Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
J Am Coll Cardiol. 2011 Oct 18;58(17):1760-5. doi: 10.1016/j.jacc.2011.06.050.
The goals of this analysis were to determine: 1) whether guideline-based care during hospitalization for a myocardial infarction (MI) varied as a function of patients' baseline risk; and 2) whether temporal improvements in guideline adherence occurred in all risk groups.
Guideline-based care of patients with MI improves outcomes, especially among those at higher risk. Previous studies suggest that this group is paradoxically less likely to receive guideline-based care (risk-treatment mismatch).
A total of 112,848 patients with MI were enrolled at 279 hospitals participating in Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) between August 2000 and December 2008. We developed and validated an in-hospital mortality model (C-statistic: 0.75) to stratify patients into risk tertiles: low (0% to 3%), intermediate (3% to 6.5%), and high (>6.5%). Use of guideline-based care and temporal trends were examined.
High-risk patients were significantly less likely to receive aspirin, beta-blockers, angiotensin-converting inhibitors/angiotensin receptor blockers, statins, diabetic treatment, smoking cessation advice, or cardiac rehabilitation referral at discharge compared with those at lower risk (all p < 0.0001). However, use of guideline-recommended therapies increased significantly in all risk groups per year (low-risk odds ratio: 1.33 [95% confidence interval (CI): 1.22 to 1.45]; intermediate-risk odds ratio: 1.30 [95% CI: 1.21 to 1.38]; and high-risk odds ratio: 1.30 [95% confidence interval: 1.23 to 1.37]). Also, there was a narrowing in the guideline adherence gap between low- and high-risk patients over time (p = 0.0002).
Although adherence to guideline-based care remains paradoxically lower in those MI patients at higher risk of mortality and most likely to benefit from treatment, care is improving for eligible patients within all risk categories, and the gaps between low- and high-risk groups seem to be narrowing.
本分析旨在确定：1）基于指南的心肌梗死（MI）住院治疗是否因患者的基线风险而异；2）所有风险组是否都存在指南依从性的时间改善。
MI 患者的基于指南的治疗可改善结局，尤其是高危患者。既往研究表明，这组患者反而不太可能接受基于指南的治疗（风险-治疗不匹配）。
共有 279 家医院参与了 2000 年 8 月至 2008 年 12 月的 Get With The Guidelines-Coronary Artery Disease（GWTG-CAD）研究，共纳入 112848 例 MI 患者。我们开发并验证了一个院内死亡率模型（C 统计量：0.75），将患者分为低危（0%至 3%）、中危（3%至 6.5%）和高危（>6.5%）三组。研究了基于指南的治疗的使用情况和时间趋势。
高危患者与低危患者相比，出院时接受阿司匹林、β受体阻滞剂、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂、他汀类药物、糖尿病治疗、戒烟建议或心脏康复转诊的可能性显著降低（均 p < 0.0001）。然而，每年所有风险组中指南推荐治疗的使用均显著增加（低危组比值比：1.33[95%置信区间（CI）：1.22 至 1.45]；中危组比值比：1.30[95%CI：1.21 至 1.38]；高危组比值比：1.30[95%置信区间：1.23 至 1.37]）。此外，随着时间的推移，低危和高危患者之间的指南依从性差距逐渐缩小（p = 0.0002）。
尽管高危 MI 患者死亡率更高，最有可能从治疗中获益，但基于指南的治疗的依从性仍存在悖论性降低，但所有风险类别中的合格患者的治疗都在改善，低危和高危组之间的差距似乎正在缩小。
