ORIGINAL ARTICLE

Monitoring quality of care in acute myocardial infarction complicated by acute heart failure using electronic medical record data
Experience of an underdeveloped country network

Miguel Alejandro Rodríguez-Ramos¹, Maikel Santos-Medina², Wilfredo Chaviano de la Paz³, Geovedys Martínez García⁴, Michel Guillermo-Segredo³, Dayani Arteaga-Guerra⁵

1 Cardiologist MD. Coronary Intensive Care Unit. Cardiology Department. Camilo Cienfuegos General Hospital. Sancti-Spirítus. Cuba.
2 Cardiologist MD. Cardiology Department. Ernesto Guevara General Hospital. Las Tunas. Cuba.
3 MD. Resident physician in training. Cardiology Department. Camilo Cienfuegos General Hospital. Sancti-Spirítus. Cuba.
4 Cardiologist MD. Cardiology Department. Enrique Cabrera General Hospital. Havana. Cuba.
5 MD. Resident physician in training. Department of Intensive Medicine and Adult Emergencies. Camilo Cienfuegos General Hospital. Sancti-Spirítus. Cuba.

Correspondence: Miguel Alejandro Rodríguez-Ramos, MD.
Cardiology Department, Camilo Cienfuegos General Hospital, Bartolomé Maso y Mirto Street, without number, Sancti-Spirítus, Cuba. Zip code 60100.
E-mail: mialero@infomed.sld.cu. Phone: 5341338636.

Received: 10/19/2020
Accepted: 01/28/2021

Summary

Background. Several improvements in performance measure (PM) have been described, in Cuba, in patients with ST Elevation Myocardial Infarction (STEMI). However, it still no clear if reported enhancement has an influence in management of STEMI complicated with Acute Heart Failure. The objective of this study is to determine if those changes in renewed protocol have improved PM of attention of this specific subgroup.
Methods and material. Gathering data of patients after June 2014 is mandatory in a web-based tool, which allows, real time following of selected PM. After a first stage, updating in protocol was written, focusing in several gaps. The first stage closed with 81 patients admitted with heart failure after STEMI, meanwhile until late December 2019, other 126 patients were included. Data regarding PM was obtained from all registries, except for those PM related with coronary intervention.
Results. Improvement in management was observed for 6 of presented PM for overall population; and in patients with cardiogenic shock, up to 6 PM were fully accomplished in both stages. Pharmacological treatments were administered fulfilling high standards, but no enhancement of in-hospital mortality was observed (19.4% vs. 18.5%; p: 0.86). Although not significant, thrombolytic decreased its prevalence in overall population (57.4 vs 48.1; p: 0.15), and in cardiogenic shock (29.4% vs 25%; p: 0.76).
Conclusion. Performance measures were enhanced after an update in protocols of attention. However, most important ones didn”™t suffer any changes. Efforts to maintain this increase in PM need to be taken.

Keywords: Acute myocardial infarction; Heart failure: Performance measures; Electronic record

Resumo
Monitoramento da qualidade do atendimento em infarto agudo do miocárdio complicado por insuficiência cardíaca aguda usando dados do prontuário eletrônico: Experiência de rede de um país subdesenvolvido

