Download Medical Milestones in Myocardial Infarction

Milestones in
Acute Myocardial Infarction
1
Celebrating 10 Years
of Insights from the
National Registry
of Myocardial Infarction
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
• Congestive heart failure
$95.6 billion/year
$20.2 billion/year
1998 Heart and Stroke Statistical Update, American Heart Association
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
1
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
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
Goal
Improve AMI patient care through evaluation/
assessment of care delivery systems
Purpose
Collect, analyze, and disseminate observational data
related to outcomes and quality of care for AMI
patients
Rationale
Ongoing assessment of practice is critical for
improving patient care
NRMI Publications
Articles
Abstracts
18
16
14
12
10
8
6
4
2
0
1992
1993
1994
1995
1996
1997
*additional abstracts and articles are expected for 2000
1998
1999 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
Median time, minutes
National Trends in AMI Management:
Door to Drug Time with Thrombolysis
NRMI 1
NRMI 2
NRMI 3
(Activase only)
(All lytics)
(All lytics)
100
91
90
80
70
60
75th percentile, 52
60
50
39
40
34
30
20
25th percentile, 22
10
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
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
National Trends in AMI Management:
Door to Balloon Time in PPTCA
Median time, minutes
120
NRMI 2
116
NRMI 3
110
108
100
90
80
1994
1995
1996
1997
1998
1999
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
Median days in hospital
No reperfusion strategy
8 7.5
NRMI 1
7
6 6.8
5
4
3
2
1
0
1990 1991 1992
Non-transfer-in patients
Reperfusion strategy used
NRMI 2
NRMI 3
4.6
3.5
1993
1994
1995
1996
1997
1998
1999
National Trends in AMI Management:
Medications Used Within 24 Hours
Patients, %
ASA
Heparin
Beta blockers
Ace inhibitors
GP IIa/IIIb inhibitors
90
NRMI 1
NRMI 2
NRMI 3
80
70
60
50
40
30
20
10
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Non-transfer-in patients
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
Hospital-level Comparison:
Baseline Characteristics
Age (mean)
Sex (% male)
White race (%)
History of
AMI (%)
Heart failure (%)
Bypass surgery (%)
Coronary angioplasty (%)
NRMI
CCP
(n=35,673)
(n=42,703)
P value
76.9
50.3
86.9
77.3
49.4
89.5
0.391
0.015
<0.001
29.0
21.3
12.2
5.3
32.0
25.1
12.9
6.7
<0.001
<0.001
0.002
<0.001
Adapted from Every N, et al. JACC 1999
Hospital-level Comparison:
Process of Care and Outcomes
Length of stay (mean days)
Cardiac catheterization (%)
Coronary angioplasty (%)
Bypass surgery (%)
Thrombolytic therapy (%)
Mortality
Stroke
NRMI
CCP
(n=35,673)
(n=42,703)
P value
8.3
33.3
12.6
7.1
15.6
19.7
1.9
8.1
32.8
12.5
7.0
14.6
18.1
3.4
<0.001
0.156
0.846
0.420
<0.001
<0.001
<0.001
Adapted from Every N, et al. JACC 1999
Patient-level Comparison:
Hospital Course
% Agreement
Stroke in hospital
Reinfarction
Shock in hospital
Thrombolytic treatment
Coronary angiography
Coronary angioplasty
Bypass surgery
Hospital mortality
(n=25, 664)
Kappa
98.0
95.2
94.7
98.3
98.2
97.9
99.7
99.3
0.57
0.21
0.63
0.94
0.96
0.91
0.97
0.98
Adapted from Every N, et al. JACC 1999
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
Factors
Treatment in the ED
Male sex
Accelerated 90-min infusion
Treatment from 6 am to 6 pm
Western US region
Advanced age*
Anterior infarct location
*Age coded as (1) <60, (2) 61-74,
and (3) >75 years of age
Odds
ratio
95% CI
3.08
1.26
1.26
1.26
1.24
0.86
0.90
2.94, 3.23
1.21, 1.31
1.24, 1.28
1.22, 1.31
1.17, 1.30
0.83, 0.88
0.87, 0.94
Maynard C, et al. Am J Cardiol 1995
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
Maynard C, et al. Am J Cardiol 1995
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
Median minutes
Men
80
70
60
50
40
30
20
10
0
Women
P = .001
