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1.
J Intern Med ; 264(3): 254-64, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18397247

RESUMO

OBJECTIVES: To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes. BACKGROUND: Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB). DESIGN AND SETTING: We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088). RESULTS: The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45). CONCLUSIONS: Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.


Assuntos
Infarto do Miocárdio/terapia , Adulto , Idoso , Fármacos Cardiovasculares/uso terapêutico , Tratamento Farmacológico/tendências , Eletrocardiografia , Medicina Baseada em Evidências , Feminino , Alemanha/epidemiologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Revascularização Miocárdica/métodos , Revascularização Miocárdica/tendências , Prognóstico , Estudos Prospectivos , Sistema de Registros , Resultado do Tratamento
2.
Eur Heart J ; 23(9): 714-20, 2002 May.
Artigo em Inglês | MEDLINE | ID: mdl-11977997

RESUMO

AIMS: To examine the general influence of the definition of fatal and non-fatal acute myocardial infarction and coronary deaths on the estimation of in-hospital case-fatality, and to show how the definition of acute myocardial infarction influences time-trends of hospital mortality over 11 years. METHODS AND RESULTS: As part of the World Health Organization's MONICA (multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project in Augsburg all patients aged 25-74 years with a suspected diagnosis of acute myocardial infarction who were hospitalized in the study region's major clinic were registered prospectively between 1985 to 1995 (n=4889). Patient information, including short-term survival status, was obtained from medical records, by interview of surviving patients, and municipal death certificate files which were validated by an extended identification and validation process. In-hospital case fatality was estimated according to different definitions which closely followed the international MONICA criteria. Epidemiological definitions comprised definite and possible acute myocardial infarction, and events with unclassifiable deaths, while the clinical definition was restricted to definite infarction. Overall, case fatality by the epidemiological definitions was 28 to 29.8% (23.5% of those treated in a coronary care unit) compared to 13.5% using the clinical definition. While over the 11 years, the reduction in case fatality according to the epidemiological definitions was modest, highly significant decreases were observed by applying the clinical definition (from 15.8% in 1985-1988 to 10.8% in 1993-1995, P<0.001 adjusted for age and sex). The discrepancy in case fatality between the definitions is explained by the high proportion of patients who die very early (about 70% of all fatal events during the first 24 h) with the consequence of missing data which may preclude a definite diagnosis of acute myocardial infarction. CONCLUSIONS: Applying a broader definition of acute myocardial infarction reveals that in-hospital mortality is higher than believed until now, and it implies that our efforts must be intensified to reduce overall in-hospital coronary heart disease mortality.


Assuntos
Mortalidade Hospitalar/tendências , Infarto do Miocárdio/mortalidade , Adulto , Fatores Etários , Idoso , Feminino , Alemanha/epidemiologia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Sistema de Registros , Análise de Sobrevida , Fatores de Tempo
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