Milestones in Acute Myocardial Infarction

Milestones in Acute Myocardial Infarction

Celebrating 10 Yearsof Insights from the National Registry

of Myocardial Infarction 1

1998 Heart and Stroke Statistical Update, American Heart Association

Cardiovascular Disease: Problems/Opportunities

• 58 million Americans have one or more types of cardiovascular disease

• Approximately 1 million Americans will have a new/recurrent myocardial infarction this year

• Coronary heart disease is the single largest cause of death in the United States

• Estimated direct/indirect cost:• Coronary heart disease $95.6 billion/year

• Congestive heart failure $20.2 billion/year

The Role of Observational Studies

• Collect data on selected demographics, practice patterns, and outcomes; describe variations and trends

• Complement controlled, randomized trials by comparing data with large groups of patients treated under “real world” conditions

• Examine treatment effects on subgroups • Access and analyze clinical issues at less cost than in

clinical trials• Generate hypotheses for more complete examination in

clinical trials

Major Observational Studies

• Cooperative Cardiovascular Project • Framingham Heart Study• Myocardial Infarction Triage and Intervention

(MITI) • National Registry of Myocardial Infarction (NRMI)• Nurses’ Health Study• Physicians’ Health Study

The Framingham Heart Study

• Collecting data for over 50 years• 5,209 adult residents of Framingham, MA (2,873

women and 2,336 men) • Collects data from

• standardized biennial cardiovascular examinations

• daily surveillance of hospital admissions

• death information

• information from physicians and other sources outside the clinic

Framingham Heart Study Contributions

• Identified major risk factors associated with heart disease, stroke, diabetes, and other diseases

• Identified hypotheses for clinical trials

• Created new and larger emphasis for preventive medicine

• Over 1,000 published articles

The Nurses' Health Study

• Collecting data prospectively for nearly 25 years

• 121,700 women aged 30 to 55

• Collects data on diet, exercise, smoking, hormone use, alcohol use

• Still in contact with 90% of the original participants

The Nurses' Health Study Contributions

• Demonstrated• drinking coffee does not increase risk of MI

• HRT reduces risk of MI and osteoporosis

• second hand smoke increases risk of heart disease

• Vitamin E can protect against heart disease

• Over 250 published articles

NRMI: Leadership in Observational Databases

1990–1994 Over 350,000 patients 1,073 hospitals Identified delays in

thrombolytic therapy

1994–1998 771,653 patients 1,506 hospitals Assisted in decreasing

door to drug time

1998 - 2000 Over 500,000 patients Approximately 1,600

hospitals Identified untreated

eligibles, timely reperfusion, and use of adjunctive therapies

1

NRMI 4

• Initiated in July 2000– Includes approximately 1,600 hospitals– Collects information on pre-hospital care– Emphasizes process improvement– Provides customized reporting for hospital systems– Identifies eligible untreated patients– Collects information on TNK, GP IIb/IIIa inhibitors, combination

therapies– Evaluates of additional medications/procedures– Monitors outcomes such as clinical events and mortality– Compatible with current ACC/AHA guidelines for AMI care

NRMI GoalGoal

Improve AMI patient care through evaluation/Improve AMI patient care through evaluation/assessment of care delivery systemsassessment of care delivery systems

RationaleRationaleOngoing assessment of practice is critical for Ongoing assessment of practice is critical for

improving patient careimproving patient care

PurposePurposeCollect, analyze, and disseminate observational data Collect, analyze, and disseminate observational data

related to outcomes and quality of care for AMI related to outcomes and quality of care for AMI patientspatients

NRMI Publications

02468

1012141618

1992 1993 1994 1995 1996 1997 1998 1999 2000*

Articles Abstracts

*additional abstracts and articles are expected for 2000

NRMI Highlights

• Trends• Study validation • Time to treatment• Diagnosis and treatment

of women • AMI subgroups • Seasonality

• Use of cardiac procedures• Complications of

MI/safety• Bundle branch block• ACE inhibitors• JCAHO/ORYX

National Trends in AMI Management:Door to Drug Time with Thrombolysis

0102030405060708090

100

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Media

n tim

e, m

inute

s

NRMI 1 NRMI 2 NRMI 3 (Activase only) (All lytics) (All lytics)

60

91

34 39

NRMI 1: Includes patients where initial ECG was the method of MI diagnosis NRMI 2 and 3: Includes patients with ST on 1st 12-lead ECG results, where 1st 12-lead ECG date/time = 1st 12-lead ECG with ST and/or BBB date/time

Non-transfer-in patients

75th percentile, 52

25th percentile, 22

National Trends in AMI Management:Door to Balloon Time in PPTCA

80

90

100

110

120

1994 1995 1996 1997 1998 1999

Media

n tim

e, m

inute

s

NRMI 2 NRMI 3 116

108

Includes patients with ST on 1st 12-lead ECG results, where 1st 12-lead ECG date/time = 1st 12-lead ECG with ST and/or BBB date/time (non-transfer-in patients)

National Trends in AMI Management:

Hospital Length of Stay

0

1

2

3

4

5

6

7

8

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Media

n d

ays

in h

osp

ital

No reperfusion strategy Reperfusion strategy used

NRMI 1 NRMI 2 NRMI 3 7.5

6.8

3.5

4.6


National Trends in AMI Management: Medications Used Within 24 Hours

0102030405060708090

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Patie

nts,

%

ASA Heparin Beta blockers Ace inhibitors GP IIa/IIIb inhibitors

NRMI 1 NRMI 2 NRMI 3


NRMI Study Validation

Background

• Compared NRMI 2 to the Cooperative Cardiovascular Project (CCP)

Objective

• To evaluate whether or not the simpler case identification and data abstraction processes used in NRMI 2 are comparable to the more rigorous processes used in the CCP

Every et al. JACC 1999

NRMI(n=35,673)

CCP(n=42,703) P value

Age (mean) 76.9 77.3 0.391Sex (% male) 50.3 49.4 0.015White race (%) 86.9 89.5 <0.001History of AMI (%) 29.0 32.0 <0.001 Heart failure (%) 21.3 25.1 <0.001 Bypass surgery (%) 12.2 12.9 0.002 Coronary angioplasty (%) 5.3 6.7 <0.001

Hospital-level Comparison: Baseline Characteristics

Adapted from Every N, et al. JACC 1999

NRMI(n=35,673)

CCP(n=42,703) P value

Length of stay (mean days) 8.3 8.1 <0.001Cardiac catheterization (%) 33.3 32.8 0.156Coronary angioplasty (%) 12.6 12.5 0.846Bypass surgery (%) 7.1 7.0 0.420Thrombolytic therapy (%) 15.6 14.6 <0.001Mortality 19.7 18.1 <0.001Stroke 1.9 3.4 <0.001

Hospital-level Comparison: Process of Care and Outcomes


Patient-level Comparison: Hospital Course

% Agreement(n=25, 664) Kappa

Stroke in hospital 98.0 0.57Reinfarction 95.2 0.21Shock in hospital 94.7 0.63Thrombolytic treatment 98.3 0.94Coronary angiography 98.2 0.96Coronary angioplasty 97.9 0.91Bypass surgery 99.7 0.97Hospital mortality 99.3 0.98


NRMI Study Validation: Conclusions

• The simpler case identification and data abstraction processes used in NRMI are comparable to the more rigorous processes used in the CCP

• NRMI is less expensive to administer and maintain, provides timely and continuous feedback, allows ongoing involvement in data collection and analysis, and facilitates QI activities

• In summary, the NRMI is a valid outcomes measurement tool

Every N, et al. JACC 1999

NRMI: Time to Treatment Studies

• Time to treatment– Established factors that can lead to delays in treatment– Suggested areas for process improvement and quality control

• Consultation– Compared the time used for consultation to patient outcomes

• Door-to-drug time– Identified that longer door-to-drug time increases rates of mortality

• Angioplasty– Examined the relationship of symptom-onset-to-balloon time and

door-to-balloon time with mortality in patients undergoing angioplasty for AMI

Factors Influencing Time to Treatment with rt-PA

Background• Very early administration of thrombolytic therapy for

AMI has significantly reduced mortality

Objectives • To evaluate factors which influence

– the time from symptom onset to hospital presentation

– the time from hospital presentation to the onset of thrombolytic treatment

Maynard C, et al. Am J Cardiol 1995

Factors that Predict Time to Treatment


FactorsOddsratio 95% CI

Treatment in the ED 3.08 2.94, 3.23 Male sex 1.26 1.21, 1.31 Accelerated 90-min infusion 1.26 1.24, 1.28 Treatment from 6 am to 6 pm 1.26 1.22, 1.31 Western US region 1.24 1.17, 1.30 Advanced age* 0.86 0.83, 0.88 Anterior infarct location 0.90 0.87, 0.94

*Age coded as (1) <60, (2) 61-74, and (3) >75 years of age

Factors Influencing Time to Treatment: Conclusions

• To shorten time to treatment, thrombolytic treatment should be initiated in the Emergency Department

• Reducing time to treatment allows more patients to benefit from thrombolytic therapy

• The effectiveness of programs aimed at reducing time to treatment should be subject to continuing quality improvement surveillance


Factors Influencing the Time to Thrombolysis in AMI

Background• The extent of myocardial salvage and the magnitude of

mortality reduction in patients with AMI are directly related to how early drug is given after the onset of symptoms and how quickly reperfusion occurs

Objective• The Time to Thrombolysis Substudy of the NRMI

identified factors that delay thrombolytic treatment of patients with ST-segment elevation AMI

Lambrew CT, et al. Arch Intern Med 1997

Time to Treatment: Cardiac Consultation by Gender

01020304050607080

Door-to-data Door-to-decision Door-to-drug

Time intervals

Med

ian

min

utes

Men Women


P = .001

P = .001

Time to Treatment: Bedside vs Telephone Consultation

01020304050607080

Door-to-data Door-to-decision Door-to-drug

Time intervals

Media

n m

inute

s

Telephone Bedside


P = .001

P = .001

Time to Treatment: Conclusions

• Hospital practices and policies can significantly delay treatment of patients with AMI

