Avaliação da qualidade da atenção aos pacientes atendidos com infarto agudo do miocárdio na Unidade Coronariana do Hospital das Clínicas da Universidade Federal de Minas Gerais

Abstract

Introduction: Standardization of best practices and tracking of quality metrics have resulted in a decline in acute myocardial infarction (AMI) mortality in the United States. In contrast, Brazilian deaths from AMI continue high. Poor adherence to performance measures (defined by the AHA/ACC) may contribute. In 2010, the Federal University of Minas Gerais (UFMG) implemented a standardized AMI system of care, in-line with the AHA/ACC consensus statement (2008), and provided ongoing education to improve compliance. Objectives: To evaluate compliance with AHA/ACC performance measures for AMI at UFMG and to investigate factors associated with compliance. Methods: Compliance with 13 prespecified AHA/ACC AMI performance measures was evaluated for patients with ST-elevation AMI (STEMI) and non ST-elevation AMI (NSTEMI) between December 2011 and 2014. Median compliance was calculated and variables independently associated with compliance rates were evaluated. Results: Over 36 months, 1,129 patients were enrolled (mean age 59±13 yrs., 68% male, STEMI 70% & NSTEMI 30%). Hospital mortality was 8.7% (9.1% STEMI vs. 7.6% NSTEMI, p=0.49). Median compliance with performance measures was 83% [IQR 75/88] (82%[IQR 72/88] STEMI vs. 86%[IQR 83/100] NSTEMI, p<0.001). Among patients with STEMI, 56% received reperfusion therapy, and only 13.6% of those receiving thrombolytics had door-to-needle time <30 min. Three-quarters (75.3%) of patients undergoing primary PCI had door-to-balloon time <90 min. Overall, 67.3% of the patients complied with 80% of the measures (58.8% STEMI vs. 87.1% NSTEMI, p<0,001). Factors independently associated with better compliance (80% of applicable measures) were later date of presentation (semester), likely reflecting ongoing teaching and training (OR=1.19, 95% CI 1.10-1.28, p<0.001), male gender (OR=1.33, 95% CI 1.00-1.76, p<0.046), Killip I/II on admission (OR=1.95, 95% CI 1.36-2.80, p<0.001) and diagnosis of NSTEMI (OR=5.0, 95% CI 3.51-7.11, p<0.001). Conclusion: Compliance with AHA/ACC AMI performance measures remains below target in Brazil, but is improving. Continuing education, reduction of system delays, and prioritizing high-risk groups are needed to optimize AMI systems of care and improve patient outcomes.