Acute interventions for myocardial reperfusion

Thirty-day in-hospital revascularization and mortality rates after acute myocardial infarction in seven Canadian provinces

BACKGROUND

Recent clinical trials have demonstrated benefit with early revascularization following acute myocardial infarction (AMI). Trends in and the association between early revascularization after (ie, 30 days or fewer) AMI and early death were determined.

METHODS AND RESULTS

The Statistics Canada Health Person-Oriented Information Database, consisting of hospital discharge records for seven provinces from the Canadian Institute for Health Information Hospital Morbidity Database, was used. If there was no AMI in the preceding year, the first AMI visit within a fiscal year for a patient 20 years of age or older was included. Times to death in hospital and to revascularization procedures were counted from the admission date of the first AMI visit. Mixed model regression analyses with random slopes were used to assess the relationship between early revascularization and mortality. The overall rate of revascularization within 30 days of AMI increased significantly from 12.5% in 1995 to 37.4% in 2003, while the 30-day mortality rate decreased significantly from 13.5% to 10.6%. There was a linearly decreasing relationship - higher regional use of revascularization was associated with lower mortality in both men and women.

CONCLUSIONS

These population-based utilization and outcome findings are consistent with clinical trial evidence of improved 30-day in-hospital mortality with increased early revascularization after AMI.

Early intervention and prevention of myocardial infarction

Although there has been a decline in the incidence of ischaemic heart disease in Western Europe, North America and Australia/New Zealand, it remains a major cause of morbidity and mortality worldwide due to rapidly increasing incidences in developing countries. Prevention is key to reducing the burden of this disease. The INTERHEART study performed in 52 countries around the world has shown that the major risk factors are tobacco smoking, elevated apolipoprotein A, hypertension, diabetes mellitus, abdominal obesity, psychosocial factors, low fruit and vegetable intake, physical inactivity and alcohol consumption. Strategies for prevention by reducing risk factors are applicable universally. Individual healthcare providers can implement primary and secondary preventive measures to individual patients. Primary prevention involves the avoidance of disease in high-risk subjects free of disease, whereas the purpose of secondary prevention is to avoid recurrence of myocardial infarction. The general principle is to encourage improved and proven lifestyle measures and to prescribe evidence-based effective medications. Primary prevention requires greater investment and planning to identify people at high risk, plus the implementation of life-style intervention and pharmacological prevention. In both situations, strategies will have to be tailored to suit individual countries and economies. Life-style measures (i.e. sensible diet, physical exercise and smoking cessation) are effective and need to be promoted. Compliance with preventive measures is achievable. Primordial prevention, which involves reducing the prevalence of risk factors, rests mainly on public education, media, legislation and government policy, and is very dependent on individual governments' commitment and determination. It requires promoting a healthier life-style in the population as a whole by encouraging people to seek alternatives and making them available.