European Heart Journal Advance Access originally published online on June 7, 2006
European Heart Journal 2006 27(13):1513-1514; doi:10.1093/eurheartj/ehl007
Gaps in myocardial infarction care: how might we best EFFECT change?
Department of Cardiovascular Medicine/F25, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
* Corresponding author: Tel: +1 216 445 4042; fax: +1 216 445 8531. E-mail address: bhattd{at}ccf.org
This editorial refers to ‘Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction’
by D.A. Alter et al., on page 1539
Despite medical advances, coronary artery disease continues to burden us. Millions worldwide have a myocardial infarction each year, and millions suffer the ravages of atherosclerosis: stable and unstable angina, congestive heart failure, and sudden cardiac death. Combating this plague has always required attention to research—biology of atherosclerosis, drug development, clinical trials—and attention to implementation—access to care, guideline dissemination, and treatment standardization.
The story of ST-elevation myocardial infarction (STEMI) illustrates the difficulty of doing this. The science has been, in relative terms, easy. Investigators have steadily progressed from using aspirin to administering thrombolytics and to employing primary percutaneous intervention; these advances, along with adjunctive therapy such as beta-blockers and ACE-inhibitors, have decreased 30-day mortality in clinical trials to an impressive 5–6%.
Unfortunately, translating these findings into practice has not been so easy. For example, trials have consistently shown importance of time from symptom onset to time to treatment in reducing STEMI mortality, yet numerous obstacles persist. Despite public education campaigns to activate the emergency medical system when symptoms of a heart attack arise, up to 50% of patients with STEMI do not call 9-1-1, but instead transport themselves.1 The medical system fares no better; despite guidelines for a door-to-balloon time of 90 min with primary percutaneous intervention, the majority of STEMI patients do not reach these targets.2 Most disturbingly, an important percentage of STEMI patients eligible for reperfusion therapy (either thrombolysis or percutaneous intervention) do not receive it.3
Alter et al.4 examine reasons for this gap. These investigators analysed data from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) project, a database of myocardial infarction patients hospitalized between 1999 and 2001 in Ontario, Canada. They reviewed data for STEMI patients who received thrombolytics, determining how many patients had neither absolute nor relative contraindications to fibrinolysis. Furthermore, they determined the number of comorbidities, calculated the risk of 30-day mortality by the Thrombolysis in Myocardial Infarction (TIMI) mortality risk index, and calculated the intracerebral haemorrhage risk. Finally, they performed a multivariate analysis for the non-use of reperfusion in ‘ideal’ candidates (no absolute or relative contraindications), using age, gender, time to presentation, number of comorbid conditions, intracerebral haemorrhage risk, and mortality risk index.
The authors should be commended for this sophisticated analysis. Prior studies identified only simple variables: age, gender, ethnicity, and so on, as determinants of reperfusion under-use, leading to the question, ‘OK, now what?’ The authors' analysis, however, included complex factors—risk indices—and the results lead to possible answers.
Foremost, the authors confirm that a substantial percentage of eligible patients, 23% in this study, do not receive reperfusion therapy. Next, the investigators found four independent predictors of non-use (in the order of importance): time to presentation, intracerebral bleeding risk, mortality risk, and comorbid conditions. Interestingly, these factors were additive and remained independent determinants when the analysis was performed excluding patients presenting after 6 h of symptom onset and patients aged 75 years or more.
This last point merits emphasis; that is, undertreatment was not driven by poor candidates: those who are very old and presenting late. For example, an 85-year-old patient presenting 11 h after the onset of chest pain with an inferior STEMI might not meet any relative or absolute contraindications, but would, nonetheless, be a poor candidate for thrombolysis, and it might be reasonable to withhold therapy. If these types of patients accounted for most of the under-treatment, then the analysis would be misleading. The authors prove otherwise, and the four factors remained independent predictors in all age groups except for the youngest (age less than 60).
One factor, intracerebral bleeding risk, represents an entirely rational reason why a physician might withhold treatment. For instance, if that same 85-year-old patient has >5% risk of intracerebral bleeding, a catastrophic complication, it would be reasonable to withhold care if the benefits are marginal.
