Treatment disparities and effect on late mortality in patients with diabetes presenting with acute myocardial infarction: observations from the ACACIA registry.

OBJECTIVES: To compare the use of evidence-based pharmacological and invasive treatments and 12-month mortality rates between patients with and without diabetes who present with acute myocardial infarction (MI), and to explore the relationship between these treatments and late clinical outcomes. DESIGN AND SETTING: Prospective, nationwide multicentre registry: the Acute Coronary Syndrome Prospective Audit (ACACIA). PATIENTS: Patients presenting to 24 metropolitan and 15 non-metropolitan hospitals with acute coronary syndrome (ACS) and a final discharge diagnosis of acute MI between November 2005 and July 2007. MAIN OUTCOME MEASURE: All-cause mortality at 12 months. RESULTS: Nearly a quarter of 1744 patients with a final diagnosis of acute MI had a history of diabetes on presentation. Patients with diabetes were older, with a greater prevalence of comorbidities than non-diabetic patients, and were less likely to be treated at discharge with evidence-based medications (aspirin, clopidogrel, a statin and/or a beta-blocker) or to receive early invasive procedures. After adjusting for baseline characteristics and therapeutic interventions, diabetes at presentation was independently associated with a higher mortality at 12 months after MI (hazard ratio, 1.79; 95% CI, 1.18-2.72; P=0.007). Early invasive management and discharge prescription of guideline-recommended medications were associated with a significantly reduced hazard of mortality at 12 months. CONCLUSION: Patients with diabetes have a higher risk than non-diabetic patients of late mortality following an acute MI, yet receive fewer guideline-recommended medications and early invasive procedures. Increased application of proven pharmacotherapies and an early invasive management strategy in patients with diabetes presenting with ACS might improve their outcomes. STUDY PROTOCOL NUMBER (SANOFI-AVENTIS): PML-0051.

Variations in the application of cardiac care in Australia.

OBJECTIVE: To evaluate the use of clinical practice guidelines for the management of acute coronary syndromes published by the National Heart Foundation (NHF) of Australia and the Cardiac Society of Australia and New Zealand (CSANZ) in patients presenting with chest pain. DESIGN: Cross-sectional study of consecutive patients admitted with chest pain. SETTING: Prospective case note review was undertaken in 2380 patients admitted to 27 hospitals across five states in Australia between January 2003 and August 2005. Patients were divided into two groups: those who presented to centres with angiography and percutaneous intervention facilities (n = 1260) and those treated at centres without these facilities (n = 1120). MAIN OUTCOME MEASURES: The proportion of patients whose care met quality of care standards for diagnostic and risk-stratification procedures and management according to NHF/CSANZ treatment guidelines. RESULTS: Significant delays were identified in performing electrocardiography, administering thrombolysis, transferring high-risk patients to tertiary centres, and performing revascularisation. Medical therapy was underused, especially glycoprotein IIb/IIIa antagonists in patients with high-risk acute coronary syndromes. Patients treated at centres without interventional facilities were less likely to receive guidelines-based medical therapy and referral for coronary angiography (20.11%) than patients treated at centres with interventional facilities (66.43%; P < 0.001). CONCLUSION: There are deficits in the implementation and adherence to evidence-based guidelines for managing chest pain in hospitals across Australia, and significant differences between hospitals with and without interventional facilities.