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European Heart Journal 1998 19(12):1784-1794; doi:10.1053/euhj.1998.1236
Copyright © 1998 by the European Society of Cardiology.
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Epidemiology of post-infarction risk stratification strategies in a country with a low volume of revascularization procedures. The GISSI Prognosis Registry

A.P. Maggioniabf1, L. Tavazzic, G. Fabbria, D. Luccia, E. Santorob, A. Canonicod, M. Gallie, F. Achillif and G. Tognonib

a ANMCO Research Center, Milan
b Istituto di Ricerche Farmacologiche Mario Negri, Milan
f Division of Cardiology, Ospedale San Gerardo, Monza
c Division of Cardiology, Policlinico S. Matteo, Pavia
d Division of Cardiology, Ospedale Cervello, Palermo
e Division of Cardiology, Fondazione Maugeri, Veruno, Italy

accepted July 12, 1998

Aims

The aims of the GISSI Prognosis Registry were to describe the diagnostic strategies initiated in acute myocardial infarction patients by a representative sample of Italian cardiological centres, and to determine which clinical or hospital characteristics were associated with the initiation of invasive diagnostic or therapeutic procedures.

Methods and Results

Baseline characteristics, major in-hospital events and the indication and results of invasive and non-invasive procedures were collected on 1489 acute myocardial infarction patients discharged alive from 65 Italian cardiological centres over a period of 3 months. Twenty-five percent of centres had on site catheterization laboratories while the rest did not. Statistical significance was analysed by chi-square tests for categorical variables. A two-sample Student t-test was used to compare continuous variables. The adjusted analysis was performed utilizing multiple logistic regression models.

The most performed procedures were standard, non-invasive: 57·8% of the patients underwent an exercise stress test, 70·8% ambulatory ECG monitoring and 95·6% two-dimensional echocardiography. Nuclear or echocardiographic imaging tests were performed in 40% of acute myocardial infarction survivors. Overall, coronary angio-graphy was planned in 549 patients (36·9%). Variables independently associated with the indication for coronary angiography were residual ischaemia, younger age, contraindication to exercise stress testing, level of patients’ education, higher volume of non-invasive diagnostic tests, and male sex. Overall, during a 6-month follow-up period, coronary angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass surgery were performed, respectively in 35%, 10% and 8% of the study population.

Conclusions

The setting where cardiologists practise determines the patterns of care in acute myocardial infarction patients more than the characteristics of the patient. The absence of evidence-based guidelines on the more complex and expensive procedures favour empirical attitudes and practices. The confirmation in a prospective cohort of patients, which aims to represent the care of a whole country, suggests that more effort should be given to the implementation of controlled studies rather than periodical reformulation of guidelines not supported by hard data.

Key Words: Myocardial infarction • risk stratification • prognosis • epidemiology

f1 Correspondence: Aldo Pietro Maggioni, MD, GISSI-Prognosis Coordinating Center, Via La Marmora 34, 50121, Firenze, Italy.


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