Introdução. Diversas melhorias na medida de desempenho (MD) foram descritas, em Cuba, em pacientes com infarto do miocárdio com elevação do segmento ST (STEMI). No entanto, ainda não está claro se o realce relatado tem uma
influência no tratamento do STEMI complicado com insuficiência cardíaca aguda. O objetivo deste estudo é determinarse essas mudanças no protocolo renovado melhoraram a atenção do MD deste subgrupo específico.
Material e métodos. A coleta de dados dos pacientes após junho de 2014 é obrigatória em uma ferramenta baseada na web, que permite o acompanhamento em tempo real dos MD selecionados. Após uma primeira etapa, foi feita a atualização do protocolo, com foco em várias lacunas. A primeira fase encerrou com 81 pacientes internados com insuficiência cardíaca após IAMCSST, enquanto até o final de dezembro de 2019, outros 126 pacientes foram incluídos. Os dados sobre MD foram obtidos de todos os registros, exceto para MD relacionados com intervenção coronária.
Resultados. Melhoria na gestão foi observada para 6 das MD apresentadas. Os tratamentos farmacológicos foram administrados de acordo com altos padrões, mas não foi observado aumento da mortalidade intra-hospitalar (21% vs. 24,6%; p: 0,54). Embora não seja significativo, o trombolítico aumenta sua prevalência fora do hospital (12/46 vs. 26/72; p: 0,256).
Conclusão. As medidas de desempenho foram aprimoradas após uma atualização nos protocolos de atenção. No entanto, os mais importantes não sofreram alterações. Esforços para manter esse aumento na MD precisam ser feitos.

Palavras-chave: Infarto Agudo do Miocárdio; Insuficiência Cardíaca; Medidas de Desempenho; prontuário eletrônico do paciente

Introduction

Acute complications of acute coronary syndromes are responsible of a great fraction of cumulative deceases in higher income settings^1,2. However, recent improvements in treatment of ST elevation myocardial infarction (STEMI) have decreased this². But, in low or middle income settings, most patients with this condition are treated with pharmacological approach rather than coronary intervention as primary treatment³.
And this decrease in mortality rate is not as marked, yet. In Cuba only 5 hospitals perform coronary interventions, 3 of them in capital city, with almost 700 km². In the remaining 108000 km², there are only 2 centers with cath lab. So, despite receive thrombolytic, they are still in great risk of presenting, among other complications, heart failure in acute phase of admission⁴.
Since 2014, REgistro de Síndromes Coronarios AgUdos [Registry of Acute Coronary Syndrome (RESCUE)], a professional web-based tool, monitors a set of performance measures (PM) of attention of STEMI in a secondary Hospital in Sancti-Spirítus, Cuba⁵.
In 2018, after updating institutional protocol of attention, an improvement of this measures, according “2017 AHA/ACC Clinical Performance and Quality Measures for Adults with ST-Elevation and Non-ST-Elevation Myocardial Infarction”⁶, in a whole population of admitted STEMI was reported⁷.
Then, administration of beta blockers increased almost twofold (52.53% vs. 94.26%, p: <0.01) without increasing the rate of in-hospital heart failure while it was up titrated (14.3% vs. 11.25%; p 0.418), nor the length of stay in days (6.87 vs. 6.27, p 0.336). Atorvastatin introduction step up until 98.36% from 85.25% (p 0.0001) and angiotensin converter inhibitor enzyme ascended from 94.45% until 97.54% (p 0.187), but this time without difference.
However, it still no clear if this reported enhancement has an influence in management of higher risk population, such as, STEMI complicated with acute heart failure. So, the objective of this study is to determine if those changes in renewed protocol⁷ have improved PM of attention of this specific subgroup.

Methods and material

This research was conducted in General Hospital Camilo Cienfuegos, from Sancti-Spirítus, Cuba. According “Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries” ⁸, this is a level 3 facility,(fibrinolysis-capable but non-PCIcapable centers, which also has a general practitionerlevel or higher-level physician capable of diagnosing STEMI confidently, assessing appropriateness for thrombolysis, and providing therapy). Has access to all necessary medications such as anticoagulation, aspirin, clopidogrel, ACE inhibitors, and oral beta blockers.

Study population
Consecutive patients with ST elevation myocardial infarction complicated with any degree of heart failure during any stage of their in-hospital or out-of-hospital evolution, from June 2014 to December 2019 were included (gathering data of patients after June 2014 is mandatory in a web-based tool, which allows, real time following of selected PM).
In early 2016 data analysis was made, and an updating in protocol was written, focusing this time in several gaps, as stated⁷. The first stage closed with 107 patients admitted with heart failure after STEMI, meanwhile until late December 2019, other 135 patients were included in a second stage.

