News:STEMI patients: the untreated, reperfusion eligible.
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August 8, 2007 By Grendel Burrell [1]
New Haven CT Reperfusion therapy reduces mortality and decreases infarct size; yet, despite more than 17 years of data, 12% of eligible patients with STEMI receive no reperfusion therapy. And this is progress? Actually, the answer is yes. Barron et al published data in the mid-90s demonstrating that 25% of eligible patients with STEMI received no reperfusion therapy. Harlan M. Krumholz, MD and colleagues reported in the August issue of the American Journal of Medicine (1) that the chance of not receiving reperfusion therapy was highest among those without chest pain, those who arrived at the hospital more than six hours after the onset of symptoms, women, patients over 75, and non-white patients.
The authors analyzed patient data from the National Registry of Myocardial Infarction (NRMI) between June 1994 and May 2003. The decade was divided into three time periods, June 1994 to May 1997, June 1997 to May 2000, and June 2000 to May 2003 to provide information on trends. While the sample size is large, not all US hospitals participated in NRMI, a retrospective analysis of not necessarily consecutive patients at participating hospitals, funded by Genentech, Inc.
In those time frames, participating registry hospitals provided data on 238,291 patients with a STEMI who were ideal candidates for fibrinolytic therapy or percutaneous coronary intervention (PCI). From 1994 through 2003, 34,701 (14.6%) did not receive either PCI or fibrinolytic therapy. On the other hand, the proportion of patients who didn't receive treatment appropriately dropped significantly. The authors found substantial improvement in the use of acute reperfusion therapy among ideal patients with STEMI between 1994 and 2003 in the U.S. The improvement occurred during the late 1990s and then leveled off for the remaining years of the analysis. 20.6% of patients went untreated in the earliest assessed period, 11.4% in the middle period, 11.6% in the most recent period (P<0.001). Harlan Krumholz, MD, SM, the Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health (Cardiology) at Yale University stated, “We found some interesting differences in treatment among subgroups, but the major finding was that there had been improvement in the use of reperfusion therapy among patients who are ideal for therapy, but many patients were still not being treated. I believe the key will be to institute systems that ensure that no patient is missed and that each person with STEMI and no contraindications is offered the opportunity to be treated.
Patients presenting to the emergency department without a complaint of chest pain were less likely to receive reperfusion therapy. How were they queried about the chest discomfort? Was the pain atypical? These patients were 71% less likely to receive reperfusion.
If a patient presented to the emergency department 6-12 hours after symptom onset, he/she was 43% less likely to get appropriate treatment. While fibrinolytic therapy was first approved only for those patients who presented early (<6 hr) from symptom onset, PCI should have been an option for many of these patients. Clearly, the number of hospitals with PCI capabilities increased over the time period of the study.
Patients ≥75 years were 37% less likely to be appropriately treated than patients 55 years old, and the odds ratio was 0.63 with a 95% confidence interval from 0.58 to 0.68. It is unlikely that all of these patients or their families refused therapy or that all of these patients also had metastatic cancer or dementia that might have precluded offering reperfusion. As the population ages, will these numbers improve? Dr. Magnus Ohman, Director of the Program for Advanced Coronary Disease, Duke University, told WikiDoc "We still have significant gaps in AMI care, where the elderly continue to be under-treated with reperfusion therapy. Ultimately using a systematic approach to better identify the reperfusion eligible patients will make it more likely for the elderly to be more appropriately treated." Dr. Ohman is a coauthor of “Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology” published earlier this year. (2)
In the Krumholz et al study, women were 12% less likely to receive treatment. Much has been learned over the past decade about women, their cardiovascular profiles, and symptomatology, but have we made enough progress? Dr. Sharonne Hayes, Director, Women’s Heart Clinic at Mayo Clinic, Rochester, MN, stated “Barriers resulting in disparities in care for women persist and must be eliminated. We need more, and better, sex-specific research reporting in order to improve the accuracy and timeliness of STEMI diagnoses in the face of women’s different presentations and symptoms. Women and providers need to be educated about the full range of symptoms in women and the importance of early action. Finally, we need to take what we already know works and use it appropriately and uniformly. Better adherence to evidence-based guidelines, especially in women and minority STEMI patients results in better outcomes”.
Kathy Kastan, LCSW/MAEd, author of the book, “From the Heart: A Woman's Guide to Living Well with Heart Disease” and current President of WomenHeart: The National Coalition for Women with Heart Disease, says “These findings should be yet another call to action for medicine and society to take heart disease in women as seriously as in men. It’s our number one killer, but study after study show women receive poorer care and fewer interventions. It’s time for a change!” Ms Kastan is herself a heart disease survivor. An avid athlete, with no known risk factors, and of normal weight, she experienced coronary artery bypass surgery at age 42 after a series of misdiagnoses and complications related to such. She speaks from experience about the differences in approach to gender.
Non-white patients were 10% less likely to obtain treatment (odds ratio 0.90, CI 95%, 0.93 to 0.97). What possible explanation is there for this? Commenting to WikiDoc, Dr. Andra Blomkans, Vice-Chairman for Education, Department of Emergency Medicine, University of Cincinnati stated,, "Previous studies in cardiovascular therapeutics have mostly white male research subjects. Symptoms of cardiovascular disease, responses to treatment, and physician and patient perceptions may vary for other populations (i.e. women, the elderly, and patients of other races)."
The authors provide no recommendations for improving these statistics, but emphasize the value of reperfusion for all eligible patients. Other recently published articles by Henry Ting, MD, and Tim Henry, MD in Circulation. August 2007, and reported by WikiDoc, detail regionalized approaches to care that will hopefully improve access to care for all patients.
