Milestones in Acute Myocardial Infarction

1
Milestones in Acute Myocardial Infarction

• Celebrating 10 Years
• of Insights from the
• National Registry
• of Myocardial Infarction

2
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

1998 Heart and Stroke Statistical Update,
American Heart Association
3
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

4
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

5
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

6
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

7
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

8
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

9
NRMI Leadership in Observational Databases

• 19901994
• Over 350,000 patients
• 1,073 hospitals
• Identified delays in thrombolytic therapy

• 19941998
• 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

10
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

11
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
12
NRMI Publications
additional abstracts and articles are expected
for 2000
13
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

14
National Trends in AMI ManagementDoor to Drug
Time with Thrombolysis
NRMI 1 NRMI 2 NRMI 3
(Activase only) (All lytics)
(All lytics)
91
60
75th percentile, 52
39
34
25th percentile, 22
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
15
National Trends in AMI ManagementDoor to
Balloon Time in PPTCA
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)
16
National Trends in AMI ManagementHospital
Length of Stay
NRMI 1 NRMI 2 NRMI 3
7.5
6.8
4.6
3.5
Non-transfer-in patients
17
National Trends in AMI Management Medications
Used Within 24 Hours
NRMI 1 NRMI 2 NRMI 3
Non-transfer-in patients
18
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
19
Hospital-level Comparison Baseline
Characteristics
Adapted from Every N, et al. JACC 1999
20
Hospital-level Comparison Process of Care and
Outcomes
Adapted from Every N, et al. JACC 1999
21
Patient-level Comparison Hospital Course
Adapted from Every N, et al. JACC 1999
22
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
23
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-ball
  oon time and door-to-balloon time with mortality
  in patients undergoing angioplasty for AMI

24
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
25
Factors that Predict Time to Treatment
Age coded as (1) lt60, (2) 61-74, and (3) gt75
years of age
Maynard C, et al. Am J Cardiol 1995
26
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
27
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
28
Time to Treatment Cardiac Consultation by Gender
P .001
P .001
Lambrew CT, et al. Arch Intern Med 1997
29
Time to Treatment Bedside vs Telephone
Consultation
P .001
P .001
Lambrew CT, et al. Arch Intern Med 1997
30
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
31
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
32
Factors that Predict Use of Consultation

• Odds ratio

95 CI P value 0.825 .0001 0.890 .0001 0.928 .047
0.949 .01 0.956 .025 1.003 .0001 1.084 .04 1.088
.009 1.126 .0001 1.184 .0001 1.195 .029 1.278 .000
1 1.390 .0001 1.391 .0001

• 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 gt70 years
• LBBB
• RBBB
• Pulmonary edema
• Normal ECG

Al-Mubarak N, et al. Am J Cardiol 1999
0.5 0 1.5 2 Consultation
Less likely
More likely
33
Elapsed Door-to-drug Time After Hospital Arrival
No consultation Consultation
0 60 120
180
Al-Mubarak N, et al. Am J Cardiol 1999
34
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
35
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)
36
Odds for Mortality Associated with Longer
Door-to-drug Time
P0.0001
P0.01
PNS
n28,624 n33,867 n11,616 n10,316
Cannon et al. JACC 2000 (Abstract, Suppl A)
37
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)
38
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
39
Relationship Between Symptom-onset-to-balloon
Time Intervals and Mortality
P0.17
P0.21
P0.35
P0.65
P0.95
Adapted from Cannon CP, et al. JAMA 2000
40
Relationship between Door-to-Balloon Time
Intervals and Mortality
Plt0.001
Plt0.001
P0.01
P0.29
P0.35
Adapted from Cannon CP, et al. JAMA 2000
41
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
42
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

43
Thrombolytic Therapy Demographics
Adapted from Chandra NC et al. Arch Intern Med
1998
P lt.001
44
Mortality in Men and Women, by Age
?
Adapted from Chandra NC et al. Arch Intern Med
1998
45
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
46
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
47
Rates of Mortality During Hospitalization, by Age
P lt0.001
Vaccarino V, et al. N Engl J Med. 1999
48
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 21 greater
  risk for mortality
• Younger women with MI are a high-risk group

Vaccarino V, et al. N Engl J Med. 1999
49
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

50
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.

