospitals have been reported, but these studies have seldom used adjustment for differences in patient characteristics. The objective was to investigate the differences in treatment of acute myocardial infarction (AMI) among different hospitals within 1 country and the possible causes and outcomes of these differences.

METHODS

Prospective cohort study using data from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA) on 32,954 consecutive primary admissions of patients with AMI admitted to the intensive coronary care units of 67 Swedish hospitals in 1999-2000. An activity index was calculated for each hospital based on the hospital's ranking regarding proportion of performed examination or given therapy among the AMI patients.

RESULTS

After adjustment for 24 background characteristics, there were few significant deviations among hospitals in the proportion treated with acute reperfusion, antiplatelets, beta-blockers, or angiotensin-converting enzyme (ACE) inhibitors. However, 3- to 10-fold differences existed among hospitals in the proportion of patients treated with intravenous beta-blockers, intravenous nitroglycerin, intravenous or subcutaneous anticoagulants, and lipid-lowering medication, and even larger discrepancies in echocardiography and revascularization within 14 days. There was a strong (r = 0.69, P < .001) correlation between hospital activity index between the years and a correlation between the hospital's activity index and 1-year mortality (r = -0.30, P = .014). There was no correlation between hospital size and activity index.

CONCLUSIONS

Even after adjustment for differences in patient characteristics, there are differences between the hospital treatment cultures for patients with AMI that persists over time. Concerning everywhere-available treatment options, the treatment activity is independent of the size of the center. A more active treatment tradition is associated with a lower short- and long-term mortality in AMI patients.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency

BACKGROUND

Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices.

METHODS

Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%).

RESULTS

Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES).

CONCLUSION

In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

Safety of elective--including "high risk"--percutaneous coronary interventions without on-site cardiac surgery

BACKGROUND

Current guidelines (American College of Cardiology/American Heart Association) for percutaneous coronary intervention (PCI) limit the performance of elective cases to hospitals with the capability for cardiac surgery. The number of hospitals in the United States with this capability is limited, which restricts availability of this proven technology.

OBJECTIVE

To determine the safety of performing elective, nonselected PCI in hospitals without cardiac surgery capability.

DESIGN, SETTING, AND PATIENTS

A single-center retrospective analysis of the first 1000 patients undergoing elective, including "high-risk," PCI in the county hospital in Phoenix, Arizona.

MAIN OUTCOME MEASURES

A database (Access Microsoft Windows) was established to follow patient characteristics, indications for the procedure, technical aspects of the procedure, outcomes and complications. The Quality Improvement Committee followed each case closely to independently assess the adequacy of indications and patient management, with a monthly case review of every patient who had a periprocedural or postprocedural complication.

RESULTS

Failure to complete target vessel revascularization occurred in 68 of the total 1756 vessels (3.8%). Seven patients (0.7%), required elective referral for coronary artery bypass graft surgery after failed PCI. Coronary perforations occurred in 9 patients (0.9%); all resolved with percutaneous techniques. Postprocedure myocardial infarction was diagnosed in 21 patients (2.1%). Two patients (0.2%) developed a stroke. Periprocedural death (within 48 hours of the procedure) occurred in 2 patients (0.2%). Out of the 1000 interventions performed, none required emergency coronary artery bypass graft surgery.

CONCLUSIONS

Technical advances in interventional cardiology allow for safe performance of PCI in hospitals without on-site cardiac surgery facilities if proposed conditions are met. Our results together with the vast experience in other countries supports a paradigm change that would increase the number of hospitals that can offer interventional cardiology procedures with a corresponding increase in the number of patients that would benefit.

