Clinical Research
Myocardial Infarction
Changes in Myocardial Infarction Guideline Adherence as a Function of Patient Risk: An End to Paradoxical Care?

https://doi.org/10.1016/j.jacc.2011.06.050Get rights and content
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Objectives

The goals of this analysis were to determine: 1) whether guideline-based care during hospitalization for a myocardial infarction (MI) varied as a function of patients' baseline risk; and 2) whether temporal improvements in guideline adherence occurred in all risk groups.

Background

Guideline-based care of patients with MI improves outcomes, especially among those at higher risk. Previous studies suggest that this group is paradoxically less likely to receive guideline-based care (risk–treatment mismatch).

Methods

A total of 112,848 patients with MI were enrolled at 279 hospitals participating in Get With The Guidelines–Coronary Artery Disease (GWTG–CAD) between August 2000 and December 2008. We developed and validated an in-hospital mortality model (C-statistic: 0.75) to stratify patients into risk tertiles: low (0% to 3%), intermediate (3% to 6.5%), and high (>6.5%). Use of guideline-based care and temporal trends were examined.

Results

High-risk patients were significantly less likely to receive aspirin, beta-blockers, angiotensin-converting inhibitors/angiotensin receptor blockers, statins, diabetic treatment, smoking cessation advice, or cardiac rehabilitation referral at discharge compared with those at lower risk (all p < 0.0001). However, use of guideline-recommended therapies increased significantly in all risk groups per year (low-risk odds ratio: 1.33 [95% confidence interval (CI): 1.22 to 1.45]; intermediate-risk odds ratio: 1.30 [95% CI: 1.21 to 1.38]; and high-risk odds ratio: 1.30 [95% confidence interval: 1.23 to 1.37]). Also, there was a narrowing in the guideline adherence gap between low- and high-risk patients over time (p = 0.0002).

Conclusions

Although adherence to guideline-based care remains paradoxically lower in those MI patients at higher risk of mortality and most likely to benefit from treatment, care is improving for eligible patients within all risk categories, and the gaps between low- and high-risk groups seem to be narrowing.

Key Words

guideline adherence
interventional
management
myocardial infarction
paradox
risk
trends

Abbreviations and Acronyms

CI
confidence interval
LDL
low-density lipoprotein
MI
myocardial infarction
OR
odds ratio
STEMI
ST-segment elevation myocardial infarction

Cited by (0)

The Get With The Guidelines Program is funded by the American Heart Association. The program is also supported in part by unrestricted educational grants to the American Heart Association by Pfizer Inc. and the Merck/Schering-Plough Partnership, who did not participate in the design, analysis, manuscript preparation, or approval. Dr. Cannon has received research grants/support from Accumetrics, AstraZeneca, GlaxoSmithKline, Intekrin Therapeutics, Merck, and Takeda; has served on the advisory board (with funds donated to charity) of the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and Novartis; and has acted as a clinical advisor-equity in Automedics Medical Systems. Dr. Hernandez has received research grants/support from Proventys, Amylin, Merck, Johnson & Johnson, and AstraZeneca. Dr. Peterson has received research grants/support from Bristol-Myers Squibb/Sanofi, Lilly, Johnson & Johnson, and Merck/Schering-Plough. Dr. Bhatt has received research grants from AstraZeneca, Bristol-Myers Squibb, Eisai, Sanofi-Aventis, and The Medicines Company. Dr. Fonarow has received research grants/support from Bristol-Myers Squibb/Sanofi, Merck/Schering-Plough, Pfizer, and AstraZeneca. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.