Transcript (TIMI) 9 Registry

Underutilization of evidence-based
medications in Acute ST Elevation
Myocardial Infarction:
Results of the Thrombolysis in
Myocardial Infarction (TIMI) 9 Registry
Christopher P. Cannon, MD * , Maria Cecilia Bahit, MD *, J. Mark
Haugland §, MD , Timothy D. Henry †, MD, Marc J. Schweiger ‡,
MD, George R. McKendall ¥, MD, Prediman K. Shah **, MD,
Sabina Murphy ***,MPH, C.Michael Gibson***, Carolyn H.
McCabe*, BS. Elliott M. Antman *, MD, Eugene Braunwald *, MD,
for the TIMI 9 Registry Investigators
Cannon CP et al. Crit Path Cardiol 2002;1:44-52.
Background

Reperfusion therapy with fibrinolysis or
primary angioplasty has proven to be a
major advance in the treatment of acute
myocardial infarction.

However,reports from studies in the
1980's and recent reports based on data
from national registries have suggested
that only one third of patients with acute
MI receive thrombolytic therapy in North
America.
Background

Fibrinolytic therapy is beneficial only in
patients with ST segment elevation (or new
left bundle branch block) presenting <12
hours, and is potentially harmful in
patients without ST elevation .

It is unclear what proportion of patients
with indications for reperfusion therapy are
receiving thrombolytic therapy or primary
percutaneous coronary intervention (PCI).
In addition, the management and outcome
of patients not treated with reperfusion
therapy is poorly characterized.
Objectives

Assess management strategies and the
outcomes of patients with acute MI
presenting with ST elevation myocardial
infarction (STEMI) in the current era of
aggressive reperfusion therapy.
Methods

All consecutive patients seen in the E.D
and/ or admitted with the diagnosis of acute
MI were prospectively screened.

Inclusion criteria:
 ST elevation  0.1 mV in 2 or more leads
 New or presumably new LBBB
Exclusion criteria:
 None
Patient demgraphics, medical treatment ,
in-hospital outcome prospectively collected


Results
TIMI 9 Registry
n=840 consecutive
patients acute STEMI/ LBBB
20 Hospitals in US and Canada
1994
Fibrinolysis
n=505
51%
TIMI 9 Trial
Primary PCI
n=76
No Reperfusion
n=276
Initial treatment
strategy in STEMI
All patients
No
Reperfusion
31%
Primary
PCI
9%
Patients presenting < 12 hours
No
Reperfusion
25%
Fibrinolysis
60%
Primary
PCI
10%
Fibrinolysis
65%
Baseline Characteristics
All Patients
Fibrinolysis
Primary PCI
No Reperfusion p-value
Age
63.413.9
Female
33%
White
86%
Prior MI 26%
Prior
angina
27%
Prior PCI 7%
Prior
CABG
7%
Prior CHF 6%
Killip
I
80%
II
15%
III
4%
IV
2%
61.9 12.6
30%
87%
17%
61.211.5
24%
85%
21%
67.0 13.9
42%
86%
26%
0.0001
0.001
0.38
0.12
26%
6%
30%
19%
28%
7%
0.73
0.001
7%
3%
5%
4%
7%
13%
0.80
0.001
83%
13%
3%
1%
81%
12%
0%
7%
71%
19%
6%
3%
0.001
Door- to-drug times for patients
treated with fibrinolytic therapy
36
40
28
30
20
16
20
10
0
0-30 min
31-60 min 61-120 min >120 min
Door- to- balloon times for patients
treated with Primary PTCA
% of Patients
60
40
31.4
21.4
20
8.6
11.4
61-90
minutes
91-120
minutes
27.14
0
0-60
minutes
121-180
minutes
>180
minutes
“Contraindications” to
Fibrinolysis
Prior stroke/TIA
Recent CPR,
trauma or surgery
Recent Bleeding
Persistent HTN
Significant illness
Fibrinolysis Prim. PCI
No Reperf
0.6%
2.6%
4.6%
0.8%
0.2%
6.0%
10.3%
15.2%
3.8%
13.9%
39.5%
12.7%
10.4%
8.1%
42.1%
Gender differences in
initial treatment strategy
p=0.153
100%
80%
No Reperfusion
Primary PCI
Fibrinolysis
60%
40%
20%
0%
Men
Women
Medications in 1st 24 hours
Overall
Fibrinolysis
Primary PCI
No Reperfusion
p
Aspirin
87%
93%
93%
72%
0.001
Heparin
91%
98%
100%
74%
0.001
Beta
blockers
61%
71%
57%
43%
0.001
ACE-I
13%
13%
7%
14%
0.22
Calcium
Channel
Blockers
13%
10%
18%
17%
0.003
In-Hospital Mortality
20
18.9 %
3 way p<0.001
16
10.5 %
12
8
7.6 %
4
0
Fibrinolysis
n=505
Primary PTCA
n= 79
No reperfusion
therapy
n=259
In-hospital outcomes
Overall
Lysis
1o PCI
Re-MI
8.1%
10.4%
5.5%
4.3%
0.01
Card
shock
7.4%
5.6%
13.5%
9.3%
0.02
20.6%
20.8%
25.1%
0.45
Mild/Mod
CHF
22.6%
No Rep.Rx
p
ICH
0.2%
0.2%
0%
0.4%
0.80
Major
Bleed
5.8%
8.3%
2.9%
1.6%
0.001
TIMI 9 Registry:
Conclusions
therapy underutilized – 1/3
STEMI failed to receive reperfusion Rx
 Reperfusion
 Door
to drug and door to balloon times
remain suboptimal
 There
is potential to increase the use of
other effective medications (e.g., ASA, Bblockers)
 Efforts
need to continue to expand the
use of guideline-recommended therapies
to all appropriate STEMI patients