P = .001
Door-to-data
Door-to-decision
Door-to-drug
Time intervals
Lambrew CT, et al. Arch Intern Med 1997
Time to Treatment: Bedside
vs Telephone Consultation
Median minutes
Telephone
80
70
60
50
40
30
20
10
0
Bedside
P = .001
P = .001
Door-to-data
Door-to-decision
Door-to-drug
Time intervals
Lambrew CT, et al. Arch Intern Med 1997
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
Lambrew CT, et al. Arch Intern Med 1997
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
Odds ratio
95% CI
0.825
0.890
0.928
0.949
0.956
1.003
1.084
1.088
1.126
1.184
1.195
1.278
1.390
1.391
ST segment elevation
Race (white)
Presence of chest pain
Male gender
ST segment depression
MI sx to ECG (per 10 min)
History of PTCA
HMO vs commercial insurance
History of CABG
Age >70 years
LBBB
RBBB
Pulmonary edema
Normal ECG
Al-Mubarak N, et al. Am J Cardiol 1999
Less likely
0.5
0
Consultation
1.5
P value
.0001
.0001
.047
.01
.025
.0001
.04
.009
.0001
.0001
.029
.0001
.0001
.0001
2
More likely
Elapsed Door-to-drug Time
After Hospital Arrival
No consultation
Patients treated, %
100
Consultation
80
60
40
20
0
0
60
120
180
Time after hospital arrival (min)
Al-Mubarak N, et al. Am J Cardiol 1999
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
Al-Mubarak N, et al. Am J Cardiol 1999
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)
MV adjusted odds of mortality
Odds for Mortality Associated
with Longer Door-to-drug Time
P=0.0001
1.4
P=0.01
1.2
P=NS
1.23
1.11
1.03
1
n=28,624
n=33,867
n=11,616
n=10,316
0.8
0-30
31-60
61-90
Door-to-drug time (min)
>90
Cannon et al. JACC 2000 (Abstract, Suppl A)
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
Cannon et al. JACC 2000 (Abstract, Suppl A)
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
Multvariate-adjusted oods of inhospital mortality
Relationship Between Symptomonset-to-balloon Time Intervals
and Mortality
2.2
2
1.8
1.6
1.4
1.2
1
0.8
0.6
P=0.21
P=0.35
P=0.17
P=0.65
P=0.95
0-2
>2-3
>3-4
>4-6
Time, hours
>6-12
>12
Adapted from Cannon CP, et al. JAMA 2000
Multvariate-adjusted oods of inhospital mortality
Relationship between Door-toBalloon Time Intervals and Mortality
2.2
2
1.8
1.6
1.4
1.2
1
0.8
0.6
P<0.001
P<0.001
P=0.01
P=0.35
0-60
61-90
P=0.29
91-120
121-150
151-180
>180
Time, minutes
Adapted from Cannon CP, et al. JAMA 2000
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
No thrombolytic
therapy
Factors
Thrombolytic
therapy
Men
Women
Men
Women
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
Number of patients
P <.001
Adapted from Chandra NC et al. Arch Intern Med 1998
Mortality in Men and Women,
by Age
Women, No TT
Men, No TT
Women, TT
Men, TT
30
Mortality, %
25
20
15
10
5
0

50
50-60
60-70
Age, years
70-80
>80
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
Men
Deaths in hospital, %
30
Women
25
20
15
10
5
0
<50
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90
Age, years
P <0.001
Vaccarino V, et al. N Engl J Med. 1999
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 group
Vaccarino 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
40000
35000
30000
25000
20000
15000
10000
5000
0
Winter
Spring
Summer
Fall
Spencer et al. JACC 1998
Regional Breakout of AMI
Cases by Season
% of AMI cases
Winter
Summer
35
30
25
20
15
10
5
0
NE
Mi
t
dA
l
t
SA
l
EN
C
ES
C
C
N
W
WS
C
Mo
u
ai
nt
n
P
if
ac
ic
Adapted from Spencer et al. JACC 1998
AMI Cases by Season:
Men and Women
Male
Female
Number of AMI cases
25000
20000
15000
10000
5000
0
Summer
Fall
Winter
Spring
Adapted from Spencer et al. JACC 1998
AMI Cases by Season:
Age Groups
Winter
Summer
Number of AMI cases
12000
10000
8000
6000
4000
2000
0
<50 yrs
55-64 yrs
65-74 yrs
>75 yrs
Adapted from Spencer et al. JACC 1998
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
Non-invasive
Cath-capable
PTCA-capable
CABG-capable
Invasive-capable,
%
Non-Invasive, %
0
10
20
30
40
50
