Therese Droste

WASHINGTON — Myocardial infarction patients who did not have documented ischemic symptoms upon hospital admission received lower quality care, were prescribed fewer established therapies, and had significantly higher risk-adjusted in-hospital mortality than patients with documented ischemic symptoms, Erik Schelbert, M.D., reported at a meeting that was sponsored by the American Heart Association.

Patients without ischemic symptoms received significantly less treatment with aspirin or β-blockers, and underwent less reperfusion therapy. These patients who lacked symptoms of ischemia were also more likely to be female, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 to June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death statistics to determine whether ischemic symptoms were documented. Trauma patients and those with acute gastrointestinal bleeding, stroke, or hip fracture were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

Although data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is ostensibly the first study that included patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic according to current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all the patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert.

It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of those with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” Dr. Schelbert said.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who did not have documented ischemic symptoms upon hospital admission received lower quality care, were prescribed fewer established therapies, and had significantly higher risk-adjusted in-hospital mortality than patients with documented ischemic symptoms, Erik Schelbert, M.D., reported at a meeting that was sponsored by the American Heart Association.

Patients without ischemic symptoms received significantly less treatment with aspirin or β-blockers, and underwent less reperfusion therapy. These patients who lacked symptoms of ischemia were also more likely to be female, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 to June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death statistics to determine whether ischemic symptoms were documented. Trauma patients and those with acute gastrointestinal bleeding, stroke, or hip fracture were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

Although data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is ostensibly the first study that included patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic according to current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all the patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert.

It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of those with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” Dr. Schelbert said.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who did not have documented ischemic symptoms upon hospital admission received lower quality care, were prescribed fewer established therapies, and had significantly higher risk-adjusted in-hospital mortality than patients with documented ischemic symptoms, Erik Schelbert, M.D., reported at a meeting that was sponsored by the American Heart Association.

Patients without ischemic symptoms received significantly less treatment with aspirin or β-blockers, and underwent less reperfusion therapy. These patients who lacked symptoms of ischemia were also more likely to be female, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 to June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death statistics to determine whether ischemic symptoms were documented. Trauma patients and those with acute gastrointestinal bleeding, stroke, or hip fracture were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

Although data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is ostensibly the first study that included patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic according to current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all the patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert.

It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of those with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” Dr. Schelbert said.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Implementing a quality improvement initiative for ST-segment elevation MI shortened the time to treatment with primary percutaneous intervention from 104 minutes to 75 minutes in less than 7 months, reported Luis Haro, M.D.

In addition, the percentage of patients with a time to PCI (called door-to-balloon time [DTBT]) of less than 90 minutes increased from 42% to 82% during the study period of May 17-December 31, 2004. Since then, that percentage has gone up to 90%, and DTBT has decreased to 72 minutes, Dr. Haro, of the department of emergency medicine at the Mayo Clinic, Rochester, Minn., told CARDIOLOGY NEWS.

Dr. Haro and colleagues implemented a quality initiative after a chart review of data from July 2002 to September 2003 showed that the hospital's DTBT was 200 minutes, he said at a meeting sponsored by the American Heart Association.

The initiative involved new processes to streamline communication between providers in the emergency department (ED), the catheterization lab, and the quality department.

“It was very hard to figure out where to find the data, since there are five or six areas to look for information, such as the ED chart and the cath lab report,” said Dr. Haro, quality chair of emergency medicine. A group from quality, communications, cardiology, nursing, and the ED met biweekly for 3 months before implementing the changes. The project's goals were to achieve a door-to-ECG time of 5 minutes, a door-to-activation time of 15 minutes, a door-to-departure-to-cath-lab time of 45 minutes, and a door-to-PCI time of 90 minutes. After closer scrutiny of the original data, the investigators adjusted the initial DTBT to 104 minutes.

The first change was to replace several ED clocks to server-based ones that display official U.S. time, since some of the original discrepancies in the data had to do with how times were recorded in the charts. “Now that every minute counts, it must be accurate,” said Dr. Haro.

Time stamps on a patient's small triage sheet track the initial door time, rather than the registration time, which was used as a point of reference in the past.

