Up to a third of patients with a severe heart attack may not be receiving reperfusion therapy, despite the well-known benefits of this treatment strategy, conclude authors of an international study in this week’s issue of THE LANCET.
The benefits of reperfusion therapy- the use of fibrinolytic agents and/or coronary angioplasty to restore coronary artery bloodflow -for patients with acute coronary syndromes have been established, but there is variation in the type of reperfusion given and in decisions about which patients are eligible for such therapy. Kim Eagle from the University of Michigan Medical Center, USA, and colleagues assessed current practices in relation to reperfusion therapy in patients with a specific heart-attack profile called ST-segment-elevation myocardial infarction using data from the multinational, prospective Global Registry of Acute Coronary Events (GRACE). This registry includes data for patients with acute coronary syndromes from 94 hospitals in 14 countries.
The investigators assessed data of the first 9251 patients enrolled in GRACE; of these, 1763 presented within 12 hours of symptom onset with ST-segment-elevation myocardial infarction, 30% of whom 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 (17%) and lowest in Australia, New Zealand, and Canada (1%). The rate at sites with a catheterisation laboratory was 19%.
Kim Eagle comments: “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.”
He concludes: “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. The fact that physicians and hospitals are partnering to improve heart attack care around the world through GRACE demonstrates how, by working together, we can make a difference.” (latter quote by e-mail; does not appear in published paper).
Paul Armstrong from the University of Alberta, Edmonton, Canada, concludes in an accompanying Commentary (p 371): "Future progress is likely to emerge from better application of clear treatment guidelines that are readily available at the point of care and that incorporate the risk-to-benefit ratio of treatment for individual patients."
Contact: Professor Kim Eagle, University of Michigan Medical Center,1500 East Medical Center Drive,3119 Taubman Center,Ann Arbor,MI 481090374,USA;T)+1 734 936 5275;F)+1 734 764 4119;E) keagle@med.umich.edu
Dr Paul W Armstrong, Department of Medicine, University of Alberta, Edmonton, Alberta T6G 2H7, Canada; E) paul.armstrong@ualberta.ca
Journal
The Lancet