JAMA: Evidence-based procedures for MI cut mortality

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When evidence-based invasive procedures and drug therapy are utilized during MI treatment, the rates of death at 30 days and one year decrease, according to an analysis of a Swedish coronary care registry published in the April 27 issue of the Journal of the American Medical Association.

Tomas Jernberg, MD, PhD, of the Karolinska University Hospital in Stockholm, Sweden, and colleagues used the Swedish care registry between 1996 and 2007 to evaluate the short-term and long-term benefits of STEMI treatments in 61,238 patients with a first-time STEMI diagnosis.

“Over the years, several generations of international and national guidelines have been presented to support the implementation of these evidence-based treatments in clinical practice,” the authors wrote. “However, only limited information is available on the speed of implementation of these new treatment strategies and its association with long-term survival in real-life healthcare.”

The researchers studied patients treated with the different medications and invasive procedures and mortality rates over the 12-year period.

The researchers found evidence-based in-hospital treatments—reperfusion treatment including thrombolysis or primary PCI—increased from 66 percent to 79 percent during the study period and primary PCI increased from 12 percent to 61 percent. Additionally, the researchers found that revascularizations—either PCI or bypass surgery—within 14 days increased from 10 percent to 84 percent and use of glycoprotein IIb/IIIa inhibitors increased from 0 percent to 55 percent.

The use of aspirin, clopidogrel, beta-blockers, statins, ACE inhibitors or ARBs increased during the study period. In fact, the use of clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis) increased from 0 percent in 1996 to 82 percent in 2007 while the use of statins also rose from 23 percent to 83 percent. Use of ACE inhibitors or ARBs increased from 39 percent to 69 percent and statin use also increased 60 percent, from 23 percent to 83 percent.

During the 12-year span, the researchers reported that in-hospital, 30-day and one-year mortality rates decreased from 12.5 percent to 7.2 percent, 15 percent to 8.6 percent and from 21 percent to 13.3 percent, respectively.

Additionally, the number of patients who experienced a new MI during hospitalization decreased from 4 percent in 1996 to 1 percent in 2007.

“The initial large variation in treatments between hospitals gradually decreased with an increase in equality of care over time. The second finding is that this increase in adherence to treatment guidelines is associated with a gradual lowering of both short- and long-term mortality, which could not be explained by changes in baseline characteristics,” the authors concluded.

The authors noted that the implementation of new treatments differed significantly between hospitals. "Variations in treatment
and deviations from guideline recommendations have negative effects on mortality and morbidity," the authors wrote. "Therefore,
identification of undue variations in the processes of care and highlighting areas of need for quality improvement programs are important tasks for the quality registries in health care," the authors concluded.

In an accompanying editorial, Debabrata Mukherjee, MD, of the Texas Tech University Health Sciences Center in El Paso wrote that Jernberg et al uncovered an opportunity to improve the quality of care to STEMI patients “by decreasing the lab time for adoption of life-saving therapies and improving adherence to evidence-based care across hospitals.”

However, Mukherjee wrote that implementing these types of strategies is difficult and adoption is slow. “Successful training of clinicians in implementing new therapies requires a balance of both didactic training, defined as the methods used for information transfer such as written materials, lectures and workshops, and competence training, defined as the process of acquiring skills necessary to administer a treatment skillfully and with fidelity,” concluded Mukherjee.