51
Number of Cases of AMI 1994-1996
Spencer et al. JACC 1998
52
Regional Breakout of AMI Cases by Season
Adapted from Spencer et al. JACC 1998
53
AMI Cases by Season Men and Women
Adapted from Spencer et al. JACC 1998
54
AMI Cases by Season Age Groups
Adapted from Spencer et al. JACC 1998
55
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
56
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

57
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
58
Distribution of Hospital Types (n1506) in NRMI 2
Rogers WJ, et al. J Am Coll Cardiol 2000
59
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 lt0.0001)
• 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
60
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
61
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
62
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
63
Use of Procedures by Payor Groups ()
Sada MJ, French WJ, et al. J Am Coll Cardiol 1998
64
Use of Angiography by Payor Status
Angiography
More likely
Less likely
Adapted from Sada MJ, French WJ, et al. J Am Coll
Cardiol 1998
65
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
66
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
67
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
68
In-hospital Mortality in Lytic-eligible Patients

• Mortality ()
• rt-PA PTCA
• Overall 5.4 5.2
• STE or LBBB 1st ECG 5.3 5.5
• Age lt75 yr 3.4 3.5
• Age gt75 yr 16.5 14.4
• Men 4.5 5.2
• Women 9.6 8.9
• Inferior MI 3.9 3.9
• Anterior MI 7.6 7.1
• Low risk 2.9 2.8
• Not low risk 7.5 7.4

• Odds ratio and 95 CI

0.5 0 1.5 rt-PA
better PTCA better
Tiefenbrunn AJ, et al. JACC 1998
69
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 gt75 yr 18.4 14.6
• Age lt75 yr 4.1 3.9

• Odds ratio and 95CI

0.5 0 1.5 rt-PA
better PTCA better
Tiefenbrunn AJ, et al. JACC 1998
70
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
71
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
72
NRMI Hospitals Ranked by Thrombolytic Therapy
Volume
Number of Patients Thrombolytic Volume
Quartile 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
gt45
Canto JG, et al. N Engl J Med 2000
73
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
74
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

75
Complications of MI/Safety

• Risk of intracranial hemorrhage (ICH)
• CABG

76
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
77
Risk Factors for Intracranial Hemorrhage

• A small number of patients (lt 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
78
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
79
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
80
Outcomes for Patients With or Without Prior CABG
P lt0.002 P lt0.005
Peterson LR, et al. Am J Cardiol 1999
81
Patients With Prior CABG Treated with rt-PA or
Angioplasty Differing Baseline Characteristics
P lt0.04 P lt0.0001
Peterson LR, et al. Am J Cardiol 1999
82
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
83
AMI Subgroups

• Patient eligibility
• Chest pain
• Patient populations
• Bundle branch block

84
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
85
Use of Thrombolytic Therapies in Eligible Patients
RTreperfusion therapy
Barron HV, et al. Circulation 1998
86
Use of Reperfusion Therapy
RT less likely
RT more likely

• LBBB
• No chest pain
• Age gt75
• Prior CHF
• Prior MI
• Killip III
• Women
• Caucasian
• Smoker
• Pre-hospital ECG
• Sx lt3 hrs

RTreperfusion therapy
0.2 0.4 0.6 0.8 1.0
1.2 1.4 1.6
Adapted from Barron HV, et al. Circulation 1998
87
In-hospital Mortality
RTreperfusion therapy
Adapted from Barron HV, et al. Circulation 1998
88
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
89
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
90
Major Risk Factors for Atypical Presentation in
MI
Canto JG, et al. JAMA 2000
91
Outcomes of MI for Patients Presenting With and
Without Chest Pain
92
Process of Care for AMI Patients With and Without
Chest Pain
93
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
94
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
95
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 lt0.001)
• 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
96
Patient Populations Blacks Compared to Whites

• Blacks presented much later after the onset of
  symptoms (median 145 vs 122 minutes, p lt0.001)
• 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
97
Use of Reperfusion in Non-white Ethnic Groups
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)
Black Hispanic Asian-PI Native Am
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
98
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
99
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
100
Treatments by Presence and Type of Bundle Branch
Block

P lt0.001
Go AS, et al. Ann Intern Med 1998
101
Association of Bundle Branch Block and
In-hospital Mortality
Controlled for differences in demographics and
clinical characteristics Further controlled
for differences in treatment
Go AS, et al. Ann Intern Med 1998
102
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
103
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 patterns

Barron HV, et al. J Am Coll Cardiol 1998
104
Discharge ACE Inhibitor Use by Clinical
Indication Group
Barron HV, et al. J Am Coll Cardiol 1998
105
Discharge ACE Inhibitor and Calcium Channel
Blocker Use by Time Period
Barron HV, et al. J Am Coll Cardiol 1998
106
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
107
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
108
ICH Rates and Immediate Beta-Blocker Use by Age
Barron HV, et al. Am J Cardiol 2000
109
ICH Rates and Immediate Beta-Blocker Use by Gender
Barron HV, et al. Am J Cardiol 2000
110
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
111
NRMI, JCAHO, ORYX, and Core Measures

• JCAHOs 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

112
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

113
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

114
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

115
Congratulations

• Thanks to the over 5000 investigators and
  coordinators who have made these accomplishments
  possible
• Remember,
• Together, Everyone Achieves More!