Nearly one in three patients with acute myocardial infarction were reported to have had other diagnoses at first medical contact, who less frequently received guideline indicated care and had significantly higher mortality rates.
A study funded by the British Heart Foundation and published in EHJACVC used the UK national heart attack register, 2004-2013 to investigate how frequently patients with STEMI (n=221,635) and NSTEMI (n=342,777) were given this diagnosis at presentation to hospital. Overall, 168,534 (29.9%) patients had an initial diagnosis which was not the same as their final diagnosis.
After multivariable adjustment, for STEMI a change from an initial diagnosis of ‘other’ diagnoses (such as pancreatitis, acute aortic dissection and non-cardiac diagnoses) was associated with a significant reduction in time to death by 21% (time ratio 0.78, 95% confidence interval 0.74–0.83). For NSTEMI, after multivariable adjustment, a change from an initial diagnosis of STEMI was associated with a reduction in time to death of 10% (time ratio 0.90, 95% confidence interval 0.83–0.97), but not for chest pain of uncertain cause (0.99, 0.96–1.02). Patients with NSTEMI who had other initial diagnoses also had a significant 14% reduction in their time to death (time ratio 0.86, 95% confidence interval 0.84–0.88).
Notably, patients who had STEMI and NSTEMI but were offered other initial diagnoses at hospitalisation had low rates of pre-hospital electrocardiograph (24.3% and 21.5%), aspirin on hospitalisation (61.6% and 48.5%), care by a cardiologist (60.0% and 51.5%), invasive coronary procedures (38.8 % and 29.2%), cardiac rehabilitation (68.9% and 62.6%) and guideline indicated medications at time of discharge from hospital. The authors suggested that had the 3.3% of patientswith STEMI and 17.9% of NSTEMI who were admitted with other initial diagnoses received an initial diagnosis of STEMI and NSTEMI, then 33 and 218 deaths per year might have been prevented, respectively.
In addition, the authors found that women who had a final diagnosis of STEMI had a 59% greater chance of a misdiagnosis compared with men, and women who had a final diagnosis of NSTEMI had a 41% greater chance of a misdiagnosis when compared with men. Women who were misdiagnosed had about a 70% increased risk of death after 30 days compared with those who had received a consistent diagnosis.
Receiving a quick diagnosis and getting the correct treatment after a heart attack is paramount to ensure the best possible recovery. The initial diagnosis is vital as it shapes treatment in the short-term, and sometimes in the long-term.
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Author: Professor Chris Gale
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