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Gaps in acute MI care linked to patient life expectancy
Treatment gaps in the evidence-based management of patients with acute MI may be partly attributable to disparities in treatment based on patient life expectancy, according to recent findings.
In an observational cohort study, researchers evaluated 7,001 patients hospitalized with acute MI between April 1, 2004, and March 31, 2005. All participants were enrolled in the EFFECT project, an analysis of the efficacy of public report cards for improving cardiac care conducted in Ontario. The study cohort had a mean age of 67.6 years, 35.2% were women and 27.1% had a history of diabetes.
The researchers estimated life expectancy for all MI patients who survived to hospital discharge, with a mean expectancy of 12.4 years. To analyze the relationship between life expectancy and treatment patterns, researchers evaluated two treatments: statin therapy and acute reperfusion therapy. Specifically, statin therapy at discharge was assessed among patients with MI, and acute reperfusion therapy was evaluated among those who experienced STEMI within 12 hours of symptom onset. These interventions were chosen to evaluate the potential effect of life expectancy on acute and chronic therapies.
Among acute MI patients considered ideal candidates for therapy, 84.3% of those with MI were prescribed a statin regimen and 72.9% of those with STEMI received acute reperfusion therapy. Both treatments were significantly linked to life expectancy (P<.001): Patients with projected life expectancies of less than 10 years were progressively less likely to receive treatment as life expectancy decreased. Among patients with life expectancies of more than 10 years, the likelihood of receiving therapy remained consistent regardless of life expectancy.
Patients in the 25th percentile of projected life expectancy had a 1.4% decreased likelihood of receiving a statin (95% CI, 1-1.8) and a 2.6% decreased likelihood of undergoing acute reperfusion therapy (95% CI, 1.8-3.3) for every 1-year reduction in projected life expectancy. Similar results were observed when analysis was limited to treatment-eligible patients rather than ideal candidates.
According to the researchers, the lower rates of treatment for patients with shorter life expectancies may be related to physician apprehension regarding adverse events in these patients, specifically with acute reperfusion therapy. However, these patients are still likely to experience meaningful improvements to life expectancy as a result of treatment, despite the increased risk for treatment-related adverse events.
“To overcome this care gap, we think a paradigm shift in improving our understanding of life expectancies is needed,” the researchers wrote. “The primary issue is that the majority of current clinical prediction tools estimate baseline risks of patients. A better approach may be to provide an estimation of baseline risks coupled with treatment-related adverse rates, and provide an overall estimation of treatment benefits and estimated life-expectancy gains.”
Disclosure: The researchers report no relevant financial disclosures.