Inclusion criteria
Data regarding PM was obtained from all registries, according 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction6, except for those PM related with coronary intervention (PM-8: Time to Primary PCI, PM-10: Time From Emergency Department Arrival at STEMI Referral Facility to ED Discharge From STEMI Referral Facility in Patients Transferred for Primary PCI, PM-11: Time From First Medical Contact [At or Before Emergency Department Arrival at STEMI Referral Facility] to Primary Percutaneous Coronary Intervention at STEMI Receiving Facility Among Transferred Patients, and PM-14: Immediate Angiography for Resuscitated Outof-Hospital Cardiac Arrest in STEMI Patients).
Two groups will be created according intervention: previous and after. Primary outcome for this study was accomplishing every measure independently. Previous reports on performance measures in this setting, show low accomplish percentage in some of them, so a composite measure which include all PM available for every patient will not be still useful. Finally, characteristics and in-hospital outcome (discharged dead or alive) were compared between these two groups. After all this, same analysis were repeated, this time, only with patients with cardiogenic shock.
Characteristics of network and protocol of attention were previously reported5. The diagnosis of AMI required the following criteria: symptoms consistent with AMI, elevated cardiac enzymes including creatinine kinase (at least two-fold increase from the normal upper limit), and ST-segment elevation or depression in electrocardiograms compatible with AMI. Diagnostic ST elevation was defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV), and the AMI patients with ST elevation were diagnosed as ST elevation myocardial infarction (STEMI).
Past medical history was defined as current medical treatment for specific risk factor and/or a history before admission. Laboratories data that couldn”™t be measured at off-hours were substituted with earliest levels since admission.
Heart failure was defined by accomplishing at least one of the following criteria:
Symptoms or signs of heart failure during admission or in any stage of in-hospital stay, according hemodynamic classifications of patients with acute myocardial infarction:
Clinical examination: crackles, S3 gallop, elevated jugular venous pressure, frank pulmonary edema, or shock.
Invasive monitoring: pulmonary congestion: pulmonary capillary wedge pressure (PCWP) > 18 mm Hg, cardiac index (CI) > 2.2 L/m/m2; peripheral hypoperfusion: PCWP < 18 mm Hg, CI < 2.2 L/m/m2; pulmonary congestion and peripheral hypoperfusion: PCWP> 18 mm Hg, CI < 2.2 L/m/m2. Though classical classification includes invasive monitoring, these measures were estimated by non-invasive methods, such as transthoracic echocardiogram.
Left ventricular ejection fraction (LVEF) lower than 40%: LVEF was measured by transthoracic echocardiography during the hospitalization. LVEF was calculated through either a modified Simpson method, a Teichholz method, or an eyeball estimation. Ejection fraction measured by a Teichholz method was adopted only when a modified Simpson method was not available. Eyeball estimation of ejection fraction was adopted only when both a modified Simpson method and a Teichholz method were not available.
No determination of BNP was carried out, as this hospital don”™t have resources to do so.
Data collected from RESCUE study were transferred into Statistical Package for Social Sciences (SPSS, version 24, IBM, Armonk, New York), which was used for data cleaning, management, and analyses.
Categorical variables are presented as number and percentage, and continuous variables as mean and standard deviation. Comparisons among different groups were performed using chi-square test for categorical variables and analysis of variance test for continuous ones.
This study conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution”™s human research committee and written informed consent was waived because of the retrospective study design.
The authors have full access to the data and take responsibility for its integrity. All the authors have read and agree with the manuscript that is reported.

Results

Table 1 shows demographics characteristics of the studied population, including risk factors and main laboratory findings. As stated, this constitutes a homogeneous population according presented parameters, except for topography of acute event: prior intervention more than 60% of heart failures in STEMI where in patients with anterior myocardial infarction; meanwhile, after intervention, only 48% of patients with heart failure presented this same topography.

