EARLY ASSESSMENT AND IN-HOSPITAL MANAGEMENT OF PATIENTS WITH ACUTE MYOCARDIAL-INFARCTION AT INCREASED RISK FOR ADVERSE OUTCOMES - A NATIONWIDE PERSPECTIVE OF CURRENT CLINICAL-PRACTICE

Background Therapeutic decision making in critically ill patients requ ires both prompt and comprehensive analysis of available information. Data derived from randomized clinical trials provide a powerful tool f or risk assessment in the setting of acute myocardial infarction (MI); however, timely and appropriate use of existing therapies and resourc es are the key determinants of outcome among high-risk patients. Metho ds Demographic, procedural, and outcome data from patients with MI wer e collected at 1073 U.S, hospitals collaborating in the National Regis try of MI (NRMI 2). Patients were classified on hospital arrival as ei ther ''low risk'' or ''high risk'' according to a modified Thrombolysi s in Myocardial Infarction II Risk Scale based on predetermined demogr aphic, electrocardiographic, and clinical features. Results Among the 170,143 patients enrolled, 115,222 (67.5%) were classified as low risk and 55,521 (32.5%) as high risk for in-hospital death, recurrent isch emia, recurrent MI, congestive heart failure, and stroke. Using a comp osite unsatisfactory outcome measure, in-hospital adverse events were had by a greater proportion of patients initially classified as high r isk compared with those classified as low risk. By multivariate analys is, age >70 years, prior MI, Killip class >1, anterior site of infarct ion, and the combination of hypotension and tachycardia were independe nt predictions of poor outcome in patients with or without ST-segment elevation on the presenting electrocardiogram. High-risk patients with ST-segment elevation were treated with thrombolytics (47.5%) or alter native forms of reperfusion therapy (9.3%) within 62 minutes and 226 m inutes of hospital arrival, respectively. High-risk patients offered r eperfusion therapy were also more likely to receive aspirin, P-blocker s (intravenous, oral) and angiotensin-converting enzyme inhibitors wit hin 24 hours of infarction (all p < 0.0001), survive their event (8.4% versus 21.4% p < 0.0001), and leave the hospital sooner than those no t reperfused. Conclusions This large registry experience included more than 150,000 nonselected patients with MI and suggests that high-risk patients can be identified on initial hospital presentation. The curr ent use of reperfusion and adjunctive therapies among high-risk patien ts is suboptimal and may directly influence outcome. Randomized trials designed to test the impact of specific management strategies on outc ome according to initial risk classification are warranted.