Browsing by Subject "myocardial infarction"
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Item Embargo A Prospective Observational Study of Inpatient Myocardial Infarction Care in Northern Tanzania(2024) Gedion, KalipaBackground: The uptake of evidence-based secondary preventative therapy among patients with myocardial infarction (MI) patients is low in northern Tanzania, and short-term mortality is high. The aim of this study was to describe current patterns of inpatient and discharge care among hospitalized patients with MI to identify opportunities for improvement.
Methods: Adult patients (18 years old) participants with acute MI were consecutively enrolled in the emergency department of a tertiary care hospital in Moshi, Tanzania, from February 2022 through January 2023. A standardized questionnaire collecing demographic and health data was administered to participants at enrollment. During hospitalization, research assistants administered a standardized questionnaire to participants on a daily basis to collect information about symptom progression and counselling received. Information about inpatient testing and treatment were obtained directly from electronic medical records. At time of discharge, a discharge survey was administered to participants to collect information about discharge counseling and post-discharge plans for appointments and medications. Discharge prescriptions were collected directly from the medical record. Thirty days after enrollment, a follow-up survey was administered via telephone to participants to assess symptom status, medication use, and appointment attendance.
Results: Of the 73 participants with MI, 21 (29%) died during their initial hospitalization. During the hospital stay: 39 (53%) participants received aspirin, 29 (40%) received clopidogrel, 28 (38%) received dual antiplatelet therapy, 25 (34%) received a beta-blocker, and 36 (49%) received a statin. Fourty-three (59%) participants reported being informed of their diagnosis during their hospitalization, and 21 (29%) reported receiving dietary counselling. Of 9 participants who reported ongoing tobacco use, 2 (22%) reported receiving smoking cessation counseling. Of the 52 participants who survived to hospital discharge, 36 (69%) were given a follow-up appointment, 18 (35%) were prescribed aspirin, 23 (44%) were prescribed clopidogrel, 14 (27%) were prescribed dual antiplatelet therapy, 15 (29%) were prescribed a beta-blocker, and 21 (40%) were prescribed a statin. Four (5%) participants died between discharge and follow-up, resulting in an overall thirty-day mortality rate of 34%. Of the 48 participants surviving to 30 days, 14 (29%) were rehospitalized, 35 (73%) reported ongoing chest pain or dyspnea, 2 (4%) reported taking aspirin, and 4 (8%) reported taking clopidogrel.
Conclusions: There are multiple opportunities to improve uptake of evidence-based MI care during the inpatient and discharge phases of care. Further study is needed to address barriers to enhance the quality of MI care and reduce MI-associated mortality.
Item Open Access Bispecific Antibody Therapy for Effective Cardiac Repair through Redirection of Endogenous Stem Cells(Advanced Therapeutics, 2019-10-01) Huang, K; Li, Z; Su, T; Shen, D; Hu, S; Cheng, KBone marrow stem cells (BMSCs) are a promising strategy for cardiac regenerative therapy for myocardial infarction (MI). However, cell transplantation has to overcome a number of hurdles, such as cell quality control, clinical practicality, low cell retention/engraftment, and immune reactions when allogeneic cells are used. Bispecific antibodies (BsAbs) have been developed as potential agents in cancer immunotherapy but their application is sparse in cardiovascular diseases. In the present study, BsAbs are designed by chemical cycloaddition of F(ab′)2 fragments from monoclonal anti-CD34 and anti- cardiac myosin heavy chain (CMHC) antibodies, which specifically targets circulating CD34-positive cells and injured cardiomyocytes simultaneously. It is hypothesized that intravenous administration of stem cell re-directing (SCRD) BsAbs (anti-CD34-F(ab′)2–anti-CMHC-F(ab′)2) can home endogenous BMSCs to the injured heart for cardiac repair. The in vivo studies in a mouse model with heart ischemia/reperfusion (I/R) injury demonstrate the safety and therapeutic potency of SCRD BsAb, which supports cardiac recovery by reducing scarring, promoting angiomyogenesis, and boosting cardiac function.Item Open Access Dark-Blood Delayed Enhancement Cardiac Magnetic Resonance of Myocardial Infarction.