We observed low use of evidence-based therapy, both medications and interventions, for Romanian patients with ST-segment elevation myocardial infarction. The quality of care was suboptimal in both county and tertiary referral hospitals. Between 10% and 20% of patients who received treatment in county hospitals did not receive antiplatelet agents, and 62% did not receive reperfusion therapy. Patients who received treatment at tertiary referral hospitals were more likely to receive appropriate medical therapy, but a large percentage of them did not undergo primary percutaneous interventions. When we limited our analysis of use of primary percutaneous interventions to patients who presented to a tertiary referral hospital within 90 minutes after onset of symptoms, we found that only 3.5% of these patients received such interventions. Excess in-hospital mortality was more pronounced among women. Delayed time to onset of treatment and lower use of primary coronary intervention, thrombolysis, ASA and anticoagulants may have all contributed to higher in-hospital mortality for women.
The rural inhabitants of Romania represent more than 50% of the country’s total population. Usual practice dictates that patients be transferred to regional county referral hospitals or to tertiary referral hospitals, where intensive coronary care units and advanced technologies are available.11
In this study, we examined in-hospital mortality rates after myocardial infarction in 21 county hospitals and 7 tertiary referral hospitals in Romania. We interpreted the mortality rates in light of the available evidence on the burden of traditional risk factors and practice patterns for cardiovascular medical care in Western Europe and the United States.
We found major differences in practice patterns between Romania and many other industrialized countries, specifically the Euro Heart Survey I and II for acute coronary syndromes12,13
and the National Registry of Myocardial Infarction-5 in the United States.14,15
The patients in our study were similar in age to those in the Euro Heart Survey I and II (mean 63.8 years v. range 62.5–63.4 years) and were 2.6 years younger than those in the US National Registry of Myocardial Infarction-5. Apart from smoking, traditional risk factors were more frequent in the Euro Heart Survey I and II and the US National Registry of Myocardial Infarction-5 than in the Romanian Registry for ST-segment Elevation Myocardial Infarction population. For the patients in our registry, the average time to receive thrombolysis was longer than times reported in the Euro Heart Survey I and II and the US National Registry of Myocardial Infarction-5 (mean 230 minutes v. range 125–210 minutes). Of the patients in the Romanian Registry for ST-segment Elevation Myocardial Infarction, 50.5% received some form of reperfusion therapy; the corresponding figure in the Euro Heart Survey II was 63.9%.13
The rate of primary percutaneous coronary intervention was lower among patients in the Romanian Registry for ST-segment Elevation Myocardial Infarction than among patients in the Euro Heart Survey II (1.9% v. 36.4%), and the rate of thrombolytic treatment was higher (49.6% v. 27.5%). Crude inhospital mortality was markedly higher for the entire cohort of the Romanian Registry for ST-segment Elevation Myocardial Infarction than for the cohorts of the Euro Heart Survey I and II and the US National Registry of Myocardial Infarction-5 (12.7% v. range from 5.3% to 8%). Our data suggest that the differences in mortality between high-income countries and Romania were not due to differences in the global burden of risk factors or age, but were probably due to differences in treatments and related factors such as time to hospital admission and care.
Our results underscore the importance of evaluating the outcomes and effectiveness of how and where health care services are delivered. In particular, we found significant differences in mortality between tertiary referral and county hospitals. The unadjusted survival advantage was about 4% for tertiary referral hospitals relative to county hospitals (OR 0.72, 95% CI 0.64–0.82). Differences in mortality were attenuated but not eliminated by adjustment for patient characteristics, time to thrombolysis and receipt of percutaneous coronary intervention and medical therapy (OR 0.82, 95% CI 0.70–0.97). As such, other factors may be important in explaining the association. For example, unmeasured patient or hospital characteristics might have affected our findings. Higher rates of misdiagnosis, worse drug information services, less participation in medical rounds and longer work hours for staff nurses and doctors may have converged to create potentially hazardous conditions for patients in the county hospitals.16
Successful reperfusion between 30 minutes and 2 hours after onset of symptoms can result in considerable myocardial salvage and improvements in outcome after 30 days.17–21
In the Romanian Registry for ST-segment Elevation Myocardial Infarction, the primary outcome was in-hospital mortality. Only a minority of women in our study (23.1%) encountered medical personnel within 2 hours, and, after adjustment for confounders, the rate of cardiovascular death was greater for women than men. Nevertheless, lack of timely fibrinolytic therapy is insufficient to explain the excess risk of death among women. In this study, after adjustment for any clinical confounders, low rate of use of an-tiplatelet drugs was an independent predictor of death and could have contributed to the higher case-fatality rate among women.
The reasons for lower use of anti-platelet agents for women are unknown.22–27
Some studies have shown that sex differences in treatment of myocardial infarction may relate to the women’s older age.28
However, we found that differences between the sexes in the use of antiplatelet agents did not differ according to age. Specifically, women were less likely than men to receive clopidogrel alone or in combination with ASA. We suggest that women were less likely to receive prompt diagnosis of myocardial infarction at admission and were therefore less likely to receive aggressive medical therapy.
The main limitation of our study was a lack of data about some variables that are potentially important in deciding whether to administer thrombolytic therapy or perform primary percutaneous interventions, including contraindications to medical therapy and interventions. However, few medical records list contraindications to the recommended care, so identifying patients who are eligible for treatment is difficult in any observational analysis.29
We found that the care Romanian patients with ST-elevation myocardial infarction was characterized by limited use of appropriate medications and interventions. At the time of the study, tertiary referral units did not routinely offer immediate cardiac catheterization services, and it would be expensive to set up such services. However, county hospitals should improve the essential elements of care for these patients. In particular, measures to minimize the time to initiation of reperfusion therapy are urgently required.