Table 1. Baseline characteristics of studied population

Table 2 shows that, for remaining 11 performance measures that could be reported in this study, there were modest improvements in 4 performance measures. Despite not being changed, rate of administration of thrombolytic maintain its trend of last 6 years, even for this complicated patients. However, those who received this drug, received earlier, (133 ± 105 vs 93 ± 74; p: <
0.01) after been assisted by a physician.

Table 2. Compliance for ACC/AHA domains of quality for patients with AMI

Other two improved measures were directly related with treatment in these patients. Administration of high intensity statin regimen, was increased within time and reached an elevated 98.1%; and beta blockers at discharge increased from 81% until 95% (p: < 0.01). However, despite improvements in medical treatments, in-hospital mortality didn”™t change and remained too high (19.4% vs 18.5%; p: 0.86).
And finally, referral for cardiac rehab increased, as experience of team of cardiac rehab with this kind of patients also increased. However, most of them didn”™t beneficiate form this kind of treatment as they weren”™t recruited in these programs.

Patients with cardiogenic shock
Table 3 shows demographics characteristics of patients with cardiogenic shock, a subgroup of studied patients. As declared, this also constitutes a homogeneous population. However, cholesterol level and ischemic time were slightly higher in subgroup prior intervention (5 + 0.9 mmol/L vs 7 + 1.4 mmol/L, p: 0.07; 312 ± 231 min vs 373 ± 301 min, p: 0.1). However, this last one presented clinical difference, despite not being statistically different. In-hospital mortality was very high and was globally greater than 50%.

Table 3. Baseline characteristics of studied population with cardiogenic shock in any moment of their clinical evolution

Table 4 shows that, for performance measures according ACC/AHA that could be reported in this study, there were 6 of them that were fully accomplished. However amount of sample should be a factor to take into account when analyzing this.

Table 4. Compliance for ACC/AHA domains of quality for patients with AMI with cardiogenic shock in any moment of their clinical evolution

And, again, where in administration of beta blockers on discharge where is presented the major difference when comparing these two subgroups. Previously intervention only 44% of discharged patients with cardiogenic shock received this kind of drug, but after, this fraction increased until 88% (p: 0.01).

