[Treatment of ST-segment elevation acute myocardial infarction in hospitals with and without cardiac catheterization laboratory]

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Versorgungsstrukturen und Mengen-Ergebnis-Beziehung beim akuten Herzinfarkt – Verlaufsbetrachtung der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2015

Hintergrund Studien haben beschrieben, dass höhere Herzinfarktfallzahlen des behandelnden Krankenhauses mit besseren Behandlungsergebnissen assoziiert sind. Vor diesem Hintergrund wird die Entwicklung der akutstationären Herzinfarktversorgung sowie der Mengen-Ergebnisbeziehung im Zeitverlauf analysiert. Ziel der Arbeit ist, die Entwicklungen zu bewerten und Anhaltspunkte für eine Verbesserung der Herzinfarktversorgung in Deutschland abzuleiten.

Methode Anhand der deutschlandweiten Krankenhausabrechnungsdaten (DRG-Statistik) von 2005 bis 2015 wurden Patienten mit akutem Herzinfarkt im erstbehandelnden Krankenhaus identifiziert und anhand der jährlichen Herzinfarktfallzahl des behandelnden Krankenhauses in fallzahlgleiche Quintile eingeteilt.

Ergebnisse Im Beobachtungszeitraum zeigte sich ein zunehmender Anteil interventionell versorgter Herzinfarktpatienten. Die Krankenhaussterblichkeit im erstbehandelnden Krankenhaus ging insgesamt von 12,1 auf 8,7% zurück. In allen Jahren wurde in den höheren Fallzahlquintilen eine geringere Sterblichkeit im Vergleich zum unteren Fallzahlquintil beobachtet. Im Jahr 2015 zeigte sich im Vergleich zur Behandlung in Krankenhäusern mit sehr geringer Fallzahl ein um 20% reduziertes Sterberisiko (adjustiertes OR jeweils 0,8 [95% KI 0,7–0,9]) in Krankenhäusern mit mittlerer, hoher oder sehr hoher Fallzahl. Mehr als 40% der Krankenhäuser mit sehr geringer Fallzahl waren in städtischen Regionen lokalisiert.

Schlussfolgerung Eine gezieltere Steuerung von Patienten mit Herzinfarktsymptomen in Krankenhäuser mit hohen Herzinfarktfallzahlen könnte die Versorgung weiter verbessern. Eine solche Versorgungssteuerung ist sowohl aus Gründen der medizinischen Qualität als auch der Wirtschaftlichkeit insbesondere in städtischen Regionen erforderlich.

Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set

Background:

We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years.

Methods:

We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization.

Results:

We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001).

Conclusions:

Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.

[Procedural aspects in primary PCI: arterial access, stent selection, thrombectomy and treatment of non-culprit lesions]

Acute myocardial infarction was one of the most common causes of death in Germany in 2011. According to the guidelines of the European Society for Cardiology, systemic fibrinolysis and primary percutaneous coronary intervention (PCI) are the methods of choice for acute treatment. Primary PCI should be given priority due to its superiority. The transradial access should be preferred due to the lower bleeding complication rate. In the selection of stents the new generation of drug-eluting stents (DES) are superior to the first generation of bare metal stents (BMS). It has now been demonstrated that the incident rates of DES (e.g. mortality, target vessel revascularization, early and late stent thrombosis and myocardial infarction) are significantly lower. For bioresorbable scaffolds (BRS) long-term results for the use in treatment of ST-elevation myocardial infarction (STEMI) are not yet available but initial results are very promising. However, the selection of a stent needs to be done on an individual basis in order to do justice to all aspects. Data with respect to thrombectomy in acute treatment are heterogeneous. Currently, a thorough consideration of all aspects is necessary because thrombus aspiration can also be associated with an increased rate of incidents. In a state of hemodynamic stability only so-called culprit lesions should currently be treated with a stent. Elective interventions on further stenoses should be carried out after consideration of individual factors and if necessary evaluation of the hemodynamic relevance.

Ubiquitin-free routes into the proteasome

The majority of proteasome substrates identified to date are marked for degradation by polyubiquitinylation. Exceptions to this principle, however, are well documented and can help us understand the process proteasomes use to recognize their substrates. Examples include ornithine decarboxylase, p21/Cip1, TCRalpha, IkappaBalpha, c-Jun, calmodulin and thymidylate synthase. Degradation of these proteins can be completely ubiquitin-independent or coexist with ubiquitin-dependent pathways. Uncoupling degradation from ubiquitin modification may reflect the evolutionary conservation of mechanisms optimized for highly specialized regulatory functions.