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Compliance with MI Guidelines Reduces Mortality

Guideline compliance reduces mortality in patients with acute MI.

Clinical guidelines often are controversial because they are based on insufficient evidence or are too rigid to be of practical use for individual patients. The ideal guideline would be supported by proof that compliance results in lower rates of negative outcomes for the condition of interest. In this study, researchers prospectively assessed compliance with guidelines for acute myocardial infarction and the effect of compliance on 1-year mortality at 12 cardiology centers in France.

Hospital and 1-year follow-up data were collected for all 754 patients (333 with STEMI and 421 with NSTEMI) who were admitted during a 6-month period in 2001. Each patient was assigned a risk score based on the Global Registry of Acute Coronary Events (GRACE) scoring system. The authors also assessed compliance, taking into account contraindications to treatment.

Compliance at the 12 centers ranged from 43.7% to 77.9%. One-year mortality rates were 13.8% in the STEMI group and 9.7% in the NSTEMI group. A 10% increase in compliance corresponded to a decrease in mortality (odds ratio for mortality, 0.74; 95% confidence interval, 0.67–0.81). In a multivariate analysis, compliance was a significant independent predictor of mortality. Patients at higher risk had lower compliance scores.

Comment: Few guidelines are tested for actual clinical effect. Although other factors might have contributed to the reduction in mortality at the highly compliant centers studied, this study is the first attempt to demonstrate overall compliance with AMI guidelines as a determinant of outcome in a logistic regression model. The findings are consistent with those of the CRUSADE studies, which evaluated individual measures against outcomes for NSTE ACS. Guidelines should be implemented with healthy skepticism, but those proven to improve outcomes, such as those for STEMI and NSTEMI, should be strongly considered.

— James M. Christenson, MD, FRCPC

Published in Journal Watch Emergency Medicine August 10, 2005

Citation(s):

Schiele F et al. Compliance with guidelines and 1-year mortality in patients with acute myocardial infarction: A prospective study. Eur Heart J 2005 May; 26:873-80.

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