Dondo Tatendashe B, Hall Marlous, Timmis Adam D, Gilthorpe Mark S, Alabas Oras A, Batin Phillip D, Deanfield John E, Hemingway Harry, Gale Chris P
1 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
2 The National Institute for Health Biomedical Research Unit, Barts Health, UK.
Eur Heart J Acute Cardiovasc Care. 2017 Aug;6(5):412-420. doi: 10.1177/2048872616647705. Epub 2016 May 3.
Adherence to guideline-indicated care for the treatment of non-ST-elevation myocardial infarction (NSTEMI) is associated with improved outcomes. We investigated the extent and consequences of non-adherence to guideline-indicated care across a national health system.
A cohort study ( ClinicalTrials.gov identifier: NCT02436187) was conducted using data from the Myocardial Ischaemia National Audit Project ( n = 389,057 NSTEMI, n = 247 hospitals, England and Wales, 2003-2013). Accelerated failure time models were used to quantify the impact of non-adherence on survival according to dates of guideline publication.
Over a period of 1,079,044 person-years (median 2.2 years of follow-up), 113,586 (29.2%) NSTEMI patients died. Of those eligible to receive care, 337,881 (86.9%) did not receive one or more guideline-indicated intervention; the most frequently missed were dietary advice ( n = 254,869, 68.1%), smoking cessation advice ( n = 245,357, 87.9%), P2Y12 inhibitors ( n = 192,906, 66.3%) and coronary angiography ( n = 161,853, 43.4%). Missed interventions with the strongest impact on reduced survival were coronary angiography (time ratio: 0.18, 95% confidence interval (CI): 0.17-0.18), cardiac rehabilitation (time ratio: 0.49, 95% CI: 0.48-0.50), smoking cessation advice (time ratio: 0.53, 95% CI: 0.51-0.57) and statins (time ratio: 0.56, 95% CI: 0.55-0.58). If all eligible patients in the study had received optimal care at the time of guideline publication, then 32,765 (28.9%) deaths (95% CI: 30,531-33,509) may have been prevented.
The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality. Greater attention to the provision of guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.
遵循非ST段抬高型心肌梗死（NSTEMI）治疗指南推荐的治疗措施与改善预后相关。我们调查了在一个国家卫生系统中不遵循指南推荐治疗措施的程度及其后果。
使用来自心肌缺血国家审计项目的数据（n = 389,057例NSTEMI患者，n = 247家医院，英格兰和威尔士，2003 - 2013年）进行队列研究（ClinicalTrials.gov标识符：NCT02436187）。根据指南发布日期，使用加速失效时间模型来量化不遵循治疗措施对生存的影响。
在1,079,044人年的时间里（中位随访2.2年），113,586例（29.2%）NSTEMI患者死亡。在符合接受治疗条件的患者中，337,881例（86.9%）未接受一项或多项指南推荐的干预措施；最常被遗漏的是饮食建议（n = 254,869例，68.1%）、戒烟建议（n = 245,357例，87.9%）、P2Y12抑制剂（n = 192,906例，66.3%）和冠状动脉造影（n = 161,853例，43.4%）。对降低生存率影响最大的遗漏干预措施是冠状动脉造影（时间比：0.18，95%置信区间（CI）：0.17 - 0.18）、心脏康复（时间比：0.49，95% CI：0.48 - 0.50）、戒烟建议（时间比：0.53，95% CI：0.51 - 0.57）和他汀类药物（时间比：0.56，95% CI：0.55 - 0.58）。如果研究中的所有符合条件的患者在指南发布时都接受了最佳治疗，那么32,765例（28.9%）死亡（95% CI：30,531 - 33,509）可能会被避免。
大多数因NSTEMI住院的患者至少遗漏了一项他们符合条件的指南推荐干预措施。这与额外的死亡率显著相关。更加关注为NSTEMI管理提供指南推荐的治疗措施将减少心血管疾病过早死亡。
