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Early recognition of the signs and symptoms of acute coronary syndromes (ACS) is essential to improving patient management and associated outcomes. It is widely reported that women might have a different ACS symptom presentation than men. Multiple review articles have examined sex differences in symptom presentation of ACS and these studies have yielded inconclusive results and/or inconsistent recommendations. This is largely because these studies have included diverse study populations, different methods of assessing the chief complaint and associated coronary symptoms, relatively small sample sizes of women and men, and lack of adequate adjustment for age or other potentially confounding differences between the sexes. There is a substantial overlap of ACS symptoms that are not mutually exclusive according to sex, and are generally found in women and men. However, there are apparent differences in the frequency and distribution of ACS symptoms among women and men. Women, on average, are also more likely to have a greater number of ACS-related symptoms contributing to the perception that women have more atypical symptoms than men. In this review, we address issues surrounding whether women should have a different ACS symptom presentation message than men, and provide general recommendations from a public policy RESUME

Background— Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy for patients with ST-segment–elevation myocardial infarction (STEMI). The quality of care and safety and efficacy of pPCI at hospitals without on-site open heart surgery (No-OHS hospitals) remains an area of active investigation. Methods and Results— The National Registry of Myocardial Infarction enrolled 58 821 STEMI patients from 214 OHS hospitals (n=54 076) and 52 No-OHS hospitals (n=4745) with PCI capabilities from 2004 to 2006. Patients presenting to OHS hospitals had substantially lower in-hospital mortality (7.0% versus 9.8%, P P P =0.025). When this model was further adjusted for differences in the use of acute reperfusion therapy, medications administered within 24 hours and hospital characteristics, the mortality difference was of borderline significance (hazard ratio, 0.87; 95% CI, 0.75 to 1.01; P =0.067). When the propensity score analysis was restricted to patients who underwent pPCI, there was no significant difference in mortality (3.8% versus 3.3%, P =0.44). Conclusions— STEMI patients presenting to No-OHS hospitals have substantially higher mortality, are less likely to receive guideline recommended medications within 24 hours, and are less likely to undergo acute reperfusion therapy, although this difference was of borderline significance after adjusting for hospital and treatment variables. There was no difference in mortality among patients undergoing pPCI.

ObjectivesThe goals of this analysis were: 1) to evaluate outcomes among non–ST-segment elevation myocardial infarction (NSTEMI) patients presenting to hospitals with on-site cardiac surgery (OHS hospitals) and without on-site cardiac surgery (No-OHS hospitals); and 2) to specifically examine outcomes among the subset of NSTEMI patients undergoing percutaneous coronary intervention (PCI).BackgroundWhether backup cardiac surgery improves outcomes among NSTEMI patients or is simply a marker of better adherence to guideline recommendations is unknown.MethodsThe NRMI (National Registry of Myocardial Infarction) enrolled 100,071 NSTEMI patients from 2004 to 2006. Outcomes were evaluated in the population as a whole and in propensity-matched analyses in the entire population and in the subset of patients undergoing PCI.ResultsIn-hospital mortality was significantly lower at OHS hospitals (5.0% vs. 8.8%, p < 0.001). Patients presenting to OHS hospitals were significantly more likely to receive aspirin, beta-blockers, and statins (p < 0.05 for all) and to undergo PCI (38.4% vs. 14.1%, p < 0.001). In the propensity-matched model, the difference in mortality remained significant (5.9% vs. 8.5%, p < 0.001). After adjusting for differences in medications administered within 24 h of arrival and hospital characteristics, the difference in mortality was nearly attenuated (hazard ratio: 0.89, 95% confidence interval: 0.79 to 1.00, p = 0.050). When the propensity-matched model was restricted to patients undergoing PCI, there was no significant difference in mortality (1.3% vs. 1.0%, p = 0.51).ConclusionsNSTEMI patients presenting to No-OHS hospitals have significantly higher mortality. This appears to be due to both modifiable (lower use of guideline-recommended medications) and nonmodifiable factors (hospital size, myocardial infarction volume). In a propensity-matched analysis of patients undergoing PCI for NSTEMI, there was no significant difference in mortality.

Background Among patients with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is associated with improved mortality. As such, door-to-needle (D2N) and door-to-balloon (D2B) times have become metrics of quality of care and targets for intense quality improvement. Methods The National Registry of Myocardial Infarction (NRMI) collected data regarding reperfusion therapy, its timing and in-hospital mortality among STEMI patients from 1990 through 2006. Results Since 1990, NRMI has enrolled 1,374,232 STEMI patients at 2,157 hospitals. Among those, 774,279 (56.3%) were eligible for reperfusion upon arrival. The proportion receiving fibrinolytic therapy fell from 52.5% in 1990 to 27.6% in 2006 ( P P P P P Conclusions Since 1990, there has been a progressive decline in D2N and D2B time among reperfusion-eligible STEMI patients. These improvements have contributed, at least in part, to a progressive decline in mortality.

Although ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (AMI) have been the focus of intense clinical investigation, limited information exists on characteristics and hospital mortality of patients not enrolled in clinical trials. Previous large databases have reported declining mortality of patients with STEMI but have not noted substantial mortality change among those with NSTEMI.The National Registry of Myocardial Infarction enrolled 2,515,106 patients at 2,157 US hospitals from 1990 to 2006. Of these, we evaluated 1,950,561 with diagnoses reflecting acute myocardial ischemia on admission.From 1990 to 2006, the proportion of NSTEMI increased from 14.2% to 59.1% (P.0001), whereas the proportion of STEMI decreased. Mean age increased (from 64.1 to 66.4 years, P.0001) as did the proportion of females (from 32.4% to 37.0%, P.0001). Patients were less likely to report prior angina, prior AMI, or family history of coronary artery disease but more likely to report history of diabetes, hypertension, current smoking, heart failure, prior revascularization, stroke, and hyperlipidemia. From 1994 to 2006, hospital mortality fell among all patients (10.4% to 6.3%), STEMI (11.5% to 8.0%), and NSTEMI (7.1% to 5.2%), (all P.0001). After adjustment for baseline covariates, hospital mortality fell among all patients by 23.6% (odds ratio [OR] 0.764, 95% CI 0.744-0.785), STEMI by 24.2% (OR 0.758, 0.732-0.784), and NSTEMI by 22.6% (OR 0.774, 0.741-0.809), all P.001.This large, observational database from 1990 to 2006 shows increasing prevalence of NSTEMI and, despite higher risk profile on presentation, falling risk-adjusted hospital mortality in patients with either STEMI or NSTEMI.

