Elsevier

The Lancet

Volume 359, Issue 9304, 2 February 2002, Pages 373-377
The Lancet

Articles
Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)

https://doi.org/10.1016/S0140-6736(02)07595-5Get rights and content

Summary

Background

The benefits of reperfusion therapy for patients with acute coronary syndromes have been established, but there is much variation in the type of reperfusion given and decisions about which patients are eligible. This study assessed current practices in relation to reperfusion therapy of ST-segment-elevation myocardial infarction from data collected in the multinational, prospective Global Registry of Acute Coronary Events.

Methods

94 hospitals in 14 countries are recruiting patients for the registry. Hospitals are organised into population-based clusters that reflect the population characteristics of the region. Information about patients' demographic characteristics, presenting symptoms, medical history, time between symptom onset and presentation, and clinical and electrocardiographic features is recorded in a standard case record.

Findings

Of the 9251 patients enrolled, 1763 presented within 12 h of symptom onset with ST-segment-elevation myocardial infarction. Of these, 30% did not receive reperfusion therapy. Elderly patients (75 years and older), those presenting without chest pain, and those with a history of diabetes, congestive heart failure, myocardial infarction, or coronary bypass surgery were less likely to receive reperfusion therapy. The rate of primary percutaneous coronary intervention was highest in the USA and lowest in Australia, New Zealand, and Canada. The rate at sites with a catheterisation laboratory was 19% compared with zero at sites without this facility.

Interpretation

A substantial proportion of patients who are eligible for reperfusion therapy still do not receive this treatment. These typically high-risk patients can be identified in advance, and reasons for the underuse of these beneficial treatments need to be clarified.

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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