Servicios Personalizados
Revista
Articulo
Indicadores
- Citado por SciELO
- Accesos
Links relacionados
- Similares en SciELO
Compartir
Acta Médica Costarricense
versión On-line ISSN 0001-6002versión impresa ISSN 0001-6012
Acta méd. costarric vol.55 no.1 San José ene./mar. 2013
Original
Coronary
syndrome and other diagnosis result in under reporting of acute
myocardial
infarction in the
Manuel Francisco Jiménez-Navarrete,1
Carlos Arguedas-Chaverri,
Luis Romero-Triana2
Departament of Medicine,
Affiliation
of the authors:
Abbreviations: CRSSS, Costa Rican Social Security System; MH,Mexico Hospital;AMI,acute myocardial infarction; STEMI, acute myocardial infarction with ST-segment elevation; NSTEMI, acute myocardial infarction without ST-segment elevation; PAHO, Pan American Health Organization; ACS, acute coronary syndrome; CU, Coronary Unit; HU, Hemodynamics Unit; ICU, Intensive Care Unit. mickeymfjn@yahoo.com
Abstract
Justification:
Acute myocardial
infarction is a major public health problem. In
Materials
and methods: Descriptive
and observational study. Data from patients which were discharged from
the
Results: The
Conclusions:
Acute
myocardial infarction is under reported in the
Key words: acute
myocardial infarction, acute coronary syndrome, underreport.
The first
report of typical angina is attributed to
William Heberden (1768), who described it
as
“the most unpleasant sensation in the chest that takes hold of patients
when walking and disappears the moment they can stand still”.1 Modern
definitions of the triad of Heberden
retain their
essential ingredients (retrosternal
oppression,
worsening with exertion and relieved by rest).
The term
“acute coronary syndrome” (ACS)
was introduced by Valentin Fuster
(1985), who along with Steele and Chesebro,
proposed
differentiate specific pathophysiological
events that
distinguish unstable angina and myocardial infarction (AMI), from the
stable
coronary disease. The clinical view included unstable angina entities,
AMI and
sudden coronary death.2 ACS is an operation term especially
useful
for the initial evaluation of patients with chest pain, which includes
any type
of AMI –with or without ST-segment elevation and unstable angina. This
syndrome continues “... subject to vertigo research. The inflammatory
aspect of the pathophysiology, the
diatribe between
the pharmacological management and implemented, genetics, even the
characterization and classification, are shown as open pathways
restless thinking”.3
The AMI is
a pathological entity characterized by
ischemic necrosis (coagulative) of an area
of the
myocardium. Its clinical definition should be based on two parameters:
the
actual diagnosis, generally anatomopathological,
and
the method (sensitive, specific and affordable) available in clinical
practice
for diagnosis.4 James Herrick suggested that the presence
of
coronary artery thrombosis was the mechanism that originated the AMI,5 and was also the first
to propose
the electrocardiographic changes in its diagnosis.6
The AMI
caused by an occlusive thrombus may be
suspected by ST segment elevation on the electrocardiogram (EKG) and
other
diagnostic parameters. However, several conditions simulating AMI can
present
that image in the EKG.7
In 2000,
the American College of Cardiology and the
European Society of Cardiology published a consensus redefining AMI,
combining
increases and decreases in biochemical markers of myocardial necrosis
with any
of the following conditions: symptoms suggestive of myocardial
ischemia,
electrocardiographic changes, and coronary intervention.8 This
caused a significant increase in the diagnosis of AMI and helped
identify a
greater number of patients with ACS who have a lot of comorbidity
and worse prognosis at 6 months, rather than the previous criteria of
the World
Health Organization in 1979 proposed . Investigation is needed to
confirm these
preliminary findings and to determine the economic implications of the
new
criteria.9
The
incidence of AMI is determined in large community
studies, concluding that the time trend in mortality is decreasing over
time,
while the incidence varies according to studies, in decline, increase
or remain
stable (Table 1).10
AMI
mortality in the
Regarding
AMI, in the national medical bibliography,
to date, only a descriptive study is located, unpublished, about
inpatient
(Fernandez R. Descriptive Study: Short and long-term progress of acute
myocardial infarction Q and non-Q. Intensive Care Unit, San Juan de
Dios
Hospital. September 1997-September 1999. Thesis for Postgraduate graduation in Internal Medicine.
The goal
of the study was to determine whether there
is an adequate record of patients discharged with AMI, in a Class A hospital of the country.
