Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)

Abstract

Background: The benefits of reperfusion therapy for patients with acute coronary syndromes have been established, but there is much variation in the type of reperfusion given and decisions about which patients are eligible. This study assessed current practices in relation to reperfusion therapy of ST-segment-elevation myocardial infarction from data collected in the multinational, prospective Global Registry of Acute Coronary Events.

Methods: 94 hospitals in 14 countries are recruiting patients for the registry. Hospitals are organised into population-based clusters that reflect the population characteristics of the region. Information about patients' demographic characteristics, presenting symptoms, medical history, time between symptom onset and presentation, and clinical and electrocardiographic features is recorded in a standard case record.

Findings: Of the 9251 patients enrolled, 1763 presented within 12 h of symptom onset with ST-segment-elevation myocardial infarction. Of these, 30% did not receive reperfusion therapy. Elderly patients (75 years and older), those presenting without chest pain, and those with a history of diabetes, congestive heart failure, myocardial infarction, or coronary bypass surgery were less likely to receive reperfusion therapy. The rate of primary percutaneous coronary intervention was highest in the USA and lowest in Australia, New Zealand, and Canada. The rate at sites with a catheterisation laboratory was 19% compared with zero at sites without this facility.

Interpretation: A substantial proportion of patients who are eligible for reperfusion therapy still do not receive this treatment. These typically high-risk patients can be identified in advance, and reasons for the underuse of these beneficial treatments need to be clarified.