Underutilization of evidence-based medications in  Acute ST Elevation Myocardial Infarction:
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Underutilization of evidence-based medications in Acute ST Elevation Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry.

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Cannon CP et al. Crit Path Cardiol 2002;1:44-52.

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Cannon cp et al crit path cardiol 2002 1 44 52

Underutilization of evidence-based medications in Acute ST Elevation Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry

Christopher P. Cannon, MD * , Maria Cecilia Bahit, MD *, J. Mark Haugland §, MD , Timothy D. Henry †, MD, Marc J. Schweiger ‡, MD, George R. McKendall ¥, MD, Prediman K. Shah **, MD, Sabina Murphy ***,MPH, C.Michael Gibson***, Carolyn H. McCabe*, BS. Elliott M. Antman *, MD, Eugene Braunwald *, MD, for the TIMI 9 Registry Investigators

Cannon CP et al. Crit Path Cardiol 2002;1:44-52.


Background

Background

  • Reperfusion therapy with fibrinolysis or primary angioplasty has proven to be a major advance in the treatment of acute myocardial infarction.

  • However,reports from studies in the 1980's and recent reports based on data from national registries have suggested that only one third of patients with acute MI receive thrombolytic therapy in North America.


Background1

Background

  • Fibrinolytic therapy is beneficial only in patients with ST segment elevation (or new left bundle branch block) presenting <12 hours, and is potentially harmful in patients without ST elevation .

  • It is unclear what proportion of patientswith indications for reperfusion therapy are receiving thrombolytic therapy or primary percutaneous coronary intervention (PCI). In addition, the management and outcome of patients not treated with reperfusion therapy is poorly characterized.


Objectives

Objectives

  • Assess management strategies and the outcomes of patients with acute MI presenting with ST elevation myocardial infarction (STEMI) in the current era of aggressive reperfusion therapy.


Methods

Methods

  • All consecutive patients seen in the E.D and/ or admitted with the diagnosis of acute MI were prospectively screened.

  • Inclusion criteria:

    • ST elevation  0.1 mV in 2 or more leads

    • New or presumably new LBBB

  • Exclusion criteria:

    • None

  • Patient demgraphics, medical treatment , in-hospital outcome prospectively collected


Results

Results

TIMI 9 Registry

n=840 consecutive

patients acute STEMI/ LBBB

20 Hospitals in US and Canada

1994

Primary PCI

n=76

No Reperfusion

n=276

Fibrinolysis

n=505

51%

TIMI 9 Trial


Initial treatment strategy in stemi

Initial treatment strategy in STEMI

All patientsPatients presenting < 12 hours

No Reperfusion

31%

No Reperfusion

25%

Primary

PCI

10%

Primary

PCI

9%

Fibrinolysis

60%

Fibrinolysis

65%


Baseline characteristics

Baseline Characteristics

All PatientsFibrinolysisPrimary PCINo Reperfusionp-value

Age 63.413.961.9 12.661.211.567.0 13.90.0001

Female 33% 30% 24% 42%0.001

White 86% 87% 85% 86%0.38

Prior MI 26% 17% 21% 26%0.12

Prior

angina 27% 26% 30% 28%0.73

Prior PCI 7% 6% 19% 7%0.001

Prior

CABG 7% 7% 5% 7%0.80

Prior CHF 6% 3% 4% 13%0.001

Killip

I 80% 83% 81% 71%

II 15% 13% 12% 19%

III 4% 3% 0% 6%

IV 2% 1% 7% 3%0.001


Cannon cp et al crit path cardiol 2002 1 44 52

Door- to-drug times for patients

treated with fibrinolytic therapy

% of Patients


Cannon cp et al crit path cardiol 2002 1 44 52

Door- to- balloon times for patients

treated with Primary PTCA

% of Patients


Contraindications to fibrinolysis

“Contraindications” to Fibrinolysis

FibrinolysisPrim. PCINo Reperf

Prior stroke/TIA0.6%2.6%4.6%

Recent CPR,

trauma or surgery0.8%15.2%12.7%

Recent Bleeding0.2%3.8%10.4%

Persistent HTN6.0%13.9%8.1%

Significant illness10.3%39.5%42.1%


Gender differences in initial treatment strategy

Gender differences in initial treatment strategy

p=0.153


Medications in 1st 24 hours

Medications in 1st 24 hours

OverallFibrinolysisPrimary PCINo Reperfusion p

Aspirin 87%93%93%72%0.001

Heparin 91%98%100%74%0.001

Beta

blockers 61%71%57%43%0.001

ACE-I 13%13%7% 14%0.22

Calcium

Channel

Blockers 13%10%18%17%0.003


Cannon cp et al crit path cardiol 2002 1 44 52

In-Hospital Mortality

%

3 way p<0.001

% of Patients

%

%

n= 79

n=259

n=505


In hospital outcomes

In-hospital outcomes

Overall Lysis 1o PCI No Rep.Rx p

Re-MI 8.1% 10.4% 5.5% 4.3%0.01

Card

shock 7.4%5.6% 13.5% 9.3%0.02

Mild/Mod

CHF 22.6% 20.6% 20.8%25.1%0.45

ICH 0.2% 0.2% 0% 0.4%0.80

Major

Bleed 5.8% 8.3% 2.9%1.6% 0.001


Timi 9 registry conclusions

TIMI 9 Registry: Conclusions

  • Reperfusion therapy underutilized – 1/3 STEMI failed to receive reperfusion Rx

  • Door to drug and door to balloon times remain suboptimal

  • There is potential to increase the use of other effective medications (e.g., ASA, B-blockers)

  • Efforts need to continue to expand the use of guideline-recommended therapies to all appropriate STEMI patients


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