Background Trends in the use of guideline-based treatment for acute myocardial infarction (AMI) as well as its association with patient outcomes have not been summarized in a large, longitudinal study. Furthermore, it is unknown whether gender-, race-, and age-based care disparities have narrowed over time. Methods and Results Using the National Registry of Myocardial Infarction database, we analyzed 2,515,106 patients with AMI admitted to 2,157 US hospitals between July 1990 and December 2006 to examine trends overall and in select subgroups of guideline-based admission, procedural, and discharge therapy use. The contribution of temporal improvements in acute care therapies to declines in in-hospital mortality was examined using logistic regression analysis. From 1990 to 2006, the use of all acute guideline-recommended therapies administered rose significantly for patients with ST-segment elevation myocardial infarction and patients with non–ST-segment myocardial infarction but remained below 90% for most therapies. Cardiac catheterization and percutaneous coronary intervention use increased in patients with ST-segment elevation myocardial infarction and patients with non–ST-segment myocardial infarction, whereas coronary bypass surgery use declined in both groups. Despite overall care improvements, women, blacks, and patients ≥75 years old were significantly less likely to receive revascularization or discharge lipid-lowering therapy relative to their counterparts. Temporal improvements in acute therapies may account for up to 37% of the annual decline in risk for in-hospital AMI mortality. Conclusion Adherence to American Heart Association/American College of Cardiology practice guidelines has improved care of patients with AMI and is associated with significant reductions in in-hospital mortality rates. However, persistent gaps in overall care as well as care disparities remain and suggest the need for ongoing quality improvement efforts.

We investigated whether a combination of clopidogrel and glycoprotein (GP) IIb/IIIa inhibitors safely decreases hospital mortality, reinfarction, and major bleeding beyond either therapy alone in patients with non-ST-elevation myocardial infarction (NSTEMI). GP IIb/IIIa inhibitors and clopidogrel, separately, have been shown to decrease adverse outcomes in patients with non-ST-elevation acute coronary syndromes, but the need for combination therapy is uncertain. Multivariate and propensity analyses compared the frequency of death, reinfarction, and major bleeding during hospitalization in 38,691 patients with NSTEMI who were enrolled in the National Registry of Myocardial Infarction 4 from July 2000 to December 2003. Of these, 65% received GP IIb/IIIa inhibitors only, 16.1% clopidogrel only, and 18.8% combination therapy. Among patients who did not undergo percutaneous coronary intervention (PCI), the composite end point of death, reinfarction, and major bleeding was significantly lower with combination therapy than with GP IIb/IIIa inhibitors alone (odds ratio 0.77, 95% confidence interval 0.67 to 0.88). In contrast, this composite end point was significantly higher when combination therapy was employed rather than clopidogrel alone (odds ratio 1.55, 95% confidence interval 1.33 to 1.81). However, among patients who underwent PCI, the composite end point was similar between combination therapy and GP IIb/IIIa inhibitor-only groups (odds ratio 1.01, 95% confidence interval 0.89 to 1.14). Further, there was a strong trend toward a higher composite end point among patients who received combination therapy rather than clopidogrel alone (odds ratio 1.31, 95% confidence interval 0.99 to 1.72). In conclusion, commonly employed strategies using a GP IIb/IIIa inhibitor alone or with the combination of clopidogrel plus GP IIb/IIIa inhibitor in NSTEMI may not be justified in comparison with a simpler strategy of clopidogrel used alone, especially in patients who have not undergone PCI.

Objectives The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times. Background Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness. Methods Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics. Results A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p Conclusions The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

Prior studies have suggested that young blacks with acute myocardial infarction (AMI) may have higher hospital mortality rates than whites of similar age. However, the influence of age and race on short-term death has not been explored in detail. We examined the relation of age and race on short-term death in a large AMI population and ascertained the factors that may have contributed to differences in mortality rates.We compared the crude and adjusted hospital mortality rates stratified by age among 40,903 blacks and 501,995 whites with AMI enrolled in the National Registry of Myocardial Infarction-2 in 1482 participating US hospitals from June 1994 through March 1998.Overall crude mortality was lower among blacks compared with whites (10.9% vs 12.0%, P.0001). However, blacks had a significantly higher crude mortality rate compared with the whites in the age groups65 years (45 years, and 5-year age groups between 45 and 64 years). There was a statistically significant interaction between age and black race on hospital death (P value for interaction.001). Each 5-year decrement in age from 85 years was associated with 7.2% higher odds of death in blacks compared with whites (95% CI, 5.7% to 7.6%). After adjusting for differences in the baseline, clinical presentation, early treatment, and hospital characteristics, 5-year decrements in age was still associated with increases in the odds for death in blacks compared with whites (5.4%; 95% CI, 3.6% to 7.2%). This interaction between age and black race was present in both sexes but was stronger among men.Blacks younger than 65 years had higher hospital mortality rates compared with whites hospitalized for AMI, and decreasing age was associated with progressively higher risk of hospital death for blacks. Differences in the clinical presentation, early treatment, and hospital characteristics could only partly explain this age-race interaction.

We examined diffusion of troponin testing in Medicare patients with unstable angina before the release of year 2000 American College of Cardiology/American Heart Association guidelines recommending measurement in all patients with acute coronary syndromes.We identified unstable angina admissions from Medicare administrative files for 22 Alabama hospitals over two time periods: 03/1997-02/1998 and 01/99-12/1999. Data were obtained from chart abstraction. Patients not confirmed for unstable angina by a clinical algorithm were eliminated.For 1997-1998, 1116 (87.7%) of all identified cases were clinically confirmed for unstable angina, and 1176 (90.3%) were confirmed for 1999. In 1997-1998, 235 (21%) of unstable angina patients had troponin measured, compared to 822 (70%) in 1999. From 1999, patients with troponin measurement, vs. those without, more likely had typical angina (50.9%, 37.4%), chest pain on arrival (72.8%, 57.1%), and chest pain at rest (45.4%, 37.2%) and more often received EKG within 20 min of presentation (46.3%, 27.9%) (P.0005 for all). Patients with abnormal troponin levels more often received angiotensin converting enzyme inhibitors (54.6%, 18.3%), cardiac catheterization (45.4%, 31.2%), and percutaneous coronary intervention (18.6%, 4.8%) (P.05 for all). These associations remained significant after multivariable adjustment for patient and hospital characteristics.This study demonstrates increasing and appropriate use of troponin before guideline release. Our findings suggest that guidelines may codify currently accepted practice rather than always disseminate new knowledge. The same forces that lead to guideline development and release may also lead to changes in clinical practice before guideline release.

