ArticlesPractice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)
Introduction
Early coronary-artery reperfusion by use of fibrinolytic agents or primary percutaneous coronary intervention lowers mortality in patients with acute myocardial infarction. Nevertheless, epidemiological studies suggest that there is great variation in the approach to reperfusion, and that some patients who seem to be eligible for reperfusion strategies do not receive them.1 For example, the National Registry of Myocardial Infarction reported that, of more than 300000 patients enrolled in the registry between 1990 and 1994, only a third received reperfusion therapy, even though half to two-thirds of these patients were probably eligible for the treatment.2 Similar findings were reported in a 1994–98 study of 772 531 patients; a quarter of those eligible did not receive any form of reperfusion therapy.1
The reasons for the underuse of reperfusion strategies in patients who can benefit from these approaches have been reported as undiagnosed acute myocardial infarction and clinicians' perceptions of contraindications.1 Most early clinical trials of reperfusion therapy excluded women3 and patients older than 70 or 75 years.4 Women have higher in-hospital death rates than men,3 and elderly patients generally have more extensive underlying coronary disease, other pre-existing cardiovascular conditions, and greater comorbidity than younger patients.5 The fear of treatment-related complications in these patients was the over-riding reason given for their exclusion from clinical trials.
Early reperfusion with primary percutaneous transluminal coronary angioplasty or fibrinolytic therapy is advocated as the standard of care by both US6 and European7 guidelines. There is still, however, much debate about the potential benefits and risks of early coronary-artery reperfusion in elderly patients.4, 8, 9, 10
The Global Registry of Acute Coronary Events (GRACE) is a continuous, multinational, observational registry of patients admitted to hospital with any acute coronary syndrome. To assess further current practices in relation to reperfusion therapy of ST-segment-elevation myocardial infarction in patients around the world, we analysed unselected data from the first 9251 patients enrolled in GRACE.
Section snippets
GRACE methods and design
Full details of the GRACE rationale and methods have been published.11 The registry is designed to reflect an unbiased population of patients with acute coronary syndromes, irrespective of geographical location. At present, 94 hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand are participating in the study. The geographic clusters were chosen to represent populations with varying demographic, clinical, and treatment characteristics. Hospital enrolment
Results
Of the 9251 patients enrolled in GRACE, 2501 (27%) were diagnosed as having myocardial infarction with ST-segment elevation. Of these, 987 (43%) received a lytic drug alone, 289 (13%) underwent percutaneous coronary intervention, and 147 (6%) received a lytic drug and underwent percutaneous coronary intervention. Among patients receiving lytic drugs, 449 (26%) were given streptokinase, 375 (21%) alteplase, 109 (6%) retaplase, and the rest another lytic drug, including those specified by a
Discussion
We found that up to a third of eligible patients presenting with ST-segment-elevation myocardial infarction within 12 h of symptom onset did not receive reperfusion therapy. The data also highlighted significant differences in the preferred type of reperfusion therapy both geographically and by hospital type.
In this study, 30% of the patients who presented within 12 h did not receive reperfusion therapy. The National Registry of Myocardial Infarction study had similar results; the proportion of
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