Public perceptions of quality care and provider profiling in New York: implications for improving quality care and public health

Despite a growing emphasis on providing health care consumers with more information about quality care, useful and valid provider-specific information often has not been available to the public or has been underutilized. To assess this issue in New York State, random telephone surveys were conducted in September 2002 and March 2003, respectively, of 1,001 and 500 English- or Spanish-speaking persons, 18 years or older. Results indicated that 33% of New Yorkers were very concerned about the quality of care, with African Americans being particularly concerned. Less than half of the respondents recalled hearing or seeing information about health care quality in the past year and less than 20% actually used this information in medical decision making. African Americans were the least likely to recall receiving or being exposed to quality-related information, whereas women and more educated adults were the most likely to report being exposed. Furthermore, New Yorkers received quality information from multiple sources, with about 20% saying that they obtained information about physician and hospital quality from media (eg, newspaper) and nonmedia (eg, recommendation by family member) sources. Evaluations of different kinds of information suggested that some types (eg, whether or not a doctor is board certified) carried more weight in health care decision making than other types (eg, government ratings). Unexpectedly, those who used information to make health care decisions were more likely to have reported experiencing a medical error in the household. Finally, in the 6-month follow-up survey, concerns about the quality of care in the state remained about the same, while fears of terrorism decreased and preparations for future terrorist attacks increased. In the survey, few major differences were found in results based on payer status (eg, private insurance versus Medicaid/no insurance). These findings have implications for both the private and public health care sectors. Specifically, they suggest that greater access to and use of provider-specific health care information by the public is a viable way to improve quality, particularly if health care professionals support the public use of these data.

Evidence-based therapies for myocardial infarction: secular trends and determinants of practice in the community

OBJECTIVES

To examine secular trends in the use of evidence-based therapies in a geographically defined cohort of patients with myocardial infarction (MI) and to test the hypotheses that baseline use is increasing and that disparities in use are diminishing,

PATIENTS AND METHODS

All consecutively hospitalized patients who were dismissed from Olmsted County, Minnesota, hospitals between 1979 and 1998 with a diagnosis of MI were identified using standardized criteria (biomarkers, cardiac pain, and electrocardiography). The entire community medical record, available via the Rochester Epidemiology Project, was reviewed to ascertain baseline characteristics including comorbidity, presence of ST-segment elevation on electrocardiography, and treatment. Logistic regression models were used to examine the association of treatment with age and sex, independent of other baseline characteristics.

RESULTS

Between 1979 and 1998, 2317 incident MIs (patient mean +/- SD age, 67+/-14 years; 43% women; 57% aged > or = 65 years) occurred in Olmsted County. The use of all evidence-based therapies increased over time, primarily reflecting the introduction of these medications at the time of Index MI. Between 1989 and 1998, age was not independently associated with use of aspirin or ACE inhibitors. Disparities in use persisted for reperfusion therapy and beta-blockers. Reperfusion therapy or revascularization was used less frequently in older persons, particularly in elderly women (P<.001). Use of beta-blockers decreased 16% among persons aged 65 years or older, independent of measurable differences in baseline characteristics and MI severity (hazard ratio, 0.84; 95% confidence interval, 0.74-0.93).

CONCLUSIONS

The use of all evidence-based therapies for MI increased markedly over time; however, residual gaps in use were noted. Reperfusion therapy or revascularization is used less frequently in women and elderly persons, and beta-blockers are used less frequently in elderly persons. These differences are not explained by measurable differences in baseline characteristics. Women and elderly persons represent an increasing proportion of patients with MIs in the community; therefore, these findings define therapeutic opportunities.

Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction

The focus for the initial approach to the treatment of acute ST-segment elevation myocardial infarction (STEMI) has shifted toward extending the benefits of mechanical reperfusion with primary percutaneous coronary intervention (PCI) to patients who present to community hospitals that have no interventional capabilities. Several randomized clinical trials have shown that transferring STEMI patients to tertiary centers for primary PCI leads to better outcomes than when fibrinolytic therapy is administered at community hospitals. Furthermore, potent pharmacologic reperfusion regimens that enhance early reperfusion of the infarct vessel before primary PCI may enhance the positive result of the transfer approach. Despite these promising findings, several obstacles have hindered the adoption of patient-transfer strategies in the U.S., including greater distances between community and tertiary hospitals, a lack of integrated emergency medical services, and the medical community's limited experience with centralized acute myocardial infarction (AMI) care networks. Nonetheless, the implementation of system-wide changes in the care of STEMI patients analogous to the creation of trauma networks could facilitate the creation and ongoing evaluation of dedicated patient transfer strategies and better early invasive care in the U.S. Within this context, a systematic, stepwise approach to the creation of AMI care networks and to the development of standard nomenclature and performance indicators is necessary to guide quality assurance monitoring and future research efforts as the care of STEMI patients is redefined. Consequently, this current evolution of reperfusion strategies has the potential to further reduce morbidity and mortality for patients presenting with STEMI.