Background— Increasing evidence suggests an inverse relationship between outcome and the total number of invasive cardiac procedures performed at a given hospital. The purpose of the present study was to determine if a similar relationship exists between the number of intra-aortic balloon counterpulsation (IABP) procedures performed at a given hospital per year and the in-hospital mortality rate of patients with acute myocardial infarction complicated by cardiogenic shock. Methods and Results— We analyzed data of 12 730 patients at 750 hospitals enrolled in the National Registry of Myocardial Infarction 2 from 1994 to 1998. The hospitals were divided into tertiles (low–, intermediate–, and high–IABP volume hospitals) according to the number of IABPs performed at the given hospital per year. The median number of IABPs performed per hospital per year was 3.4, 12.7, and 37.4 IABPs at low-, intermediate-, and high-volume hospitals, respectively. Of those patients who underwent IABP, there were only minor differences in baseline patient characteristics between the 3 groups. Crude mortality rate decreased with increasing IABP volume: 65.4%, lowest volume tertile; 54.1%, intermediate volume tertile; and 50.6%, highest volume tertile ( P for trend Conclusions— Among the myocardial infarction patients with cardiogenic shock who underwent IABP placement, mortality rate was significantly lower at high–IABP volume hospitals compared with low–IABP volume hospitals.

OBJECTIVES We sought to identify patient and hospital features associated with early glycoprotein (GP) IIb/IIIa inhibitor therapy for non-ST-elevation (NSTE) myocardial infarction (MI) and to relate this treatment to in-hospital outcomes. BACKGROUND Glycoprotein IIb/IIIa inhibitors have improved outcomes in randomized trials of NSTE MI, leading national treatment guidelines to recommend their use. Their actual use, safety, and effectiveness have not been well characterized beyond trial populations. METHODS We studied 60,770 patients with NSTE MI treated between July 2000 and July 2001 at 1,189 hospitals in a U.S. registry. Using logistic regression, we identified patient and hospital features associated with GP IIb/IIIa inhibition within 24 h after presentation. We also compared outcomes by early treatment versus no treatment after adjusting for patient and hospital characteristics and treatment propensity. RESULTS Only 25% of eligible patients received early GP IIb/IIIa therapy. Elderly patients, women, minority patients, and those without private insurance received such therapy less often than their counterparts. Treated patients had lower unadjusted in-hospital mortality (3.3% vs. 9.6%, p < 0.0001) remaining significantly lower after adjustment for patient risk, treatment propensity, and hospital characteristics (adjusted odds ratio, 0.88; 95% confidence interval, 0.79 to 0.97). Hospitals that adopted early GP IIb/IIIa inhibition more rapidly also had lower adjusted mortality rates than those slower to adopt such therapy. CONCLUSIONS Glycoprotein IIb/IIIa inhibitor therapy appears to be underused in early management of NSTE MI patients. Because this therapy is associated with better outcomes, it represents a target for quality improvement.

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.

Chest pain is a hallmark symptom in patients with unstable angina pectoris (UAP). However, little is known regarding the prevalence of an atypical presentation among these patients and its relation to subsequent care. We examined the medical records of 4,167 randomly sampled Medicare patients hospitalized with unstable angina at 22 Alabama hospitals between 1993 and 1999. We defined typical presentation as (1) chest pain located substernally in the left or right chest, or (2) chest pain characterized as squeezing, tightness, aching, crushing, arm discomfort, dullness, fullness, heaviness, pressure, or pain aggravated by exercise or relieved with rest or nitroglycerin. Atypical presentation was defined as confirmed UAP without typical presentation. Among patients with confirmed UAP, 51.7% had atypical presentations. The most frequent symptoms associated with atypical presentation were dyspnea (69.4%), nausea (37.7%), diaphoresis (25.2%), syncope (10.6%), or pain in the arms (11.5%), epigastrium (8.1%), shoulder (7.4%), or neck (5.9%). Independent predictors of atypical presentation for patients with UAP were older age (odds ratio 1.09, 95% confidence interval 1.01 to 1.17/decade), history of dementia (odds ratio 1.49, 95% confidence interval 1.10 to 2.03), and absence of prior myocardial infarction, hypercholesterolemia, or family history of heart disease. Patients with atypical presentation received aspirin, heparin, and beta-blocker therapy less aggressively, but there was no difference in mortality. Thus, over half of Medicare patients with confirmed UAP had "atypical" presentations. National educational initiatives may need to redefine the classic presentation of UAP to include atypical presentations to ensure appropriate quality of care.

Background Although postmenopausal hormone therapy (HRT) commonly is used in hope of preventing coronary heart disease, the effect of HRT on case fatality of myocardial infarction has never been studied. We evaluated HRT as a predictor of survival after MI in postmenopausal women. Methods and Results The present study was performed with 114 724 women of age ≥55 years with confirmed myocardial infarction who presented between April 1998 and January 2000 to 1 of 1674 hospitals participating in the National Registry of Myocardial Infarction-3. Presenting characteristics, treatment, and clinical outcome data were obtained by chart review. At time of hospitalization, 7353 (6.4%) women reported current use of HRT, defined as use of estrogen, progestin, or estrogen/progestin for reasons other than contraception. Unadjusted mortality was 7.4% in users of HRT and 16.2% in nonusers (odds ratio 0.41, 95% confidence interval 0.36 to 0.43). After adjustments were made for prior medical history, clinical characteristics, treatments received in-hospital, and likelihood of receiving HRT, HRT remained associated with an improved rate of survival (odds ratio 0.65, 95% confidence interval 0.59 to 0.72). Significant association of HRT with decreased mortality after myocardial infarction was observed in all age strata. Conclusions Postmenopausal HRT appears to be associated with reduced mortality after myocardial infarction. This finding could be caused by therapeutic effect of HRT, selection and adherence bias, or some combination of both.

