Myocardial Infarction Guidelines Research Articles

ExTRACT-TIMI 25 in perspective: key lessons regarding enoxaparin as an adjunct to fibrinolytic therapy

Unfractionated heparin (UFH) for 48 h has been the traditional standard anticoagulant with fibrinolytics. The Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction (ExTRACT)-Thrombolysis in Myocardial Infarction (TIMI) 25 trial prospectively studied the usefulness of enoxaparin and found that in patients treated with fibrinolysis, enoxaparin administered throughout the index hospitalization was superior to the standard 48-h UFH infusion. However, enoxaparin increased major bleeding. The data from this large trial were further analyzed across various subgroups and these results support the use of enoxaparin in a broad range of patients. The ExTRACT-TIMI 25 trial employed a novel dosing regimen for enoxaparin adjusted for age and renal function, which was designed to minimize bleeding risk while maintaining the beneficial effects of enoxaparin. Based on the evidence from this trial, the 2007 ST-segment elevation myocardial infarction guidelines now preferentially recommend enoxaparin to be administered throughout the index hospitalization as per the dosing regimen used in ExTRACT-TIMI 25 in most patients treated with fibrinolytic therapy.

Decline in Incident Coronary Heart Disease

In the fall of 1979, the National Heart, Lung, and Blood Institute held a conference on the decline in coronary heart disease (CHD) death rates. It was apparent that in the previous 10 to 15 years, the epidemic crested and began to fall.1 The reasons for this decline were unclear, but many hypotheses were offered. Explanations ranged from death classification artifact, new coronary care units, and coronary surgery to broad social change. Many were more than willing to take credit for this change, but few data were available. A search for explanations began. Article p 598 Three major themes emerged as possible explanations: (1) primary prevention through risk factor reduction, including public health measures such as reduction in cigarettes and clinical approaches such as lipid and blood pressure management; (2) modern care for acute coronary syndromes, including emergency services, coronary care units, and revascularization strategies; and (3) secondary prevention in those with known CHD, including revascularization, medications, and lifestyle approaches. Each of these has substantial clinical trial evidence to support its utility in reducing new cases (incidence), recurrent events, and/or death. Early attempts to understand the causes were hampered by a lack of data. Stern2 suggested that a decline in mortality was related to improved diet, reduced smoking, …

ACC/AHA Non‐ST Elevation Myocardial Infarction Guidelines' Revision 2007: Implications for Nursing Practice

ACC/AHA Non‐ST Elevation Myocardial Infarction Guidelines' Revision 2007: Implications for Nursing Practice

TIA offers a warning sign that a stroke may be on its way.

Transient ischaemic attack (TIA) produces brief stroke-like symptoms due to temporary disruption of blood to the brain. It is characterised by focal symptoms, specific to one location or function, lasting less than 24 hours. TIAs are a warning sign that the individual is at risk of a stroke or myocardial infarction and national stroke guidelines recommend assessment at a neurovascular clinic within seven days. They are most severe at onset and gradually resolve. Symptoms usually involve loss of movement, speech or sensation rather than positive symptoms such as pins and needles. Despite the short duration of symptoms, ignoring the episode can have serious consequences. Risk of stroke is 8 per cent in the first seven days after a TIA and 12 per cent in the first month but the most likely cause of death post TIA is heart disease. The high level of risk means that patients should not drive during the month following a TIA.

Contemporary challenges in the management of acute myocardial infarction: ST-elevation myocardial infarction guidelines and the real world

Timely reperfusion is the primary treatment goal for ST-segment elevation myocardial infarction. The recent American College of Cardiology/American Heart Association guidelines utilize time since symptom onset, anticipated time to treatment, patient risk factors, and center volume and experience to determine the optimal reperfusion strategy. There continues to be a considerable number of patients who do not receive reperfusion therapy and treatment delays are still too long. Institution-specific protocols which reflect current guidelines may increase the number of ST-segment elevation myocardial infarction patients who receive timely reperfusion.

Primer: implementation of guideline-based programs for coronary care

The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice program in Michigan, USA, was an initiative designed to improve the quality of cardiovascular care by bringing the American College of Cardiology/American Heart Association practice guidelines to the point of care. The program consisted of three different projects, involving a total of 33 hospitals. The program was implemented in five phases-planning, tool implementation, monitoring of tool use, remeasurement and reporting of results-by use of a collaborative model, which included a series of learning sessions for staff members that focused on the five phases. The goal was to identify the highest care priorities for patients with acute coronary syndromes and to incorporate these into the care itself. This aim was achieved with a standardized set of clinical-care tools, such as admission orders and discharge contracts; the use of such tools is associated with improvement in adherence to guidelines. Strategies were, however, tailored to each hospital by local teams. Performance was assessed by the use of tracking tools, which facilitate rapid improvement by enabling key performance indicators founded on the guidelines to be monitored. Using qualitative surveys of the project leaders, we identified an optimum timeline and correlations between hospital-specific attributes and greater or lesser success in achieving positive change. In this review, we describe our experience and identify the most useful strategies for future implementation of such a project.

ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction

Preamble......237 Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The

The Impact of an Acute Myocardial Infarction Guideline and Pathway on Racial Outcomes at a University Hospital

Historically, African Americans who present with acute myocardial infarction were less likely to survive or be revascularized compared to Whites in the United States. Variation in practice has been implicated as a cause. Some researchers have proposed that the explanation for this variation was that coronary artery disease (CAD) was less severe in African Americans than Whites. A university hospital compared the extent of CAD by race for its acute myocardial infarction (AMI) patients and determined the effect of implementing evidenced-based guidelines on racial differences in cardiovascular outcomes. From 1991 to 1994, using the National Registry for Myocardial Infarction 1 and the hospital AMI database, 323 of the 521 consecutive patients were catheterized during their initial admission. The extent of CAD was defined as the frequency of CAD stenosis > or =70% seen in the major coronary arteries and/ or their major branches. Cardiac function was measured by left ventricular ejection fraction (LVEF). Short-term hospitalized outcomes were determined for death, treatment, and coronary revascularization. We assessed 82 (25.4%) African Americans and 241 (74.6%) Whites. No significant difference in the frequency of stenosis > or =70% or clinical outcomes existed between races. However, African Americans had a lower LVEF of 49.13% compared to 54.98% for Whites (P=.04). African Americans were 2.54 times more likely to have LVEF <45% (P=0.024). We saw no racial difference in death, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or thrombolytic therapy. In high-risk AMI patients, this study found no difference in the burden of CAD by race. However, for African Americans, left ventricular function was more depressed. The use of an AMI management guideline and pathway-driven protocol resulted in no significant racial difference in cardiac interventions or clinical outcomes. A guideline or protocol-driven approach to the management of AMI may significantly reduce the observed racial

Can the wrong statistic be bad for health? Improving the reporting of door-to-needle time performance in acute myocardial infarction

Current acute myocardial infarction (AMI) guidelines call for reperfusion to be given to all eligible patients within a set time interval after hospital arrival, yet current hospital performance benchmarks are based on the median door-to-intervention time among treated patients. Our objective is to compare hospital performance rankings when door-to-needle time (DNT) is measured at the current benchmark (median < or = 30 minutes) versus those obtained with more stringent benchmarks common for other AMI treatments. A secondary analysis of data from the EFFECT study from 52 small, community and teaching hospitals in Ontario. All Ontario hospital corporations that treated > or = 30 patients with AMI from 1999 to 2001 participated. The charts of approximately 125 patients with AMI per hospital were reviewed; median and 85th percentile DNTs were then calculated for patients with ST-elevation AMI given thrombolysis at each site along with the proportion of patients thrombolysed within the recommended time. Hospitals were then ranked according to each indicator. Data were obtained on 1,578 patients given thrombolytic drugs at 52 hospitals. The median and 85th percentile DNTs were 37 and 82 minutes, respectively; the proportion of patients treated in < or = 30 minutes ranged from 8.5% to 60%. Hospitals that achieved a median DNT of < or = 30 minutes treated 40% to 50% of their patients outside that time frame. The ranks of the top 15 median DNT hospitals changed substantially when re-ranked according to the 85th percentile (average change in rank -16, range +6 to -40). If DNT improved such that a 30-minute median target was achieved, the estimated reduction for the average patient would be 13 minutes versus a 43-minute reduction if the 85th percentile target was achieved. Hospitals that achieve a 30-minute median DNT benchmark still treat 40% to 50% of their patients outside the recommended time, which is not consistent with current AMI treatment guidelines. Door-to-needle time for the average patient would be up to 43 minutes faster if the DNT target was achieved at the 85th percentile.

Implementation of Acute Myocardial Infarction Guidelines in Community Hospitals

To obtain information regarding the current use of guidelines and protocols and quality assessment practices for the management of ST-segment elevation myocardial infarction in Minnesota hospitals without cardiac catheterization laboratories. Structured surveys were mailed in 2003 to emergency department medical directors or nurse managers in 111 hospitals in Minnesota that did not have cardiac catheterization laboratories. Of the 111 hospitals surveyed, 104 (94%) responded. Sixty-three percent of responding hospitals have guidelines or protocols; 57% use standing orders for ST-segment elevation myocardial infarction. Thirty-three percent have neither. Of those with guidelines, protocols, or standing orders, 8% address triage and transfer criteria, 86% thrombolytics, 91% aspirin, and 71% beta-blockers. Fifty percent have quality assessment processes in place for ST-segment elevation myocardial infarction. Recommendations from the National Heart Attack Alert Program issued more than ten years ago and, more recently, the updated American College of Cardiology/American Heart Association Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction suggest development of emergency department and hospital-specific guidelines and protocols for ST-segment elevation myocardial infarction. Currently, only two thirds of community hospitals in Minnesota have these in place; when present, these guidelines are often incomplete and rarely address transfer criteria to hospitals with percutaneous coronary intervention capability. Quality assessment occurred in 50% of hospitals surveyed. Programs to help community hospitals develop and implement guidelines and quality improvement should be encouraged and supported.

Implementation of Acute Myocardial Infarction Guidelines in Community Hospitals

Implementation of Acute Myocardial Infarction Guidelines in Community Hospitals

Enhancing quality of care for acute myocardial infarction: Shifting the focus of improvement from key indicators to process of care and tool use: The American College of Cardiology acute myocardial infarction guidelines applied in practice project in Michigan: Flint and Saginaw expansion

Enhancing quality of care for acute myocardial infarction: Shifting the focus of improvement from key indicators to process of care and tool use: The American College of Cardiology acute myocardial infarction guidelines applied in practice project in Michigan: Flint and Saginaw expansion

New ST-elevation Myocardial Infarction Guidelines Emphasize Speed and Aggressive Treatment and Lower Low-density Lipoprotein Cholesterol Levels

<p />

Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use: The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion

ObjectivesThis project evaluated if by focusing on process changes and tool use rather than key indicator rates, the use of evidence-based therapies in patients with acute myocardial infarction (AMI) would increase. BackgroundThe use of tools designed to improve quality of care in the American College of Cardiology AMI Guidelines Applied in Practice Pilot Project resulted in improved adherence to evidence-based therapies for patients, but overall, tool use was modest. MethodsThe current project, implemented in five hospitals, was modeled after the previous project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001 to June 30, 2001) and post-measurement (December 15, 2001 to March 31, 2002) samples. ResultsOne or more tools were used in 93% of patients (standard orders = 82%, and discharge document = 47%). Tool use was associated with significantly higher adherence to most discharge quality indicator rates with increases in aspirin, angiotensin-converting enzyme inhibitors, and smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had low rates of discharge indicators. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies. ConclusionsThese data validate the results of the pilot project that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality improvement efforts.

1077-70 Implementation of acute myocardial infarction guidelines in community hospitals without cardiac catheterization labs: Are we there yet?

1077-70 Implementation of acute myocardial infarction guidelines in community hospitals without cardiac catheterization labs: Are we there yet?

A rapid-cycle collaborative model to promote guidelines for acute myocardial infarction.

This American College of Cardiology (ACC) Acute Myocardial Infarction (AMI) Guidelines Applied in Practice (GAP) collaborative in Michigan represented ACC's third initiative, in partnership with local health care coalitions and the Michigan Peer Review Organization. The GAP Pilot Project formed the basis for this project, which supported caregivers' efforts to improve their processes and consistently apply the evidence-based guidelines for AMI care. The Institute for Healthcare Improvement (IHI) Breakthrough Series model of improvement was modified to merge the GAP Pilot Project's design with a rapid-cycle quality improvement model. The collaborative included learning sessions that focused on five phases--planning, tool implementation, monitoring tool use, remeasurement, and results--and on increasing tool use rates in each phase. Building on the work of two previous efforts, the ACC AMI GAP projects yielded substantial collective knowledge. Developing and fostering a collaborative culture allowed hospital teams to avoid barriers or overcome them successfully based on others' experiences and collectively solve problems, and it shortened the learning curve and accelerated QI.

P2996 American College of Cardiology (ACC) acute myocardial infarction guidelines applied in practice Southern Michigan Expansion Project: a model of collaborative quality

P2996 American College of Cardiology (ACC) acute myocardial infarction guidelines applied in practice Southern Michigan Expansion Project: a model of collaborative quality

Taking the National Guideline for Care of Acute Myocardial Infarction to the Bedside: Developing the Guideline Applied in Practice (GAP) Initiative in southeast Michigan

The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.

New Recommendations from the 1999 American College of Cardiology/American Heart Association Acute Myocardial Infarction Guidelines

New Recommendations from the 1999 American College of Cardiology/American Heart Association Acute Myocardial Infarction Guidelines

Lower-dose heparin with fibrinolysis is associated with lower rates of intracranial hemorrhage

Background The optimal heparin dose as an adjunct to fibrinolysis and its role in causing intracranial hemorrhage (ICH) is unclear. Methods We reviewed the heparin regimens and rates of ICH in 3 sets of recent fibrinolytic trials: (1) studies with accelerated recombinant tissue plasminogen activator (TPA, alteplase) plus intravenous heparin, in which the heparin regimen was changed during the course of the trial; (2) phase III trials with accelerated TPA plus intravenous heparin; and (3) trials of new single-bolus fibrinolytic agents. Results Lower rates of ICH were observed among studies of accelerated TPA that reduced the heparin dose mid-trial (TIMI 9A → 9B: 1.87% → 1.07%, GUSTO-IIa → IIb: 0.92% → 0.71%, TIMI 10B: 2.80% → 1.16%). Rates of ICH with accelerated TPA gradually increased from GUSTO-I (0.72%) in 1990 to 1993 to ASSENT-2 (0.94%) in 1997 to 1998. However, this trend was reversed in InTIME-II, which used the lowest heparin dose and most aggressive activated partial thromboplastin time monitoring and observed an ICH rate of 0.64% with accelerated TPA. Lower ICH rates were also observed when the heparin dose was reduced with single-bolus tenecteplase (TNK-TPA) and lanoteplase. Conclusions Nonrandomized comparisons with accelerated TPA suggest that lower doses of intravenous heparin are associated with lower rates of ICH. This observation also appears to apply to single-bolus TNK-TPA and novel plasminogen activator. A lower-dose, weight–adjusted heparin regimen (60 U/kg bolus; maximum, 4000 U; 12 U/kg per hour infusion; maximum, 1000 U/h) with earlier monitoring of activated partial thromboplastin time is currently recommended in the revised American College of Cardiology/American Heart Association myocardial infarction guidelines and should be used in clinical practice. (Am Heart J 2001;141:742-50.)