Quality of care by classification of myocardial infarction: treatment patterns for ST-segment elevation vs
Matthew T Roe1, Lori S Parsons, Charles V Pollack
1Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
Insights
Patients with ST-segment elevation myocardial infarction (STEMI) received guideline-recommended care more often than those with non-STEMI (NSTEMI). Improving NSTEMI care could reduce high acute myocardial infarction mortality rates.
Area of Science:
- Cardiology
- Clinical Practice Guidelines
- Health Services Research
Background:
- Practice guidelines recommend similar therapies for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI).
- Contemporary differences in care patterns between MI categories are not well-described.
- Acute myocardial infarction (MI) remains a significant cause of mortality.
Purpose of the Study:
- To compare in-hospital treatment patterns and outcomes for STEMI versus NSTEMI patients.
- To identify disparities in the application of guideline-recommended therapies.
- To inform quality improvement initiatives for acute MI care.
Main Methods:
- Analysis of 185,968 patients with STEMI or NSTEMI from the National Registry of Myocardial Infarction 4 (July 2000 - June 2002).
- Comparison of guideline-recommended in-hospital treatments and discharge therapies.
- Hierarchical logistic regression modeling to determine adjusted differences in treatment patterns.
Main Results:
- Unadjusted in-hospital mortality was high for both NSTEMI (12.5%) and STEMI (14.3%).
- Patients with STEMI had a higher adjusted likelihood of receiving early aspirin, beta-blockers, and ACE inhibitors.
- STEMI patients were more likely to receive guideline-recommended medications and interventions at discharge.
Conclusions:
- Evidence-based medications and lifestyle interventions were underutilized in NSTEMI patients.
- Significant gaps in care exist between STEMI and NSTEMI management.
- Quality improvement interventions are needed to improve adherence to guidelines for all MI patients and reduce mortality.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:27Coronary Artery Disease V: Interprofessional Care
01:27Myocarditis II: Clinical Features and Diagnostic Tests