Abstract 4000: Characteristics of Patients with ST-Segment Elevation Myocardial Infarction who Refuse But Have No Contraindications to Reperfusion Therapy: The Do Not RePerfuse Study
Background: Clinicians are focused on providing potentially life-saving treatments such as initial reperfusion therapy (IRT) to STEMI patients. Yet, there is an unknown proportion of AMI patients and/or their families who choose comfort care strategies instead of IRT and an overall paucity of data regarding IRT refusal in AMI patients.
Objective: To identify characteristics associated with otherwise eligible patients who refuse IRT.
Methods: From April 2004 to February 2006, the National Registry of Myocardial Infarction 5 enrolled 130,601 AMI patients. Of these, 12,607 had STEMI/LBBB and were IRT-eligible after applying these exclusions: symptom onset to door time ≥12 hours, missing IRT data, transfer from or to another facility, or received intracoronary thrombolytics. The primary dependent variable was Do Not RePerfuse (DNRP) (yes|no). Patients were classified as DNRP if they had documentation of not receiving IRT for at least one of the following: quality of life decision, co-morbid disease, patient/family refusal, or a do not resuscitate order in place.
Results: There were 481 DNRP patients (3.82%; 95% CI of 3.48 – 4.15%). Compared to IRT-treated patients, DNRP patients were 18.3 years older and were more often female (56.5%) and white (87.1%). The West and Midwest regions had the highest rates (32.6% and 33.3%, respectively) of DNRP compared to the South and Northeast (21.2% and 12.9%, respectively). DNRP patients were 11 times more likely to experience in-hospital mortality. Via logistic regression, characteristics (and adjusted odds ratios) associated with DNRP were 1-year increase in age (1.1), female sex (1.7), histories of MI (2.0), heart failure (2.9), stroke (1.8), renal insufficiency (1.6), CABG surgery (1.8), PVD (1.8), lipid disorders (0.6), and payor statuses of PPO (0.6) and HMO (0.6).
Conclusion: There is a low but nonnegligible prevalence of DNRP in patients hospitalized for STEMI. Regional variation and insurance status may indicate a restriction rather than an expression of patient/family autonomy. The underlying reasons for choosing DNRP should be explored, with a goal of developing standardized approaches and policies for clinicians to use in discussing treatment and palliative care options with patients and their families.