Materials
y methods
This is a
descriptive and observational study, which
compiles data at a point in time where the phenomena to investigate is
“captured” in appearance. We observed the occurrence of the
phenomenon and the factors associated with it.
Classification
of AMI is used, according to the
consensus of the American College of Cardiology and the European
Society of
Cardiology: criteria for AMI evolved or recent (typical rise and
gradual fall
of troponin or more rapid rise and fall of
creatine kinase
MB, with at least
one of the following: ischemic symptoms, development of pathological Q
waves to
EKG, EKG changes indicative of ischemia, coronary artery intervention)
or a
pathological findings of an AMI.13
Inclusion
criteria: patients over 18 years of age, of
both sexes, discharged from Mexico Hospital (MH) with diagnoses of AMI
and ACS
in the period of one year (August 1, 2005 to July 31, 2006). Exclusion
criteria: Patients who did not meet the diagnostic criteria for
determining
whether an AMI what was presented, and it is erroneously coded as such.
Patients with insufficient information in the medical record to meet
the
objectives of the study, or whose medical records, did not appear on
file. Patients who had AMI episodes outside the
study period.
Patients hospitalized for complications of AMI which have occurred
outside the
study.
There were
noted characteristics of continuous
variables, discrete and attributes: sex, age in years (age groups for
decades,
for example 20-29 years), full name, medical record number, residence
(province) origin, month of hospitalization, MH department where the
patient
was hospitalized and use of troponin.
The
initial sample collection was carried out
according to the records of the
Patients
are recorded based there in “ischemic
heart disease”, the International Classification Manual of Diseases of
the Pan American Health Organization, document of official use of the
Costa
Rican Social Security System (CRSSS).14
The
following sources were analyzed to collect the
information gathered in the Biostatistics Office: Cardiology Service:
patient
record of the Coronary Unit, records of echocardiograms and records of
procedures of the Hemodynamics Unit, and
of the
Intensive Care Unit, the book of patients records.
They
Ministry of Health’s offices were visited
(Statistical Information Unit) and the Department of Health Statistics
(headquarters, CRSSS), and information was collected on the AMI
received at the
The
investigation forms were entered in Excel, Windows
environment, and the results were processed by using the Epi
Info package.
The
research was approved by the Medical Director of
the
Results
From the
records of the Biostatistics Office, 110
patients were obtained (n = 35 August to December 2005 and n = 75 from
January
to July 2006). On examination of the records of the Biostatistics
Office, the
Coronary Unit (CU), the Intensive Care Unit (ICU) and Hemodynamics
Unit (HU), the figure rose to 172 with the diagnosis of AMI. 36% of
users seen
for AMI or its complications in the
34
patients were excluded for: complications of AMI
occurred outside the study period (n = 18); AMI occurred outside the
study
period (n = 7), absence of criteria for diagnosis of AMI despite being
discharged as such (n = 5), lack of file or lack of codification in
Hospital
Archives and Biostatistics, despite registering in ICU (n = 2), poor
coding (n
= 1), lack of file and inability to contact the patient or family
(n=1).
By
comparing these records with those recorded in the
Biostatistics Office, ICU, CU and HU, had found that patients with AMI
were
discharged under other diagnoses (ACS, coronary artery disease,
ischemic heart
disease, unstable angina), by which were not officially listed in the
records
of the CRSSS (Biostatistics Office of the MH and CRSSS headquarters)
nor in the
Ministry of Health, as AMI.
Of the
patients who then were characterized (n = 138),
they were located at the following locations within the hospital:
Biostatistics
(n = 64), Biostatistics and Coronary Unit (n = 31), Coronary Unit only
(n =
23), Intensive Care Unit (n = 17) and HU (n = 3). The percentage of
patients
discharged with other diagnoses and bearers of AMI, which occurred in
the study
period was 20.3% after applying the exclusion criteria.
A sample
was then characterized of 138 users: 108 men
(78.1%) and 30 women (21.9%). The average age of the sample was 65.2
years
(60.8 for men and 65.2 for women). The ages of most heart attack
patients were
50 to 59 years and ≥ 70 years (both with 29%) (Table
2).
The
Cardiology Department responded to 76.8% of the
sample. Almost a quarter of patients with AMI or its complications were
not
assessed in the cardiology (Table 3).
No troponin test was
performed on 49.3% of the sample. Of those conducted, 46.3% reported
positive
of men and 40% of women. We found several measurements of troponin,
quantitative and qualitative. For various reasons (lack of reagent,
mostly),
almost 50% of patients was not determined in this test, crucial for
diagnosis,
along with other parameters of AMI. Among patients with positive troponin reports (n = 62), 28% of men died and
50% of
women. Among patients who did not undergo troponin
testing (n = 68), 23.5% of men died and 47% of women (Table 4)
Discussion
At an
international level, it has been reported that
at least a fifth of AMI are not recognized clinically, because of
atypical
symptoms (especially in the elderly) or absence of chest pain.
Also, the
silent AMI can occur in the elderly,
diabetics and postoperative patients. The elders infarcted
with positive troponin tend to not be
treated
properly. Sometimes the AMI can be seen only in retrospect, when
identifying a
complication such as peripheral embolization
of mural
thrombus or development of congestive heart failure, or mitral
regurgitation
syncope de novo. 15-17
Many AMI
are not identified clinically or its
diagnosis is delayed, hurting the appropriate approach. At least a
quarter of
IMA will not be recognized clinically. Prevalence, predisposing factors
and
prognosis are similar to those that are recognized, such as morbimortality.
18 Failure to diagnose AMI has been associated with a poor quality of
care from
admission until discharge, and with a high hospital mortality.19,20
Roughly
speaking, about a
third of patients admitted with AMI in the Mexico Hospital, not
discharged as
such, which may even be higher the figure, that shows an underreporting
impacting both medically and financially, and is a phenomenon that may
occur in
other hospitals in the country, although not known whether the same
magnitude.
Reported
cases of AMI by the Ministry of Health
(January to November 2006) were 278 at the national level; 28.7%
belonged to
the
Since
It is
necessary to standardize the diagnosis of AMI in
all levels of care and multidisciplinary teams. The definition of AMI
proposed
by the entities mentioned above could be generalized in
What
explains the difference between the 110 patients
registered in the
In
analyzing the registration form with officials of
the Biostatistics Office, it was determined that, in accordance with
the Manual
of International Statistical Classification of Diseases and Related
Health
Problems of PAHO,14 there are no codes to classify “acute
coronary syndrome”, as noted mostly within I-20 (angina pectoris) and
I-25 (chronic ischemic heart disease). In addition, many doctors do not
list
“acute myocardial infarction” among discharge diagnoses. The staff
of Biostatistics has not been informed that there are patients with AMI
under
these diagnoses, and are modified, as it must, to that manual.
In record
sources consulted in the
Regarding
the number of patients without troponin
test requested, is known internationally that the
markers of myocardial ischemia are not always available for routine use.25
Additionally, troponin T may rise
for various
cardiovascular, pulmonary, gastrointestinal and kidney causes, as was
found in
an English study, according to which, 38% corresponded to patients
without ACS
but with elevated levels of troponin.26
It is
recommended that medical and administrative
authorities of the
It is not
advisable to accept discharge diagnoses in
the Biostatistics Office, in which it is listed as only “acute coronary
syndrome”, without knowing whether or not it is an AMI, being recent or
old. It must be specified if it’s a hospitalization for AMI per se, one
of its complications, or to one of the procedures to treat this event,
as all
are recorded in different codes. It must be emphasized that it’s listed
at discharge, if a patient had an AMI or not to and collaborate to not
list
discharge diagnoses only with initials.
The Pan
American Health Organization should be aware
of this, in an attempt to consider whether the absence of ACS in the
disease
groups listed in the Manual of International Classification of
Diseases, is a
phenomenon of repercussion in other Costa Rican hospitals and other
countries.
In
summary, listing as discharge diagnosis, ACS,
unstable angina or ischemic heart disease, without specifying whether
it’s an AMI or not, it shows a lack of diagnostic clarity, which
becomes
a matter of medical and administrative repercussion, and limits dealing
with
appropriate statistical incidence and prevalence of this condition, in
the
hospital studied.
It is
recommended to create a standardized and uniform
management of patients admitted with AMI in Costa Rican hospitals, and
develop
technical, administrative and academic, multidisciplinary participation
involving CRSSS authorities, the Ministry of Health and PAHO to discuss
what’s mentioned above.