(JACC Cardiovasc Imaging, 2017-12-08) Kim, Han W; Rehwald, Wolfgang G; Jenista, Elizabeth R; Wendell, David C; Filev, Peter; van Assche, Lowie; Jensen, Christoph J; Parker, Michele A; Chen, Enn-Ling; Crowley, Anna Lisa C; Klem, Igor; Judd, Robert M; Kim, Raymond JOBJECTIVES: This study introduced and validated a novel flow-independent delayed enhancement technique that shows hyperenhanced myocardium while simultaneously suppressing blood-pool signal. BACKGROUND: The diagnosis and assessment of myocardial infarction (MI) is crucial in determining clinical management and prognosis. Although delayed enhancement cardiac magnetic resonance (DE-CMR) is an in vivo reference standard for imaging MI, an important limitation is poor delineation between hyperenhanced myocardium and bright LV cavity blood-pool, which may cause many infarcts to become invisible. METHODS: A canine model with pathology as the reference standard was used for validation (n = 22). Patients with MI and normal controls were studied to ascertain clinical performance (n = 31). RESULTS: In canines, the flow-independent dark-blood delayed enhancement (FIDDLE) technique was superior to conventional DE-CMR for the detection of MI, with higher sensitivity (96% vs. 85%, respectively; p = 0.002) and accuracy (95% vs. 87%, respectively; p = 0.01) and with similar specificity (92% vs, 92%, respectively; p = 1.0). In infarcts that were identified by both techniques, the entire length of the endocardial border between infarcted myocardium and adjacent blood-pool was visualized in 33% for DE-CMR compared with 100% for FIDDLE. There was better agreement for FIDDLE-measured infarct size than for DE-CMR infarct size (95% limits-of-agreement, 2.1% vs. 5.5%, respectively; p < 0.0001). In patients, findings were similar. FIDDLE demonstrated higher accuracy for diagnosis of MI than DE-CMR (100% [95% confidence interval [CI]: 89% to 100%] vs. 84% [95% CI: 66% to 95%], respectively; p = 0.03). CONCLUSIONS: The study introduced and validated a novel CMR technique that improves the discrimination of the border between infarcted myocardium and adjacent blood-pool. This dark-blood technique provides diagnostic performance that is superior to that of the current in vivo reference standard for the imaging diagnosis of MI.Item Embargo Designing an Intervention to Improve MI Care in a Tanzanian Emergency Department(2023) Stark, KristenBackground: Myocardial Infarction (MI) was previously thought to be rare in sub-Saharan Africa (SSA) but a growing body of evidence suggests MI is in reality under-diagnosed. Multiple studies from Tanzania show there is a need for intervention to improve MI diagnosis, treatment, and outcomes. Our objective was to create an intervention targeting MI care in the emergency department of a Tanzanian referral hospital. Methods: To address this gap an interdisciplinary group of individuals from Tanzania and the United States formed a Design Team to co-create an intervention. The group utilized the ADAPT-ITT model to guide the process of assessing need, identifying an intervention to adapt, and begin the process of adaptation and production to meet the needs of the target population. Results: In the Assessment phase, the team found substantial under-diagnosis of MI, a low rate of aspirin administration, and a lack of both patient and provider awareness. In the Decision phase, the team reviewed 10 interventions of various types before deciding upon the BRIDGE-ACS study as an ideal target for adaptation. In the Adaptation phase, the team discussed intervention content with a focus on ensuring appropriateness for local context. The team is currently in the Production phase creating the necessary materials for implementation of the intervention. Conclusions: In the emergency department of a Tanzanian referral hospital, intervention is needed to improve MI diagnosis, treatment, and outcomes. While the adaptation process is still ongoing, this paper can serve as a guide for others wanting to engage in collaborative intervention development targeting clinical care.
Item Open Access Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry.(J Am Heart Assoc, 2014-04-14) Sherwood, Matthew W; Wiviott, Stephen D; Peng, S Andrew; Roe, Matthew T; Delemos, James; Peterson, Eric D; Wang, Tracy YBACKGROUND: P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices. METHODS AND RESULTS: Using ACTION Registry-GWTG (Get-with-the-Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non-ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients. CONCLUSIONS: With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.Item Open Access High-sensitivity troponin assays: evidence, indications, and reasonable use.(J Am Heart Assoc, 2014-01-27) Sherwood, Matthew W; Kristin Newby, LItem Open Access How Reliable are Patient-Reported Rehospitalizations? Implications for the Design of Future Practical Clinical Studies.(J Am Heart Assoc, 2016-01-25) Krishnamoorthy, Arun; Peterson, Eric D; Knight, J David; Anstrom, Kevin J; Effron, Mark B; Zettler, Marjorie E; Davidson-Ray, Linda; Baker, Brian A; McCollam, Patrick L; Mark, Daniel B; Wang, Tracy YBACKGROUND: Longitudinal clinical investigations often rely on patient reports to screen for postdischarge adverse outcomes events, yet few studies have examined the accuracy of such patient reports. METHODS AND RESULTS: Patients with acute myocardial infarction (MI) in the TRANSLATE-ACS study were asked during structured interviews at 6 weeks, 6 months, and 12 months postdischarge to report any rehospitalizations. The accuracy of patient-reported rehospitalizations within 1 year of postdischarge was determined using claims-based medical bill validation as the reference standard. The cumulative incidence of rehospitalizations was compared when identified by patient report versus medical bills. Patients were categorized by the accuracy in reporting events (accurate, under-, or over- reporters) and characteristics were compared between groups. Among 10 643 MI patients, 4565 (43%) reported 7734 rehospitalizations. The sensitivity and positive predictive value of patient-reported rehospitalizations were low at 67% and 59%, respectively. A higher cumulative incidence of rehospitalization was observed when identified by patient report versus medical bills (43% vs 37%; P<0.001). Overall, 18% of patients over-reported and 10% under-reported the number of hospitalizations. Compared with accurate reporters, under-reporters were more likely to be older, female, African American, unemployed, or a non-high-school graduate, and had greater prevalence of clinical comorbidities such as diabetes and past cardiovascular disease. CONCLUSIONS: The accuracy of patient-reported rehospitalizations was low with patients both under- and over-reporting events. Longitudinal clinical research studies need additional mechanisms beyond patient report to accurately identify rehospitalization events. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT01088503.Item Open Access Incidence of Acute Myocardial Infarction in Northern Tanzania: A Modeling Approach Within a Prospective Observational Study.(Journal of the American Heart Association, 2021-08) Hertz, Julian T; Madut, Deng B; Rubach, Matthew P; William, Gwamaka; Crump, John A; Galson, Sophie W; Maro, Venance P; Bloomfield, Gerald S; Limkakeng, Alexander T; Temu, Gloria; Thielman, Nathan M; Sakita, Francis MBackground Rigorous incidence data for acute myocardial infarction (AMI) in sub-Saharan Africa are lacking. Consequently, modeling studies based on limited data have suggested that the burden of AMI and AMI-associated mortality in sub-Saharan Africa is lower than in other world regions. Methods and Results We estimated the incidence of AMI in northern Tanzania in 2019 by integrating data from a prospective surveillance study (681 participants) and a community survey of healthcare-seeking behavior (718 participants). In the surveillance study, adults presenting to an emergency department with chest pain or shortness of breath were screened for AMI with ECG and troponin testing. AMI was defined by the Fourth Universal Definition of AMI criteria. Mortality was assessed 30 days following enrollment via in-person or telephone interviews. In the cluster-based community survey, adults in northern Tanzania were asked where they would present for chest pain or shortness of breath. Multipliers were applied to account for AMI cases that would have been missed by our surveillance methods. The estimated annual incidence of AMI was 172 (207 among men and 139 among women) cases per 100 000 people. The age-standardized annual incidence was 211 (263 among men and 170 among women) per 100 000 people. The estimated annual incidence of AMI-associated mortality was 87 deaths per 100 000 people, and the age-standardized annual incidence was 102 deaths per 100 000 people. Conclusions The incidence of AMI and AMI-associated mortality in northern Tanzania is much higher than previously estimated and similar to that observed in high-income countries.Item Open Access Myocardial Infarction in People Living with HIV in northern Tanzania(2022) Prattipati, Sai NikithaBackground: People living with HIV (PLWH) are at increased risk for ischemic heart disease (IHD) and myocardial infarction (MI). Our objectives in this study were the following: identify the prevalence of prior MI and myocardial ischemia among PLWH, compare with HIV-uninfected participants, identify correlates of prior MI among PLWH; examine PLWH knowledge, attitudes, and practices (KAP) regarding IHD, identify predictors of improved knowledge, and explore patient and provider perspectives on barriers to MI care. Methods: Adults presenting for routine HIV-care were recruited. Trained research assistants collected basic sociodemographic information and medical history and administered a standardized knowledge, attitudes, and practices survey regarding IHD. An IHD knowledge score between 0 and 10 was calculated for each participant based on the number of correct answers on the KAP knowledge questions. Associations between participant characteristics and IHD knowledge scores were assessed via Welch’s t-test. Age- and sex- matched participants without HIV were selected as controls from an outpatient department in the same district. Both PLWH and control participants underwent 12-lead resting ECG testing. ECG criteria for prior MI was defined as pathologic Q waves in ≥2 contiguous lead and myocardial ischemia as ST segment depression or T wave inversion in ≥2 contiguous leads. Each ECG was reviewed by two independent physician adjudicators, and Pearson’s chi-squared test was used to compare the prevalence of ischemic ECG findings among those with and without HIV. Multivariate logistic regression was also performed to identify patient characteristics correlating with prior MI in PLWH on ECG. Finally, PLWH with ECG findings of prior MI and physicians caring for PLWH were recruited via purposive sampling for in-depth interviews regarding barriers to MI care in PLWH. Inductive thematic analysis was conducted to identify emergent themes and all transcripts were independently coded in NVivo 12. Results: Of 500 enrolled PLWH, the mean (sd) age was 45.3 (11.4) years and 139 were (27.8%) males. The study found an average knowledge score of 5.6, with higher IHD knowledge scores being associated with post-primary education (mean = 6.27 vs 5.35, p = 0.001) and with >10% five-year risk of cardiovascular event (mean = 5.97 vs 5.41, p = 0.045). Control participants without HIV were recruited for 497 participants with HIV. Prior MI (11.1% vs 2.4%, OR 4.97, 95% CI: 2.71-9.89, p<0.001), and myocardial ischemia (18.7% vs 12.1% OR 1.67, 95% CI: 1.18-2.39, p=0.004) were significantly more common among participants with HIV than those without HIV. On multivariate analysis, prior MI among participants with HIV was associated with male sex (OR 2.05, 95% CI: 1.06-3.89, p=0.030) and self-reported family history of cardiovascular disease (OR 2.05, 95% CI: 1.05-3.88, p=0.031). The 24 in-depth interviews of providers and patients revealed barriers related to perceptions and understanding of MI among patients and providers, delays in MI diagnosis and initiation of treatment, and challenges in the provision of long-term MI care. Conclusions: Tanzanians with HIV have a significantly higher burden of IHD than those without HIV, but significant barriers exist to high quality cardiovascular care in this population. Further study is required to characterize cardiovascular disease burden and improve care for PLWH.
Item Open Access Predicting Outcomes Over Time in Patients With Heart Failure, Left Ventricular Systolic Dysfunction, or Both Following Acute Myocardial Infarction.(J Am Heart Assoc, 2016-06-27) Lopes, Renato D; Pieper, Karen S; Stevens, Susanna R; Solomon, Scott D; McMurray, John JV; Pfeffer, Marc A; Leimberger, Jeffrey D; Velazquez, Eric JBACKGROUND: Most studies of risk assessment or stratification in patients with myocardial infarction (MI) have been static and fail to account for the evolving nature of clinical events and care processes. We sought to identify predictors of mortality, cardiovascular death or nonfatal MI, and cardiovascular death or nonfatal heart failure (HF) over time in patients with HF, left ventricular systolic dysfunction, or both post-MI. METHODS AND RESULTS: Using data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial, we developed models to estimate the association between patient characteristics and the likelihood of experiencing an event from the time of a follow-up visit until the next visit. The intervals are: hospital arrival to discharge or 14 days, whichever occurs first; hospital discharge to 30 days; 30 days to 6 months; and 6 months to 3 years. Models were also developed to predict the entire 3-year follow-up period using baseline information. Multivariable Cox proportional hazards modeling was used throughout with Wald chi-squares as the comparator of strength for each predictor. For the baseline model of overall mortality, the 3 strongest predictors were age (adjusted hazard ratio [HR], 1.35; 95% CI, 1.28-1.42; P<0.0001), baseline heart rate (adjusted HR, 1.17; 95% CI, 1.14-1.21; P<0.0001), and creatinine clearance (≤100 mL/min; adjusted HR, 0.86; 95% CI, 0.84-0.89; P<0.0001). According to the integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices, the updated model had significant improvement over the model with baseline covariates only in all follow-up periods and with all outcomes. CONCLUSIONS: Patient information assessed closest to the time of the outcome was more valuable in predicting death when compared with information obtained at the time of the index hospitalization. Using updated patient information improves prognosis over using only the information available at the time of the index event.Item Open Access Relationship of T2-Weighted MRI Myocardial Hyperintensity and the Ischemic Area-At-Risk.(Circ Res, 2015-07-17) Kim, Han W; Van Assche, Lowie; Jennings, Robert B; Wince, W Benjamin; Jensen, Christoph J; Rehwald, Wolfgang G; Wendell, David C; Bhatti, Lubna; Spatz, Deneen M; Parker, Michele A; Jenista, Elizabeth R; Klem, Igor; Crowley, Anna Lisa C; Chen, Enn-Ling; Judd, Robert M; Kim, Raymond JRATIONALE: After acute myocardial infarction (MI), delineating the area-at-risk (AAR) is crucial for measuring how much, if any, ischemic myocardium has been salvaged. T2-weighted MRI is promoted as an excellent method to delineate the AAR. However, the evidence supporting the validity of this method to measure the AAR is indirect, and it has never been validated with direct anatomic measurements. OBJECTIVE: To determine whether T2-weighted MRI delineates the AAR. METHODS AND RESULTS: Twenty-one canines and 24 patients with acute MI were studied. We compared bright-blood and black-blood T2-weighted MRI with images of the AAR and MI by histopathology in canines and with MI by in vivo delayed-enhancement MRI in canines and patients. Abnormal regions on MRI and pathology were compared by (a) quantitative measurement of the transmural-extent of the abnormality and (b) picture matching of contours. We found no relationship between the transmural-extent of T2-hyperintense regions and that of the AAR (bright-blood-T2: r=0.06, P=0.69; black-blood-T2: r=0.01, P=0.97). Instead, there was a strong correlation with that of infarction (bright-blood-T2: r=0.94, P<0.0001; black-blood-T2: r=0.95, P<0.0001). Additionally, contour analysis demonstrated a fingerprint match of T2-hyperintense regions with the intricate contour of infarcted regions by delayed-enhancement MRI. Similarly, in patients there was a close correspondence between contours of T2-hyperintense and infarcted regions, and the transmural-extent of these regions were highly correlated (bright-blood-T2: r=0.82, P<0.0001; black-blood-T2: r=0.83, P<0.0001). CONCLUSION: T2-weighted MRI does not depict the AAR. Accordingly, T2-weighted MRI should not be used to measure myocardial salvage, either to inform patient management decisions or to evaluate novel therapies for acute MI.Item Open Access Stroke in Patients With Peripheral Artery Disease.(Stroke, 2019-05-16) Kolls, Brad J; Sapp, Shelly; Rockhold, Frank W; Jordan, J Dedrick; Dombrowski, Keith E; Fowkes, F Gerry R; Mahaffey, Kenneth W; Berger, Jeffrey S; Katona, Brian G; Blomster, Juuso I; Norgren, Lars; Abramson, Beth L; Leiva-Pons, Jose L; Prieto, Juan Carlos; Sokurenko, German; Hiatt, William R; Jones, W Schuyler; Patel, Manesh RBackground and Purpose- Predictors of stroke and transient ischemic attack (TIA) in patients with peripheral artery disease (PAD) are poorly understood. The primary aims of this analysis were to (1) determine the incidence of ischemic/hemorrhagic stroke and TIA in patients with symptomatic PAD, (2) identify predictors of stroke in patients with PAD, and (3) compare the rate of stroke in ticagrelor- and clopidogrel-treated patients. Methods- EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) randomized 13 885 patients with symptomatic PAD to receive monotherapy with ticagrelor or clopidogrel for the prevention of major adverse cardiovascular events (cardiovascular death, myocardial infarction, or ischemic stroke). Ischemic/hemorrhagic stroke and TIA were adjudicated and measured as incidence rates postrandomization and cumulative incidence (per patient-years). Post hoc multivariable competing risk hazards analyses were performed using baseline characteristics to determine factors associated with all-cause stroke in patients with PAD. Results- A total of 458 cerebrovascular events in 424 patients (317 ischemic strokes, 39 hemorrhagic strokes, and 102 TIAs) occurred over a median follow-up of 30 months, for a cumulative incidence of 0.87, 0.11, and 0.27 per 100 patient-years, respectively. Age, prior stroke, prior atrial fibrillation/flutter, diabetes mellitus, geographic region, ankle-brachial index <0.60, prior amputation, and systolic blood pressure were independent baseline factors associated with the occurrence of all-cause stroke. After adjustment for baseline factors, the rates of ischemic stroke and all-cause stroke remained lower in patients treated with ticagrelor as compared with those receiving clopidogrel. There was no significant difference in the incidence of hemorrhagic stroke or TIA between the 2 treatment groups. Conclusions- In patients with symptomatic PAD, ischemic stroke and TIA occur frequently over time. Comorbidities such as age, prior stroke, prior atrial fibrillation/flutter, diabetes mellitus, higher blood pressure, prior amputation, lower ankle-brachial index, and geographic region were each independently associated with the occurrence of all-cause stroke. Use of ticagrelor, as compared with clopidogrel, was associated with a lower adjusted rate of ischemic and all-cause stroke. Further study is needed to optimize medical management and risk reduction of all-cause stroke in patients with PAD. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01732822.Item Open Access Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry.(J Am Heart Assoc, 2016-10-06) Hira, Ravi S; Bhatt, Deepak L; Fonarow, Gregg C; Heidenreich, Paul A; Ju, Christine; Virani, Salim S; Bozkurt, Biykem; Petersen, Laura A; Hernandez, Adrian F; Schwamm, Lee H; Eapen, Zubin J; Albert, Michelle A; Liang, Li; Matsouaka, Roland A; Peterson, Eric D; Jneid, HaniBACKGROUND: Timely reperfusion after ST-elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI-capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI-capable hospital is not feasible. METHODS AND RESULTS: We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in-hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect-free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door-to-needle times ≤30 minutes. Median door-to-needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door-to-balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In-hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect-free care compared with their PPCI counterparts. CONCLUSIONS: Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door-to-needle times. Over the same time period, use of PPCI increased with improvement in door-to-balloon times. In-hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door-to-needle times and outcomes do not worsen.Item Open Access Trends in clinical, demographic, and biochemical characteristics of patients with acute myocardial infarction from 2003 to 2008: a report from the american heart association get with the guidelines coronary artery disease program.(J Am Heart Assoc, 2012-08) Boyer, Nathan M; Laskey, Warren K; Cox, Margueritte; Hernandez, Adrian F; Peterson, Eric D; Bhatt, Deepak L; Cannon, Christopher P; Fonarow, Gregg CBACKGROUND: An analysis of the changes in the clinical and demographic characteristics of patients with acute myocardial infarction could identify successes and failures of risk factor identification and treatment of patients at increased risk for cardiovascular events. METHODS AND RESULTS: We reviewed data collected from 138 122 patients with acute myocardial infarction admitted from 2003 to 2008 to hospitals participating in the American Heart Association Get With The Guidelines Coronary Artery Disease program. Clinical, demographic, and laboratory characteristics were analyzed for each year stratified on the electrocardiogram at presentation. Patients with non-ST-segment-elevation myocardial infarction were older, more likely to be women, and more likely to have hypertension, diabetes mellitus, and a history of past cardiovascular disease than were patients with ST-elevation myocardial infarction. In the overall patient sample, significant trends were observed of an increase over time in the proportions of non-ST-segment-elevation myocardial infarction, patient age of 45 to 65 years, obesity, and female sex. The prevalence of diabetes mellitus decreased over time, whereas the prevalences of hypertension and smoking were substantial and unchanging. The prevalence of "low" high-density lipoprotein increased over time, whereas that of "high" low-density lipoprotein decreased. Stratum-specific univariate analysis revealed quantitative and qualitative differences between strata in time trends for numerous demographic, clinical, and biochemical measures. On multivariable analysis, there was concordance between strata with regard to the increase in prevalence of patients 45 to 65 years of age, obesity, and "low" high-density lipoprotein and the decrease in prevalence of "high" low-density lipoprotein. However, changes in trends in age distribution, sex ratio, and prevalence of smokers and the magnitude of change in diabetes mellitus prevalence differed between strata. CONCLUSIONS: There were notable differences in risk factors and patient characteristics among patients with ST-elevation myocardial infarction and those with non-ST-segment-elevation myocardial infarction. The increasing prevalence of dysmetabolic markers in a growing proportion of patients with acute myocardial infarction suggests further opportunities for risk factor modification. (J Am Heart Assoc. 2012;1:e001206 doi: 10.1161/JAHA.112.001206.).