MANAGEMENT OF MYOCARDIAL-INFARCTION IN TH E RHONE-ALPS REGION - ARE THERE MANY VARIATIONS IN PRACTICE

The aim of this study was to determine the diagnostic and therapeutic strategies after myocardial infarction and to examine variations in me dical and surgical practice with respect to the severity of disease, s tatus of the hospital and patients' characteristics. The method used w as a prospective study with follow-up at 30 days and 18 months. The su bjects came from an exhaustive cohort of all patients admitted to hosp ital for myocardial infarction during the month of April 1991 in 57 pu blic and private hospitals in the Rhone-Alps region (n = 311). The pat ients were identified after admission by consulting physicians of the Department of Social Security. The study included all patients with ac ute myocardial infarction with at least two of the three usual diagnos tic criteria (prolonged, constrictive chest pain, enzyme increases and electrocardiographic changes). The study excluded patients who were d ead before arrival at hospital. The parameters analysed included the c linical management, use of echocardiography, exercise stress testing, myocardial scintigraphy, coronary angiography, thrombolysis, angioplas ty and coronary bypass surgery in the first 30 days after admission. T he severity of infarction was assessed by seven clinical, enzymatic an d electrocardiographic criteria by physicians from the Department of S ocial Security (pain, syncope, shock, left ventricular dysfunction, el evation of CPK > 1000 IU, anterior or extensive necrosis, arryhthmias) . The mortality rate of this cohort was calculated from hospital stati stics and then by enquiring in the town halls of the region. The demog raphic features of the cohort were marked by a predominance of men (69 .5%) and a relatively high mean age (69 years; 23% over 80 years). Com plementary investigations were used with the following frequencies : e chocardiography, 61.1%; coronary angiography, 26.4%; exercise stress t esting 22.8%; myocardial scintigraphy, 5.5%. Of the 82 coronary angiog raphies performed, 37(45%) were undertaken without previous echocardio graphy or exercise stress testing. During the first 30 days, thromboly sis was administered in 32.5% of cases and coronary angioplasty in 7.4 % of cases, and/or coronary bypass surgery in 3.5% of cases. The morta lity was significantly correlated with the score of severity of the in farction (p < 0.001, odds ratio = 3.58). Exercise stress testing was p erformed much more frequently in patients under 65 years of age (p < 0 .0001) and in patients admitted to university hospitals (p < 0.01>. Af ter correction by a logistic regression model, the frequency of corona ry angiography was significantly higher in patients under 65 years of age (p < 0.0001), in men (p = 0.006) and lower in patients with severe infarction (p = 0.007). The referrals for coronary angiography were n ot significantly related to the use of exercise stress testing or the type of hospital. This study shows that the use of invasive diagnostic methods was closely correlated with the age and gender of the patient after correcting for the severity of infarction and type of hospital. Analysis of a larger cohort should provide information about the vari ability of interventional therapeutic techniques (angioplasty, bypass surgery), according to the same characteristics and with respect geogr aphic region.