“When a patient has chest pain, we place them in a bed immediately and start the evaluation and initial management. Before, we had artificial times, since charts were sometimes generated after a patient had aspirin, oxygen, or an electrocardiogram, meaning 10–15 minutes were spent before their door time was recorded,” said Dr. Haro. Door-to-ECG times dropped from 14.4 minutes to 9.1 minutes.

Several other changes were made. Registration personnel use wireless laptops at patients' bedsides to help capture real-time data, which is immediately displayed on a monitor in the ED. This allows providers to assess whether their performance goals are being accomplished for that given patient.

The ED physician now activates the cardiac catheterization team without a cardiac consultation. Previously, time was wasted through numerous phone calls made among the ED, the CCU and cath team to try and organize a PCI. Now, the entire team is activated by a single group page within 15 minutes of the patient's arrival. The pagers display text to state the problem, the patient's location, and when the patient will be on the table. “It runs similar to a trauma system,” said Dr. Haro. Cath team members make one call in to a communications center to acknowledge the page, whereas CCU personnel just show up to join the team.

To improve door-to-departure times, 2-hour priority parking was given to cath lab members, who previously parked at a distance from the hospital; a dedicated phone line was established between the ED and the cath lab; and elevator keys were given to cath team members to bypass stopping at floors, which used to slow them down.

The American College of Cardiology recommends a 60–120 minute DTBT, while the Joint Commission on the Accreditation of Healthcare Organizations recently changed recommended times from 90 to 120 minutes.

WASHINGTON — Implementing a quality improvement initiative for ST-segment elevation MI shortened the time to treatment with primary percutaneous intervention from 104 minutes to 75 minutes in less than 7 months, reported Luis Haro, M.D.

In addition, the percentage of patients with a time to PCI (called door-to-balloon time [DTBT]) of less than 90 minutes increased from 42% to 82% during the study period of May 17-December 31, 2004. Since then, that percentage has gone up to 90%, and DTBT has decreased to 72 minutes, Dr. Haro, of the department of emergency medicine at the Mayo Clinic, Rochester, Minn., told CARDIOLOGY NEWS.

Dr. Haro and colleagues implemented a quality initiative after a chart review of data from July 2002 to September 2003 showed that the hospital's DTBT was 200 minutes, he said at a meeting sponsored by the American Heart Association.

The initiative involved new processes to streamline communication between providers in the emergency department (ED), the catheterization lab, and the quality department.

“It was very hard to figure out where to find the data, since there are five or six areas to look for information, such as the ED chart and the cath lab report,” said Dr. Haro, quality chair of emergency medicine. A group from quality, communications, cardiology, nursing, and the ED met biweekly for 3 months before implementing the changes. The project's goals were to achieve a door-to-ECG time of 5 minutes, a door-to-activation time of 15 minutes, a door-to-departure-to-cath-lab time of 45 minutes, and a door-to-PCI time of 90 minutes. After closer scrutiny of the original data, the investigators adjusted the initial DTBT to 104 minutes.

The first change was to replace several ED clocks to server-based ones that display official U.S. time, since some of the original discrepancies in the data had to do with how times were recorded in the charts. “Now that every minute counts, it must be accurate,” said Dr. Haro.

Time stamps on a patient's small triage sheet track the initial door time, rather than the registration time, which was used as a point of reference in the past.

“When a patient has chest pain, we place them in a bed immediately and start the evaluation and initial management. Before, we had artificial times, since charts were sometimes generated after a patient had aspirin, oxygen, or an electrocardiogram, meaning 10–15 minutes were spent before their door time was recorded,” said Dr. Haro. Door-to-ECG times dropped from 14.4 minutes to 9.1 minutes.

Several other changes were made. Registration personnel use wireless laptops at patients' bedsides to help capture real-time data, which is immediately displayed on a monitor in the ED. This allows providers to assess whether their performance goals are being accomplished for that given patient.

The ED physician now activates the cardiac catheterization team without a cardiac consultation. Previously, time was wasted through numerous phone calls made among the ED, the CCU and cath team to try and organize a PCI. Now, the entire team is activated by a single group page within 15 minutes of the patient's arrival. The pagers display text to state the problem, the patient's location, and when the patient will be on the table. “It runs similar to a trauma system,” said Dr. Haro. Cath team members make one call in to a communications center to acknowledge the page, whereas CCU personnel just show up to join the team.

