Long-Term Clinical Outcomes With Defect-Free Care Adherent to the Performance Measures in Patients with STEMI...

Adherence to the clinical performance measures has been advocated in ST-segment-elevation acute myocardial infarction (STEMI) care worldwide. We aimed to examine the association between adherence to these performance measures and long-term clinical outcomes in patients with STEMI undergoing percutaneous coronary intervention.

The CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) AMI Registry Wave-2 was a multicenter registry conducted at 22 centers in Japan between 2011 and 2013, enrolling consecutive acute myocardial infarction patients who underwent coronary revascularization. The exposures were adherence to 9 guideline-based performance measures for STEMI care, including early reperfusion, evidence-based medical therapy, and cardiac rehabilitation. The primary outcome measure was all-cause death. The secondary outcome measures included cardiovascular death, myocardial infarction, stroke, heart failure hospitalization, major bleeding, and repeat coronary revascularization. Outcomes were assessed over a median follow-up of 6.0 years (interquartile range, 5.1-6.8). Adjusted hazard ratios with 95% CIs were estimated using Cox proportional hazards models, adjusting for baseline characteristics.

Among 2892 patients with STEMI who underwent percutaneous coronary intervention within 24 hours after symptom onset and survived to discharge (mean age, 67±13 years; 23% women), patients were categorized according to the number of fulfilled performance measures (PMs=9: N=551, PMs=8: N=985, PMs=7: N=794, and PMs≤6: N=562). As the adherence categories decreased from PMs=9 to PMs≤6, the cumulative 5-year incidence of all-cause death increased from 8.9% to 23.6%. Relative to PMs=9, the adjusted hazard ratio (95% CI) for all-cause death was 1.14 (0.83-1.57) in PMs=8, 1.36 (0.99-1.87) in PMs=7, and 1.96 (1.43-2.69) in PMs≤6, respectively. These inverse associations were observed between adherence to performance measures and most clinical outcomes except for repeat coronary revascularization (adjusted hazard ratio, 1.00 [95% CI, 0.82-1.21] in PMs=8, 0.89 [0.72-1.09] in PMs=7, and 0.91 [0.72-1.15] in PMs≤6, respectively).

Defect-free care adherent to the performance measures was associated with improved long-term clinical outcomes, including lower mortality, among patients with STEMI undergoing percutaneous coronary intervention, whereas no association was observed for repeat coronary revascularization.