No reperfusion therapy for 30% of MI patients
No reperfusion therapy for 30% of MI patients
Thu, 31 Jan 2002 23:30:00
Ann Arbor, MI - Almost a third of patients with ST-elevation MI who are eligible for reperfusion treatment are not receiving it, according to preliminary results from the Global Registry of Acute Coronary Events (GRACE). This "treatment gap" is much more important than the cardiology community's ongoing debate about whether percutaneous coronary intervention or drug therapy is the better option for achieving reperfusion, the study authors say. The study appears in the February 2, 2001 issue of the Lancet.
Led by Dr Kim A Eagle (University Hospital, Ann Arbor, MI), the GRACE researchers report the results from the first 9000 patients enrolled in the registry in this week's Lancet. As well as identifying the treatment gap, they found that certain clinical subgroups were particularly unlikely to receive reperfusion therapy, including the elderly, those with diabetes and patients with congestive heart failure (CHF).
"We hope that the perspectives from GRACE will provide impetus for the development of early recognition strategies and optimization of treatment protocols for patients with ST-segment-elevation MI and, in particular, for those in subsets that are particularly unlikely to receive reperfusion therapy at present," the researchers say.
Geographic differences in type of reperfusion therapy employed
GRACE has been running since April 1999, and spans 94 hospitals in 14 countries across the world. It plans to accumulate data on 10000 patients, each followed for 6 months, over a period of 5 years. The project is sponsored by Aventis, but the data is collected and handled by the Center for Disease Outcomes Research in the US. The results from the first 9251 patients enrolled are reported in the Lancet; of these, 1763 presented within 12 hours of symptom onset with ST-segment-elevation MI and were therefore eligible for reperfusion. There were substantial geographic differences in the type of reperfusion strategy used (see Table 1) but overall 30% (range 28-33%) of patients did not receive any reperfusion therapy.
Percentages of patients receiving reperfusion therapy in different regions
*Single chi squared test, p<0.0001 for each four-by-four table
Among patients receiving lytic drugs 26% were given streptokinase, 21% alteplase, 6% reteplase and the remainder another lytic, including those specified by a clinical trial protocol in 5% of cases.
The groups who were less likely to receive reperfusion therapy included those aged 75 and over, women, patients presenting without chest pain but with some other symptom, diabetics, those with a history of CHF or MI, and patients who had previously undergone bypass surgery. Neither hospital characteristics nor geographical region were associated with the lack of reperfusion therapy in these groups in a multivariate logistic regression analysis. The odds ratio of not receiving reperfusion therapy after adjustment was significant for the groups listed in table 2:
Mutivariate correlates of failure to receive reperfusion therapy
Although they noted that the data highlight differences in reperfusion strategies between types of hospital and geographic regions, Eagle and colleagues say the much more important finding is that "nearly a third of patients who seem to be eligible for any type of reperfusion therapy did not receive it. The opportunity to provide reperfusion to a larger proportion of patients worldwide represents a far greater health issue than attempts to tease out small differences that may exist among populations treated with percutaneous coronary interventions versus drug therapy."
Absolute benefits of therapy in the undertreated may be greater
With regard to the subgroups, the researchers say their findings are particularly important, because, often, patients such as these are at higher risk of death than the average MI patient, so "the absolute benefits of reperfusion therapy could be greater than those in the general population." They suggest that undertreatment in these groups may be due to fear of the risks involved; for example, "there is general agreement that the risks of reperfusion therapy are greater in an elderly population" they note, although "studies suggest that elderly people tend to derive a benefit equal to, if not greater, than that obtained by younger patients."
Eagle says, "Further studies are needed to clarify which treatment options are most suitable for elderly patients; for other subgroups, a more aggressive approach to earlier identification of high-risk patients suitable for reperfusion therapy is required."
Study has limitations but message is "important and familiar"
The GRACE researchers note that methods used in their collection of data "are subject to several problems that could restrict the ability to generalize the study findings," such as the fact that neither Asia nor Africa are represented in the study. In an accompanying commentary, Dr Paul W Armstrong (University of Alberta, Edmonton, AB) also lists five caveats of the study that he says "require reflection."
However, Armstrong notes the "important and familiar message" of the report, and that its strengths "are its attempts to provide a denominator from representative geographic clusters...in the hope of improving the accuracy of characterizing prescribing patterns." He says there are "three strong bases for re-assessing where and how best to deliver therapy." First, the inability of community educational interventions to modify patient's arrival times; second, the advent of new and simpler bolus forms of pharmacological therapy ("because fibrinolysis is likely to remain the dominant reperfusion therapy globally for the foreseeable future"); and third, the emergence of computer-based algorithms facilitating therapy by well-trained paramedical personnel.
