Introduction The management of patients with ST-elevation myocardial infarction (STEMI) involves a number of evidence-based therapies. However, all recommended opportunities for care may not be achieved during the hospital stay. We quantified the missed opportunities for hospitals to provide care and investigated the impact of this on 30-day and 6-month mortality.
Methods We studied 54 118 patients discharged alive from hospital with STEMI between 1 January 2008 and 31 December 2009 from 196 NHS hospitals participating in the Myocardial Ischaemia National Audit Project (MINAP). A composite score of missed opportunities for care including the prescription of aspirin, thienopyridine inhibitor, β-blocker, ACE inhibitor, HMG CoA reductase enzyme inhibitor at discharge from hospitals, enrolment in cardiac rehabilitation and timely reperfusion (call-to-needle/balloon time ≤60/150 min) was aggregated for each hospital. The impact on 30-day and 6-month mortality was studied by hospital quartile of missed opportunities for care (Q1–Q4).
Results Of the 31 052 with complete data, mean (SD) age was 64.9 (13.5) years and 28% were female (table 1). The proportion of missed opportunities for care was low (median 7.8%, range 0–19.6%). Crude mortality increased by hospital quartile of missed opportunities for care (Q1–Q4: 30-day 1.30–2.15%; 6-month 3.44–4.86%, respectively) (figure 1). After adjustment for mini-GRACE variables, the significant positive association with increasing missed opportunities for care was upheld for 30-day and 6-month mortality (OR 1.06, 95% CI 1.03 to 1.10 and 1.05, 1.03 to 1.07, respectively).
Conclusions Overall a high proportion of opportunities for evidence-based care for STEMI were achieved. However, missed opportunities were significantly associated with early and longer term mortality. There are, therefore, substantial opportunities to improve outcomes in patients hospitalised with STEMI in England and Wales.