• Delays in hospital arrival for women are compounded by delays in decisions and initiation of therapy in those women who receive consultation compared with men

• ED physicians should have the authority to initiate thrombolytic therapy

• Monitoring should be part of a multidisciplinary, continuous QI effort


Consultation Before Thrombolytic Therapy in AMI

Background• In-hospital delay is often the largest factor impacting time-to-thrombolytic

treatment. Time-consuming ED protocols and practices may explain some of these delays

Objectives• To determine whether patients for whom consultation was obtained before

initiation of therapy differ in presenting characteristics from their counterparts for who consultation was not obtained

• To ascertain differences in time to treatment due to consultation

• To determine if time delays associated with consultation affect outcomes

Al-Mubarak N, et al. Am J Cardiol 1999

Factors that Predict Use of Consultation

ST segment elevationRace (white)Presence of chest painMale genderST segment depressionMI sx to ECG (per 10 min)History of PTCAHMO vs commercial insuranceHistory of CABGAge >70 yearsLBBBRBBBPulmonary edemaNormal ECG

Odds ratio

0.5 0 1.5 2 Consultation


95% CI P value0.825 .00010.890 .00010.928 .0470.949 .010.956 .0251.003 .00011.084 .041.088 .0091.126 .00011.184 .00011.195 .0291.278 .00011.390 .00011.391 .0001

More likelyLess likely

0

20

40

60

80

100

Time after hospital arrival (min)

Pat

ien

ts t

reat

ed,

%

Elapsed Door-to-drug Time After Hospital Arrival


0 60 120 180

No consultation Consultation

Consultation Before Thrombolytic Therapy: Conclusions

• Consultation was sought in 64% of patients although presenting features were typical, rather than atypical, in most patients

• Consultation significantly delayed the administration of lytic therapy and was associated with increased hospital mortality

• This study led to the empowerment of ED physicians to initiate thrombolytic therapy


Longer Door-to-drug Time Associated with Increased Mortality

Background• It has been recommended that all hospitals work to

decrease door-needle-time, yet the relationship between door-needle-time and mortality had not been examined

Objective• To evaluate whether longer door-to-needle times

increase the rate of mortality

Cannon et al. JACC 2000 (Abstract, Suppl A)

Odds for Mortality Associated with Longer Door-to-drug Time

1.03

1.11

1.23

0.8

1

1.2

1.4

0-30 31-60 61-90 >90Door-to-drug time (min)

MV

adju

sted

odds

of m

ort

ality

n=28,624 n=33,867 n=11,616 n=10,316

P=NS

P=0.01

P=0.0001


Longer Door-to-drug Time: Conclusions

• Delays in door-to-needle times over 60 minutes increases the rate of mortality

• Delays in door-to-needle times over 30 minutes increases the development of left ventricular dysfunction post-MI

• These data provide direct evidence of the need to reduce door-to-needle times in order to improve the chances of survival post AMI


Symptom-onset-to-balloon Time and Door-to-balloon Time with Mortality in Patients Undergoing Angioplasty for AMI

Background• Rapid time to treatment with thrombolytic therapy is

associated with lower mortality in patients with AMI. However, data on time to primary angioplasty and its relationship to mortality are inconclusive

Objective• To test the hypothesis that more rapid time to reperfusion

results in lower mortality with primary angioplasty

Cannon CP, et al. JAMA 2000

0.6

0.81

1.2

1.4

1.61.8

2

2.2

0-2 >2-3 >3-4 >4-6 >6-12 >12Time, hours

Multva

riat

e-ad

just

ed o

ods

of in

-hos

pita

l mor

talit

y

Relationship Between Symptom-onset-to-balloon Time Intervals and Mortality

Adapted from Cannon CP, et al. JAMA 2000

P=0.95

P=0.21 P=0.35P=0.17

P=0.65

Relationship between Door-to-Balloon Time Intervals and Mortality

Adapted from Cannon CP, et al. JAMA 2000

0.60.8

1

1.21.41.61.8

22.2

0-60 61-90 91-120 121-150 151-180 >180

Time, minutes

Mul

tvar

iate

-adj

uste

d oo

ds o

f in-

hosp

ital m

orta

lity

P=0.35 P=0.29

P=0.01

P<0.001P<0.001

Time to Treatment in Angioplasty: Conclusions

• More rapid time to reperfusion results in lower mortality with primary angioplasty

• Physicians and health care systems should work toward reducing door-to-balloon times to less than 90 minutes (plus or minus 30 minutes)

• Door-to-balloon time should be considered when choosing a reperfusion strategy

Cannon CP, et al. JAMA 2000

Women: Risk of AMI, Treatment Patterns, and Outcomes

• Women have a worse prognosis than men after AMI

• Women present at an older age, may have more advanced disease, often have coexisting conditions, and may get less aggressive referral, diagnosis, and treatment

• Two key studies have used the NRMI database to examine sex-based differences in patients with AMI