Percutaneous coronary intervention for ST-segment and non-ST-segment elevation myocardial infarction at hospitals with and without on-site cardiac surgical capability

OBJECTIVE

To compare the safety and efficacy of percutaneous coronary intervention (PCI) for acute myocardial infarction performed at a hospital without cardiac surgical capability with PCI performed for acute myocardial infarction at a center with on-site surgery.

PATIENTS AND METHODS

We included patients with acute myocardial infarction in whom PCI was performed from March 1, 2000, through May 31, 2002, at a community hospital (Immanuel St Joseph's) without on-site surgery. The procedural success, in-hospital adverse cardiac events, and 6-month follow-up were compared with those of PCI performed for acute myocardial infarction in matched controls from January 1, 2000, through February 28, 2002, at a center with cardiac surgery (Saint Marys Hospital).

RESULTS

One hundred sixty patients (and 160 matched controls) underwent PCI for acute myocardial infarction. The procedural success rate was high and similar for the 2 groups (96% vs 95%; P=.79). In-hospital mortality, Q-wave myocardial infarction, and target vessel revascularization were low and similar for the 2 groups. No patient was referred for emergency coronary artery bypass graft surgery for failed PCI. Six-month survival from all-cause mortality was 96% for the Immanuel St Joseph's group and 94% for the Saint Marys Hospital group (P=.92). Subgroup analysis of patients with primary PCI for ST-segment elevation acute myocardial infarction revealed high procedural success and low and similar rates of major cardiac adverse events in the 2 groups.

CONCLUSION

This study shows that PCI for acute myocardial infarction can be performed safely and effectively in a community hospital without on-site cardiac surgery.

Primary Angioplasty in Acute Myocardial Infarction at Hospitals With No Surgery On-Site (the PAMI-No SOS study) versus transfer to surgical centers for primary angioplasty

OBJECTIVES

To investigate primary angioplasty (PA) for high-risk acute myocardial infarction (AMI) at hospitals with no cardiac surgery on-site (No SOS), we hypothesized that a nonrandomized registry of such patients treated with PA would show clinical outcomes similar to those of a group randomized to transfer for PA, and that reperfusion would occur faster.

BACKGROUND

Primary angioplasty provides outcomes superior to fibrinolytic therapy in AMI, but its use in community hospitals with No SOS has been limited.

METHODS

Fibrinolytic-eligible patients with high-risk AMI prospectively consented if they had one or more high-risk characteristic. Nineteen hospitals with No SOS prospectively enrolled 500 patients for PA on-site. Seventy-one similar Air Primary Angioplasty in Myocardial Infarction trial patients were randomized to transfer for PA.

RESULTS

Primary angioplasty was performed in 88% of patients. Patients transferred for PA had a longer mean time to treatment (187 vs. 120 min; p < 0.0001). Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was achieved in 96% for on-site PA, 86% in the transfer group (p = 0.004). The combined primary end point of 30-day mortality, re-infarction, and disabling stroke occurred in 27 (5%) on-site PA patients and 6 (8.5%) transfer patients (p = 0.27). Unadjusted one-year mortality was improved in on-site PA patients compared with those transferred (6% vs. 13%, p = 0.043), but after adjustment for differences in baseline variables, this difference was not significant.

CONCLUSIONS

On-site PA and transfer groups had similar 30-day outcomes and more rapid reperfusion for on-site PA. Primary angioplasty in high-risk AMI patients at hospitals with No SOS is safe, effective, and faster than PA after transfer to a surgical facility.

