Bahit, M. C., Murphy, S. A., Gibson, C. M., Cannon, C. P. Critical pathway for acute ST-segment elevation myocardial infarction: estimating its potential impact in the TIMI 9 Registry Critical pathways in cardiology. 2002;1(2):107-12.

BACKGROUND: Physicians are under increasing pressure to reduce costs and maintain high quality of care. Critical pathways may help accomplish this goal.

METHODS: We assessed the potential impact of implementation of a critical pathway in the Thrombolysis in Myocardial Infarction (TIMI 9) Registry, in which 840 consecutive patients with ST-elevation myocardial infarction (STEMI) were enrolled at 20 hospitals in the United States and Canada. The proposed critical pathway targets 100% use of fibrinolysis in fibrinolytic-eligible patients, 95% use of aspirin, and 90% use of beta-blockers and angiotensin-converting enzyme inhibitors (ACE-I) and incorporates a strategy of early hospital discharge for low-risk patients. Risk reduction for each intervention was estimated based on the benefits seen in large randomized controlled clinical trials or meta-analysis.

RESULTS: In the TIMI 9 Registry, fibrinolysis was used in 60% of the patients; primary percutaneous coronary intervention, in 9%; and no reperfusion therapy, in 31%. Only 87% of the registry patients took aspirin during hospitalization. Of those with documented left ventricular dysfunction or congestive heart failure, 32% were discharged on ACE-I; and of those with normal ejection fraction and no evidence of congestive heat failure, only 58% were treated with beta-blockers at discharge. For early benefit and by increasing the use of reperfusion therapy and aspirin to 95% and improving the time to treatment, one could potentially save 13 lives per 1,000 patients treated per year. Similarly, if beta-blocker and ACE-I use increased up to 90% for the long term, almost 2 lives per 1,000 patients treated per year could potentially be saved. In summary, by expanding the use of a critical pathway for thrombolysis in STEMI, 15 lives per 1,000 patients treated per year could be saved. To evaluate the potential economic impact of this critical pathway on low-risk patients, 358 of 505 thrombolysis patients had no recurrent ischemia, MI, shock, or congestive heart failure through day 5. Their median length of stay was 6.7 days (25-75th percentiles, range, 4.8-10.3 days), with 73% staying in-hospital more than the target of 5 days, with similar findings for patients treated with primary angioplasty.

CONCLUSIONS: These findings demonstrate that significant opportunities exist for improving medical management of patients with acute MI. Critical pathways may help reduce costs while improving quality of care.

Trial: TIMI 9 REG