Characterization and clinical course of patients not receiving aspirin for acute myocardial infarction: Results from the MITRA and MIR studies

doi:10.1067/mhj.2001.112681

American Heart Journal

Volume 141, Issue 2, February 2001, Pages 200-205

https://doi.org/10.1067/mhj.2001.112681 Get rights and content

Abstract

Background Clinical trials have shown the efficacy of aspirin for acute myocardial infarction (AMI). However, not all patients receive aspirin for AMI. The aim of this study was to provide information on characteristics and clinical course of patients not treated with aspirin for AMI. Methods We analyzed the data of the Myocardial Infarction Registry (MIR) and the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) registry. MITRA and MIR were prospective multicenter registries of patients with ST segment elevation myocardial infarction in Germany. Results Of 22,572 patients registered from 1994 to 1998, 1767 (7.8%) did not receive aspirin within the first 48 hours after admission. Multivariate analysis revealed two main factors associated with withholding aspirin for AMI: relative contraindications to aspirin (gastric ulcer [odds ratio (OR) 4.9, 95% confidence interval (CI) 3.7-5.7], renal insufficiency [OR 1.4, 95% CI 1.1-1.8]), and critical clinical state at admission (cardiogenic shock [OR 1.5, 95% CI 1.2-2.1] and prehospital resuscitation [OR 1.8, 95% CI 1.4-2.2]). In addition, these patients were significantly less likely to receive reperfusion therapy and adjunctive medical therapy such as β-blockers and angiotensin-converting enzyme inhibitors. In-hospital mortality after adjustment for baseline characteristics was 27.2% in patients without aspirin compared with 11.1% in patients treated with aspirin. Conclusions Only a minority of AMI patients (7.8%) did not receive aspirin. Relative contraindications to aspirin and a critical clinical state at admission were the main factors associated with withholding aspirin for AMI. Even after adjustment for patient characteristics, the mortality of patients without aspirin was almost three times higher. (Am Heart J 2001;141:200-5.)

Section snippets

Methods

The Maximal Individual Ther apy in Acute Myocardial Infarction (MITRA) study and the Myocardial Infarction Registry (MIR) were prospective multicenter registries of the current treatment of ST elevation myocardial infarction in Germany. In MITRA, 8194 patients were recruited from 1994 to 1998 in 54 hospitals ranging from universities to small community hospitals in the southwest of Germany. MIR was a nationwide registry that included 14,378 patients in 217 mainly community hospitals from 1996

Results

Of 22,572 patients included in the MITRA and MIR registries from 1994 to 1998, 1767 (7.8%) did not receive aspirin within the first 48 hours after AMI.

Discussion

We used data of the MITRA and MIR registries, collected between 1994 and 1998, and analyze patient demographics and clinical courses of patients without aspirin for AMI. These registries provide data on a wide range of patients in routine clinical practice all over Germany. Although randomized clinical trials (RCTs) are the best scientific technique for evaluating the effect of therapies in medicine, they do not provide data on current clinical practice. Patients in RCTs are also usually highly

Conclusions

In current clinical practice in Germany, only a minority of patients (7.8%) do not receive aspirin for AMI. Our study revealed two main factors influencing the application of aspirin:

1.
Patients in critical condition at admission. If these patients survived the early phase of AMI, they were most likely to receive aspirin later during their hospital stay.
2.
Absolute contraindications account for only a small number of patients without aspirin. Relative contraindications to aspirin such as gastric or

