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Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction |
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| Authors: | Alter, David A. Ko, Dennis T. Newman, Alice Tu, Jack V. |
| Affiliation: | 1 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5 2 University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Canada 3 Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Science Centre, and the, University of Toronto, Canada 4 Department of Health Policy, Management, and Evaluation, University of Toronto, Canada |
| 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 burdenon the likelihood of not receiving reperfusion therapy amongST-segment elevation myocardial infarction (STEMI) patientswithout contraindications to treatment. Methods and results Retrospective population-based cohort of3994 patients admitted to 103 acute care hospitals with chestpain and STEMI within 12 h of symptom onset in Ontario,Canada, between 1999 and 2001. Patients with one or more documentedabsolute or relative contraindication (n=909) were excludedfrom the analyses. Reperfusion therapy was defined as the receiptof either fibrinolysis or primary percutaneous coronary intervention.Multivariable analysis and likelihood  2 was used to quantifythe importance of each factor in predicting the non-utilizationof therapy. In total, 23.1% of patients received no reperfusiontherapy. Listed in order from greatest to least importance,predictors of non-utilization of reperfusion therapy includedincreasing time to hospital presentation (likelihood 2 31.6,P<0.001), higher intracerebral haemorrhage risk (likelihood2 27.1, P<0.001), higher baseline cardiovascular risk (likelihood2 25.4, P<0.001), and greater number of chronic comorbidconditions (likelihood 2 15.4, P<0.001). The importance ofeach factor on non-utilization was independent, additive, notexplained by age effects alone, or driven by subgroups traditionallyunder-represented in clinical trials. Conclusion Care gaps in the use of reperfusion therapy widenwith both increasing baseline cardiovascular risk and increasingintracerebral haemorrhage risk. Future studies should examinewhether the implementation of clinical decision tools whichallow for more accurate riskbenefit tradeoff predictionsimprove the treatment gaps when using life-saving therapiesin this patient population. |
| Keywords: | Reperfusion therapy ST-segment elevation acute myocardial infarction Utilization |
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