Thrombolytic Therapy Demographics

Adapted from Chandra NC et al. Arch Intern Med 1998

No thrombolytictherapy

Thrombolytictherapy

Factors Men Women Men Women

Number of patients 136,401 92,335 87,392 34,941

Mean age (years) 65.8 72.4 59.1 65.2

Mean weight (kg) 83.2 68.7 85.9 71.6

Mean time to treatment (min)

NA NA 90.3 104.2

P <.001

Mortality in Men and Women, by Age

0

5

10

15

20

25

30

50 50-60 60-70 70-80 >80Age, years

Mort

alit

y, %

Women, No TT Men, No TT Women, TT Men, TT

Adapted from Chandra NC et al. Arch Intern Med 1998

Treatment of Women with MI: Conclusions

• Women have higher mortality rates and are less likely to receive thrombolytic therapy, cardiac catheterization, coronary artery bypass surgery, aspirin, heparin, and beta-blockers

• These findings contribute to the growing body of evidence suggesting that women receive insufficient referral and treatment for AMI

Chandra NC et al. Arch Intern Med 1998

Sex-based Differences in Early Mortality

Background• To further investigate mortality patterns among

women with AMI, Vaccarino and colleagues analyzed NRMI 2 data

Objective• To test the hypothesis that younger, but not older,

women have higher in-hospital mortality rates than their male peers

Vaccarino V, et al. N Engl J Med. 1999

Rates of Mortality During Hospitalization, by Age

0

5

10

15

20

25

30

<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90

Age, years

Death

s in

hosp

ital,

%

Men Women

Vaccarino V, et al. N Engl J Med. 1999P <0.001

Sex-based Differences in Early Mortality After MI: Conclusions

• The younger the women, the greater the relative risk for mortality compared to men

• The risk for mortality is greater for women less than 75 years, but after the age of 75, the risk for men is greater

• Under the age of 50, women have a 2:1 greater risk for mortality

• Younger women with MI are a high-risk groupVaccarino V, et al. N Engl J Med. 1999

Sex-based Differences in AMI: Conclusions

• Many earlier observational studies on AMI did not analyze sex-based differences

• The size and scope of the NRMI databases allow identification of important findings on the treatment of women: – younger women with AMI are a high risk group requiring special

attention

– substantial differences exist in the way women and men are treated for AMI

• Further research is warranted

Seasonality in AMI

• Seasonal patterns in mortality from AMI have been established. However, it is unclear if a seasonal rhythm for onset of AMI exists.

• Two studies used NRMI databases was to determine if there is a seasonal variation in the occurrence of AMI and if so, if it is present in all geographic areas.

Number of Cases of AMI 1994-1996

0

5000

10000

15000

20000

25000

30000

35000

40000

Winter Spring Summer Fall

Spencer et al. JACC 1998

Regional Breakout of AMI Cases by Season

0

5

10

15

20

25

30

35

NEMid Atl

S Atl

ENC ESCWNC

WSC

Mountain

Pacific

% o

f A

MI ca

ses

Winter Summer

Adapted from Spencer et al. JACC 1998

AMI Cases by Season: Men and Women

0

5000

10000

15000

20000

25000

Summer Fall Winter Spring

Num

ber of A

MI ca

ses

Male Female


AMI Cases by Season: Age Groups

0

2000

4000

6000

8000

10000

12000

<50 yrs 55-64 yrs 65-74 yrs >75 yrs

Num

ber of A

MI ca

ses

Winter Summer


Seasonality in AMI: Conclusions

• 53% more cases of AMI occur in winter vs summer

• Though there are regional differences in the occurrences of AMI, the same general pattern of seasonality occurs across the United States

• Results are also consistent for seasonality when looking at gender and age

Spencer et al. JACC 1998; Ornato JP, et al. JACC 1996

NRMI: Focus on Procedures that Affect Patient Outcomes

• Hospital capabilities and equipment

• Influence of payor status on outcomes

• Comparison of reperfusion strategies

• Hospital volume (experience) of MIs and overall outcomes

Treatment and Outcomes for AMI Patients in Hospitals With and Without Invasive Capability

Background• Patients with AMI are usually transported to the closest hospital

• However, relatively few hospitals have the capability for immediate coronary arteriography, PTCA, or CABG

Objective• To determine the extent to which the capability of a hospital to

perform invasive cardiovascular procedures influences treatment and outcome of patients admitted with AMI

Rogers WJ, et al. J Am Coll Cardiol 2000

Distribution of Hospital Types (n=1506) in NRMI 2

0 10 20 30 40 50 60 70 80

Non-Invasive, %

Invasive-capable,%

Non-invasive Cath-capable PTCA-capable CABG-capable


Invasive Capability and AMI Outcome: Findings


The proportion of patients receiving initial reperfusion intervention was only slightly higher at the more invasive hospitals

Among thrombolytic recipients, median door-to-drug time interval differed little among hospital types

The proportion of patients transferred out to other facilities was 51.0% (noninvasive), 42.2% (cath-capable), 39.9% (PTCA-capable), and 4.4% (CABG-capable) (P <0.0001)

Mortality at 90 days post-infarction was similar among patients initially admitted to each of the four hospital types

Invasive Capability and AMI Outcome: Conclusions

• Patients with AMI admitted to hospitals without invasive cardiac facilities have a high likelihood of subsequent transfer to other facilities

• Yet, 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

• Data suggest that a policy of initial treatment of AMI at the closest medical facility is appropriate medical practice


Payor Status, Use of Invasive Cardiac Procedures, and Outcomes after MI

Background• The use of invasive procedures affects the cost of cardiovascular

care and may be influenced by payor status

Objective• To determine the influence of payor status on the use and

appropriateness of cardiac procedures.

