Abstract 5594: The Impact of Prior Stroke on the Use of Evidence-based Therapies, and In-Hospital Outcomes in MI Patients: A Report of the NCDR ACTION GWTG Registry
Background: Patients with prior stroke are at high-risk for myocardial infarction (MI). Concern regarding increased risk of bleeding or recurrent stroke in this population might alter therapeutic decisions resulting in under utilization of medical or procedural interventions.
Methods: Data were collected from 281 US hospitals in the NCDR ACTION Registry. Patients with STEMI (N=15997) or NSTEMI (N=25514) enrolled between January 1, 2007 and December 31, 2007 were included. We assessed the use of evidence-based medications and procedures in patients with and without prior stroke. Rates were calculated among patients without contraindication to a given therapy. Risk-adjusted odds ratio of death, non-CABG major bleeding, and a composite outcome (MACE = death/MI/stroke/cardiogenic shock/CHF) were calculated using logistic regression.
Results: Prior stroke was reported in 5.1% of STEMI and 9.3 % of NSTEMI patients. Patients with prior stroke were older with more co-morbidities. Among STEMI patient eligible for reperfusion therapy, those with prior stroke were more likely to not receive reperfusion therapy (10.6 vs. 4.5%, P<0.0001). Among those getting reperfusion, prior stroke patients had longer door-to-balloon, and door-to-needle times (p=0.018). Among both STEMI and NSTEMI patients, prior stroke patients were less likely to receive early aspirin, clopidogrel, GP IIb/IIIa inhibitors, or cardiac catheterization. Death, MACE and major bleeding were more common with prior stroke. When adjusted for baseline risk, patients with prior stroke were at increased risk of MACE but not bleeding (Table⇓).
Conclusions: MI patients with prior stroke are at increased risk for death and MACE but not bleeding events. Despite this, prior stroke patients are less likely to receive guideline indicated MI therapies. These results may reflect the underutilization of medications and procedures and signal a need to further study the optimal treatment strategy in this population.