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The 2015 CoSTR recommended the administration of aspirin to adults with chest pain due to suspected myocardial infarction.2,3 This recommendation was based on the evidence from four studies.58–61 A second 2015 CoSTR recommended aspirin administration early (i.e. prehospital or the first few hours after symptom onset) rather than late (at hospital).2,3
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In the pre-hospital environment, administer 150-300 mg chewable aspirin early to adults with chest pain due to suspected myocardial infarction (ACS/AMI). There is a relatively low risk of complications particularly anaphylaxis and serious bleeding.836–840 Aspirin should not be administered to patients who have a known allergy or contraindication to aspirin.
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As the plaque contents leak into the artery, platelets clump around them and coronary thrombosis occurs completely or partially occluding the lumen of the artery, leading to myocardial ischemia and possible infarction. The use of aspirin as an antithrombotic agent to potentially reduce mortality and morbidity in ACS/AMI is considered beneficial even when compared with the low risk of complications, particularly anaphylaxis and serious bleeding (requiring transfusion).45–49 The early administration of aspirin in the pre-hospital environment, within the first few hours of the onset of symptoms, also reduces cardiovascular mortality,50,51 supporting the recommendation that first aid providers should administer aspirin to those individuals with chest pain from suspected myocardial infarction.
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We also found very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from 1 RCT71 enrolling 100 patients with acute MI showing benefit to aspirin (100 mg, capsule) administration (RR, 0.11; 95% CI, 0.05–0.98). We identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study73 with a total of 22 572 patients with acute MI showing no benefit to aspirin (500 mg oral or intravenous loading, 100 mg oral maintenance recommended) administration (RR, 1.05; 95% CI, 0.78–1.42). For the critical outcome of incidence of cardiac arrest, we identified high-quality evidence from 1 RCT70 enrolling 16 981 patients with acute MI showing benefit to aspirin (162.5 mg, enteric-coated) administration (RR, 0.87; 95% CI, 0.79–0.96).
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estudio de las características de los episodios de infarto agudo de miocardio (IAM) producidos en Navarra en el año 1997 por edad.
investigación de los casos de IAM mediante la revisión de las historias clínicas y de los Boletines Estadísticos de Defunción.
en 1997 se registraron 903 casos de IAM en Navarra (509 hospitalarios y 394 extrahospitalarios). El 54,8% de las personas que presentaron un IAM falleció en los primeros 28 días del inicio de los síntomas, letalidad que aumentó con la edad (el 36% en menores de 65 años y el 71,9% en los mayores de 75 años). Uno de cada 3 varones ingresados por IAM y 1 de cada 2 mujeres tenían 75 años o más. El factor de riesgo coronario más frecuente entre los pacientes jóvenes fue el tabaquismo y en ancianos la hipertensión arterial. La edad fue un importante condicionante para la utilización de trombólisis (el 46,7% en menores de 60 años frente al 20,2% en mayores de 75 años). Se observó un menor uso de antiagregantes y bloqueadores beta y un mayor uso de inhibidores de la enzima de conversión de la angiotensina y nitratos entre los mayores de 75 años, tanto en el momento del ingreso como en el del alta.
los datos sobre los tratamientos aplicados a pacientes ancianos muestran un menor seguimiento de las recomendaciones de las guías de práctica clínica que lo observado entre los pacientes más jóvenes. Existe la necesidad de optimizar la aplicación de las guías de tratamiento del infarto agudo de miocardio en los pacientes ancianos en Navarra.
to describe the characteristics of episodes of acute myocardial infarction (AMI) occurring in 1997 in Navarre according to age.
a search was made for possible cases of AMI through a review of patients’ medical records and death certificates.
in 1997, 903 cases of AMI were registered in Navarre (509 hospital cases and 394 outside the hospital). A total of 54.8% of patients with AMI died in the 28 days following the onset of the symptoms and lethality increased with age (36% in those aged below 65 years and 71.9% in those aged more than 75 years). One out of every three men admitted for AMI and one out of every two women was aged 75 years or more. The most frequent coronary risk factor in younger patients was smoking and that in the elderly was hypertension. Age was a factor determining the use of thrombolytic therapy (46.7% in those below 60 years of age versus 20.2% in those over 75). A lower use of antiagregants and beta-blockers and a higher use of angiotensin-converting enzyme inhibitors (ACEI) and nitrates was observed in patients over 75 years of age, both during admission and after discharge.
data on the treatments applied to elderly patients with AMI in Navarre show a lesser adherence to the recommendations of the care guidelines than was observed amongst younger patients. There is a need to optimise the application of AMI treatment guidelines in elderly patients in Navarre.

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^*: Supported in part by Bristol Myers-Squibb, ASTRA-Zeneca, Ministerium für Gesundheit, Arbeit und Soziales des Landes Rheinland-Pfalz, Landesversicherungsanstalt Rheinland-Pfalz, and Barmer und Betriebskrankenkassen Rheinland-Pfalz.

^**: Reprint requests: Birgit Frilling, Herzzentrum Ludwigshafen, Department of Cardiology, Bremserstr 79, 67063 Ludwigshafen, Germany. E-mail: [email protected]

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Acute Ischemic Heart DiseaseCharacterization and clinical course of patients not receiving aspirin for acute myocardial infarction: Results from the MITRA and MIR studies*,**

Abstract

Section snippets

Methods

Results

Discussion

Conclusions

Am J Cardiol

Am Heart J

Am J Cardiol

Clinical features of sudden obstruction of the coronary arteries

JAMA

Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2

Lancet

A randomized controlled trial of acetyl salicylic acid in the secondary prevention of mortality from myocardial infarction

BMJ

A randomized controlled trial of aspirin in persons recovered from myocardial infarction

JAMA

A comparison between heparin and low-dose aspirin as adjunctive therapy with tissue plasminogen activator for acute myocardial infarction

N Engl J Med

Acute Ischemic Heart Disease
Characterization and clinical course of patients not receiving aspirin for acute myocardial infarction: Results from the MITRA and MIR studies*,**