As for the
limitations of the study, despite efforts
to quantify all inpatients with a diagnosis of AMI, it was unable to
completely
review other diagnostic groups that could have included this condition,
for
example: dyspnea study, thoracic pain
study. The
implications of the estimate of total users per year for AMI
hospitalized in
the
References
1. Akita A and McGee SR. Bedside Diagnosis of Coronary Artery Disease: A Systematic Review. Am J Med 2004; 117: 334-343. [ Links ]
2. Fuster V, Steele PM and Chesebro JH. Role of platelets and thrombosis in coronary atherosclerotic disease and sudden death. J Am Coll Cardiol 1985; 5: 175B- 184B. [ Links ]
3. Albalá N y Ancillo P.El síndrome coronario agudo en su clasificación actual. Med Intensiva 2006; 30: 74-76. [ Links ]
4. López- Sendón J. y López de Sá. Nuevos criterios de diagnóstico de infarto de miocardio: orden en el caos. Rev Esp Cardiol 2001; 54: 669-674. [ Links ]
5. Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015-19.Reproducido en JAMA 1983; 250: 1757-65. [ Links ]
6. Herrick JB. Concerning thrombosis of the coronary arteries. Trans Assoc Am Phys 1918; 33: 408-15. [ Links ]
7. Wang K, A singer RW and Marriott HJL.ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. NEngl J Med 2003; 349: 2128-35. [ Links ]
8. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36:959-69. [ Links ]
9. Meier MA, Al-Badr WH, Cooper JV, Kline-Rogers EM, Smith DE, Eagle KM, et al. The New Definition of Myocardial Infarction. Arch Intern Med 2002; 162: 1585-1589. [ Links ]
10. Roger VL. Epidemiology of Myocardial Infarction. Med Clin N Am 2007; 91: 541-544. [ Links ]
11. 2004 Chartbook on cardiovascular lung and blood diseases.
12. Singh M and
13. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am CollCardiol 2000; 36:959-69. [ Links ]
14. Organización Panamericana de la Salud. Clasificación Estadística Internacional de Enfermedades y Problemas relacionados con la Salud. X revisión, volumen 1. Publicación científica No. 554. Organización Panamericana de la Salud.
15. Reeder GS y GershBJ. Modern Management of Acute Myocardial Infarction. Current Problems in Cardiology 2000; 25: 689-690. [ Links ]
16. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WE, Rich M, et al. Acute Coronary Care in the Eldery, Part II.ST-Segment-Elevation Myocardial Infarction. A Scientific Statement for Healthcare Professionals From the American Heart Association Council on Clinical Cardiology. Circulation 2007; 115: 2570-2589. [ Links ]
17. Shah R, Selter J, Wang Y, Greenspan M, Foody JM. Association of troponin status with guideline-based management of acute myocardial infarction in older persons. Arch Intern Med 2007; 167: 1621-1628. [ Links ]
18. Sheifer SE, Manolio TA and Gersh BJ. Unrecognized Myocardial Infarction. Ann Intern Med 2001; 135: 801-811. [ Links ]
19. Schelbert EB, Rumsfeld JS, Krumholz HM, Canto JG, Magid DJ, Masoudi FA et al. Ischaemic Symptoms, Quality of Care, and Mortality during Myocardial Infarction. Heart 2008;94: 2 Publicado en línea el 16 julio 2007. [ Links ]
20. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM. Challenges and Opportunities in Quantifying the Quality of Care for Acute Myocardial Infarction. Circulation 2003; 107: 1681-1691. [ Links ]
21. Ministerio de Salud. Unidad de Información Bioestadística. Registro de Pacientes con Infarto Agudo del Miocardio. San José, Costa Rica, enero 2007. [ Links ]
22. Caja Costarricense de Seguro Social. Departamento Estadística de Salud. Registro de pacientes egresados con el diagnóstico de infarto agudo del miocardio. Años 2005 y 2006. Oficinas Centrales. San José, Costa Rica. [ Links ]
23. Presidencia de la República de Costa Rica y Ministerio de Salud. Decreto No. 30945-d. Artículo 9, II. Otros subsistemas de vigilancia. La Gaceta No. 18 del 27/01/03. [ Links ]
24. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Circulation, 2007; 116: 2634-2653. [ Links ]
25. Jaffe AS. Use of Biomarkers in the Emergency Department and Chest Pain Unit. Cardiol Clin 2005; 23: 453-465. [ Links ]
26. Wong P, Murray S, Ramsewak A, Robinson A, Van Heyningen C, Rodrigues E. Raised cardiac troponin T levels in patients without acute coronary syndrome. Postgrad Med J 2007; 83: 200-205. [ Links ]
Received: November
30,
2011 Accepted: November 8, 2012