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

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 Elevation Myocardial Infarction:

  • 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 Elevation Myocardial Infarction:

  • 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 Elevation Myocardial Infarction:

  • 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 Elevation Myocardial Infarction:

  • 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 Elevation Myocardial Infarction:

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 Elevation Myocardial Infarction:

All patients Patients presenting < 12 hours

No Reperfusion

31%

No Reperfusion

25%

Primary

PCI

10%

Primary

PCI

9%

Fibrinolysis

60%

Fibrinolysis

65%


Baseline characteristics
Baseline Characteristics Elevation Myocardial Infarction:

All Patients Fibrinolysis Primary PCI No Reperfusion p-value

Age 63.413.9 61.9 12.6 61.211.5 67.0 13.9 0.0001

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 Elevation Myocardial Infarction:

treated with fibrinolytic therapy

% of Patients


Cannon cp et al crit path cardiol 2002 1 44 52

Door- to- balloon times for patients Elevation Myocardial Infarction:

treated with Primary PTCA

% of Patients


Contraindications to fibrinolysis
“Contraindications” to Fibrinolysis Elevation Myocardial Infarction:

Fibrinolysis Prim. PCI No Reperf

Prior stroke/TIA 0.6% 2.6% 4.6%

Recent CPR,

trauma or surgery 0.8% 15.2% 12.7%

Recent Bleeding 0.2% 3.8% 10.4%

Persistent HTN 6.0% 13.9% 8.1%

Significant illness 10.3% 39.5% 42.1%


Gender differences in initial treatment strategy
Gender differences in initial treatment strategy Elevation Myocardial Infarction:

p=0.153


Medications in 1st 24 hours
Medications in 1st 24 hours Elevation Myocardial Infarction:

Overall Fibrinolysis Primary PCI No 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 Elevation Myocardial Infarction:

%

3 way p<0.001

% of Patients

%

%

n= 79

n=259

n=505


In hospital outcomes
In-hospital outcomes Elevation Myocardial Infarction:

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 Elevation Myocardial Infarction:

  • 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