The role of low-molecular-weight heparin in the management of acute coronary syndromes

A substantial number of clinical studies have consistently demonstrated that low-molecular-weight heparin (LMWH) compounds are effective and safe alternative anticoagulants to unfractionated heparins (UFHs). They have been found to improve clinical outcomes in acute coronary syndromes and to provide a more predictable therapeutic response, longer and more stable anticoagulation, and a lower incidence of UFH-induced thrombocytopenia. Of the several LMWH agents that have been studied in large clinical trials, including enoxaparin, dalteparin, and nadroparin, not all have shown better efficacy than UFH. Enoxaparin is the only LMWH compound to have demonstrated sustained clinical and economic benefits in comparison with UFH in the management of unstable angina/ non-ST-segment elevation myocardial infarction (NSTEMI). Also, LMWH appears to be a reliable and effective antithrombotic treatment as adjunctive therapy in patients undergoing percutaneous coronary intervention. Clinical trials with enoxaparin indicate that LMWH is effective and safe in this indication, with or without the addition of a glycoprotein IIb/IIIa inhibitor. The efficacy demonstrated by enoxaparin in improving clinical outcomes in unstable angina/NSTEMI patients has led to investigations of its role in the management of ST-segment elevation myocardial infarction. Initial results are very encouraging, and they indicate that enoxaparin may potentially substitute for UFH as adjunctive therapy in fibrin-specific thrombolytic regimens and improve coronary reperfusion rates in streptokinase-based regimens.

Safety and effectiveness of combined low molecular weight heparin and glycoprotein IIb/IIIa inhibitors

This study examines the safety and efficacy of low molecular weight heparin (LMWH) in combination with platelet glycoprotein (GP) IIb/IIIa inhibitors in patients with acute myocardial infarction (AMI). LMWH has been shown to be as effective as unfractionated heparin (UFH) in the treatment of acute coronary syndrome (ACS), but there are limited data regarding the safety and efficacy of LMWH in combination with GP IIb/IIIa inhibitors. We studied 37,320 patients in the National Registry of Myocardial Infarction 3 who were treated with GP IIb/IIIa receptor antagonists from April 1998 to September 2000. Using univariate analysis, clinical events were compared between 2,482 patients who received LMWH and 34,838 patients who were treated with UFH. To adjust for confounding covariates, a multivariate regression analysis was also performed. Major bleeding rates were 4.0% in patients on LMWH versus 4.2% in patients who were treated with UFH (odds ratio [OR] 0.99, 95% confidence interval [CI] 0.80 to 1.23, p = 0.92). Similarly, there was no significant difference in the occurrence of recurrent myocardial ischemia (OR 0.93, 95% CI 0.82 to 1.06, p = 0.26), and in-hospital death (OR 0.86, 95% CI 0.71 to 1.05, p = 0.14) between groups. There was a trend toward a decreased risk of recurrent AMI in patients who received LMWH compared with those on UFH (1.5% vs 1.9%, OR 0.74, 95% CI 0.53 to 1.05, p = 0.09). LMWH appears to be a safe and effective alternative to UFH in patients with AMI who receive IIb/IIIa inhibitors.

Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability

OBJECTIVES

This study evaluated clinical outcomes in patients with acute myocardial infarction (MI) treated with fibrinolytic therapy in hospitals with and without coronary revascularization capability.

BACKGROUND

Patients with MI may have better outcomes when admitted to certain hospitals with coronary revascularization capability. Development of regional heart care centers for the treatment of MI has been proposed.

METHOD

We performed a retrospective analysis of 25,515 U.S. patients enrolled in the Global Use of Streptokinase and TPA (alteplase) for Occluded Coronary arteries (GUSTO)-I trial. Outcomes of patients admitted to hospitals with and without coronary revascularization capability were analyzed. We also analyzed patients who remained in hospitals without coronary revascularization capability compared with those transferred to hospitals with revascularization capability.

RESULTS

Baseline characteristics and complications were similar between patients in the two hospital types. Patients in hospitals with coronary revascularization capability more often underwent cardiac catheterization (78.1% vs. 59.2%; p < 0.001), angioplasty (34.6% vs. 22.6%; p < 0.001), or bypass surgery (14.1% vs. 10.4%; p < 0.001) but had a similar adjusted 30-day (odds ratio [OR] 0.91, 95% confidence interval [CI] 82 to 1.02) and one-year (OR 0.98, 95% CI 0.90 to 1.07) mortality. Forty percent of patients admitted to hospitals without revascularization capability were transferred, with 94% of transfer patients undergoing angiography. Almost 80% of transfers occurred >48 h after hospital admission.

