title: Adherence to ACC/AHA performance measures for myocardial infarction in six Middle-Eastern countries: association with in-hospital mortality and clinical characteristics.
abstract: OBJECTIVE
  This study assesses adherence to performance measures for acute myocardial infarction (AMI) in six Middle-Eastern countries, and its association with in-hospital mortality. Few studies have previously assessed these performance measures in the Middle East.
  
  
  METHODS
  This cohort study followed 5813 patients with suspected AMI upon admission to discharge. Proportions of eligible participants receiving the following performance measures were calculated: medications within 24 hours of admission (aspirin and beta-blocker) and on discharge (aspirin, beta-blockers, angiotensin converting enzyme inhibitors [ACEI], and lipid-lowering therapy), reperfusion therapy, and low-density lipoprotein (LDL) cholesterol measurement. A composite adherence score was calculated. Associations between performance measures and clinical characteristics were assessed using multivariate logistic regression.
  
  
  RESULTS
  Adherence was above 90% for aspirin, reperfusion, and lipid-lowering therapies; between 60% and 82% for beta-blockers, ACEI, statin therapy, time-to-balloon within 90 minutes, and LDL-cholesterol measurement; and 33% for time-to-needle within 30 minutes. After adjustment, factors associated with high composite performance score (>85%) included Asian ethnicity (Odds Ratio, OR=1.3; p=0.01) and history of hyperlipidemia (OR=1.4; p=0.001). Factors associated with a lower score included atypical symptoms (OR=0.6; p=0.003) and high GRACE score (OR=0.6; p<0.001). Lower in-hospital mortality was associated with provision of reperfusion therapy (OR=0.54, p=0.047) and beta-blockers within 24 hours (OR=0.33, p=0.005).
  
  
  CONCLUSIONS
  Overall adherence was lowest among the highest-risk patients. Lower in-hospital mortality was independently associated with adherence to early performance measures, comprising observational evidence for their effectiveness in a Middle East cohort. These data provide a focus for regional quality improvement initiatives and research.
authors.affiliation: Department of Community Medicine, Faculty of Medicine, Kuwait University, Kuwait. jlongene@hsc.edu.kw
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Longenecker
authors.forename: Abdulhamied
authors.initials: A
authors.lastname: Alfaddagh
authors.forename: Mohammad
authors.initials: M
authors.lastname: Zubaid
authors.forename: Wafa
authors.initials: W
authors.lastname: Rashed
authors.forename: Mustafa
authors.initials: M
authors.lastname: Ridha
authors.forename: Fahad
authors.initials: F
authors.lastname: Alenezi
authors.forename: Rashed
authors.initials: R
authors.lastname: Alhamdan
authors.forename: Mousa
authors.initials: M
authors.lastname: Akbar
authors.forename: Bassam Y
authors.initials: BY
authors.lastname: Bulbanat
authors.forename: Jassim
authors.initials: J
authors.lastname: Al-Suwaidi
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality / Q000208:ethnology*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D055118:Medication Adherence / Q000208:ethnology*; D008875:Middle Aged; D008877:Middle East / Q000208:ethnology; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000208:ethnology* / Q000401:mortality; D011446:Prospective Studies; D012042:Registries; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin