CLINICAL IMPACT OF LOCAL IMPLEMENTATION OF AGREED GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

OBJECTIVE: This study sought to assess the impact of local implementation of clinical practice guidelines on the pattern of care and outcome in patients admitted to the Coronary Care Unit (CCU) with acute myocardial infarction. BACKGROUND: Development of clinical practice guidelines is among the most popular of the methods intended to promote translation of results from clinical trials into routine care. However, very little is known about the actual impact on routine care of the clinical guidelines for managing patients with acute myocardial infarction. METHODS: We reviewed a prospectively collected cohort of consecutive patients discharged with a diagnosis of acute myocardial infarction from S. Maria degli Angeli, a large community-based hospital in northeast Italy. Eighty-six patients treated in 1996 (before guideline implementation) were compared with 70 patients treated in 1997 (after guideline implementation) with respect to patterns of use of guideline-directed pharmacotherapies for acute myocardial infarction, diagnostic testing, length of CCU stay and clinical outcome. RESULTS: The two groups were similar in male gender, age, infarct location and severity. Patients managed before guideline implementation were less likely to receive thrombolysis (36 vs 50%; p = 0.05), i.v. beta-blockers at admission (13 vs 31%; p = 0.002), oral beta-blockers at CCU discharge (45 vs 74%; p = 0.0003). When these were given, patients managed before guideline implementation received lower dosages of i.v. heparin, as manifested by a lower proportion of patients reaching adequate aPTT levels at 24 hours (14 vs 62%, p < 0.0001), and of oral beta-blockers (-50%, p < 0.0001), and higher dosage of aspirin (+100%, p < 0.0001). The time to mobilization (+1 day) and the length of CCU stay (+0.5 day) were longer in patients managed before guideline implementation (p < 0.0001). Incidence of major complications was similar between the two groups (19 vs 13%, respectively; p = ns). CONCLUSIONS: Patients with myocardial infarction managed after local implementation of clinical practice guidelines were more likely to receive evidence-based effective pharmacotherapies, and to have earlier mobilization and earlier discharge from CCU. This study strongly supports the role of local implementation of clinical practice guidelines to optimize management of patients with acute myocardial infarction.