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Cannon CP et al. Crit Path Cardiol 2002;1:44-52.

Underutilization of evidence-based medications in Acute ST Elevation Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry.

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Cannon CP et al. Crit Path Cardiol 2002;1:44-52.

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  1. Underutilization of evidence-based medications in Acute ST Elevation Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry Christopher P. Cannon, MD * , Maria Cecilia Bahit, MD *, J. Mark Haugland §, MD , Timothy D. Henry †, MD, Marc J. Schweiger ‡, MD, George R. McKendall ¥, MD, Prediman K. Shah **, MD, Sabina Murphy ***,MPH, C.Michael Gibson***, Carolyn H. McCabe*, BS. Elliott M. Antman *, MD, Eugene Braunwald *, MD, for the TIMI 9 Registry Investigators Cannon CP et al. Crit Path Cardiol 2002;1:44-52.

  2. Background • Reperfusion therapy with fibrinolysis or primary angioplasty has proven to be a major advance in the treatment of acute myocardial infarction. • However,reports from studies in the 1980's and recent reports based on data from national registries have suggested that only one third of patients with acute MI receive thrombolytic therapy in North America.

  3. Background • Fibrinolytic therapy is beneficial only in patients with ST segment elevation (or new left bundle branch block) presenting <12 hours, and is potentially harmful in patients without ST elevation . • It is unclear what proportion of patientswith indications for reperfusion therapy are receiving thrombolytic therapy or primary percutaneous coronary intervention (PCI). In addition, the management and outcome of patients not treated with reperfusion therapy is poorly characterized.

  4. Objectives • Assess management strategies and the outcomes of patients with acute MI presenting with ST elevation myocardial infarction (STEMI) in the current era of aggressive reperfusion therapy.

  5. Methods • All consecutive patients seen in the E.D and/ or admitted with the diagnosis of acute MI were prospectively screened. • Inclusion criteria: • ST elevation  0.1 mV in 2 or more leads • New or presumably new LBBB • Exclusion criteria: • None • Patient demgraphics, medical treatment , in-hospital outcome prospectively collected

  6. Results TIMI 9 Registry n=840 consecutive patients acute STEMI/ LBBB 20 Hospitals in US and Canada 1994 Primary PCI n=76 No Reperfusion n=276 Fibrinolysis n=505 51% TIMI 9 Trial

  7. Initial treatment strategy in STEMI All patients Patients presenting < 12 hours No Reperfusion 31% No Reperfusion 25% Primary PCI 10% Primary PCI 9% Fibrinolysis 60% Fibrinolysis 65%

  8. Baseline Characteristics All Patients Fibrinolysis Primary PCI No Reperfusion p-value Age 63.413.9 61.9 12.6 61.211.5 67.0 13.9 0.0001 Female 33% 30% 24% 42% 0.001 White 86% 87% 85% 86% 0.38 Prior MI 26% 17% 21% 26% 0.12 Prior angina 27% 26% 30% 28% 0.73 Prior PCI 7% 6% 19% 7% 0.001 Prior CABG 7% 7% 5% 7% 0.80 Prior CHF 6% 3% 4% 13% 0.001 Killip I 80% 83% 81% 71% II 15% 13% 12% 19% III 4% 3% 0% 6% IV 2% 1% 7% 3% 0.001

  9. Door- to-drug times for patients treated with fibrinolytic therapy % of Patients

  10. Door- to- balloon times for patients treated with Primary PTCA % of Patients

  11. “Contraindications” to Fibrinolysis Fibrinolysis Prim. PCI No Reperf Prior stroke/TIA 0.6% 2.6% 4.6% Recent CPR, trauma or surgery 0.8% 15.2% 12.7% Recent Bleeding 0.2% 3.8% 10.4% Persistent HTN 6.0% 13.9% 8.1% Significant illness 10.3% 39.5% 42.1%

  12. Gender differences in initial treatment strategy p=0.153

  13. Medications in 1st 24 hours Overall Fibrinolysis Primary PCI No Reperfusion p Aspirin 87% 93% 93% 72% 0.001 Heparin 91% 98% 100% 74% 0.001 Beta blockers 61% 71% 57% 43% 0.001 ACE-I 13% 13% 7% 14% 0.22 Calcium Channel Blockers 13% 10% 18% 17% 0.003

  14. In-Hospital Mortality % 3 way p<0.001 % of Patients % % n= 79 n=259 n=505

  15. In-hospital outcomes Overall Lysis 1o PCI No Rep.Rx p Re-MI 8.1% 10.4% 5.5% 4.3% 0.01 Card shock 7.4% 5.6% 13.5% 9.3% 0.02 Mild/Mod CHF 22.6% 20.6% 20.8% 25.1% 0.45 ICH 0.2% 0.2% 0% 0.4% 0.80 Major Bleed 5.8% 8.3% 2.9% 1.6% 0.001

  16. TIMI 9 Registry: Conclusions • Reperfusion therapy underutilized – 1/3 STEMI failed to receive reperfusion Rx • Door to drug and door to balloon times remain suboptimal • There is potential to increase the use of other effective medications (e.g., ASA, B-blockers) • Efforts need to continue to expand the use of guideline-recommended therapies to all appropriate STEMI patients

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