Ann Arbor, MI - Almost a third of patients with ST-elevation MI who are eligible for reperfusion treatment are not receiving it, according to preliminary results from the Global Registry of Acute Coronary Events (GRACE). This "treatment gap" is much more important than the cardiology community's ongoing debate about whether percutaneous coronary intervention or drug therapy is the better option for achieving reperfusion, the study authors say. The study appears in the February 2, 2001 issue of the Lancet.
Led by Dr Kim A Eagle (University Hospital, Ann Arbor, MI), the GRACE researchers report the results from the first 9000 patients enrolled in the registry in this week's Lancet. As well as identifying the treatment gap, they found that certain clinical subgroups were particularly unlikely to receive reperfusion therapy, including the elderly, those with diabetes and patients with congestive heart failure (CHF).
"We hope that the perspectives from GRACE will provide impetus for the development of early recognition strategies and optimization of treatment protocols for patients with ST-segment-elevation MI and, in particular, for those in subsets that are particularly unlikely to receive reperfusion therapy at present," the researchers say.
Geographic differences in type of reperfusion therapy employed
GRACE has been running since April 1999, and spans 94 hospitals in 14 countries across the world. It plans to accumulate data on 10000 patients, each followed for 6 months, over a period of 5 years. The project is sponsored by Aventis, but the data is collected and handled by the Center for Disease Outcomes Research in the US. The results from the first 9251 patients enrolled are reported in the Lancet; of these, 1763 presented within 12 hours of symptom onset with ST-segment-elevation MI and were therefore eligible for reperfusion. There were substantial geographic differences in the type of reperfusion strategy used (see Table 1) but overall 30% (range 28-33%) of patients did not receive any reperfusion therapy.
Percentages of patients receiving reperfusion therapy in different regions
Therapy |
Australia, Canada & New Zealand (n=269) |
USA (n=327) |
Argentina & Brazil (n=339) |
Europe (n=739) |
| 1.1 |
17.7 |
13.9 |
16.2 |
|
| 66.9 |
30.6 |
53.1 |
49.4 |
|
| 2.2 |
18.7 |
5.0 |
4.9 |
Among patients receiving lytic drugs 26% were given streptokinase, 21% alteplase, 6% reteplase and the remainder another lytic, including those specified by a clinical trial protocol in 5% of cases.
The groups who were less likely to receive reperfusion therapy included those aged 75 and over, women, patients presenting without chest pain but with some other symptom, diabetics, those with a history of CHF or MI, and patients who had previously undergone bypass surgery. Neither hospital characteristics nor geographical region were associated with the lack of reperfusion therapy in these groups in a multivariate logistic regression analysis. The odds ratio of not receiving reperfusion therapy after adjustment was significant for the groups listed in table 2:
Mutivariate correlates of failure to receive reperfusion therapy
Variable |
Odds Ratio (95% CI) |
| 2.28 (1.35-3.87) |
|
| 1.46 (1.11-1.94) |
|
| 2.92 (1.84-4.67) |
|
| 3.23 (2.13-4.89) |
Although they noted that the data highlight differences in reperfusion strategies between types of hospital and geographic regions, Eagle and colleagues say the much more important finding is that "nearly a third of patients who seem to be eligible for any type of reperfusion therapy did not receive it. The opportunity to provide reperfusion to a larger proportion of patients worldwide represents a far greater health issue than attempts to tease out small differences that may exist among populations treated with percutaneous coronary interventions versus drug therapy."
Absolute benefits of therapy in the undertreated may be greater
With regard to the subgroups, the researchers say their findings are particularly important, because, often, patients such as these are at higher risk of death than the average MI patient, so "the absolute benefits of reperfusion therapy could be greater than those in the general population." They suggest that undertreatment in these groups may be due to fear of the risks involved; for example, "there is general agreement that the risks of reperfusion therapy are greater in an elderly population" they note, although "studies suggest that elderly people tend to derive a benefit equal to, if not greater, than that obtained by younger patients."
Eagle says, "Further studies are needed to clarify which treatment options are most suitable for elderly patients; for other subgroups, a more aggressive approach to earlier identification of high-risk patients suitable for reperfusion therapy is required."
Study has limitations but message is "important and familiar"
The GRACE researchers note that methods used in their collection of data "are subject to several problems that could restrict the ability to generalize the study findings," such as the fact that neither Asia nor Africa are represented in the study. In an accompanying commentary, Dr Paul W Armstrong (University of Alberta, Edmonton, AB) also lists five caveats of the study that he says "require reflection."
However, Armstrong notes the "important and familiar message" of the report, and that its strengths "are its attempts to provide a denominator from representative geographic clusters...in the hope of improving the accuracy of characterizing prescribing patterns." He says there are "three strong bases for re-assessing where and how best to deliver therapy." First, the inability of community educational interventions to modify patient's arrival times; second, the advent of new and simpler bolus forms of pharmacological therapy ("because fibrinolysis is likely to remain the dominant reperfusion therapy globally for the foreseeable future"); and third, the emergence of computer-based algorithms facilitating therapy by well-trained paramedical personnel.
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