To improve door-to-departure times, 2-hour priority parking was given to cath lab members, who previously parked at a distance from the hospital; a dedicated phone line was established between the ED and the cath lab; and elevator keys were given to cath team members to bypass stopping at floors, which used to slow them down.

The American College of Cardiology recommends a 60–120 minute DTBT, while the Joint Commission on the Accreditation of Healthcare Organizations recently changed recommended times from 90 to 120 minutes.

WASHINGTON — Implementing a quality improvement initiative for ST-segment elevation MI shortened the time to treatment with primary percutaneous intervention from 104 minutes to 75 minutes in less than 7 months, reported Luis Haro, M.D.

In addition, the percentage of patients with a time to PCI (called door-to-balloon time [DTBT]) of less than 90 minutes increased from 42% to 82% during the study period of May 17-December 31, 2004. Since then, that percentage has gone up to 90%, and DTBT has decreased to 72 minutes, Dr. Haro, of the department of emergency medicine at the Mayo Clinic, Rochester, Minn., told CARDIOLOGY NEWS.

Dr. Haro and colleagues implemented a quality initiative after a chart review of data from July 2002 to September 2003 showed that the hospital's DTBT was 200 minutes, he said at a meeting sponsored by the American Heart Association.

The initiative involved new processes to streamline communication between providers in the emergency department (ED), the catheterization lab, and the quality department.

“It was very hard to figure out where to find the data, since there are five or six areas to look for information, such as the ED chart and the cath lab report,” said Dr. Haro, quality chair of emergency medicine. A group from quality, communications, cardiology, nursing, and the ED met biweekly for 3 months before implementing the changes. The project's goals were to achieve a door-to-ECG time of 5 minutes, a door-to-activation time of 15 minutes, a door-to-departure-to-cath-lab time of 45 minutes, and a door-to-PCI time of 90 minutes. After closer scrutiny of the original data, the investigators adjusted the initial DTBT to 104 minutes.

The first change was to replace several ED clocks to server-based ones that display official U.S. time, since some of the original discrepancies in the data had to do with how times were recorded in the charts. “Now that every minute counts, it must be accurate,” said Dr. Haro.

Time stamps on a patient's small triage sheet track the initial door time, rather than the registration time, which was used as a point of reference in the past.

“When a patient has chest pain, we place them in a bed immediately and start the evaluation and initial management. Before, we had artificial times, since charts were sometimes generated after a patient had aspirin, oxygen, or an electrocardiogram, meaning 10–15 minutes were spent before their door time was recorded,” said Dr. Haro. Door-to-ECG times dropped from 14.4 minutes to 9.1 minutes.

Several other changes were made. Registration personnel use wireless laptops at patients' bedsides to help capture real-time data, which is immediately displayed on a monitor in the ED. This allows providers to assess whether their performance goals are being accomplished for that given patient.

The ED physician now activates the cardiac catheterization team without a cardiac consultation. Previously, time was wasted through numerous phone calls made among the ED, the CCU and cath team to try and organize a PCI. Now, the entire team is activated by a single group page within 15 minutes of the patient's arrival. The pagers display text to state the problem, the patient's location, and when the patient will be on the table. “It runs similar to a trauma system,” said Dr. Haro. Cath team members make one call in to a communications center to acknowledge the page, whereas CCU personnel just show up to join the team.

To improve door-to-departure times, 2-hour priority parking was given to cath lab members, who previously parked at a distance from the hospital; a dedicated phone line was established between the ED and the cath lab; and elevator keys were given to cath team members to bypass stopping at floors, which used to slow them down.