CONCLUSION

Patients receiving fibrinolytic therapy for acute MI admitted to hospitals without coronary revascularization capability appear to have outcomes similar to those of patients admitted to hospitals with such capability when aspirin and beta-adrenergic blocking agents are given appropriately and transfer is available for angiography and angioplasty as needed.

Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal

Since the early 1990s, with significant improvement in the procedural success of percutaneous coronary interventions (PCIs), there has been a concomitant reduction in the need for emergency coronary artery bypass graft surgery. This review article focuses on the need for on-site cardiac surgery in patients with acute myocardial infarction undergoing primary angioplasty at centers without on-site cardiac surgical backup. It gives an overview of the need for emergency bypass surgery in both the large trial setting and the community hospital setting. Special consideration is also given to the risks and benefits of primary angioplasty compared with thrombolytic therapy, transfer to an institution with an on-site cardiac surgical facility compared with primary PCI, the frequency and indications for emergency cardiac surgery related and unrelated to primary angioplasty and the requirements for primary angioplasty that must be met in hospitals without the capability of on-site cardiac surgery.

Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study

BACKGROUND

Randomised trials of early revascularisation in acute coronary syndromes have yielded conflicting results with respect to effects on survival. We assessed the association between revascularisation within 14 days after the index event and 1-year mortality in individuals who survived for at least 14 days after an acute myocardial infarction.

METHODS

We studied a prospective cohort of patients admitted to the coronary care units of 61 Swedish hospitals between 1995 and 1998. We obtained 1-year mortality data from the Swedish National Cause of Death Register. We assessed 21,912 individuals with first registry-recorded acute myocardial infarction, who were younger than age 80 years, and alive at day 14. Relative risk of 1-year mortality in patients who had revascularisation (n=2554) or those who did not (n=19,358) within 14 days was calculated by Cox regression analysis, adjusting for multiple covariates that affect mortality and with a propensity score that adjusted for covariates that affected the likelihood of early revascularisation.

FINDINGS

At 1 year, unadjusted mortality was 9.0% (1751 deaths) in the conservative group and 3.3% (84 deaths) in the early revascularisation group. In the Cox regression analysis early revascularisation was associated with a reduction in 1-year mortality (relative risk 0.47; 95% CI 0.37-0.60; p<0.001). This relative reduction of mortality was similar in all subgroups irrespective of age, sex, baseline characteristics, previous disease manifestations, or treatment.

INTERPRETATION

Early revascularisation in individuals with acute myocardial infarction is associated with substantial reduction in 1-year mortality. Our findings lend support to the use of an invasive approach early after an acute myocardial infarction.

Hospital transfer of patients with acute myocardial infarction: the effects of age, race, and insurance type

BACKGROUND

Many factors precipitate the transfer of patients hospitalized for acute myocardial infarction, including clinical status and the need for diagnostic testing and therapeutic interventions not available at the admitting hospital. The objectives of this study were to assess the frequency of transfer to another hospital and to determine whether nonmedical factors, such as age, sex, race, and insurance status, are associated with transfer.

METHODS

We conducted a prospective study of patients with acute myocardial infarction who were enrolled in the National Registry of Myocardial Infarction 2 from June 1994 through March 1998. The Registry involves 1674 hospitals in the United States. All patients survived to the time of hospital discharge or until transfer. Multivariable logistic regression models, with transfer as the outcome variable, were developed for the entire sample, as well as for subgroups determined by the interventional capabilities of the admitting hospital.

RESULTS

Of 537,283 patients with acute myocardial infarction, 152,310 (28%) were transferred to another hospital after admission. After adjustment for differences in clinical and hospital characteristics, factors that were most associated with a reduced odds of transfer included older age (odds ratio [OR] = 0.43; 95% confidence interval [CI]: 0.42 to 0.44 for those aged >75 vs. <65 years), African-American race (OR = 0.69; 95% CI: 0.67 to 0.71 for African Americans vs. whites), and Medicaid/self-pay insurance status (OR = 0.68; 95% CI: 0.66 to 0.70 for Medicaid/self-pay vs. commercial insurance). These effects were most apparent for patients admitted to hospitals without full invasive diagnostic and therapeutic capabilities, but persisted to some extent among those admitted to hospitals with full invasive services.

