Birga Maier

Present treatment of acute myocardial infarction in patients over 75 years

SummaryAimsGuidelines issued by European and German cardiology societies clearly define procedures for treatment of acute myocardial infarction (AMI). These guidelines, however, are based on clinical studies in which older patients are underrepresented. Older patients, on the other hand, represent a large and growing portion of the infarction population. It was our goal in the present paper to analyse the present treatment of AMI patients over 75 years of age in the city of Berlin, Germany, with data gained from the Berlin Myocardial Infarction Registry (BHIR).MethodsWe prospectively collected data from 5079 patients (3311 men and 1768 women, mean age 65.6) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the period 1999–2003. 1319 patients (25.9%) were older than 75 (mean age 82.5 years).ResultsOverall hospital mortality rate was 11.6%. In patients over 75, this rate was 23.9%; among the younger infarction population, it was 7.3%. In contrast to the younger AMI patients, the majority of those over 75 were female (62.5 vs 25.1% for the younger) and demonstrated a significantly higher frequency of all prognostically meaningful comorbidities (heart failure 14.4% vs. 3.5%; renal failure 11.5 vs 3.9%; diabetes 37.3 vs 24.3%). Clinical signs of severe infarction, moreover, were more common among the aged patients (pulmonary congestion 45.4 vs 19.7%; left bundle branch block 12.7 vs 3.6%). Pre–hospital time was prolonged (2.8 vs 2 h) and guideline–recommended therapy was applied significantly less frequently to AMI patients over 75 (reperfusion therapy 39.8 vs 71.7%, beta–blockers 62.8 vs 78.3%, statins 26.5 vs 45.5%). Multivariate analysis revealed the following factors to be independent predictors of hospital mortality in patients over 75: age (OR 1.05 per year), acute heart failure (OR 2.39), pre–hospital resuscitation (OR 10.6), cardiogenic shock (OR 2.73), pre–hospital delay >12 h (OR 1.68), and ST elevation in the first ECG (OR 2.09). Independent predictors of a favourable hospital course were as follows: admission to a hospital >600 beds (OR 0.64), reperfusion therapy (OR 0.63), early betablocker treatment (OR 0.46), and early application of ACE inhibitors (OR 0.48).ConclusionInfarction patients over 75 have a very high hospital complication and mortality rate. They are typically treated with delay, and with less adherence to relevant guidelines than are younger patients. Reperfusion therapy, early administra tion of beta–blockers and ACE inhibitors, as well as admission to large medical centres are all factors that contribute to a favourable prognosis of high–aged AMI patients.

Influence of gender on treatment and short-term mortality of patients with acute myocardial infarction in Berlin

Frühere Studien bei Patienten mit akutem Myokardinfarkt zeigten eine höhere Krankenhaussterblichkeit von Frauen, speziell jüngeren Frauen, im Vergleich zu Männern. Da die Behandlung des akuten Myokardinfarktes sich schnell entwickelt und nachdem geschlechtsspezifische Aspekte in den letzten Jahren detailliert diskutiert wurden, war es unser Ziel die Determinanten der Krankenhaussterblichkeit, insbesondere geschlechtsspezifische Aspekte, in Berlin erneut zu untersuchen. In einem prospektiven Register wurden die Daten von 5133 Patienten (3330 Männer und 1803 Frauen) mit akutem Myokardinfarkt, welche in den Jahren 1999–2002 in 25 Berliner Krankenhäusern behandelt wurden, gesammelt. Während des Krankenhausaufenthaltes betrug die Gesamtmortalität 18,6% bei den Frauen und 8,4% bei den Männern. Frauen waren älter (mittleres Alter: Männer 62 Jahre, Frauen 73 Jahre) und seltener (noch) verheiratet (Männer 74,6%, Frauen 36,9%) als Männer. Frauen benötigten nach dem Infarktereignis länger bis zum Eintreffen im Krankenhaus (Median: Männer 2,0 h, Frauen 2,6 h) und litten häufiger an Diabetes mellitus (Männer 22,8%; Frauen 36,5%) sowie arterieller Hypertonie (Männer 58,0%; Frauen 69,3%). Eine rekanalisierende Behandlung (Männer 68,8%; Frauen 49,7%) und die Gabe von Betablockern (Männer 76,0%; Frauen 66,0%) wurde bei Frauen seltener angewendet. In einer multivariaten Analyse zeigten sich folgende Parameter als unabhängige Prädiktoren der Krankanhaussterblichkeit: Alter, Geschlecht, Diabetes mellitus, Hypercholesterinämie, vorbestehende Herzinsuffizienz, Reanimation, kardiogener Schock und Lungenstauung bei Aufnahme, Aufnahme in einem Krankenhaus mit mehr als 600 Betten, ST-Streckenhebung im initialen EKG, eine rekanalisierende Therapie, Betablocker und ACE-Hemmer Gabe innerhalb von 48 h nach der Aufnahme. Nach Adjustierung in einer multivariaten Analyse zeigen Frauen mit einem akuten Myokardinfarkt weiterhin ein höheres Risiko im Krankenhaus zu sterben als Männer. Previous studies have shown higher hospital mortality rates in women, especially younger women, than in men. In light of the fact that myocardial infarction therapy is rapidly developing, and since gender-specific aspects have been discussed in detail during recent years, it was our goal to re-evaluate factors influencing hospital mortality rate, especially those involving gender-specific differences, in the city of Berlin, Germany. We prospectively collected data from 5133 patients (3330 men and 1803 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the years 1999 to 2002. During hospitalization the overall mortality rate was 18.6% among women and 8.4% among men. Women were older (mean age for men 62 years; women 73 years) and less likely to be married (men 74.6%; women 36.9%) than men. Women generally took longer to arrive at the hospital after infarction than did men (median time: men 2.0 h; women 2.6 h). Women furthermore demonstrated a higher proportion of diabetes (men 22.8%; women 36.5%) and hypertension (men 58.0%; women 69.3%). Reperfusion therapy (men 68.8%; women 49.7%) and administration of beta-blockers (men 76.0%; women 66.0%) took place less often for women than for men. A multivariate analysis revealed the following factors to be independent predictors of hospital mortality: age, gender, diabetes mellitus, hypercholesterolemia, pre-existing heart failure, pre-hospital cardiopulmonary resuscitation, cardiogenic shock and pulmonary congestion on admission, admission to a hospital with >600 beds, ST-elevation in the initial ECG, reperfusion therapy, as well as beta-blocker and ACE inhibitor treatment within 48 h of hospitalization. Even after adjustment in multivariate analysis, women with acute myocardial infarction still demonstrate a higher risk for in-hospital death than men.