Sada MJ, French WJ, et al. J Am Coll Cardiol 1998

Comparison of Payor Groups: Methods

Compared treatment and outcomes of MI among four payor groups:

fee for service (FFS) health maintenance organization (HMO) Medicaid uninsured

Performed multivariate comparison on the use of invasive cardiac procedures, length of stay and in-hospital mortality

Compared use of coronary angiography in patients at low and high risk for cardiac events


FFS(n=10,498)

HMO(n=3,273)

Medicaid(n=1,354)

Uninsured(n=2,475)

Invasive Angiography* 85.5 80.4 61.0 74.9 Angioplasty† 35.6 34.0 20.8 29.3 Bypass surgery‡ 19.4 16.1 11.0 13.5Other Echocardiography# 42.2 40.8 50.2 44.6 IABP§ 6.6 5.6 5.8 5.2 Mechanical ventilation¶ 18.0 15.3 18.4 14.4 Pacemaker§ 4.2 3.2 4.1 4.3 Stress testing¶ 15.4 19.6 16.9 16.5


Use of Procedures by Payor Groups (%)

Use of Angiography by Payor Status

Adapted from Sada MJ, French WJ, et al. J Am Coll Cardiol 1998

More likely

Medicaid

Uninsured

HMO

0 0.5 1 1.5 2 2.5

Odds ratio

Angiography

Less likely

Factors Affecting In-hospital Mortality by Payor Status

Adapted from Sada MJ, French WJ, et al. J Am Coll Cardiol 1998

HMO

Uninsured

Medicaid

0 0.5 1 1.5 2 2.5 3

Higher mortality

Odds ratio

Payor Status and Outcomes: Conclusions

• Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction

• The higher in-hospital mortality in the Medicaid cohort merits further study


Primary PTCA Compared with rt-PA in Patients with AMI

Background

• PTCA and thrombolytic therapy are alternative means of achieving reperfusion in patients with AMI

Objective

• To compare outcomes after primary PTCA or thrombolytic therapy for AMI

Tiefenbrunn AJ, et al. JACC 1998

In-hospital Mortality in Lytic-eligible Patients


Mortality (%)

rt-PAPTCA

Overall 5.4 5.2STE or LBBB 1st ECG 5.3 5.5Age <75 yr 3.4 3.5Age >75 yr 16.5 14.4Men 4.5 5.2Women 9.6 8.9Inferior MI 3.9 3.9Anterior MI 7.6 7.1Low risk 2.9 2.8Not low risk 7.5 7.4

Odds ratio and 95% CI

0.5 0 1.5 rt-PA better PTCA better

In-hospital Mortality Plus Non-fatal Stroke


Mortality plus

nonfatal stroke (%)

rt-PA PTCAAll (lytic eligible without shock) 6.2 5.6

STE or LBBB 1st ECG 6.1 5.9

Age >75 yr 18.4 14.6

Age <75 yr 4.1 3.9

Odds ratio and 95%CI

0.5 0 1.5 rt-PA better PTCA better

Primary PTCA Compared with rt-PA: Conclusions

• Data suggest that for lytic-eligible patients not in shock, PTCA and rt-PA are comparable alternative methods of reperfusion when analyzed in terms of – in-hospital mortality– mortality plus nonfatal stroke – reinfarction


Canto JG,et al. N Engl J Med 2000

Volume of Primary Angioplasty Procedures and Survival after AMI

Background• There is an inverse relation between mortality from

cardiovascular causes and the number of elective cardiac procedures performed by individual practitioners or hospitals

• It is not known whether patients with AMI fare better at higher volume centers versus lower volume centers

Objective• Analyze data from the NRMI to determine the relation

between the number of patients receiving reperfusion therapy and subsequent in-hospital mortality

NRMI Hospitals Ranked by Thrombolytic Therapy Volume

Canto JG, et al. N Engl J Med 2000

Number of Patients Thrombolytic VolumeQuartile Hospitals with MI (n) Therapy (n) (#/yr)

1 129 38,964 3,929 5-15

2 129 48,003 8,385 16-28

3 129 74,380 14,694 29-45

4 129 115,809 55,666 >45

Hospital and Patient Characteristics and Outcomes: Conclusions

Canto JG, et al. N Engl J Med 2000

• In-hospital mortality was 28% lower for patients receiving primary angioplasty at high-volume centers

• There was no association between volume and mortality among patients treated with thrombolytic therapy