OBJECTIVES We examined the association of hormone therapy (HRT) with hemorrhagic and ischemic stroke among postmenopausal women with acute myocardial infarction (AMI). BACKGROUND Hemorrhagic and ischemic strokes are common complications of AMI, and women are at increased risk for hemorrhagic stroke after thrombolytic therapy. This risk may be related to female hormones. METHODS Using data from the National Registry of Myocardial Infarction-3, we studied 114,724 women age 55 years or older admitted to the hospital for AMI, of whom 7,353 reported HRT use on admission. We determined rates of in-hospital hemorrhagic and ischemic stroke stratified by HRT use and estimated the independent association of HRT with each stroke type using multivariable logistic regression. RESULTS The HRT users were younger than non-users, had fewer risk factors for stroke including diabetes and prior stroke, and received more pharmacologic and invasive therapy including cardiac catheterization. A total of 2,152 (1.9%) in-hospital strokes occurred, with 442 (0.4%) hemorrhagic, 1,017 (0.9%) ischemic and 693 (0.6%) unspecified. Among HRT users and non-users, the rates of hemorrhagic stroke (0.40% vs. 0.42%, p = 1.00) and ischemic stroke (0.80% vs. 0.96%, p = 0.11) were similar. Among 13,328 women who received thrombolytic therapy, the rate of hemorrhagic stroke was not significantly different for users and non-users (1.6% vs. 2.1%, p = 0.22). After adjustment for baseline and treatment differences, HRT was not associated with hemorrhagic (odds ratio [OR], 0.88; 95% confidence intervals [CI], 0.58 to 1.35) or ischemic stroke (OR, 0.89; CI, 0.66 to 1.18). CONCLUSIONS Acute myocardial infarction is a high-risk setting for stroke among postmenopausal women, but HRT does not appear to modify that risk. Clinicians should not alter their approach to thrombolytic therapy based on HRT use.

Immediate reperfusion therapy to restore coronary blood flow is recommended for all eligible patients with acute myocardial infarction. However, reperfusion therapy is reportedly underutilized among African Americans, even when they are eligible. Reasons for the lack of use have not been fully explored.We examined the demographic, clinical, and treatment data of 10,469 African Americans with acute myocardial infarction who were eligible for reperfusion therapy, enrolled in the National Registry of Myocardial Infarction-2 from June 1994 through March 1998.The mean age was 62.58 (+/-14.4) years, and 44.7% were female. Although eligible, 47% of the African Americans in this study did not receive reperfusion therapy. In a multivariate analysis, the absence of chest pain at presentation (odds ratio [OR] 0.31, 95% CI 0.26-0.37) and initial admission diagnoses other than definite myocardial infarction (OR for receipt of reperfusion0.12) were the strongest predictors of lack of early reperfusion therapy. Progressive delays in hospital arrival and hospital evaluation predicted a lower likelihood of early reperfusion. Prior stroke (OR 0.63, 95% CI 0.50-0.78), myocardial infarction (OR 0.75, 95% CI 0.65-0.86), and congestive heart failure (OR 0.49, 95% CI 0.40-0.60) were all associated with lack of reperfusion therapy.Almost half of eligible African American patients with myocardial infarction did not receive reperfusion therapy. Potential reasons may include atypical presentation, patient and institutional delay, and underappreciation of myocardial infarction by care providers. Strategies to address these factors may improve the rate of use of reperfusion therapy.

OBJECTIVES We sought to determine trends in the treatment of myocardial infarction from 1990 through 1999 in the U.S. and to relate these trends to current guidelines. BACKGROUND Limited data are available to show how recent clinical trials and clinical guidelines have impacted treatment of myocardial infarction. METHODS Temporal trends in myocardial infarction treatment and outcome were assessed by using data from 1,514,292 patients in the National Registry of Myocardial Infarction (NRMI) 1, 2 and 3 from 1990 through 1999. Results During this interval, the use of intravenous thrombolytic therapy declined from 34.3% to 20.8%, but the use of primary angioplasty increased from 2.4% to 7.3% (both p = 0.0001). The median “door-to-drug” time among thrombolytic therapy recipients fell from 61.8 to 37.8 min (p = 0.0001), primarily owing to shorter “door-to-data” and “data-to-decision” times. The prevalence of non–Q wave infarctions increased from 45% in 1994 to 63% in 1999 (p = 0.0001). From 1994 through 1999, there was increased usage of beta-blockers, aspirin and angiotensin-converting inhibitors, both during the first 24 h after admission and on hospital discharge (all p = 0.0001). Between 1990 and 1999, the median duration of hospital stay fell from 8.3 to 4.3 days, and hospital mortality declined from 11.2% to 9.4% (both p = 0.0001). CONCLUSIONS The NRMI data from 1990 through 1999 demonstrate that the recommendations of recent clinical trials and published guidelines are being implemented, resulting in more rapid administration of intravenous thrombolytic therapy, increasing use of primary angioplasty and more frequent use of adjunctive therapies known to reduce mortality, and may be contributing to the higher prevalence of non–Q wave infarctions, shorter hospital stays and lower hospital mortality.

OBJECTIVESWe sought to determine the importance of chest pain on presentation as a predictor of in-hospital treatment and mortality in myocardial infarction (MI) patients with left bundle-branch block (LBBB).BACKGROUNDLeft bundle-branch block patients have a high mortality after MI but are unlikely to receive reperfusion therapy despite evidence from clinical trials demonstrating the efficacy of thrombolytic therapy. Nearly half of MI patients with LBBB present without chest pain.METHODSWe studied the clinical features, treatment and in-hospital survival of 29,585 patients with LBBB enrolled in the National Registry of MI 2 (June 1994 through March 1998). Multivariate logistic regression was used to assess the independent effect of chest pain on reperfusion decisions and in-hospital mortality.RESULTSLeft bundle-branch block patients with chest pain were greater than five-fold more likely to receive reperfusion therapy (13.6% vs. 2.6%) than LBBB patients without chest pain; they were also more likely to receive aspirin, beta-adrenergic blocking agents, heparin and nitrates (all p < 0.0001). Unadjusted in-hospital mortality was 18% in patients with chest pain and 27% in patients without chest pain. Adjusting for patient characteristics reduced the odds ratio associated with the absence of chest pain from 1.47 (95% confidence interval: 1.41 to 1.54) to 1.21 (95% confidence interval: 1.12 to 1.30). The remainder of the mortality difference was caused by the undertreatment of patients without chest pain, particularly the low utilization of aspirin and beta-blockers.CONCLUSIONSLeft bundle-branch block patients with MI who present without chest pain are less likely to receive optimal therapy and are at increased risk of death. Prompt recognition and treatment of this high-risk subgroup should improve survival.

