Tran Chau T T, Laupacis Andreas, Mamdani Muhammad M, Tu Jack V
University of Toronto, Institute of Medical Sciences, Toronto, Ontario, Canada.
Am Heart J. 2004 Nov;148(5):834-41. doi: 10.1016/j.ahj.2003.11.028.
Previous studies have documented an underuse of evidence-based therapies in patients with acute myocardial infarction (AMI). However, many of these studies failed to consider contraindications to therapy, the effect of age (ie, elderly vs non-elderly patients) on use, or both. The objective of this study was to determine whether elderly patients are less likely than non-elderly patients to receive evidence-based AMI treatments, both before and after the consideration of contraindications to therapy.
A retrospective chart review of a random sample of 5131 patients with AMI who were admitted to 1 of 44 hospitals in Ontario was conducted for the fiscal years 1994 to 1996. Using the Canadian Cardiovascular Research Team (CCORT)/Canadian Cardiovascular Society (CCS) Quality Indicators for AMI Care, we classified patients as being eligible or ideal (ie, no contraindications to treatment) candidates to receive aspirin, beta-blockers, thrombolysis, angiotensin-converting enzyme inhibitors (ACEIs), or statins or to undergo lipid profiling. The proportions of eligible and ideal patients who received treatment were calculated, and the latter were compared with benchmarks.
The median age of the cohort was 69 years; 63% were of the patients were aged > or =65 years. There was underperformance of prescribing treatments in ideal candidates relative to benchmarks (eg, aspirin at discharge: 78.6% vs 90% benchmark). The odds of ideal (ie, no contraindications) elderly candidates receiving various evidence-based AMI treatments were consistently less than that of non-elderly patients with AMI, with the exception of ACEIs at discharge (odds ratio, 1.46; 95% CI, 1.22-1.74).
Despite adjustments for contraindications to therapy, the underuse of AMI treatments, particularly in elderly patients, was found.
既往研究已证明，急性心肌梗死（AMI）患者对循证治疗的应用不足。然而，这些研究中有许多未能考虑治疗的禁忌症、年龄（即老年患者与非老年患者）对治疗应用的影响，或两者皆未考虑。本研究的目的是确定在考虑治疗禁忌症前后，老年患者接受循证AMI治疗的可能性是否低于非老年患者。
对1994年至1996财年安大略省44家医院之一收治的5131例AMI患者的随机样本进行回顾性病历审查。使用加拿大心血管研究团队（CCORT）/加拿大心血管学会（CCS）的AMI护理质量指标，我们将患者分类为接受阿司匹林、β受体阻滞剂、溶栓治疗、血管紧张素转换酶抑制剂（ACEI）或他汀类药物治疗或进行血脂分析的合格或理想（即无治疗禁忌症）候选人。计算接受治疗的合格和理想患者的比例，并将后者与基准进行比较。
队列的中位年龄为69岁；63%的患者年龄≥65岁。相对于基准，理想候选人的治疗处方表现不佳（例如，出院时使用阿司匹林：78.6%对90%的基准）。除出院时使用ACEI外（优势比，1.46；95%CI，1.22 - 1.74），理想（即无禁忌症）的老年候选人接受各种循证AMI治疗的几率始终低于非老年AMI患者。
尽管对治疗禁忌症进行了调整，但仍发现AMI治疗存在应用不足的情况，尤其是在老年患者中。