• Better outcomes were not associated with referral/transfer patterns or greater total volume of patients

• The time to treatment interval was significantly shorter at high volume centers

Lessons in Patient Outcomes From the NRMI

• ED personnel can employ immediate reperfusion strategies for patients with AMI to save lives and improve outcomes

• Hospitals should be aware of the possible influence of payor status on how patients are treated

• Patient characteristics and hospital capabilities are factors to consider when choosing a reperfusion strategy

• Practices at hospitals with the best outcomes can be examined for ideas of where to begin process improvements

Complications of MI/Safety

• Risk of intracranial hemorrhage (ICH)

• CABG

Risk for Intracranial Hemorrhage after rt-PA Treatment for AMI

Background The efficacy of thrombolytic therapy in reducing mortality from

AMI has been unequivocally shown. However, thrombolysis is related to bleeding complications, including intracranial hemorrhage (ICH)

Objective To determine the frequency of and risk factors for intracranial

hemorrhage after rt-PA given for AMI in patients receiving usual care

Gurwitz JH, et al. Ann Intern Med 1998

Risk Factors for Intracranial Hemorrhage


• A small number of patients (< 1%) had an ICH during hospitalization for AMI; of the patients with confirmed ICH, 53% died during hospitalization and an additional 25.3% had residual neurologic deficit

• There was a substantial increase in the incidence of ICH in older patients

• An increased dose of rt-PA was a risk factor for ICH• Other risk factors are elevated systolic blood pressure,

female sex and black ethnicity

Risk for Intracranial Hemorrhage: Conclusions

• ICH is a rare but serious complication of rt-PA in patients with AMI

Appropriate drug dosing may reduce the risk for this complication

• Other therapies, such as primary coronary angioplasty, may be preferable in patients with AMI who have a history of stroke


Reperfusion Therapy in Patients with AMI and Prior CABG Surgery

Background• The number of patients presenting with AMI who have

had previous CABG has been increasing

Objectives• To review data from NRMI 2 to determine the

differences in characteristics and outcomes– in patients with AMI who have undergone CABG and those who

have not– in post-CABG patients who were treated with rt-PA and those who

were treated with PTCAPeterson LR, et al. Am J Cardiol 1999

Patients treatedwith rt-PA

Patients treated withangioplasty

Withprior CABG

Without priorCABG

Withprior CABG

Without priorCABG

Mortality (all) 7.7% 5.3%* 8.0% 4.4% *

For patients >75 years 15.9% 16.8% 14.0% 11.5%

For patients <75 years 5.9% 3.3%* 6.6% 3.1% *

Mortality plus nonfatal stroke (all) 8.6% 6.1%* 8.5% 4.9% †

For patients >75 years 17.5% 18.2% 15.5% 12.4%

For patients <75 years 6.7% 4.0%* 6.9% 3.5% †

Outcomes for Patients With or Without Prior CABG

Peterson LR, et al. Am J Cardiol 1999*P <0.002; †P <0.005

Patients With Prior CABG Treated with rt-PA or Angioplasty: Differing Baseline Characteristics

rt-PA PTCAn=2,544 n=735

Smoker 24.4% 19.5%*

LBBB 3.8% 6.1%*

>4 hours to treatment 21.0% 44.0%†

Treatment with aspirin 91.2% 83.7%†

Treatment with intravenous beta blocker

23.5% 11.5%†

*P <0.04; †P <0.0001 Peterson LR, et al. Am J Cardiol 1999

AMI and Prior CABG Surgery: Conclusions

• Prior CABG is an independent predictor of mortality

• The post-CABG patients who were treated with either rt-PA or PTCA had similar baseline characteristics

• There was no significant difference in in-hospital mortality rate or the combined end point of mortality and nonfatal stroke in the post-CABG patients who received rt-PA or underwent PTCA

Peterson LR, et al. Am J Cardiol 1999

AMI Subgroups

• Patient eligibility

• Chest pain

• Patient populations

• Bundle branch block

Untreated Reperfusion-eligible Patients

Background• There is an under-utilization of reperfusion therapy in the

United States

Objectives• Determine what proportion of patients with MI who are

eligible for reperfusion therapy do not receive it• Identify demographic, clinical and electrocardiographic

factors that are associated with the decision to not use this therapy

Barron HV, et al. Circulation 1998

Eligible patients, 31% (n=84,663)

24%

76%

No RT (n=20,319)RT (n=64,344)

Use of Thrombolytic Therapies in Eligible Patients

RT=reperfusion therapy


Use of Reperfusion Therapy

Adapted from Barron HV, et al. Circulation 1998

LBBBNo chest painAge >75Prior CHFPrior MIKillip IIIWomenCaucasianSmokerPre-hospital ECGSx <3 hrs

0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

RT less likely RT more likely


In-hospital Mortality

Adapted from Barron HV, et al. Circulation 1998

7.95.7

14.8

9.3

17.9

10.5

18.9

0

5

10

15

20

Alleligible

RT No RT WomenRT

Womenno RT

>65 yrsRT

>65 yrsno RT

Patients

, %


Untreated Reperfusion-eligible Patients: Conclusions

• Women, the elderly, patients from ethnic minorities, and patients presenting without chest pain were less likely to undergo reperfusion therapy