Background There is an inverse relation between mortality from cardiovascular causes and the number of elective cardiac procedures (coronary angioplasty, stenting, or coronary bypass surgery) performed by individual practitioners or hospitals. However, it is not known whether patients with acute myocardial infarction fare better at centers where more patients undergo primary angioplasty or thrombolytic therapy than at centers with lower volumes. Methods We analyzed data from the National Registry of Myocardial Infarction to determine the relation between the number of patients receiving reperfusion therapy (primary angioplasty or thrombolytic therapy) and subsequent in-hospital mortality. A total of 450 hospitals were divided into quartiles according to the volume of primary angioplasty. Multiple logistic-regression models were used to determine whether the volume of primary angioplasty procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Similar analy...

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

OBJECTIVESWe sought to determine the extent to which the capability of a hospital to perform invasive cardiovascular procedures influences treatment and outcome of patients admitted with acute myocardial infarction (AMI).BACKGROUNDPatients with AMI are usually transported to the closest hospital. However, relatively few hospitals have the capability for immediate coronary arteriography, percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG), should these interventions be needed.METHODSThe 1,506 hospitals participating in the National Registry of Myocardial Infarction 2 were classified according to their highest level of invasive capability: 1) none (noninvasive, 28.1%); 2) coronary arteriography (cath-capable, 25.2%); 3) coronary angioplasty (PTCA-capable, 7.4%); and 4) bypass surgery (CABG-capable, 39.2%). Treatment and in-hospital outcomes were assessed for 305,812 patients admitted from June 1994 through October 1996. Follow-up through 90 days was ascertained in a subset of 30,402 patients enrolled simultaneously in both the National Registry of Myocardial Infarction (NRMI) 2 and the Cooperative Cardiovascular Project (CCP).RESULTSThe proportion of patients receiving initial reperfusion intervention was only slightly higher at the more invasive hospitals (noninvasive 32.5%, cath-capable 31.2%, PTCA-capable 32.9% and CABG-capable 35.9%, p < 0.001 by chi-square statistic). Among thrombolytic recipients, median door-to-drug time interval differed little among hospital types and ranged from 42 to 45 minutes. At cath-capable, PTCA-capable and CABG-capable hospitals, coronary arteriography was performed in 32.9%, 37.4% and 64.9%, respectively, and PTCA in 0.0%, 5.1% and 31.4%, both p < 0.001 by chi-square statistic. The proportion of patients transferred out to other facilities was 51.0%, 42.2%, 39.9% and 4.4% (p < 0.0001) among noninvasive, cath-capable, PTCA-capable and CABG-capable hospitals, respectively. Among patients in the combined NRMI and CCP data set, mortality at 90 days postinfarction was similar among patients initially admitted to each of the four hospital types.CONCLUSIONSAlthough patients with AMI admitted to hospitals without invasive cardiac facilities have a high likelihood of subsequent transfer to other facilities, their likelihood of receiving a reperfusion intervention at the first hospital, their door to thrombolytic drug intervals and their 90-day survival rates are similar to those of patients initially admitted to more invasively equipped hospitals. These data suggest that a policy of initial treatment of myocardial infarction at the closest medical facility is appropriate medical practice.

Outcomes research using analysis of preexisting data is a relatively new field with the potential to improve the quality and effectiveness of medical care, and may provide a useful complement to randomized studies. Motivated by the growth of this research in the cardiovascular literature, this review offers a framework to identify the core concepts of outcomes research from database analyses by comparing and contrasting it with the randomized clinical trial.

Background: Prior studies have suggested that in-hospital availability may be an important determinant for the use of invasive cardiac services; however, whether this association is influenced by payer status remains unclear. Hypothesis: The interaction of payer status and the on-site availability of coronary arteriography is associated with increased utilization of this procedure. Methods: In-hospital availability and utilization of coronary arteriography was ascertained in 275,046 patients with acute myocardial infarction (AMI) enrolled in the National Registry of Myocardial Infarction 2 from June 1994 to April 1996. Logistic regression analyses were performed to determine the association between the on-site availability of cardiac catheterization at the initial hospital and subsequent utilization of coronary arteriography. Similar analyses were performed within Medicare, Medicaid, Commercial, Health Maintenance Organization (HMO), and Uninsured payer groups. Results: Patients initially admitted to hospitals having on-site cardiac catheterization facilities were almost twice as likely to receive coronary arteriography as patients admitted to hospitals without such facilities and later transferred out [un-adjusted odds ratio (OR) = 1.69,95% confidence interval (CI) 1.66–1.73, p < 0.0001; adjusted OR = 2.08,95% CI 2.01–2.15, p < 0.0001]. Furthermore, this relationship of increased utilization with greater availability was evident within each payer group, but was highest among those with Commercial insurance and lowest among Medicaid recipients: [Commercial insurance (OR = 2.19,95% CI 2.07–2.31, p < 0.0001); Uninsured (OR = 1.74,95% CI 1.57–1.92, p < 0.0001); HMO (OR = 1.67,95% CI 1.54–1.82, p < 0.0001); Medicare 1.60,95% CI 1.55–1.64, p < 0.0001); Medicaid (1.46,95% CI 1.29–1.65, p < 0.0001)]. Conclusions: Our results show a strong association between in-hospital availability and subsequent utilization of invasive cardiac procedures following AMI among all patients, but the strength of these associations varied among payer status.

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p

Data from a national registry (cohort) of myocardial infarction, which has enrolled 275,046 patients from June 1994 to April 1996, were analyzed to compare the baseline demographic and clinical characteristics, treatment patterns, and clinical outcomes among Hispanics, Asian-Pacific islanders, and native Americans with those of white Americans presenting to the hospital with acute myocardial infarction. Non-black minorities were younger, had a higher proportion of men, used the emergency medical services less frequently, and presented later to the hospital after the onset of symptoms (135 vs 122 minutes, p0.001) than whites. Also, non-black minorities were less likely to receive beta-blocker therapy at discharge (crude odds ratio 0.86, confidence interval 0.82 to 0.90) than whites, but they were generally as likely to receive intravenous thrombolytic therapy (with the exception of Asian-Pacific islanders) and undergo both coronary arteriography and revascularization procedures as their white counterparts. There were no significant differences in hospital mortality for non-black minorities compared with whites.

