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European Heart Journal Advance Access published online on June 7, 2006
European Heart Journal, doi:10.1093/eurheartj/ehl066
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European Heart Journal © The European Society of Cardiology 2006; all rights reserved
Received January 26, 2006
Revised May 1, 2006
Accepted May 12, 2006

Clinical research

Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction

David A. Alter 1 *, Dennis T. Ko 2, Alice Newman 3, and Jack V. Tu 4

1 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5; University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Canada; Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Science Centre, and the University of Toronto, Canada; Department of Health Policy, Management, and Evaluation, University of Toronto, Canada
2 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5; University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Canada; Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Science Centre, and the University of Toronto, Canada
3 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5
4 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5; University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Canada; Department of Health Policy, Management, and Evaluation, University of Toronto, Canada

* To whom correspondence should be addressed.
David A. Alter, E-mail: david.alter{at}ices.on.ca


  Abstract

Aims To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment.

Methods and results Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication (n=909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood {chi}2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood {chi}2 31.6, P<0.001), higher intracerebral haemorrhage risk (likelihood {chi}2 27.1, P<0.001), higher baseline cardiovascular risk (likelihood {chi}2 25.4, P<0.001), and greater number of chronic comorbid conditions (likelihood {chi}2 15.4, P<0.001). The importance of each factor on non-utilization was independent, additive, not explained by age effects alone, or driven by subgroups traditionally under-represented in clinical trials.

Conclusion Care gaps in the use of reperfusion therapy widen with both increasing baseline cardiovascular risk and increasing intracerebral haemorrhage risk. Future studies should examine whether the implementation of clinical decision tools which allow for more accurate risk-benefit tradeoff predictions improve the treatment gaps when using life-saving therapies in this patient population.

Keywords: Reperfusion therapy; ST-segment elevation acute myocardial infarction; Utilization.
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