• Patients at highest risk for dying in the hospital were less likely to receive therapy than their lower-risk counterparts

• There is a need for additional education for physicians regarding the potential of reperfusion therapy to improve survival


Chest Pain at Presentation

Background• Although chest pain is widely considered a key symptom in the

diagnosis of MI, not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown

Objective• To determine the frequency with which patients with MI present

without chest pain and to examine their subsequent management and outcome

Canto JG, et al. JAMA 2000

Major Risk Factors for Atypical Presentation in MI


Withchest pain

Withoutchest pain

Prior heart failure 49.0% 51.0%

Prior stroke 53.0% 47.0%

Age >75 years 55.1% 44.9%

Diabetes mellitus 61.5% 38.5%

Nonwhite 66.3 % 33.7%

Women 61.4 % 38.6%

Outcomes of MI for Patients Presenting With and Without Chest Pain

Withchest pain

Withoutchest pain

Heart failure requiringintervention, %

15.0 29.3

Hypotension, % 14.0 18.7

Stroke, % 1.2 2.0Time in ICU, mean days 3.0 3.1Length of stay, mean days 7.0 8.8Hospital arrival to time to

death, mean days5.1 6.0

In-hospital death, % 9.3 23.3

Canto JG, et al. JAMA 2000P <.001

Process of Care for AMI Patients With and Without Chest Pain

With chest pain

Withoutchest pain

Reperfusion therapy, % 74.0 25.3

Time interval from hospital arrival, min

First ECG 15.6 31.8Thrombolysis 65.4 139.8

PTCA 171.6 282.0

Aspirin within 24 hours, % 84.5 60.4

Any catheter-based revascularization, % 28.8 9.4

Canto JG, et al. JAMA 2000P <.001

AMI Patients With and Without Chest Pain: Conclusions

• Patients without chest pain on presentation represent 33% of the AMI population– They are more likely to delay seeking medical

attention– They often receive less aggressive treatments– They are at greater risk of in-hospital mortality


Canto JG, et al. Am J Cardiol 1998; Taylor HA Jr, et al. Am J Cardiol 1998

Patient Populations

Background• A number of studies have explored differences between black and

white Americans with AMI, little data exist on treatment patterns in the current thrombolytic era

• There is even less data for non-black minorities experiencing AMI

Objectives• To examine demographics, clinical characteristics, treatment

patterns, and clinical outcomes among Hispanics, Asian-Pacific Islanders, and Native Americans with AMI

• To compare characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients

Patient Populations: Non-black Minorities Compared to Whites

• Non-black populations (Hispanics, Asian-Pacific Islanders, and Native Americans)– Presented later to the hospital after the onset of symptoms (135 vs

122 minutes, p <0.001)– Were as likely to have IV thrombolytic therapy,* coronary

arteriography, and revascularization– Were less likely to receive beta blocker therapy at discharge

• There were no significant differences in hospital mortality for non-black minorities compared with whites

*For all groups except Asian-Pacific Islanders Canto JG, et al. Am J Cardiol 1998

Patient Populations: Blacks Compared to Whites

• Blacks presented much later after the onset of symptoms (median 145 vs 122 minutes, p <0.001)

• Blacks were significantly more likely to have atypical cardiac symptoms and nondiagnostic ECGs during the initial evaluation period

• Blacks were less likely to receive IV thrombolytic therapy, coronary arteriography, other elective catheter-based procedures, and coronary artery bypass surgery

• Despite differences in treatment, there were no significant differences in hospital mortality between blacks and whites

Taylor HA Jr, et al. Am J Cardiol 1998

Use of Reperfusion in Non-white Ethnic Groups


Black

Hispanic

Asian-PI

Native Am

0.7 0.8 0.9 1.0 1.1 1.2 1.3

Use by race compared to Caucasians

0.76 (0.70-0.82)

0.97 (0.86-1.09)

0.84 (0.72-0.99)

1.18 (0.90-1.54)

Less likely More likely

Patient Populations: Conclusions

• Nonwhite patients enrolled in the NRMI 2 presented significantly longer after symptom onset than white patients

• Blacks and Asian Pacific Islanders were less likely than whites to receive IV thrombolytic therapy than whites; Hispanics and Native Americans were equally likely to receive this therapy as whites

• There were no differences in adjusted in-hospital mortality rates between white and non-white patients


Bundle Branch Block in AMI

Background• LBBB is an important predictor of poor outcome in patients with

AMI, but the consequences of RBBB are not well understood

Objectives• To estimate the prevalence of left and right BBB in patients with MI

• To compare the clinical characteristics of and treatments received by patients with left, right, or no BBB

• To determine the independent association of LBBB and RBBB with in-hospital mortality

Go AS, et al. Ann Intern Med 1998

Treatments by Presence and Type of Bundle Branch Block

No BBB (%) RBBB (%) LBBB (%)

