Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women.

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 perspective. In the future, our goal should be to standardize ACS symptom presentation and to elucidate the full range of ACS and myocardial infarction symptoms considering the substantial overlap of symptoms among women and men rather than use conventional terms such as "typical" and "atypical" angina.

Atherosclerotic risk factors and their association with hospital mortality among patients with first myocardial infarction (from the National Registry of Myocardial Infarction).

Few studies have examined associations between atherosclerotic risk factors and short-term mortality after first myocardial infarction (MI). Histories of 5 traditional atherosclerotic risk factors at presentation (diabetes, hypertension, smoking, dyslipidemia, and family history of premature heart disease) and hospital mortality were examined among 542,008 patients with first MIs in the National Registry of Myocardial Infarction (1994 to 2006). On initial MI presentation, history of hypertension (52.3%) was most common, followed by smoking (31.3%). The least common risk factor was diabetes (22.4%). Crude mortality was highest in patients with MI with diabetes (11.9%) and hypertension (9.8%) and lowest in those with smoking histories (5.4%) and dyslipidemia (4.6%). The inclusion of 5 atherosclerotic risk factors in a stepwise multivariate model contributed little toward predicting hospital mortality over age alone (C-statistic = 0.73 and 0.71, respectively). After extensive multivariate adjustments for clinical and sociodemographic factors, patients with MI with diabetes had higher odds of dying (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.20 to 1.26) than those without diabetes and similarly for hypertension (OR 1.08, 95% CI 1.06 to 1.11). Conversely, family history (OR 0.71, 95% CI 0.69 to 0.73), dyslipidemia (OR 0.62, 95% CI 0.60 to 0.64), and smoking (OR 0.85, 95% CI 0.83 to 0.88) were associated with decreased mortality (C-statistic = 0.82 for the full model). In conclusion, in the setting of acute MI, histories of diabetes and hypertension are associated with higher hospital mortality, but the inclusion of atherosclerotic risk factors in models of hospital mortality does not improve predictive ability beyond other major clinical and sociodemographic characteristics.

Differences in symptom presentation and hospital mortality according to type of acute myocardial infarction.

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.

Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

CONTEXT: 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. OBJECTIVE: 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. DESIGN, SETTING, AND PATIENTS: Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). MAIN OUTCOME MEASURES: We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. RESULTS: 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). CONCLUSION: 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.

Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction.

CONTEXT: Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice. OBJECTIVE: To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality. DESIGN: Observational study from the National Registry of Myocardial Infarction, 1994-2006. PATIENTS: 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. MAIN OUTCOME MEASURE: All-cause in-hospital mortality. RESULTS: 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. CONCLUSION: 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.

Outcomes among patients with ST-segment-elevation myocardial infarction presenting to interventional hospitals with and without on-site cardiac surgery.

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<0.001) and were more likely to receive any form of acute reperfusion therapy (80.8% versus 70.8%, P<0.001). Patients who presented to OHS hospitals were more likely to receive guideline recommended medications within 24 hours of arrival. In a propensity score model matching for patient characteristics and transfer status, in-hospital mortality remained significantly lower among patients presenting to OHS hospitals (7.2% versus 9.3%, 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.

Outcomes among patients with non-ST-segment elevation myocardial infarction presenting to interventional hospitals with and without on-site cardiac surgery.

OBJECTIVES: The 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). BACKGROUND: Whether backup cardiac surgery improves outcomes among NSTEMI patients or is simply a marker of better adherence to guideline recommendations is unknown. METHODS: The 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. RESULTS: In-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). CONCLUSIONS: NSTEMI 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.

Non-ST-elevation myocardial infarction patients who present during off hours have higher risk profiles and are treated less aggressively, but their outcomes are not worse: a report from Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines CRUSADE initiative.

Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes.We examined NSTEMI patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality improvement initiative (January 2001-April 2003) and compared demographics, risk profiles, intensity of medical management, and timing and intensity of intervention by whether presentation occurred during usual or off hours. We analyzed 34,297 NSTEMI presentations; 15,090 (44%) occurred during usual hours; 19,207 (56%) occurred during off hours. Off-hours-presenting patients had generally higher cardiac risk and received initial ECGs more quickly than patients who presented during usual hours (median 15 minutes vs. 18 minutes, P < 0.0001), and received similar (although suboptimal) medical management. In contrast, those who presented during off hours were less likely to receive timely diagnostic angiography, PCI, and bypass surgery (cath: median 32.9 hours vs. 24.3 hours, P < 0.0001; PCI: 28.6 hours vs. 23.6 hours, P < 0.0001). Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation.

Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006.

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 < .001), while the proportion undergoing primary percutaneous coronary intervention (pPCI) increased from 2.6% to 43.2%. Among reperfusion-eligible patients who received fibrinolytic therapy, there was a nearly linear decline in median D2N time from 59 minutes in 1990 to 29 minutes in 2006 (P < .001 for trend) as well as a decrease in mortality from 7.0% in 1994 to 6.0% in 2006 (P < .001). Among those undergoing pPCI, D2B time among nontransfer patients declined linearly from 111 minutes in 1994 to 79 minutes in 2006 (P < .001) with a decline in mortality from 8.6% to 3.1% (P < .001). The relative improvement in mortality attributable to improvements in D2N time was 16.3% and to D2B time was 7.5%. 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.

Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006.

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 > or =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.

Symptom presentation of women with acute coronary syndromes: myth vs reality.

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.

Acute reperfusion therapy in ST-elevation myocardial infarction from 1994-2003.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 patients <55 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). CONCLUSIONS: 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.

Effectiveness and safety of glycoprotein IIb/IIIa inhibitors and clopidogrel alone and in combination in non-ST-segment elevation myocardial infarction (from the National Registry of Myocardial Infarction-4).

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.

Door-to-drug and door-to-balloon times: where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI).

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 (20435 patients receiving fibrinolytic therapy in 693 hospitals, and 13387 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 pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4.

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 < 0.0001), 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]; p < 0.0001). 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.