Long-Term Clinical Outcomes With Defect-Free Care Adherent to the Performance Measures in Patients with STEMI Undergoing PCI in Japan

Background: Adherence to the clinical performance measures has been advocated in ST-segment–elevation acute myocardial infarction (STEMI) care worldwide. We aimed to examine the association between adherence to these performance measures and long-term clinical outcomes in patients with STEMI undergoing percutaneous coronary intervention. Methods: The CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) AMI Registry Wave-2 was a multicenter registry conducted at 22 centers in Japan between 2011 and 2013, enrolling consecutive acute myocardial infarction patients who underwent coronary revascularization. The exposures were adherence to 9 guideline-based performance measures for STEMI care, including early reperfusion, evidence-based medical therapy, and cardiac rehabilitation. The primary outcome measure was all-cause death. The secondary outcome measures included cardiovascular death, myocardial infarction, stroke, heart failure hospitalization, major bleeding, and repeat coronary revascularization. Outcomes were assessed over a median follow-up of 6.0 years (interquartile range, 5.1–6.8). Adjusted hazard ratios with 95% CIs were estimated using Cox proportional hazards models, adjusting for baseline characteristics. Results: Among 2892 patients with STEMI who underwent percutaneous coronary intervention within 24 hours after symptom onset and survived to discharge (mean age, 67±13 years; 23% women), patients were categorized according to the number of fulfilled performance measures (PMs=9: N=551, PMs=8: N=985, PMs=7: N=794, and PMs≤6: N=562). As the adherence categories decreased from PMs=9 to PMs≤6, the cumulative 5-year incidence of all-cause death increased from 8.9% to 23.6%. Relative to PMs=9, the adjusted hazard ratio (95% CI) for all-cause death was 1.14 (0.83–1.57) in PMs=8, 1.36 (0.99–1.87) in PMs=7, and 1.96 (1.43–2.69) in PMs≤6, respectively. These inverse associations were observed between adherence to performance measures and most clinical outcomes except for repeat coronary revascularization (adjusted hazard ratio, 1.00 95% CI, 0.82–1.21 in PMs=8, 0.89 0.72–1.09 in PMs=7, and 0.91 0.72–1.15 in PMs≤6, respectively). Conclusions: Defect-free care adherent to the performance measures was associated with improved long-term clinical outcomes, including lower mortality, among patients with STEMI undergoing percutaneous coronary intervention, whereas no association was observed for repeat coronary revascularization.