Any reperfusion 84.8 44.6 23.6

Thrombolytic therapy 22.0 13.0 5.3

Primary PTCA 8.9 5.8 2.6

Go AS, et al. Ann Intern Med 1998P <0.001

Association of Bundle Branch Block and In-hospital Mortality


Odds ratio (95% CI)

Baselinecharacteristics*

Baselinecharacteristics*plus treatment†

RBBB 1.64 (1.57–1.71) 1.64 (1.57–1.71)

LBBB 1.33 (1.28–1.38) 1.34 (1.28–1.39)

ST segment elevation with no BBB 1.35 (1.31–1.39) 1.53(1.49–1.58)

* Controlled for differences in demographics and clinical characteristics

† Further controlled for differences in treatment

Bundle Branch Block in AMI: Conclusions

• Prevalence of RBBB and LBBB are similar in patients with AMI

• Patients with BBB – have more comorbid conditions

– are less likely to receive therapy

– have an increased risk for in-hospital mortality

• Compared with LBBB, RBBB seems to be a stronger independent predictor of in-hospital mortality


Use of Angiotensin-converting Enzyme (ACE) Inhibitors at Discharge

Background• There is a significant mortality benefit in patients treated with

ACE inhibitors after AMI• Beneficial treatments for patients with AMI are often under-

used

Objectives• To examine recent trends in the use of ACE inhibitor therapy

in patients discharged after AMI • To identify clinical factors associated with ACE inhibitor

prescribing patternsBarron HV, et al. J Am Coll Cardiol 1998

Discharge ACE Inhibitor Use by Clinical Indication Group

05

1015202530354045

"Definite" "Probable" "Possible"

Clinical indication

Tre

ate

d w

ith A

CE in

hib

itors

, %

Barron HV, et al. J Am Coll Cardiol 1998

Discharge ACE Inhibitor and Calcium Channel Blocker Use by Time Period

0

5

10

15

20

25

30

35

6/94-12/94 1/95-6/95 7/95-12/95 1/96-6/96

ACE inhibitors Calicium blockers


Discharge ACE Inhibitor Use: Conclusions

• Physicians are prescribing ACE inhibitors in patients with MI with increasing frequency

• Those patients with the greatest expected benefit receive ACE inhibitor treatment most often

• However, the majority of even these high risk patients were not discharged with this life-saving therapy


Intracranial Hemorrhage Rates and Immediate Beta-Blocker Use

Background• Immediate beta blocker therapy reduces the incidence of

reinfarction and recurrent chest pain in patients receiving rt-PA

• Data from the TIMI-2 trial raises the possibility that such therapy may reduce the rate of ICH

Objective• Analyze data from NRMI 2 to reexamine whether immediate beta

blocker therapy in AMI patients treated with rt-PA is associated with a lower rate of ICH

Barron HV, et al. Am J Cardiol 2000

ICH Rates and Immediate Beta-Blocker Use by Age

0

0.5

1

1.5

2

2.5

<65 yr 65-74 yr 75 yr and older

Immediate beta blocker No immediate beta blocker


ICH Rates and Immediate Beta-Blocker Use by Gender

00.20.40.60.8

11.21.41.61.8

Men Women

Immediate beta blocker No immediate beta blocker


ICH and Beta Blocker Therapy: Conclusion

• Immediate beta blocker therapy is associated with lower ICH rates in patients treated with rt-PA

• The ACC/AHA guidelines recommend immediate beta blocker therapy for patients with suspected AMI

• This study should serve to strengthen this recommendation


NRMI, JCAHO, ORYX, and Core Measures

• JCAHO’s ORYX requires hospitals to participate in one or more measurement systems on its approved list

• NRMI accepted measures include:– Early aspirin usage

– Door to drug time for thrombolysis– No initial reperfusion strategy in eligible patients

• Hospitals currently required to select 6 measures• In 2002, data collection for the JCAHO core measures will

begin

NRMI: 10 years of CV Healthcare Solutions

NRMI 4 EnhancementsNRMI 4 Enhancements• Updated to reflect revised 1999 ACC/AHA Guidelines

for management of patients with AMI

• Developing process improvement reports

• Continued submission of ORYX data for HCOs

• Validated data with extensive edits

• Enhanced use of technology in study management

NRMI Advisors

John G. Canto, MD, MSPH, FACC

William J. French, MD

Costas T. Lambrew, MD

Joseph P. Ornato, MD, FACC, FACEP

Janice B. Penney, RN, CCRN, MSN

William J. Rogers, MD

Alan J. Tiefenbrunn, MD, FACC

Robert J. Zalenski, MD

Summary

• With NRMI and other databases, we can access and analyze almost every aspect of patient care to examine how we can improve our practices and provide better information for our patients

• During the last 10 years, we have seen measurable improvements in the care of patients with AMI

• Our challenge is to further improve AMI care in the 21st century

Congratulations

• Thanks to the over 5000 investigators and coordinators who have made these accomplishments possible

• Remember,

Together, Everyone Achieves More!

Documents

Milestones in Acute Myocardial Infarction