Guidelines-based treatment of anaemic STEMI patients: practice patterns and effects on in-hospital mortality: a retrospective analysis from the NCDR

Abstract

Background:

Anaemia is associated with an increased risk for morbidity and mortality in ST-elevation myocardial infarction (STEMI) patients. While several physiological mechanisms have been proposed to explain this association, decreased receipt of guidelines-based care may also contribute. We examined the relationship between admission haemoglobin (Hgb) level, receipt of ACC/AHA guidelines-based treatments, and in-hospital outcomes among STEMI patients. We also evaluated whether administration of these treatments modified the association between anaemia and in-hospital mortality in this group.

Methods and results:

We analysed data from 92,686 patients diagnosed with STEMI included in the NCDR ACTION Registry-GWTG database from January 2007 to March 2011. Patients were stratified by initial Hgb value: 83.1% (n=77,035) were classified as non-anaemic (Hgb >13.0 g/dl for men, >12.0 g/dl for women), 11.6% (n=10,710) as mildly anaemic (11.1−13.0 g/dl for men, 11.1−12.0 g/dl for women), 4.4% (n=4059) as moderately anaemic (9.1−11.0 g/dl), and 1.0% (n=882) as severely anaemic (<9.0 g/dl). Anaemia was associated with a significantly increased prevalence of other baseline comorbidities and decreased odds of receiving several class I recommended pharmacological treatments (heparin, beta-blockers, and angiotensin-converting enzyme inhibitors, p<0.01). The overall use of reperfusion therapy (fibrinolytic therapy and/or percutaneous coronary intervention) was also lower in anaemic vs. non-anaemic patients (p<0.01). Anaemia was associated higher in-hospital mortality risk, which remained significant after adjustment for use of guidelines-recommended therapies and interventions (p<0.01).

Conclusions:

In a national sample of STEMI patients, anaemia on presentation was associated with decreased receipt of ACC/AHA guidelines-based care and higher in-hospital mortality. However, the higher mortality rates could not be fully explained by differences in in-hospital treatment.

Keywords

Anaemia guidelines outcomes ST-segment myocardial infarction (STEMI)treatment

Get full access to this article

View all access options for this article.

References

Sabatine

Morrow

Giugliano

. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111: 2042–2049.

Maluenda

Lemesle

Collins

. The clinical significance of hematocrit values before and after percutaneous coronary intervention. Am Heart J 2009; 158: 1024–1030.

Rao

Jollis

Harrington

. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004; 292: 1555–1562.

McKechnie

Smith

Montoye

. Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention. Circulation 2004; 110: 271–277.

van Straten

Bekker

Soliman Hamad

. Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact Cardiovasc Thorac Surg 2010; 10: 37–42.

Bassand

J-P

Afzal

Eikelboom

.; on behalf of the OASIS 5 and OASIS 6 Investigators. Relationship between baseline haemoglobin and major bleeding complications in acute coronary syndromes. Eur Heart J 2010; 31: 50–58.

Peterson

Roe

Rumsfeld

. A call to ACTION (Acute Coronary Treatment and Intervention Outcomes Network): a national effort to promote timely clinical feedback and support continuous quality improvement for acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2009; 2: 491–499.

World Health Organization. Nutritional anemias: report of a WHO Scientific Group. Geneva: World Health Organization, 1968.

Kushner

Hand

Smith

. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2009; 54: 2205–2241.

10.

Krumholz

Anderson

Bachelder

. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on performance measures (writing committee to develop performance measures for ST-elevation and non-ST-elevation myocardial infarction). Circulation 2008; 118: 2596–2648.

11.

Van de Werf

Bax

Betriu

.; for the Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. Eur Heart J 2008; 29: 2909–2945.

12.

Zeger

Liang

. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42: 121–130.

13.

Chin

Chen

Wang

. Risk adjustment for in-hospital mortality of contemporary patients with acute myocardial infarction: the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry − get with the guidelines (GWTG) acute myocardial infarction mortality model and risk score. Am Heart J 2011; 161: 113–122.

14.

Weiskopf

Viele

Feiner

. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA 1998; 279: 217–221.

15.

Hagl

Heimisch

Meisner

. The effect of hemodilution on regional myocardial function in the presence of coronary stenosis. Basic Res Cardiol 1977; 72: 344–364.

16.

Moscucci

Fox

Cannon

. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2003; 24: 1815–1823.

17.

Steg

James

Atar

.; for The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569–2619.

18.

Hamm

Bassand

J-P

Agewall

.; for The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2011; 32: 2999–3054.

19.

Chen

Pan

Chen

. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366: 1622–1632.

20.

Levine

Bates

Blankenship

. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124: e574–651.

21.

Wang

Chen

Peterson

. Impact of home warfarin use on treatment patterns and bleeding complications for patients with non-ST-segment elevation acute coronary syndromes: observations from the CRUSADE quality improvement initiative. Eur Heart J 2008; 29: 1103–1109.

22.

Mathews

Peterson

Chen

. In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the Action Registry®-GWTG™. Am J Cardiol 2011; 107: 1136–1143.