Objectives. This study sought to examine the management and subsequent outcomes of patients with a prehospital electrocardiogram (ECG) in a large, voluntary registry of myocardial infarction.Background. The prehospital ECG has been proposed as a means of rapidly identifying patients with acute myocardial infarction who might be eligible for reperfusion therapy.Methods. The characteristics and outcomes of patients with a prehospital ECG were compared with those without a prehospital ECG in the National Registry of Myocardial Infarction 2 data base. Included in the analysis were those patients who presented to the hospital within 12 h of an acute myocardial infarction. Excluded were patients with an in-hospital infarction, transferred-in referrals and self-transported patients.Results. Prehospital ECGs were obtained in 3,768 (5%) of 66,995 National Registry of Myocardial Infarction 2 patients meeting study criteria. Median time from myocardial infarction symptom onset until hospital arrival was longer among those having a prehospital ECG (152 vs. 91 min, p < 0.001). However, once in the hospital, the prehospital ECG group experienced a shorter median time to the initiation of either thrombolysis (30 vs. 40 min, p < 0.001) or primary angioplasty (92 vs. 115 min, p < 0.001). The prehospital ECG group was more likely to receive thrombolytic therapy (43% vs. 37%, p < 0.001) and to undergo primary angioplasty (11% vs. 7%, p < 0.001). Also, the prehospital ECG group was more likely to undergo coronary arteriography (55% vs. 40%, p < 0.001), angioplasty (24% vs. 16%, p < 0.001) or bypass surgery (10% vs. 6%, p < 0.001). The in-hospital mortality rate was 8% in patients with a prehospital ECG and 12% in those without a prehospital ECG (p < 0.001). After adjusting for baseline covariates utilizing multiple logistic regression analysis, this mortality difference remained statistically significant (odds ratio 0.83, 95% confidence interval 0.71 to 0.96, p = 0.01).Conclusions. The prehospital ECG is infrequently utilized for diagnosing myocardial infarction, and among patients with a prehospital ECG, is associated with a longer time from symptom onset to hospital arrival. Despite these shortcomings, the prehospital ECG is a test that may potentially influence the management of patients with acute myocardial infarction through wider, faster in-hospital utilization of reperfusion strategies and greater usage of invasive procedures, factors that may possibly reduce short-term mortality. Efforts to implement the prehospital ECG more widely and more rapidly may be indicated.(J Am Coll Cardiol 1997;29:498–505)

Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality.To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI.Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men).We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality.The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P.001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P.001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P.001).In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

Item does not contain fulltext BACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS: At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P=0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. CONCLUSIONS: Among patients with unstable angina or myocardial infarction without ST-segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.).

Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice.To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality.Observational study from the National Registry of Myocardial Infarction, 1994-2006.We examined the presence and absence of 5 major traditional coronary heart disease risk factors (hypertension, smoking, dyslipidemia, diabetes, and family history of coronary heart disease) and hospital mortality among 542,008 patients with first myocardial infarction and without prior cardiovascular disease.All-cause in-hospital mortality.A majority (85.6%) of patients who presented with initial myocardial infarction had at least 1 of the 5 coronary heart disease risk factors, and 14.4% had none of the 5 risk factors. Age varied inversely with the number of coronary heart disease risk factors, from a mean age of 71.5 years with 0 risk factors to 56.7 years with 5 risk factors (P for trend.001). The total number of in-hospital deaths for all causes was 50,788. Unadjusted in-hospital mortality rates were 14.9%, 10.9%, 7.9%, 5.3%, 4.2%, and 3.6% for patients with 0, 1, 2, 3, 4, and 5 risk factors, respectively. After adjusting for age and other clinical factors, there was an inverse association between the number of coronary heart disease risk factors and hospital mortality adjusted odds ratio (1.54; 95% CI, 1.23-1.94) among individuals with 0 vs 5 risk factors. This association was consistent among several age strata and important patient subgroups.Among patients with incident acute myocardial infarction without prior cardiovascular disease, in-hospital mortality was inversely related to the number of coronary heart disease risk factors.

Background Chest pain/discomfort (CP) is the hallmark symptom of acute myocardial infarction (MI), but some patients with MI present without CP. We hypothesized that MI type (ST-segment elevation MI [STEMI] or non-STEMI [NSTEMI]) may be associated with the presence or absence of CP. Methods We investigated the association between CP at presentation and MI type, hospital care, and mortality among 1,143,513 patients with MI in the National Registry of Myocardial Infarction (NRMI) from 1994 to 2006. Results Overall, 43.6% of patients with NSTEMI and 27.1% of patients with STEMI presented without CP. For both MI type, patients without CP were older, were more frequently female, had more diabetes or history of heart failure, were more likely to delay hospital arrival, and were less likely to receive evidence-based medical therapies and invasive cardiac procedures. Multivariable analysis indicated that NSTEMI (vs STEMI) was the strongest predictor of atypical symptoms (adjusted odds ratio [95% CI], 1.93 [1.91-1.95]). Within the 4 CP/MI type categories, hospital mortality was highest for no CP/STEMI (27.8%), followed by no CP/NSTEMI (15.3%) and CP/STEMI (9.6%), and was lowest for CP/NSTEMI (5.4%). The adjusted odds ratio of mortality was 1.38 (1.35-1.41) for no CP (vs CP) in the STEMI group and 1.31 (1.28-1.34) in the NSTEMI group. Conclusions Hospitalized patients with NSTEMI were nearly 2-fold more likely to present without CP than patients with STEMI. Patients with MI without CP were less quickly diagnosed and treated and had higher adjusted odds of hospital mortality, regardless of whether they had ST-segment elevation.

Previous studies have shown that women younger than 55 years have higher hospital mortality rates after acute myocardial infarction (MI) than age-matched men. We examined whether such mortality differences have decreased in recent years.We investigated temporal trends in the hospital case-fatality rates of MI by sex and age from June 1, 1994, through December 31, 2006. The study population included 916,380 patients from the National Registry of Myocardial Infarction with a confirmed diagnosis of MI.In-hospital mortality decreased markedly between 1994 and 2006 in all patients but more so in women than men. The mortality reduction in 2006 relative to 1994 was largest in women younger than 55 years (52.9%) and lowest in men younger than 55 years (33.3%). In patients younger than 55 years, the absolute decrease in mortality was 3 times larger in women than men (2.7% vs 0.9%). As a result, the excess mortality in younger women (55 years) compared with men was less pronounced in 2004-2006 (unadjusted odds ratio, 1.32; 95% confidence interval, 1.07-1.67) than it was in 1994-1995 (unadjusted odds ratio, 1.93; 95% confidence interval, 1.67-2.24). The sex difference in mortality decrease was lower in older patients (P = .004 for the interaction among sex, age, and year). Changes in comorbidity and clinical severity features at admission accounted for more than 90% of these mortality trends.In recent years, women, particularly younger ones, experienced larger improvements in hospital mortality after MI than men. The narrowing of the mortality gap between younger women and men is largely attributable to temporal changes in risk profiles.

Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI).Retrospective cohort study.1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006.126 172 STEMI and 235 257 NSTEMI patients.Hospital death.For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p0.0001 for the age-sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age50 years, age 50-59, age 60-69, age 70-79 and age 80-89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15-20%, while a better survival of older NSTEMI women compared with men persisted.Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.

Background Optimal diagnosis and timely treatment of patients with an acute coronary syndrome (ACS) depends on distinguishing differences between popular “myths” about ischemic symptoms in women and men. Chest pain or discomfort is regarded as the hallmark symptom of ACS, and its absence is regarded as “atypical” presentation. This review describes the presenting symptoms of ACS in women compared with men and ascertains whether women should have a symptom message that is separate or different from that for men. Methods MEDLINE (1970-2005), bibliographies of articles, and pertinent abstracts were reviewed, focusing on studies of ACS presentation, especially those reporting differences in symptoms by sex. This analysis included 69 of 361 possible studies. Data regarding symptom presentation were recorded. Results The published literature lacks standardization in characterizing ACS presentation, data collection, and reporting of symptoms. Approximately one-third of patients in the large cohort studies and one-quarter of patients in the smaller reports and direct patient interviews presented without chest pain or discomfort. The absence of chest pain or discomfort with ACS was noted more commonly in women than in men in both the cumulative summary from large cohort studies (37% vs 27%) and the single-center and small reports or interviews (30% vs 17%). Conclusions Women are significantly less likely to report chest pain or discomfort compared with men. These differences, however, are not likely large enough to warrant sex-specific public health messages regarding the symptoms of ACS at the present time. Further research must systematically investigate sex differences in the clinical presentation of ACS symptoms and must include standardized data collection efforts.

Appropriate utilization of acute reperfusion therapy is not a national performance measure for ST-elevation myocardial infarction at this time, and the extent of its contemporary use among ideal patients is unknown.From the National Registry of Myocardial Infarction, we identified 238,291 patients enrolled from June 1994 to May 2003 who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention. We determined rates of not receiving therapy across 3 time periods (June 1994-May 1997, June 1997-May 2000, June 2000-May 2003) and evaluated factors associated with underutilization.The proportion of ideal patients not receiving acute reperfusion therapy decreased by one half throughout the past decade (time period 1: 20.6%; time period 2: 11.4%; time period 3: 11.6%; P.001). Utilization remained significantly lower in key subgroups in the most recent time period: those without chest pain (odds ratio [OR] 0.29; 95% confidence interval [CI], 0.27-0.32); those presenting 6 to 12 hours after symptom onset (OR 0.57; 95% CI, 0.52-0.61); those 75 years or older (OR 0.63 compared with patients55 years old; 95% CI, 0.58-0.68); women (OR 0.88; 95% CI, 0.84-0.93); and non-whites (OR 0.90; 95% CI, 0.83-0.97).Utilization of acute reperfusion therapy in ideal patients has improved over the last decade, but more than 10% remain untreated. Measuring and improving its use in this cohort represents an important opportunity to improve care.

The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times.Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness.Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics.A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p0.0001).The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

Efforts to improve the quality of medical care increasingly permeate modern medicine. Recent cardiovascular care innovations such as drug-eluting stents, cardiac defibrillators, computed tomography angiography of the heart, and cholesteryl ester transfer protein inhibitors among many others have attracted considerable national attention. In the face of this technology explosion, there are multiple long-established therapies that improve survival after myocardial infarction but are not always fully adopted. Examples of the latter are smoking cessation counseling, h-blocker therapy, antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors, especially when left ventricular ejection fraction is b0.40. These bolderQ therapies have been included in evidence-based guidelines and adherence to them is known to have a profound impact. Based on evidence-based guidelines, quality performance measures are now widely used to compare providers and to improve care by feeding back their performance to the individual providers. Commonly, such feedback involves a comparison of individual provider performance to a bbenchmarkQ level of performance. Frequently, the benchmark used is the median (or mean) performance on a given measure. Predictably, from the statistical definition of median, about half of a provider group will perform worse than the median performance on any given measure. Thus, setting a benchmark based on average performance could be viewed as encouraging mediocrity. To address the above, previous work such as the achievable benchmarks of care (ABC) methodology has focused on data-driven definitions of benchmarks

Background To better understand hospital performance in door-to-drug and door-to-balloon times for patients with STEMI, we examined hospital-level variation in key subintervals of door-to-drug time (door-to-electrocardiogram [ECG] and ECG-to-drug) and of door-to-balloon time (door-to-ECG, ECG-to-lab, lab-to-balloon). We sought to identify achievable subinterval times based on the experience of top performing hospitals . Methods We conducted a cross-sectional analysis, using data from the National Registry of Myocardial Infarction, of admissions between January 1, 2001, and December 31, 2002 (20 435 patients receiving fibrinolytic therapy in 693 hospitals, and 13 387 patients receiving percutaneous coronary intervention in 340 hospitals). Using hierarchical regression modeling, we estimated hospital-level geometric means of each subinterval, adjusted for patient clinical characteristics. We ranked hospitals based on the proportion of patients treated within 30 minutes for door-to-drug time and 90 minutes for door-to-balloon times and compared adjusted subinterval times across these groups. Results The higher performing hospitals (top 20%) in door-to-drug time and door-to-balloon times had significantly shorter times in nearly all subintervals compared with other hospitals, adjusted for patient clinical characteristics. Adjusted mean subinterval times in higher performing hospitals in door-to-drug time were 6.8 minutes (SD = 1.7) for door-to-ECG and 18.7 minutes (SD = 3.5) for ECG-to-drug. Adjusted mean subinterval times in higher performing hospitals in door-to-balloon time were 7.9 minutes (SD = 1.7) for door-to-ECG, 47.8 minutes (SD = 7.1) for ECG-to-lab, and 29.0 minutes (5.4) for lab-to-balloon, adjusted for patient clinical characteristics. Conclusions Substantial national attention is being directed at improving time to treatment of patients with STEMI. These data suggest achievable subinterval times for hospitals seeking to improve performance in this important quality indicator.