CONCLUSION

Our findings suggest that nonmedical factors, including age, race, and insurance type, affect decisions regarding the transfer of patients hospitalized with acute myocardial infarction. As only a minority of the nation's hospitals offers a full range of cardiovascular diagnostic and therapeutic procedures, these findings reinforce ongoing concerns about disparities in access to health care services for some patients.

Rate of and risk factors for acute inpatient mortality after orthopaedic surgery

BACKGROUND

Orthopaedic surgeons operate on a diverse group of patients, and many of these patients have concomitant medical problems. The purpose of this study was to identify the rate of mortality and to evaluate the risk factors associated with mortality after orthopaedic surgery.

METHODS

Data from the National Hospital Discharge Survey, a nationwide sample of hospital admissions, were obtained for the years 1995 through 1997. The study was limited to hospital admissions. Univariate and multivariate analyses were performed.

RESULTS

The 43,215 inpatient orthopaedic operations that we evaluated were associated with a mortality rate of 0.92%. Seventy-seven percent of all deaths occurred after procedures performed for patients who were more than seventy years old, and 50% of all deaths occurred after operations performed for the treatment of hip fractures. The independent preoperative medical risk factors for death included chronic renal failure, congestive heart failure, metastasis to bone, atrial fibrillation, chronic obstructive pulmonary disease, and osteomyelitis. The risk factors of diabetes, coronary artery disease, peripheral vascular disease, septic arthritis, and rheumatoid arthritis did not achieve significance. Among orthopaedic subspecialty categories, operations for tumors, trauma, and infection were associated with elevated mortality rates. In a predictive model, five critical risk factors were identified as most helpful in identifying patients at risk for death: chronic renal failure, congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and an age of greater than seventy years. The mortality rate was 0.25% for patients with no critical risk factors. A linear increase in mortality was seen with increasing numbers of critical risk factors (p < 0.005).

CONCLUSION

Death is rare after orthopaedic operations. In the United States, the rate of acute mortality after inpatient orthopaedic surgical procedures is approximately 1% for all patients, 3.1% for patients with a hip fracture, and 0.5% for patients without a hip fracture. These data will aid orthopaedic surgeons in predicting operative mortality for their patients.

Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)

BACKGROUND

The benefits of reperfusion therapy for patients with acute coronary syndromes have been established, but there is much variation in the type of reperfusion given and decisions about which patients are eligible. This study assessed current practices in relation to reperfusion therapy of ST-segment-elevation myocardial infarction from data collected in the multinational, prospective Global Registry of Acute Coronary Events.

METHODS

94 hospitals in 14 countries are recruiting patients for the registry. Hospitals are organised into population-based clusters that reflect the population characteristics of the region. Information about patients' demographic characteristics, presenting symptoms, medical history, time between symptom onset and presentation, and clinical and electrocardiographic features is recorded in a standard case record.

FINDINGS

Of the 9251 patients enrolled, 1763 presented within 12 h of symptom onset with ST-segment-elevation myocardial infarction. Of these, 30% did not receive reperfusion therapy. Elderly patients (75 years and older), those presenting without chest pain, and those with a history of diabetes, congestive heart failure, myocardial infarction, or coronary bypass surgery were less likely to receive reperfusion therapy. The rate of primary percutaneous coronary intervention was highest in the USA and lowest in Australia, New Zealand, and Canada. The rate at sites with a catheterisation laboratory was 19% compared with zero at sites without this facility.

INTERPRETATION

A substantial proportion of patients who are eligible for reperfusion therapy still do not receive this treatment. These typically high-risk patients can be identified in advance, and reasons for the underuse of these beneficial treatments need to be clarified.

Use of thrombolytic therapy for acute myocardial infarction: effects of gender and age on treatment rates

BACKGROUND

Although there have been efforts to increase the utilization of thrombolytic therapy, there are still many patients who might benefit from this treatment who do not receive it. Women and the elderly have been particularly undertreated, despite evidence that their survival can be improved with thrombolysis. This study was undertaken to determine the relative rates of treatment of women vs. men and the elderly vs. younger subjects and to examine factors that might explain differences in treatment frequency.

