Use of coronary angiography after acute myocardial infarction in Germany: a comparison of daily clinical practice with international guidelines

Objectives: Two third of patients with acute myocardial infarction are admi tted to hospitals without cardiac catheterization facilities, Whether a pos tinfarction patient will undergo cardiac catheterization or not is more oft en decided by general physicians than by cardiologists, The purpose of this presentation is to investigate the determinants for decision making to use cardiac catheterization in patients after myocardial infarction. Methods: MITRA is a prospective, multicenter registry, which enrolls all co nsecutive patients with acute Q wave infarction admitted to 54 hospitals in Southwestern Germany. During the pilot phase 949 consecutive survivors of acute myocardial infarc tion were included, and inhospital outcome as well as therapeutic strategie s were registered. Results: Only half of the patients underwent cardiac catheterization regard less of whether a catheterization facility was available or not. In 63% of the patients under 65 years-of age coronary angiography was performed; howe ver, every fourth patient with age above 70 years was transferred to an inv asive therapeutic strategy. The percentage of male patients was twice as hi gh in the invasive group, whereas patients with prior infarction, clinical signs of congestive heart failure, patients with moderately or severely imp aired left ventricular function, and finally patients with a prehospital de lay of more than 4 hours were more frequent in the conservative group, The following three parameters were calculated to be independent determinants o f an invasive strategy: pathological stress ECG (OR: 2.8; CI: 1.80-4.60), p atients < 70 years without stress ECG (OR: 2.18; CI: 1.5-3.18), and male ge nder (OR: 1.45: CI: 1.10-2.00). Independent factors of a conservative strat egy were primary PTCA (OR: 0.2; CI: 0.09-0.46), prehospital delay > 4 hours (OR: 0.71; CI: 0.51-0.97), and the combination of age > 70 years and the a bsence of a stress ECG (OR: 0.78; CI: 0.55-1.11). Conclusions: In Germany, patients with acute myocardial infarction are less likely to undergo cardiac catheterization compared to patients in other We stern countries (e.g., the United States). Despite recommended guidelines, invasive strategies are more frequent in low risk groups (younger patients, male gender) than in postinfarction patients at high risk (severely impair ed left ventricular function, clinical signs of congestive heart failure, t he elderly).