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Ischaemic Symptoms, Quality of Care, and Mortality during Myocardial Infarction
  1. Erik B Schelbert (schelberteb{at}
  1. National Heart, Lung, and Blood Institute, United States
    1. John S Rumsfeld (john.rumsfeld{at}
    1. Denver VA Medical Center, Denver, CO, United States
      1. Harlan M Krumholz (harlan.krumholz{at}
      1. Yale University, New Haven, CT, United States
        1. John G Canto (johngcanto{at}
        1. Center for Cardiovascular Prevention, Research, & Education Watson Clinic, Lakeland, FL and Division, United States
          1. David J Magid (david.j.magid{at}
          1. Colorado Permanente Medical Group, Denver, CO, United States
            1. Frederick A Masoudi (fred.masoudi{at}
            1. Denver Health Medical Center, Denver, CO, United States
              1. Kimberly J Reid (kreid{at}
              1. Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO, United States
                1. John A Spertus (spertusj{at}
                1. Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO, United States


                  Objective We studied whether documentation of ischemic symptoms from myocardial infarction (MI) is associated with quality of care and outcomes, and interviewed patients to compare their reports of ischaemic symptoms with chart documentation

                  Design Observational acute myocardial infarction study from 2003-2004 (Prospective Registry Evaluating Myocardial Infarction: Event and Recovery)

                  Setting 19 diverse US hospitals

                  Patients 2,094 consecutive MI patients (10,911 patients screened; 3,953 patients were eligible and enrolled) with both positive cardiac enzymes and other evidence of infarction (e.g., symptoms, electrocardiographic changes). Transferred patients and those with confounding noncardiac 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 MI patients (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 beta-blockers (77% vs. 90%) within 24hr, reperfusion therapy for STEMI (7% vs. 58%) or to survive their hospitalization (adjusted OR=3.2, 95% CI 1.8-5.8). Survivors without documented symptoms were also less likely (p<0.05) to be discharged with aspirin (87% vs. 93%), beta-blockers (81% vs. 91%), ACE/ARB (67% vs. 80%), or smoking cessation counseling (46% vs. 66%). In the subset of 1,356 (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.

                  • Diagnosis
                  • Mortality
                  • Myocardial Infarction
                  • Quality Indicators
                  • Registries

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