METHODS AND RESULTS

This is a retrospective study of patients who presented to the Emergency Departments of four local hospitals in 1993 and 1994 with evidence for acute ST-elevation myocardial infarction. Demographic data, past medical history, information on co-morbid illnesses, and times to hospital arrival, first electrocardiogram, physician notification, and thrombolytic therapy were recorded as was survival to hospital discharge. Data for patients who did or did not receive thrombolytic therapy were compared. Men were treated more frequently in both tertiary and community hospitals. Women were older, but within each age bracket, men were treated more often. The time of arrival was similar for men and women, but men who arrived within 6 hours or 6-12 hours after pain onset were treated at a higher rate than women. For patients without contraindications, treatment was not affected by gender or age. However, treatment rates decreased with increased prevalence of exclusionary factors, and since both women and the elderly tended to have more such factors, elderly women were treated at a markedly lower rate. The single clinical factor that increased thrombolytic usage in women compared to men was a history of prior myocardial infarction.

CONCLUSION

Despite convincing evidence that thrombolytic therapy is beneficial in women and the elderly, these groups have been relatively neglected unless attention is called to clinical risk, for example, by history of prior myocardial infarction.

The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction

OBJECTIVE

To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI).

DESIGN

Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database.

SETTING

All Queensland public hospitals, July 1991 - June 1999.

STUDY POPULATION

Patients with AMI admitted through the emergency department.

INTERVENTION

Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995.

MAIN OUTCOME MEASURES

Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions.

RESULTS

Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97).

CONCLUSIONS

Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.

The role of low-molecular-weight heparin in the management of acute coronary syndromes

Optimized medical treatment for the non-ST segment elevation acute coronary syndromes (NSTE ACS) should consist of a combined antithrombotic/anti-anginal regimen. Standard antithrombotic treatment is currently unfractionated heparin and aspirin, and in high-risk patients glycoprotein IIb/IIIa inhibitors. However, low-molecular-weight heparins (LMWHs) have practical and clinical advantages over UFH and can be considered an effective alternative in the medical treatment of ACS and in patients proceeding to surgical interventions. Benefits include a more predictable and stable therapeutic response, no need for coagulation monitoring and a reduced incidence heparin-induced thrombocytopenia. In this context, the LMWH enoxaparin has demonstrated sustained clinical and economic benefits compared with UFH, with no increase in major bleeding complications. In addition, recently published studies indicate that LMWHs can improve reperfusion of the arteries and reduce reocclusion when used as adjunctive anticoagulant therapy in patients with ST segment elevation (STE) ACS undergoing thrombolysis with fibrin-specific agents or streptokinase.

[Management of myocardial infarction in Spain (1995-99). Data from the registry of the Ischaemic Heart Disease Working Group (RISCI) of the Spanish Society of Cardiology]

INTRODUCTION AND OBJECTIVES

Limited information is available on how patients with myocardial infarction are treated in Spain. In order to make up for this deficiency, in October 1994, the Ischaemic Heart Disease Working Group of the Spanish Society of Cardiology initiated a myocardial infarction registry, which is currently active.

METHODS

Patients are recruited from hospitals with intensive coronary care facilities. Demographic characteristics coronary risk factors and previous conditions are collected, as well as clinical events, and diagnostic and therapeutic procedures performed during the stay in the coronary care unit.

RESULTS

From 1995 to 1999, 28,357 patients were registered. During this period the mean age increased slightly (from 64.4 +/- 12.2 to 65.2 +/- 12.7; p < 0.001), although the male proportion remained stable (from 76.7% to 77.1%). The median "onset of symptoms-hospital arrival for 1st emergency" time fell from 135 min to 120 min, and the median "onset of symptoms-needle" time from 180 to 175 (NS). The use of thrombolytic therapy did not change (from 42.4 to 43.9%), but the use of aspirin (from 87.4 to 91.7%), beta-blockers (from 32.7 to 39.6%) and angiotensin-converting inhibitors (from 27.9 to 34.8%) increased significantly (p < 0.001). The Swan-Ganz catheter and the intra-aortic balloon counterpulsation were rarely placed during the five years (4.2% and 1.2% respectively in 1999). Both early mortality (11.4 to 9.3%) and the median duration of intensive coronary care stay declined, in these 5 years.