The WISE workshop was convened to review results from the Women’s Ischemic Syndrome Evaluation (WISE) study and other studies of ischemic heart disease to examine the nature and scope of gender differences in both chronic and acute cardiac ischemia, in terms of clinical manifestations, detection, and treatment. This section addresses research needs in the diagnosis and treatment of acute coronary syndromes in women and in the effective implementation of these findings into the community. There is a substantial body of scientific literature about the presentation of acute cardiac ischemia (ACI) in women, including acute myocardial infarction (AMI) and unstable angina pectoris, which can lead to AMI. However, the diagnosis and treatment of ACI in women in the emergency department (ED) is not optimal, resulting in missed diagnoses and treatments and leading to excess mortality.1 Women present at older ages, in different social support environments, with more comorbidity, and with some differences in symptoms compared with men, and women are more likely to present with unstable angina pectoris than with AMI.2–8 Also, gender-specific clinical practices are not well understood or implemented.9–18 Particularly needed for improving health outcomes in women with ACI is a better understanding of how care for women with (and without) ACI can be effectively delivered in the wide range of care settings in this country. Thus, there is a clear need to supplement prior, excellent, disease-targeted “efficacy research” with “effectiveness research” that targets the development and testing of approaches that are broadly applicable to usual clinical practice settings.19,20 This next phase of research must avoid the incomplete inclusion of all patients with …

We sought to identify patient and hospital features associated with early glycoprotein (GP) IIb/IIIa inhibitor therapy for non-ST-elevation (NSTE) myocardial infarction (MI) and to relate this treatment to in-hospital outcomes.Glycoprotein IIb/IIIa inhibitors have improved outcomes in randomized trials of NSTE MI, leading national treatment guidelines to recommend their use. Their actual use, safety, and effectiveness have not been well characterized beyond trial populations.We studied 60,770 patients with NSTE MI treated between July 2000 and July 2001 at 1,189 hospitals in a U.S. registry. Using logistic regression, we identified patient and hospital features associated with GP IIb/IIIa inhibition within 24 h after presentation. We also compared outcomes by early treatment versus no treatment after adjusting for patient and hospital characteristics and treatment propensity.Only 25% of eligible patients received early GP IIb/IIIa therapy. Elderly patients, women, minority patients, and those without private insurance received such therapy less often than their counterparts. Treated patients had lower unadjusted in-hospital mortality (3.3% vs. 9.6%, p0.0001) remaining significantly lower after adjustment for patient risk, treatment propensity, and hospital characteristics (adjusted odds ratio, 0.88; 95% confidence interval, 0.79 to 0.97). Hospitals that adopted early GP IIb/IIIa inhibition more rapidly also had lower adjusted mortality rates than those slower to adopt such therapy.Glycoprotein IIb/IIIa inhibitor therapy appears to be underused in early management of NSTE MI patients. Because this therapy is associated with better outcomes, it represents a target for quality improvement.

Background— National practice guidelines strongly recommend activation of the 9-1-1 Emergency Medical Systems (EMS) by patients with symptoms consistent with an acute myocardial infarction (MI). We examined use of the EMS in the United States and ascertained the factors that may influence its use by patients with acute MI. Methods and Results— From June 1994 to March 1998, the National Registry of Myocardial Infarction 2 enrolled 772 586 patients hospitalized with MI. We excluded those who transferred in, arrived at the hospital >6 hours from symptom onset, or who were in cardiogenic shock. We compared baseline characteristics and initial management for patients who arrived by ambulance versus self-transport. EMS was used in 53.4% of patients with MI, a proportion that did not vary significantly over the 4-year study period. Nonusers of the EMS were on average younger, male, and at relatively lower risk on presentation. In addition, payer status was significantly associated with EMS use. Use of EMS was independently associated with slightly wider use of acute reperfusion therapies and faster time intervals from door to fibrinolytic therapy (12.1 minutes faster, P P Conclusions— Only half of patients with MI were transported to the hospital by ambulance, and these patients had greater and significantly faster receipt of initial reperfusion therapies. Wider use of EMS by patients with suspected MI may offer considerable opportunity for improvement in public health.

Almost one-third of patients with acute myocardial infarction (AMI) are aged >75 years, and this proportion is expected to increase as the population ages. Mortality and complication rates are particularly high in the elderly, yet reperfusion therapies, including thrombolysis and primary percutaneous transluminal coronary angioplasty (PTCA), are under-utilised among eligible patients. There is a concern, whether real or perceived, that the risks of such therapies may outweigh the potential benefits. Presently, there are no randomised clinical trials of thrombolytic therapy in the elderly that definitively assess its efficacy in patients aged >75 years. In the meta-analysis of randomised trials by the Fibrinolytic Therapy Trialists, thrombolysis was associated with a mortality reduction among patients aged >75 years, though this reduction did not meet formal statistical significance. Because the point estimates for mortality reduction were in the direction that favoured use of thrombolytic therapy, the American Heart Association/American College of Cardiology AMI guidelines recommend thrombolysis as a Class 2a therapy in this age group. Observational studies using data from the Cooperative Cardiovascular Project database and the National Registry of Myocardial Infarction have recently cast some doubt on the benefit of thrombolysis among the elderly, but definitive answers from a randomised trial are still lacking. Meanwhile, primary PTCA, which has been compared to thrombolysis in both trial and observational settings, appears to offer the mortality benefit of reperfusion with lower stroke rates. Since primary PTCA is not widely available, efforts must be made to maximise available therapies in the elderly. Early diagnosis is essential, as is prompt reperfusion among eligible patients, since delay is so strongly associated with mortality with both thrombolysis and PTCA. Finally, newer, more fibrin-specific thrombolytics may decrease the bleeding risk associated with thrombolytic therapy.

ContextAlthough chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown.ObjectivesTo determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome.DesignProspective observational study.Setting and PatientsA total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States.Main Outcome MeasuresPrevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain.ResultsOf all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25.4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), β-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2.21 [95% confidence interval, 2.17-2.26]).ConclusionsOur results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality.