Haddad H, Searles G, Gillis A
Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia B3H 3A7, Canada.
Can J Cardiol. 2001 Feb;17(2):179-83.
The standard of management after acute myocardial infarction (MI) includes beta-blockers and acetylsalicylic acid (ASA). Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents are indicated for some patients, and calcium channel blockers should generally be avoided. It is suspected that many patients with MI are not discharged from hospital with optimal medical management.
To determine what proportion of patients in a tertiary care hospital with acute MI are discharged on optimal medical therapy, and to identify what barriers exist to obtaining optimal treatment for as many patients as possible.
Charts were retrospectively reviewed for 717 patients with acute MI admitted to the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia from January 1, 1997 to April 30, 1999. Charts were reviewed for demographics, comorbidities, investigations performed, and medications on admission and discharge. When discharge medications did not match the optimal medical management, the chart was reviewed for the reasoning behind the decisions.
In-hospital mortality was 9.6%. Among 648 patients who survived to discharge, 577 (89.0%) were discharged on a beta-blocker, 261 (40.3%) on an ACE inhibitor, 105 (16.2%) on a calcium channel blocker and 578 (89.2%) on ASA. Patients 65 years of age or older were less likely than their younger counterparts to be discharged on a beta-blocker (272 of 315 [86.3%] versus 305 of 333 [91.6%], P<0.04) and more likely to be discharged on a calcium channel blocker (70 of 315 [22.2%] versus 35 of 333 [10.5%], P<0.0001). No significant difference in the use of beta-blockers or calcium channel blockers was found between men and women (beta-blockers: 385 of 432 [89.1%] men versus 192 of 216 [89.9%] women, P<0.92); calcium channel blockers (67 of 432 men [15.5%] versus 38 of 216 women [17.6%], P<0.50). Among patients with low density lipoprotein greater than 3.5 mmol/L, 158 of 200 (79.0%) were discharged on a lipid-lowering agent. Among patients with documented ejection fraction less than 40%, 94 of 103 (91.3%) were discharged on an ACE inhibitor. Most patients had acceptable contraindications to the medications that they did not receive.
The study centre showed much better use of appropriate medications than has been previously described, showing that optimal medical therapy can be achieved for the vast majority of patients with acute MI.
急性心肌梗死（MI）后的管理标准包括使用β受体阻滞剂和阿司匹林（ASA）。血管紧张素转换酶（ACE）抑制剂和降脂药物适用于部分患者，而钙通道阻滞剂一般应避免使用。有人怀疑，许多心肌梗死患者出院时并未接受最佳药物治疗。
确定三级护理医院中接受急性心肌梗死治疗的患者中，接受最佳药物治疗出院的比例，并找出为尽可能多的患者获得最佳治疗存在哪些障碍。
回顾性分析了1997年1月1日至1999年4月30日期间入住新斯科舍省哈利法克斯伊丽莎白二世健康科学中心的717例急性心肌梗死患者的病历。查阅病历以了解人口统计学、合并症、所进行的检查以及入院和出院时的用药情况。当出院用药与最佳药物治疗不匹配时，则查阅病历以了解决策背后的理由。
住院死亡率为9.6%。在648例存活至出院的患者中，577例（89.0%）出院时使用了β受体阻滞剂，261例（40.3%）使用了ACE抑制剂，105例（16.2%）使用了钙通道阻滞剂，578例（89.2%）使用了ASA。65岁及以上的患者比年轻患者出院时使用β受体阻滞剂的可能性更小（315例中的272例[86.3%]对333例中的305例[91.6%]，P<0.04），而使用钙通道阻滞剂出院的可能性更大（315例中的70例[22.2%]对333例中的35例[10.5%]，P<0.0001）。男性和女性在使用β受体阻滞剂或钙通道阻滞剂方面未发现显著差异（β受体阻滞剂：432例男性中的385例[89.1%]对216例女性中的192例[89.9%]，P<0.92）；钙通道阻滞剂（432例男性中的67例[15.5%]对216例女性中的38例[17.6%]，P<0.5）。在低密度脂蛋白大于3.5 mmol/L的患者中，200例中的158例（79.0%）出院时使用了降脂药物。在记录的射血分数小于40%的患者中，103例中的94例（91.3%）出院时使用了ACE抑制剂。大多数患者对未接受的药物有可接受的禁忌证。
该研究中心对适当药物的使用情况比先前描述的要好得多，表明绝大多数急性心肌梗死患者可以实现最佳药物治疗。
