背景:在非ST段抬高型心肌梗死(NSTEMI)的治疗中坚持指南指定的护理与改善预后相关。我们调查了整个国家卫生系统不遵守指南指示护理的程度和后果。
方法:使用来自心肌缺血国家审计项目的数据进行了一项队列研究(ClinicalTrials.gov标识符:NCT02436187)(n=389,057NSTEMI,n=247家医院,英格兰和威尔士,2003-2013)。根据指南发布日期,使用加速失效时间模型来量化不依从性对生存的影响。
结果:在1,079,044人年的时间内(平均2.2年随访),113,586例(29.2%)NSTEMI患者死亡。在那些有资格接受护理的人中,337,881(86.9%)没有接受一个或多个指南指定的干预;最常见的是饮食建议(n=254,869,68.1%)。戒烟建议(n=245,357,87.9%),P2Y12抑制剂(n=192,906,66.3%)和冠状动脉造影(n=161,853,43.4%)。对降低生存率影响最大的错过干预措施是冠状动脉造影(时间比:0.18,95%置信区间(CI):0.17-0.18),心脏康复(时间比:0.49,95%CI:0.48-0.50),戒烟建议(时间比:0.53,95%CI:0.51-0.57)和他汀类药物(时间比:0.56,95%CI:0.55-0.58)。如果研究中所有符合条件的患者在指南发布时都接受了最佳护理,然后32,765(28.9%)死亡(95%CI:30,531-33,509)可能已被预防。
结论:大多数住院的NSTEMI患者错过了至少一项符合指南要求的干预措施。这与死亡率过高显著相关。更加重视为NSTEMI的管理提供指南指示的护理将减少过早的心血管死亡。
BACKGROUND: Adherence to
guideline-indicated care for the treatment of non-ST-elevation myocardial infarction (NSTEMI) is associated with improved outcomes. We investigated the extent and consequences of non-adherence to
guideline-indicated care across a national health system.
METHODS: A cohort study ( ClinicalTrials.gov identifier: NCT02436187) was conducted using data from the Myocardial Ischaemia National Audit Project ( n = 389,057 NSTEMI, n = 247 hospitals, England and Wales, 2003-2013). Accelerated failure time models were used to quantify the impact of non-adherence on survival according to dates of guideline publication.
RESULTS: Over a period of 1,079,044 person-years (median 2.2 years of follow-up), 113,586 (29.2%) NSTEMI patients died. Of those eligible to receive care, 337,881 (86.9%) did not receive one or more
guideline-indicated intervention; the most frequently missed were dietary advice ( n = 254,869, 68.1%), smoking cessation advice ( n = 245,357, 87.9%), P2Y12 inhibitors ( n = 192,906, 66.3%) and coronary angiography ( n = 161,853, 43.4%). Missed interventions with the strongest impact on reduced survival were coronary angiography (time ratio: 0.18, 95% confidence interval (CI): 0.17-0.18), cardiac rehabilitation (time ratio: 0.49, 95% CI: 0.48-0.50), smoking cessation advice (time ratio: 0.53, 95% CI: 0.51-0.57) and statins (time ratio: 0.56, 95% CI: 0.55-0.58). If all eligible patients in the study had received optimal care at the time of
guideline publication, then 32,765 (28.9%) deaths (95% CI: 30,531-33,509) may have been prevented.
CONCLUSIONS: The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality. Greater attention to the provision of
guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.