Discussion

This report sought to investigate if described changes in performance measures after renewed protocol have improved PM of attention of STEMI patients complicated with acute heart failure.
As this center doesn”™t have cath lab facilities, no further discussion about “PM-11: Time to Primary PCI among Transferred Patients”, nor “PM-14: Immediate Angiography after Cardiac Arrest” will take place. Also, as this hospital participates in a registry of STEMI, “PM-17 AMI Registry Participation” was fulfilled. Finally, as this network doesn”™t investigate transfers time PM-10 Door-in-Door-Out Time”, will not appear in additional sections, and “PM-7: Door-to-Needle Time” and “PM-8: First Medical Contact-Device Time” will be adapted to “First Medical Contact-Needle Time”. About Quality Measures, only QM-4 “Aldosterone Antagonist Prescribed at Discharge” was recorded, but only for patients after 2017. This parameter was included in electronic health record after publication of the report of American College of Cardiology/American Heart Association Task Force on Performance Measures.
Also, one of the improved measures, “First Medical Contact-Needle Time”, is still far away from suggested cut-off point of 90 minutes. In this study, very few patients accomplish this measure, with an improvement after updating protocol. However, in a small setting according number of patients assisted, there were only 49 patients (11.8%), over a total of 414, in 6 years, which arrived after 12 hours t their first medical contact⁹. However, sample studied had a larger number of patients in this condition. Gho et al¹⁰ reported that despite previous description of significant association of gender with HF incidence after MI, they could not replicate this finding⁹. But, this kind of analysis was impossible to perform, as that wasn”™t the primary objective of this study. Perhaps, in a future should be interesting to recognize patients which evolve to heart failure after a first medical contact without clinical evidence of this complication.
Though not studied in this report, Silveira et al¹¹ found that recourse to the Emergency Medical System significantly reduced ischemic times. It was associated with higher rates of effective reperfusion that were reflected in lower in-hospital mortality. In this setting, this kind of resource is very scarce. That is why spreading units where a patient may receive thrombolytic, is paramount.
Other pharmacological treatments were administered fulfilling high standards. Although for 2 of them, the cutoff point of 90% wasn”™t achieved, it is easily to acquire. A review of discharge treatment for every patient, focusing on gaps detected in this report, should increase them beyond this point. In a recent report¹², was stated that highdose ACEI/ARB, but not beta-blocker, was associated with lower rate of all-cause death and heart failure in patients with STEMI. Dose of administered drug was not included in this study, so comparison don”™t seem suitable for doses reports.
However, in case of beta blockers it seems that its effect would be more marked in patients with heart failure. Unadjusted 1-year mortality was lower for patients who received beta blockers compared with those who did not (4.9% vs 11.2%; p < 0.001). However, after weighting and adjustment, there was no significant difference in mortality between those with and without beta blocker use¹³. Similarly, others state that independent risk factors for HF hospitalization within 1 year included older age, previous myocardial infarction, HF at STEMI, left ventricular dysfunction, anterior AMI, and onset-to-balloon time >3 hours, use of β blocker, and nonuse of statin at discharge¹⁴. During this study, several intensive care units were broadened in the province, diminishing system delay in order to administer thrombolysis. Although not significant, this procedure increases its out-of-hospital prevalence,which may be a reason for decreasing system delay time and observed increase in administration rate, as described^15-17. Several patients should have received it close to cut-off time of 12 hours, in their nearest health facility; otherwise, if they should have waited a transfer to hospital, they probably have arrived later than 12 hours. However, the administration rate didn”™t change after updating protocol, and it is still very low.
In a similar setting¹⁸, with patients treated with thrombolytic, clinical variables such as prolonged ischemic time, dyspnea at presentation, baseline Killip class>I, cardiogenic shock, TIMI score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented a cluster of predictors for failed thrombolysis. So, if patients with heart failure receive thrombolytic, will have a poor success rate which may explain elevated mortality in this study, making complications in acute stage more common.
Although, 2017 AHA/ACC Clinical Performance and Quality Measures for Adults with ST-Elevation and Non-ST-Elevation Myocardial Infarction3 clearly state exceptions and exclusions, supported by evidence, for numerator and denominator for each measure, this brief report from underdeveloped country show results without them. In order to search for strategies to decrease gaps in attention, an underestimation of performance measures is better than an overestimation. For example, taking into account exceptions and exclusions for PM-9: Reperfusion
Therapy in this study, the corrected values would increase to 65.71% before updating and 69.23% after doing it (p:0.626).
Perhaps, several patients who couldn”™t reach a proper facility in time would receive pharmacological reperfusion, if it would be wide available in the area.
Finally, as coronary intervention increased in last years in most settings, analysis of patients with pharmacological reperfusion become rarer and scarce¹⁸. And, though comparisons with quality measures of foreign associations is useful^19-21, it would be better to create our own performance measures in view of disparities in focusing treatment in Cuba and underdeveloped countries, comparing to world leaders.

Conclusion

Performance measures of attention of patients with heart failure after STEMI were enhanced after an update in protocols of attention. However, those who may impact in prognosis or outcome didn”™t suffer any changes. Efforts to maintain this increase in PM need to be maintained.

Acknowledgments

The authors wish to thank to researchers of REgistro CUbano de Infarto de Miocardio Agudo (Cuban Registry of Acute Myocardial Infarction).

Financial resources

No funding or subsidy was granted for the development of this research.

Conflict of interests

The authors of the research papers clarify that there is no type of commercial or economic relationship with any company whose products appear prominently in the submitted work or that constitute competition with it.

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