Epidemiology of post-infarction risk stratification strategies in a country with a low volume of revascularization procedures - The GISSI Prognosis Registry

Aims The aims of the GISSI Prognosis Registry were to describe the diagnost ic strategies initiated in acute myocardial infarction patients by a repres entative sample of Italian cardiological centres, and to determine which cl inical or hospital characteristics were associated with the imitiation of i nvasive diagnostic or therapeutic procedures. Methods and Results Baseline characteristics, major in-hospital events and the indication and results of invasive and non-invasive procedures were col lected on 1489 acute myocardial infarction patients discharged alive from 6 5 Italian cardiological centres over a period of 3 months. Twenty-five perc ent of centres had on site catheterization laboratories while the rest did not. Statistical significance was analysed by chi-square tests for categori cal variables. A two-sample Student t-test was used to compare continuous v ariables. The adjusted analysis was performed utilizing multiple logistic r egression models, The most performed procedures were standard, noninvasive: 57.8% of the pati ents underwent an exercise stress test, 70.8% ambulatory ECG monitoring and 95.6% two-dimensional echocardiography. Nuclear or echocardiographic imagi ng tests were performed in 40% of acute myocardial infarcticon survivors. O verall, coronary angiography was planned in 549 patients (36.9%). Variables independently associated with the indication for coronary angiography were residual ischaemia, younger age, contraindication to exercise stress testi ng, level of patients' education, higher volume of non-invasive diagnostic tests, and male sex. Overall, during a 6-month follow-up period, coronary a ngiography, percutaneous transluminal coronary angioplasty and coronary art ery bypass surgery were performed, respectively in 35%, 10% and 8% of the s tudy population. Conclusions The setting where cardiologists practise determines the pattern s of care in acute myocardial infarction patients more than the characteris tics of the patient. The absence of evidence-based guidelines on the more c omplex and expensive procedures favour empirical attitudes and practices. T he confirmation in a prospective cohort of patients, which aims to represen t the care of a whole country, suggests that more effort should be given to the implementation of controlled studies rather than periodical reformulat ion of guidelines not supported by hard data.