CONCLUSIONS

In Spain, during the 1995-1999 period, the use of aspirin, beta-blockers, and angiotensin-converting inhibitors increased significantly during the acute phase of infarction in the coronary care unit. However, both the usage of thrombolytic therapy and the delay between the onset of symptoms and therapy initiation remained unchanged. At the same time, the length of stay in the coronary care unit and early mortality declined, although the clinical profile of the patients did not improve.

A prediction model for prehospital triage of patients with suspected cardiac ischemia

The American College of Cardiology recommends that patients with high risk acute myocardial infarction (AMI) be triaged to hospitals with percutaneous transluminal coronary angioplasty capability. However, there are no prehospital triage criteria to select candidates for bypassing community hospitals and being taken directly to "cardiac centers." This article assesses which independent variables predict death within 7 days in patients with suspected AMI transported by EMS. This is a retrospective study of 291 AMI patients transported by ambulance to 3 hospitals during 1996-1997. Included were patients who were (n = 244) > or =18 years of age, had a ED chief complaint of chest pain or dyspnea for whom we had mortality data. Mortality at 7 days, our primary outcome measure, was obtained by using a metropolitan Detroit tricounty death index records. Differences between the survivors and nonsurvivors were assessed using the Student's t-test and chi-square tests. Multiple triage criteria were assessed for optimal identification of high risk patients by constructing a logistic multivariate model. Among the study population, 15% died within 7 days (95% confidence interval (CI) 10.3-19.2), and this group represented 63.2% of all deaths over a 2 year surveillance period. Survivors, compared to nonsurvivors, were 14.1 years younger (P < or = .001) and more often men (P < or = 0.001). The dispatch time to ED arrival was less among survivors than nonsurvivors (42.8 vs. 50.6 min, P < or = .01). EMS vital signs differed by survivor status. Among survivors, HR was lower (-11.9 bpm; P < or = 0.01), RR was lower (-6.7 rpm; P < or = .001), SBP was higher (+14.5 mmHg; P < or = 0.05) and DBP was higher (+13.2 mm Hg; P < or = .01). A multivariate model identified the following as independent predictors of early mortality: female gender (OR = 2.3; P < or = .05), age > or =65 (OR = 5.9; P < or = .01), RR > or = 20 (OR = 4.6; P < or = .001), SBP < 120 (OR = 2.4; P < or = .05). The overall model was 86% sensitive and 53% specific with an area under the receiving operating characteristic curve of 0.8 (P < or = .001). A triage rule based on a multivariate model can identify the group at high risk of early cardiac death. This decision rule needs to be prospectively validated.

ECG scores for a triage of patients with acute myocardial infarction transported by the emergency medical system

Prehospital triage of cardiac patients for bypass from community hospitals to cardiac centers may improve survival. This article determines if electrocardiogram (ECG)-based scoring triage methods (Aldrich MI scoring, QRS distortion, and the TIMI classification) and location of infarct (via 12 lead ECG) are associated with mortality before and after adjusting for age, sex, and race. It is a retrospective study of 291 AMI adult patients transported by ambulance to community hospitals or cardiac centers. Patients with an ED chief complaint of chest pain or dyspnea, presence of MI as defined by ECG findings of 0.1 mV of ST segment elevation in two leads or positive CPK-MB were eligible for the study. The primary outcome variable was 2-year mortality as determined with a metropolitan Detroit tri-county death index. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (with 95% CIs) of the predictor variables with mortality. Of the initial population selected for the study (n = 291), 229 patients were eligible for the analysis. The mean age was 66 years (SD of 14.4) with 63.8% being male and 54% being white. The overall mortality point estimate was 21.3% (95% CI of 15.2 to 27.3%). Aldrich scores and QRS distortion (yes/no) were not associated with mortality. Patients classified as a "high risk" for AMI per TIMI status were almost 3 times more likely to die than those at "low risk" and reached borderline statistical significance (P = .06) after adjusting for the covariates. Having an anterior infarct, as opposed to an inferior infarct, was significantly associated with death before and after adjusting for the covariates (Unadjusted OR = 2.6, Adjusted OR = 2.8). Properly training emergency medical system professionals in this area may prove useful for identifying higher risk AMI patients in the prehospital setting.