60
70
80
Rogers WJ, et al. J Am Coll Cardiol 2000
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
Rogers WJ, et al. J Am Coll Cardiol 2000
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
Rogers WJ, et al. J Am Coll Cardiol 2000
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
Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
Use of Procedures by Payor
Groups (%)
FFS
HMO Medicaid
Uninsured
(n=10,498)
(n=3,273)
(n=1,354)
(n=2,475)
85.5
35.6
19.4
80.4
34.0
16.1
61.0
20.8
11.0
74.9
29.3
13.5
42.2
6.6
18.0
4.2
15.4
40.8
5.6
15.3
3.2
19.6
50.2
5.8
18.4
4.1
16.9
44.6
5.2
14.4
4.3
16.5
Invasive
Angiography*
Angioplasty†
Bypass surgery‡
Other
Echocardiography#
IABP§
Mechanical ventilation¶
Pacemaker§
Stress testing¶
Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
Use of Angiography by Payor
Status
Angiography
Less likely
More likely
Medicaid
Uninsured
HMO
0
0.5
1
1.5
2
2.5
Odds ratio
Adapted from Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
Factors Affecting In-hospital
Mortality by Payor Status
Higher mortality
HMO
Uninsured
Medicaid
0
0.5
1
1.5
2
2.5
3
Odds ratio
Adapted from Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
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
Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
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 Lyticeligible Patients
Mortality (%)
rt-PA
Overall
5.4
STE or LBBB 1st ECG 5.3
Age <75 yr
3.4
Age >75 yr
16.5
Men
4.5
Women
9.6
Inferior MI
3.9
Anterior MI
7.6
Low risk
2.9
Not low risk
7.5
Tiefenbrunn AJ, et al. JACC 1998
Odds ratio and 95% CI
PTCA
5.2
5.5
3.5
14.4
5.2
8.9
3.9
7.1
2.8
7.4
0.5
rt-PA better
0
1.5
PTCA better
In-hospital Mortality Plus
Non-fatal Stroke
Mortality plus
nonfatal stroke (%)
rt-PA
PTCA
All (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
Tiefenbrunn AJ, et al. JACC 1998
Odds ratio and 95%CI
0.5
rt-PA better
0
1.5
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
Tiefenbrunn AJ, et al. JACC 1998
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
Canto JG,et al. N Engl J Med 2000
NRMI Hospitals Ranked by
Thrombolytic Therapy Volume
Quartile
Number of
Hospitals
Patients
Thrombolytic
with MI (n) Therapy (n)
Volume
(#/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
Canto JG, et al. N Engl J Med 2000
Hospital and Patient Characteristics
and Outcomes: Conclusions
• 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
Canto JG, et al. N Engl J Med 2000
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
Gurwitz JH, et al. Ann Intern Med 1998
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
Gurwitz JH, et al. Ann Intern Med 1998
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 PTCA
Peterson LR, et al. Am J Cardiol 1999
Outcomes for Patients With
or Without Prior CABG
Patients treated
with rt-PA
With
Without prior
prior CABG
CABG
Mortality (all)
7.7%
5.3%*
8.0%
15.9%
For patients <75 years
5.9%
3.3%*
6.6%
3.1% *
8.6%
6.1%*
8.5%
4.9% †
17.5%
6.7%
18.2%
4.0%*
15.5%
6.9%
12.4%
3.5% †
For patients >75 years
For patients <75 years
*P <0.002; †P <0.005
14.0%
4.4% *
For patients >75 years
Mortality plus nonfatal
stroke (all)
16.8%
Patients treated with
angioplasty
With
Without prior
prior CABG
CABG
11.5%
Peterson LR, et al. Am J Cardiol 1999
Patients With Prior CABG Treated with
rt-PA or Angioplasty: Differing Baseline
Characteristics
rt-PA
PTCA
n=2,544
n=735
24.4%
19.5%*
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%†
Smoker
LBBB
*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 rtPA 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 Reperfusioneligible 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
Use of Thrombolytic
Therapies in Eligible Patients
No RT (n=20,319)
RT (n=64,344)
Eligible patients, 31% (n=84,663)
24%
RT=reperfusion therapy
76%
Barron HV, et al. Circulation 1998
Use of Reperfusion Therapy
RT less likely
LBBB
No chest pain
Age >75
Prior CHF
Prior MI
Killip III
Women
Caucasian
Smoker
Pre-hospital ECG
Sx <3 hrs
0.2
RT more likely
RT=reperfusion therapy
0.4
0.6
0.8
Adapted from Barron HV, et al. Circulation 1998
1.0
1.2
1.4
1.6
In-hospital Mortality
Patients, %
20
14.8
15
10
18.9
17.9
9.3
7.9
10.5
5.7
5
0
All
eligible
RT=reperfusion therapy
RT
No RT
Women Women >65 yrs >65 yrs
RT
no RT
RT
no RT
Adapted from Barron HV, et al. Circulation 1998
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
Barron HV, et al. Circulation 1998
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
With
chest pain
49.0%
Without
chest pain
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%
Prior heart failure
Canto JG, et al. JAMA 2000
Outcomes of MI for Patients Presenting
With and Without Chest Pain
Heart failure requiring
intervention, %
Hypotension, %
Stroke, %
Time in ICU, mean days
Length of stay, mean days
Hospital arrival to time to
death, mean days
In-hospital death, %
P <.001
With
chest pain
Without
chest pain
15.0
29.3
14.0
1.2
3.0
7.0
5.1
18.7
2.0
3.1
8.8
6.0
9.3
23.3
Canto JG, et al. JAMA 2000
Process of Care for AMI Patients
With and Without Chest Pain
With
chest pain
Reperfusion therapy, %
Without
chest pain
74.0
25.3
15.6
65.4
171.6
84.5
31.8
139.8
282.0
60.4
28.8
9.4
Time interval from hospital arrival, min
First ECG
Thrombolysis
PTCA
Aspirin within 24 hours, %
Any catheter-based revascularization, %
P <.001
Canto JG, et al. JAMA 2000
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. JAMA 2000
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
Canto JG, et al. Am J Cardiol 1998; Taylor HA Jr, et al. Am J Cardiol 1998
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 Nonwhite Ethnic Groups
Use by race compared to Caucasians
Less likely
More likely
Black
0.76 (0.70-0.82)
Hispanic
0.97 (0.86-1.09)
Asian-PI
0.84 (0.72-0.99)
Native Am
1.18 (0.90-1.54)
0.7
0.8
0.9
1.0
1.1
1.2
1.3
Canto JG, et al. Am J Cardiol 1998; Taylor HA Jr, et al. Am J Cardiol 1998
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
Canto JG, et al. Am J Cardiol 1998; Taylor HA Jr, et al. Am J Cardiol 1998
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
8.9
5.8
2.6
Primary PTCA
P <0.001
Go AS, et al. Ann Intern Med 1998
Association of Bundle Branch
Block and In-hospital Mortality
Odds ratio (95% CI)
Baseline
characteristics*
Baseline
characteristics*
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
Go AS, et al. Ann Intern Med 1998
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
Go AS, et al. Ann Intern Med 1998
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 underused
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 patterns
Barron HV, et al. J Am Coll Cardiol 1998
Treated with ACE inhibitors,
%
Discharge ACE Inhibitor Use
by Clinical Indication Group
45
40
35
30
25
20
15
10
5
0
"Definite"
"Probable"
"Possible"
Clinical indication
Barron HV, et al. J Am Coll Cardiol 1998
Discharge ACE Inhibitor and Calcium
Channel Blocker Use by Time Period
ACE inhibitors
Calicium blockers
35
30
25
20
15
10
5
0
6/94-12/94
1/95-6/95
7/95-12/95
1/96-6/96
Barron HV, et al. J Am Coll Cardiol 1998
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
Barron HV, et al. J Am Coll Cardiol 1998
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
Immediate beta blocker
No immediate beta blocker
2.5
2
1.5
1
0.5
0
<65 yr
65-74 yr
75 yr and older
Barron HV, et al. Am J Cardiol 2000
ICH Rates and Immediate
Beta-Blocker Use by Gender
Immediate beta blocker
No immediate beta blocker
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Men
Women
Barron HV, et al. Am J Cardiol 2000
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
Barron HV, et al. Am J Cardiol 2000
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 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!