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Ischaemic symptoms, quality of care and mortality during myocardial infarction
  1. E B Schelbert1,
  2. J S Rumsfeld2,
  3. H M Krumholz3,
  4. J G Canto4,
  5. D J Magid5,
  6. F A Masoudi6,
  7. K J Reid7,
  8. J A Spertus7
  1. 1
    University of Iowa, Iowa City, IA, USA
  2. 2
    Denver VA Medical Center, Denver, CO, USA
  3. 3
    Yale University, New Haven, CT, USA
  4. 4
    Center for Cardiovascular Prevention, Research and Education Watson Clinic, Lakeland, FL, USA and Division of Cardiovascular Diseases, and University of Alabama at Birmingham, Birmingham, AL, USA
  5. 5
    Colorado Permanente Medical Group, Denver, CO, USA
  6. 6
    Denver Health Medical Center, Denver, CO, USA
  7. 7
    Mid America Heart Institute and University of Missouri—Kansas City, Kansas City, MO, USA
  1. Dr E B Schelbert, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Room B1D416, MSC 1061, Bethesda, MD 20892–1061, USA; schelberteb{at}


Objective: To study in myocardial infarction (MI) whether documentation of ischaemic symptoms is associated with quality of care and outcomes, and to compare patient reports of ischaemic symptoms during interviews with chart documentation.

Design: Observational acute MI study from 2003 to 2004 (Prospective Registry Evaluating Myocardial Infarction: Event and Recovery).

Setting: 19 diverse US hospitals.

Patients: 2094 consecutive patients with MI (10 911 patients screened; 3953 patients were eligible and enrolled) with both positive cardiac enzymes and other evidence of infarction (eg, symptoms, electrocardiographic changes). Transferred patients and those with confounding non-cardiac comorbidity were not included (n = 1859).

Main outcome measures: Quality of care indicators and adjusted in-hospital survival.

Results: The records of 10% of all patients with MI (217/2094) contained no documented ischaemic symptoms at presentation. Patients without documented symptoms were less likely (p<0.05) to receive aspirin (89% vs 96%) or β-blockers (77% vs 90%) within 24 hours, reperfusion therapy for ST-elevation MI (7% vs 58%) or to survive their hospitalisation (adjusted odds ratio = 3.2, 95% CI 1.8 to 5.8). Survivors without documented symptoms were also less likely (p<0.05) to be discharged with aspirin (87% vs 93%), β-blockers (81% vs 91%), ACE/ARB (67% vs 80%), or smoking cessation counselling (46% vs 66%). In the subset of 1356 (65%) interviewed patients, most of those without documented ischaemic symptoms (75%) reported presenting symptoms consistent with ischaemia.

Conclusions: Failure to document patients’ presenting MI symptoms is associated with poorer quality of care from admission to discharge, and higher in-hospital mortality. Symptom recognition may represent an important opportunity to improve the quality of MI care.

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  • Competing interests: None declared.

  • Funding: This project was principally supported by CV Therapeutics, Inc, Palo Alto, CA, USA and P50 HL077113 from the National Heart, Lung and Blood Institute, Bethesda, MD, USA. EBS was supported by a Cardiovascular Interdisciplinary Fellowship (HL 07121) from the University of Iowa Division of Cardiovascular Diseases and the Cardiovascular Research Center, where he was an Iowa Scholar in Clinical Investigation Program K30 trainee (K30HL04117-01A1). JSR is supported by a VA Health Services Research and Development Advanced Research Career Development Award (ARCD 98341-2).