Miller Amy Leigh, Dib Chadi, Li Li, Chen Anita Y, Amsterdam Ezra, Funk Marjorie, Saucedo Jorge F, Wang Tracy Y
Brigham and Women's Hospital, Cardiovascular Electrophysiology, 75 Francis St., Boston, MA 02115, USA.
Circ Cardiovasc Qual Outcomes. 2012 Sep 1;5(5):662-71. doi: 10.1161/CIRCOUTCOMES.112.965012. Epub 2012 Sep 4.
The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized.
We examined rates of in-hospital LVEF assessment among 77 982 non-ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non-ST-elevation myocardial infarction patients (95.1% versus 91.6%; P<0.001). Excluding patients with prior heart failure did not alter these observations. Significant interhospital variability in LVEF assessment rates was observed. Compared with patients with in-hospital LVEF assessment, patients who did not have LVEF assessed were older and more likely to have clinical comorbidities. In multivariable modeling, lower overall hospital quality of AMI care was also associated with lower likelihood of LVEF assessment (odds ratio for failure to assess LVEF, 1.09; 95% confidence interval, 1.05-1.13 per 10% decrease in defect-free care). Patients with in-hospital LVEF assessment were more likely to be discharged on evidence-based secondary prevention medication therapies compared with patients without LVEF assessment.
The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.
急性心肌梗死（AMI）后，左心室射血分数（LVEF）具有预后和治疗指导作用。尽管LVEF评估是AMI患者的一项关键性能指标，但目前院内评估的比例及其与治疗应用的关系尚未得到充分描述。
我们在急性冠状动脉治疗与干预结果网络注册研究-遵循指南（Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines）中，对2007年1月至2009年9月期间的77982例非ST段抬高型心肌梗死患者和50863例ST段抬高型心肌梗死患者进行了院内LVEF评估率的研究，排除了院内死亡、转至其他急性护理机构、出院接受临终关怀或LVEF评估状态缺失的患者。LVEF评估率随时间显著增加，ST段抬高型心肌梗死患者的评估率高于非ST段抬高型心肌梗死患者（95.1%对91.6%；P<0.001）。排除既往有心力衰竭的患者并未改变这些观察结果。观察到LVEF评估率存在显著的医院间差异。与接受院内LVEF评估的患者相比，未进行LVEF评估的患者年龄更大，更可能有临床合并症。在多变量模型中，AMI护理的总体医院质量较低也与LVEF评估的可能性较低相关（未评估LVEF的比值比为1.09；每降低10%的无缺陷护理，95%置信区间为1.05-1.13）。与未进行LVEF评估的患者相比，接受院内LVEF评估的患者出院时更可能接受基于证据的二级预防药物治疗。
随着时间的推移，AMI患者的LVEF评估有了显著改善，但仍存在显著的医院间差异。未进行院内LVEF评估的患者出院时接受基于证据的药物治疗的可能性较小。这些患者是未来质量改进工作的目标。