Does Diabetes Mellitus Explain the Higher Hospital Mortality of Women with Acute Myocardial Infarction? Results from the Berlin Myocardial Infarction Registry

Background Women with acute myocardial infarction (AMI) exhibit greater hospital mortality than do men. In general, diabetes mellitus is one of the major factors influencing the outcome of patients with AMI. The aim of this study was to analyze the interaction between diabetes and gender, specifically with regard to the higher hospital mortality of female AMI patients aged ≤ 75 years. Methods We prospectively collected data from 3,715 patients aged ≤ 75 (2,794 men, 921 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin, Germany, from 1999 to 2002. In a multivariate analysis, we specifically studied the interaction between the factors diabetes mellitus and gender in their effects on hospital mortality. Results After adjustment in multivariate analysis, the interaction between gender and diabetes was statistically significant, and the estimated odds ratios were as follows: female diabetic patients compared with male diabetic patients, odds ratio (OR) = 2.28 (95% confidence interval [CI] 1.42-3.68); female diabetic patients compared with male nondiabetic patients, OR = 2.90 (95% CI 1.90-4.42); and female diabetic patients compared with female nondiabetic patients, OR = 2.92 (95% CI 1.75-4.87). There was no statistically significant difference between the risk of dying for female nondiabetic patients or for male diabetic patients when compared with male nondiabetic patients. Conclusions In AMI patients aged ≤ 75 years, female gender alone is not an independent predictor of hospital mortality. Detailed, multivariate analysis reveals that specifically diabetic women demonstrate higher hospital mortality than do men. Special attention should be provided to these female diabetic patients.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome in the real world: Data from the Berlin AFibACS Registry

BACKGROUND Guidelines for the management of atrial fibrillation (AFib) recommend antithromboembolic treatment strategies for patients with AFib and acute coronary syndrome (AFibACS). Our study assessed how current guidelines are implemented in the metropolitan area of Berlin and which therapeutic options were chosen in light of stroke and bleeding riskin everyday practice. METHODS AND RESULTS Between April 2008 and January 2012, we included 1,295 AFibACS patients in the AFibACS Registry, as part of the Berlin Myocardial Infarction Registry. Meanage of the patients was 76 years with numerous comorbidities (15.4% former stroke, 35.0% renal failure, 43.5% diabetes, 92.8% hypertension). Of all the patients, 888 were treated with stent implantation, 91 with balloon angioplasty, and 316 conservatively. Overall mortality was 11.6%, and 8.3% in stented patients. At hospital discharge, triple therapy was administered to 49.9% of stented cases. After adjustment, odds of receiving triple therapy were lower within creasing age and renal failure. Odds were higher after stent implantation, with a higher CHA₂DS₂-VASc score, and with any AFib category compared to initially diagnosed AFib. Between 2008 and 2011, triple therapy increased from 33.3% to 49.8% for stented patients and did not change significantly for those treated conservatively or with balloon angioplasty. CONCLUSIONS These data suggest that in AFibACS patients, antithrombotic treatment focused on dual antiplatelet therapy for ACS, rather than on anticoagulation therapy for stroke prevention. Factors influencing therapy at discharge were age, renal failure, stent implantation, AFib category, and CHA₂DS₂-VASc score. During the study period, triple therapy increased for stented patients.

