Pharmacological management of acute myocardial infarction in the municipal district of Rio de Janeiro
Keywords:
Acute myocardial infarction, Healthcare assurance, Quality assurance, Thrombolytic therapyAbstract
CONTEXT: International studies have shown a large variation in the utilization patterns of interventions, in acute myocardial infarction. OBJECTIVE: To analyze utilization patterns of pharma- cological interventions inacute myocardial infarction and their corresponding effects on hospital mortality. DESIGN: Cross-sectional study. LOCAL: Hospitals of the Brazilian National Health System (SUS) in the municipal district of Rio de Janeiro. SAMPLE: A stratified hospital sample of 391 medical records selected from the 1,936 admissions regis- tered in the SUS Hospital Information System (SIH/ SUS) with a main diagnosis of acute myocardial infarction, in the studied district in 1997. MAIN MEASUREMENTS: Sex, age, time to treatment, risk factors, severity factors,diagnosis confirmation, use of pharmacological interventions, hospital death, contra indication of the use of thrombolytic therapy, contra indication of aspirin use. RESULTS: We reviewed 98.2% of the sampled medical records.Acute myocardial infarction diagnosis was confirmed in 91.7% (95% CI 88.3 to 94.2). 61.5% were men and 38.5% women, with an average age of 60.2 years (SD 2.4). The median time inter- val between symptomon setand hospital admission was11 hours. Hospital mortality was 20.6%(95% CI 16.7 to 25.0). Intravenous thrombolytic therapy was used in 19.5% (95% CI 15.8 to 23.9) of the cases; aspirin in 86.5% (95% CI 82.5 to 89.6); beta-blockers in 49.0% (95% CI 43.8 to 54.1); angiotensin-converting enzyme (ACE) inhibitors in 63.3% (95% CI 58.2 to 68.1); nitrates in 82.0% (95% CI 82.4 to 89.6); heparin in 81.3% (95% CI 76.9 to 85.0); calcium antagonists in 30.5% (95% CI 26.0 to 35.4). There was a significant variation in the use of thrombolytic therapy, beta-blockers, ACE inhibitors, calcium antagonists and heparin among hospitals of different juridical nature. CONCLUSIONS: There was underutilization of some interventions with well-established efficacy (thrombolytic therapy, aspirin, beta-blockers and intravenous nitrates). The use of calcium antagonists, not supported by scientific evidence inacute myocardial infarction, was quite frequent. Alogistic model documented the benefit of aspirin, beta-blockers and ACE inhibitor use in reducing the chance of hospital death.
Downloads
References
CENEPI (Centro Nacional de Epidemiologia). SUS Epidemiological Inform/Fundação Nacional de Saúde. Brasília: Ministry of Health; 1992: year 1, no. 1 (June).
Lolio CA, Lotufo PA, Lira AC, Zanetta DMT, Massad E. Trends of coronary heart disease mortality in the capitals of the metropolitan regions of Brazil, 1979-89. Arq Bras Cardiol 1995;64:213-16.
ACC/AHA (American College of Cardiology/American Heart Association - task force report). 1999 update: Guidelines for the management of patients with acute myocardial infarction. Guideline. J Am Coll Cardiol 1999;34:890-911. WEB version.
SBC (Sociedade Brasileira de Cardiologia). Brazilian consensus for thrombolytic therapy: guidelines of the Brazilian Society of Cardiology on acute myocardial infarction care. Arq Bras Cardiol 1994;63(suppl II):1-8.
Becker RC, Burns M, Gore JM, Lambrew C, French W, Rogers WJ. Early and pre-discharge aspirin administration among patients with acute myocardial infarction: current clinical practice and trends in the United States. J Thromb Thrombol 2000;9:207-15.
Scott IA, Eyeson-Annan ML, Huxley SL, West MJ. Optimizing care of acute myocardial infarction: results of a regional quality improvement project. J Qual Clin Pract 2000;20:12-19.
O’Connor GT, Quinton HB, Traven ND, et al. Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project. JAMA 1999;281:627-33.
Venturini F, Romero M, Tognoni G. Patterns of practice for acute myocardial infarction in a population from ten countries. Eur J Clin Pharmacol 1999;54:877-86.
Reikvam A, Aursnes I. Hospital mortality from acute myocardial infarction has been modestly reduced after introduction of thrombolytics and aspirin: results from a new analytical approach. European Secondary Prevention Study Group. J Clin Epid 1999;52:609-13.
Mahon NG, O’Rourke C, Codd MB, McCann HA, McGarry K, Sugrue DD. Hospital mortality of acute myocardial infarction in the thrombolytic era. Heart 1999;81:478-82.
Brown N, Young T, Gray D, Skene AM, Hampton JR. Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham Heart Attack Register. BMJ 1997;315:159-64.
Passos LCS, Lopes AA, Souza LAM, et al. Hospital mortality predictors in the thrombolytic era for acute myocardial infarction in Salvador (BA). Arq Bras Cardiol 1997;68:249-55.
McGovern PG, Pankow JS, Shahar E, et al. Recent trends in acute coronary heart disease: mortality, morbidity, medical care and risk factors. New Engl J Med 1996;334:884-90.
Pilote L, Califf RM, Sapp S, et al. Regional variation across the United States in the management of acute myocardial infarction. New Engl J Med 1995;333:565-72.
Bourquin MG, Wietlisbach C, Rickenbach M, Perret F, Paccaud F. Time trends in the treatment of acute myocardial infarction
in Switzerland from 1986 to 1993: do they reflect the advances in scientific evidence from clinical trials? J Clin Epid 1998;51:723-32.
Marcopito LF, Goldfeder AJ, Schenkman S. Acute myocardial infarction in São Paulo State: hospital deaths, from 1979 to 1996, and hospital mortality in the SIH/SUS, from 1984 to 1998. Arq Bras Cardiol 2000;74:39-42.
Every NR, Frederick PD, Robinson M, Sugarman J, Bowlby L, Barron HV. A comparison of the national registry of myocardial infarction 2 with the cooperative cardiovascular project. J Am Coll Cardiol 1999,33:1886-94.
Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction: National Registry of Myocardial Infarction 2 participants. N Engl J Med 1999; 341:217-25.
Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decade (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol 1999;33:1533-39.
Escosteguy CC, Medronho RA, Portela MP. Evaluation of the hospital mortality of acute myocardial infarction in Rio de Janeiro using the SUS Hospital Information System. Cadernos de Saúde Coletiva 1999;7:39-59.
Escosteguy CC. Evaluation of the quality of the acute myocardial infarction hospital care in the municipal district of Rio de Janeiro. Thesis, PhD. Rio de Janeiro: Escola Nacional de Saúde Pública/ FIOCRUZ; 2000.
Cochran WG. Sampling Techniques. 3rd Ed. New York: John Wiley & Sons; 1977.
WHO MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project. Myocardial infarction and coronary death in the World Health Organization MONICA project: registration procedures, event rates, and case- fatality rates in 38 populations from 21 countries in four continents. Circulation 1994;90:583-612.
Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients. Am J Cardiol 1967;20:457-464.
Poses RM, Smith WR, McClish DK, Anthony M. Controlling for confounding by indication for treatment: are administrative data equivalent to clinical data? Medical Care 1995;33:AS36-AS46.
ISIS-2 Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both or neither among 17187 cases of suspected acute myocardial infarction. Lancet 1988;i:349-60.
APTC (Antiplatelet Trialists’ Collaboration). Collaborative overview of randomized of antiplatelet therapy – I: Prevention of death, myocardial infarction and stroke by prolonged therapy in various categories of patients. BMJ 1994;308:81-106
Krauss Silva L, Escosteguy CC, Machado CV. Methodology for estimating quality patterns: the acute myocardial infarction case. Cadernos de Saúde Pública 1996;125(suppl 2):71-83.
Collins R, Peto R, Baigent C, Sleight P. Aspirin, heparin and fibrinolytic therapy in suspected acute myocardial infarction. N Engl J Med 1997;336:847-60.
Barron HV, Rundle A, Gurwitz J, Tiefenbrunn A. Reperfusion therapy for acute myocardial infarction: observations from the National Registry of Myocardial Infarction 2. Cardiology in Review 1999;7:156-60.