The American College of Cardiology recommends a 60–120 minute DTBT, while the Joint Commission on the Accreditation of Healthcare Organizations recently changed recommended times from 90 to 120 minutes.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003-June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death to determine whether ischemic symptoms were documented. Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin, compared with 96% of those with symptoms. A total of 64% received β-blockers within 24 hours, compared with 85% of those with symptoms, and 18% received reperfusion therapy, compared with 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely than symptomatic patients to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

The unadjusted in-hospital mortality rates were also higher in those patients who did not have ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003-June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death to determine whether ischemic symptoms were documented. Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin, compared with 96% of those with symptoms. A total of 64% received β-blockers within 24 hours, compared with 85% of those with symptoms, and 18% received reperfusion therapy, compared with 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely than symptomatic patients to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

The unadjusted in-hospital mortality rates were also higher in those patients who did not have ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003-June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death to determine whether ischemic symptoms were documented. Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care persisted through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin, compared with 96% of those with symptoms. A total of 64% received β-blockers within 24 hours, compared with 85% of those with symptoms, and 18% received reperfusion therapy, compared with 71% of patients with symptoms, all significant differences.

At discharge, those without ischemic symptoms were less likely than symptomatic patients to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL-cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%).

The unadjusted in-hospital mortality rates were also higher in those patients who did not have ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 through June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death data to learn whether ischemic symptoms were documented.

Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care were found to persist through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of patients with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At hospital discharge, patients without ischemic symptoms were less likely than patients with ischemic symptoms to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%). Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 through June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death data to learn whether ischemic symptoms were documented.

Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care were found to persist through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of patients with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At hospital discharge, patients without ischemic symptoms were less likely than patients with ischemic symptoms to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%). Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.

WASHINGTON — Myocardial infarction patients who lacked documented ischemic symptoms upon hospital admission received lower quality care, were issued fewer established therapies, and had significantly higher risk-adjusted, in-hospital mortality than those with symptoms, Erik Schelbert, M.D., reported at a meeting sponsored by the American Heart Association.

There was significantly less use of aspirin, β-blockers, and reperfusion therapy in those without ischemic symptoms, who were also more likely to be women, nonwhite, and older than the symptomatic patients.

“Curiously, these trends continued until discharge,” said Dr. Schelbert of the University of Iowa, Iowa City.

He presented data from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study, which enrolled 3,960 MI patients in 19 centers during January 2003 through June 2004.

Dr. Schelbert and his coinvestigators reviewed the charts of 3,825 patients, comparing Centers for Medicare and Medicaid Services performance measures and in-hospital death data to learn whether ischemic symptoms were documented.

Trauma patients and those with acute GI bleeds, strokes, and hip fractures were excluded.

A subgroup of 2,480 patients was interviewed within 2 days of admission to get their point of view of what brought them to the hospital.

While data from other studies have shown that women, minorities, and older patients often don't show traditional symptoms for MI, this is the first study to include patient interviews in order to link symptoms with outcomes.

Overall, 6.2% of the 3,825 patients had no ischemic symptoms documented in their charts upon admission, but of those who were interviewed, 72% had at least one symptom that would be considered ischemic by current American Heart Association/American College of Cardiology guidelines.

The undocumented symptoms included shortness of breath (50%), chest pain (40%), and nausea (31%).

Although troponin assays confirmed myocardial damage in all patients, the disparities in care were found to persist through discharge.

“Because the lack of documented symptoms of MI and the following lesser-quality care were linked, we inferred that patients' symptoms were not recognized. Clearly, most patients actually did have symptoms, as the interviews then showed,” said Dr. Schelbert. It's possible that these patients had comorbidities that made a diagnosis of MI more difficult, he added.

Of those asymptomatic patients eligible during hospital admission, 85% received aspirin vs. 96% of those with symptoms, 64% received β-blockers within 24 hours vs. 85% of patients with symptoms, and 18% received reperfusion therapy vs. 71% of patients with symptoms, all significant differences.

At hospital discharge, patients without ischemic symptoms were less likely than patients with ischemic symptoms to receive aspirin (86% vs. 94%), β-blockers (80% vs. 89%), or ACE inhibitors (58% vs. 69%).

Asymptomatic patients also were less likely to receive statin therapy for secondary MI prevention at LDL cholesterol thresholds of 100 mg/dL (70% vs. 87%) or 70 mg/dL (61% vs. 84%). Unadjusted in-hospital mortality rates were also higher in patients without ischemic symptoms (15% vs. 3%).

“There is evidence of a significant breakdown in communication, and patient symptoms are being missed. The cause of this needs further investigation,” said Dr. Schelbert.

The study was funded by grants from the Agency for Healthcare Research and Quality and CVT Therapeutics.