How, then, do we decide when benefits are marginal and not worth the risk of intracerebral haemorrhage? This is tricky because like intracerebral bleeding risk, mortality risk is an independent predictor of under-use. Therefore, increasing bleeding risk predicts under-use, but a higher mortality risk also predicts under-use despite the fact that patients with higher mortality risks receive more absolute benefit from therapy. This ‘treatment paradox’ occurs because physicians face a difficult dilemma: the same patient factors that increase cardiovascular risk (thus benefit of therapy) also tend to increase haemorrhage risk (thus harm of therapy). The authors' diagnosis of this problem suggests a treatment: decision analysis.
Widely used in cost-effectiveness research, decision analysis is a useful tool in helping to decide between several alternatives when there are competing risks and benefits that change depending on the patient's profile. Because the benefit of thrombolysis has been clearly defined in a variety of subgroups (e.g. patients with anterior STEMI benefit more than patients with inferior STEMI), it is possible to calculate expected benefit (absolute reduction in mortality or re-infarction) versus expected harm (absolute increase in intracerebral bleeding). Furthermore, given widespread availability of personal digital assistants and advanced software, it is reasonable to imagine physicians utilizing these types of tools at the bedside.
Employing this strategy is vital because, as the authors correctly point out, absolute risks of life-saving treatments, such as thrombolysis, rarely exceed benefits in patients with high cardiovascular risk. Despite this, treatment gaps do exist because physicians perceive absolute risks to be higher than benefits in many such patients. A readily available decision analysis might correct this ‘eyeball’ impression with hard numbers.
Thus, Alter et al. have produced an exceptionally important study that helps us tackle our persistent failure in implementation. Obviously, evidence-based medications and procedures will only meet our expectations if they are administered in a timely fashion or, indeed, are administered at all. By showing us that gaps in care exist because of gaps in perception, these investigators point a way out. Now, more research needs to continue on the science of implementation.
This science has broader implications because many other cardiovascular patients (e.g. patients with non-ST-elevation acute coronary syndromes, with heart failure, or with stable cardiovascular disease) often do not receive indicated care.5–7 These gaps in care need not be immutable and insurmountable, but should serve as reminders that our clinical success does not stop with the completion of a clinical trial, but with the completion of a patient's care. Only then will we see the desired effect of projects like EFFECT.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehl066 
References
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[Abstract/Free Full Text] - Eagle KA, Goodman SG, Avezum A, Budaj A, Sullivan CM, Lopez-Sendon J. (2002) Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 359:373–377.[CrossRef][Web of Science][Medline]
- Alter DA, Ko DT, Newman A, Tu JV. (2006) Factors explaining the under-use of reperfusion among ideal patients with ST-segment elevation myocardial infarction. Eur Heart J 27:1539–1549 First published on June 7, 2006, doi:10.1093/eurheartj/ehl066.
[Abstract/Free Full Text] - Bhatt DL, Roe MT, Peterson ED, Li Y, Chen AY, Harrington RA, Greenbaum AB, Berger PB, Cannon CP, Cohen DJ, Gibson CM, Saucedo JF, Kleiman NS, Hochman JS, Boden WE, Brindis RG, Peacock WF, Smith SC Jr, Pollack CV Jr, Gibler WB, Ohman EM. CRUSADE Investigators. (2004) Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 292:2096–2104.
[Abstract/Free Full Text] - Lee DS, Tu JV, Juurlink DN, Alter DA, Ko DT, Austin PC, Chong A, Stukel TA, Levy D, Laupacis A. (2005) Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA 294:1240–1247.
[Abstract/Free Full Text] - Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, Goto S, Liau CS, Richard AJ, Rother J, Wilson PW. REACH Registry Investigators. (2006) International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA 295:180–189.
[Abstract/Free Full Text]
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Related articles in EHJ:
- Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction
- David A. Alter, Dennis T. Ko, Alice Newman, and Jack V. Tu
EHJ 2006 27: 1539-1549.[Abstract] [FREE Full Text]
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