Comparing routine administrative data with registry data for assessing quality of hospital care in patients with myocardial infarction using deterministic record linkage

BackgroundAssessment of quality of care in patients with myocardial infarction (MI) should be based on data that effectively enable determination of quality. With the need to simplify measurement techniques, the question arises whether routine data can be used for this purpose. We therefore compared data from a German sickness fund (AOK) with data from the Berlin Myocardial Infarction Registry (BMIR).MethodsWe included patients hospitalised for treatment of MI in Berlin from 2009-2011. We matched 2305 patients from AOK and BMIR by using deterministic record linkage with indirect identifiers. For matched patients we compared the frequency in documentation between AOK and BMIR for quality assurance variables and calculated the kappa coefficient (KC) as a measure of agreement.ResultsThere was almost perfect agreement in documentation between AOK and BMIR data for matched patients for: catheter laboratory (KC: 0.874), ST elevation MI (KC: 0.826), diabetes (KC: 0.818), percutaneous coronary intervention (KC: 0.860) and hospital mortality (KC: 0.952). The remaining variables compared showed moderate or less than moderate agreement (KC < 0.6), and were grouped in Category II with less frequent documentation in AOK for risk factors and aspects of patients’ history; in Category III with more frequent documentation in AOK for comorbidities; and in Category IV for medication at and after hospital discharge.ConclusionsRoutine data are primarily collected and defined for reimbursement purposes. Quality assurance represents merely a secondary use. This explains why only a limited number of variables showed almost perfect agreement in documentation between AOK and BMIR. If routine data are to be used for quality assessment, they must be constantly monitored and further developed for this new application. Furthermore, routine data should be complemented with registry data by well-established methods of record linkage to realistically reflect the situation – also for those quality-associated variables not collected in routine data.

The Emergency Medical Care of Patients With Acute Myocardial Infarction.

BACKGROUND Optimizing the emergency medical care chain might shorten the time to treatment of patients with ST-elevation myocardial infarction (STEMI). The initial care by a physician, and, in particular, correct ECG interpretation, are critically important factors. METHODS From 1999 onward, data on the care of patients with myocardial infarction have been recorded and analyzed in the Berlin Myocardial Infarction Registry. In the First Medical Contact Study, data on initial emergency medical care were obtained on 1038 patients who had been initially treated by emergency physicians in 2012. Their pre-hospital ECGs were re-evaluated in a blinded fashion according to the criteria of the European Society of Cardiology. RESULTS The retrospective re-evaluation of pre-hospital ECGs revealed that 756 of the 1038 patients had sustained a STEMI. The emergency physicians had correctly diagnosed STEMI in 472 patients (62.4%), and they had correctly diagnosed ventricular fibrillation in 85 patients (11.2%); in 199 patients (26.3%), the ECG interpretation was unclear. The pre-hospital ECG interpretation was significantly associated with the site of initial hospitalization and the ensuing times to treatment. In particular, the time from hospital admission to cardiac catheterization was longer in patients with an unclear initial ECG interpretation than in those with correctly diagnosed STEMI (121 [54; 705] vs. 36 [19; 60] minutes, p <0.001). After multivariate adjustment, this corresponded to a hazard ratio* of 2.67 [2.21; 3.24]. CONCLUSION Pre-hospital ECG interpretation in patients with STEMI was a trigger factor with a major influence on the time to treatment in the hospital. The considerable percentage of pre-hospital ECGs whose interpretation was unclear implies that there is much room for improvement.

Quo vadis Datenlinkage in Deutschland? Eine erste Bestandsaufnahme

In recent years, linking different data sources, also called data linkage or record linkage, to address scientific questions, is being increasingly used in Germany. However, there are very few published reports and new projects develop the necessary tools independently of each other. Therefore, a team of researchers joined together to exchange their experiences on data linkage and to give suggestions on how linkage could be done for scientists, reviewers as well as members of data privacy boards and ethics committees. It is the aim of this article to assist future projects that want to link German data on an individual level. In addition to the legal framework conditions (data privacy), also examples of types of data linkage, their fields of application und potential pitfalls as well as the methods of preventing them will be described in an application-oriented fashion.

Patienten mit Herzinfarkt in Berlin

Zusammenfassung: Das Berliner Herzinfarktregister erhebt seit 1999 Daten zur Versorgung von Herzinfarktpatienten in Berliner Kliniken. Mit diesen Daten lassen sich Entwicklungen zum Risikofaktorenprofil und zur Versorgung der Patienten über die Zeit darstellen. Es nahmen Patienten mit Hypertonie und Hypercholesterinämie zu. Mit 76% war der Anteil an Rauchern bei den <55 Jährigen sehr hoch. Die Akutversorgung bewegt sich auf hohem Niveau und die Krankenhaussterblichkeit ging über die Zeit zurück.