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Clinic and pathologic study in 460 patients died with acute myocardial infarction. Report of two series (1985-1987 and 1991-1993)

Espinosa-Brito Alfredo D; Alvarez-Li Frank C; Borges-Rodríguez Emilio; Quintana-Pérez Santiago; Fernández-Turner Manuel

"Dr. Gustavo Aldereguía Lima" Hospital (Department of Internal Medicine)
Cienfuegos, CUBA.

Introduction
Objectives
Results
Discussion
Conclussion

Introduction

Necropsy continues being the "gold standard" for our clinical successes and errors in patients who died, overall in those with diseases that produce particular anatomopathologic changes, as the Acute Myocardial Infarction (AMI). Furthermore, clinic-pathologic correlation (CPC) in patients who died with AMI is a timeliness topic. Several are the factors that make difficult the correct clinical diagnosis of AMI, including the "atypical" clinical pictures and the limitation of complementary exams, especially the electrocardiogram (ECG). As a consequence, not insignificant number of patients died due to AMI without a correct diagnosis. Therefore, at the present time, they do not receive the advantages of the complex diagnostic and therapeutic available resources for their intensive care. In the future, new reliable diagnostic methods –i.e., enzimatic ones- could be developed , and new and well equipped coronary intensive care units could be built, with advanced therapeutic protocols, but if AMI is not clinically suspected, this arsenal will be not used in all of its potentiality.

It was planned and carried out this research work with two series –three years each- of deceased patients, in order to determine our clinic-pathologic correlation in patients who died with AMI, as well as to identify the factors associated to the "gap" between the clinical diagnosis and the findings of the necropsy, what is possible and what is true.

Objectives

1. To estimate the CPC in patients died with AMI. 2. To identify the factors associated with a complete, partial or none CPC

Material and Methods: It was studied the CPC of 460 patients died in our hospital (92% of necropsy rate) with the anatomopathologic diagnosis of AMI, in 1985-1987 (Series I, n=257) and in 1991-1993 (Series II, n=203). In each case, it was recorded: age, gender, race, antecedents of previous myocardial infarction, smoking, personal pathologic antecedents, clinical picture at onset, changes and localization in the ECG, seric enzymes and department of the hospital where the death occurred.

The CPC was classified, as follows: a) Complete: When the clinical diagnosis of AMI was correctly identified at the admission or during the evolution of the patient; b) Partial: When the main clinical diagnosis was in the group of heart diseases; c) No correlation: When the main diagnosis was out of the group of heart diseases.

Results

In the Series I (1985-1987), there was a complete clinic-pathologic concordance in 148 deceased patients (59,6%) out of 257 died with AMI; in 75 (29,2%), the concordance was partial, and there was not in 34 (11,2%). In the Series II (1991-1993), the was a complete clinic-pathologic concordance in 145 (71,4%) out of 203 died with AMI –significantly higher when it was compared with the Series I-, in 20 (9,9%) there was a partial clinic-pathologic concordance and there was not in 38 (18,7%). When the total of cases from both series were put together , it was observed that in 2 out of 3 cases there was a complete clinic-pathologic concordance, and there was not in 15,6% (Table 1).

Table 1. Clinic-pathologic study in two series of patients died
with Acute Myocardial Infarction
"Dr. Gustavo Aldereguía Lima" Hospital. (1985-1987 and 1991-1993)
.
* p=0.04.

The following variables were significantly associated with a complete CPC in the both series: Chest pain, unequivocal changes and signs of anterior wall infarction in the ECG, elevated figures of the biochemical markers, and the Intensive Care Unit (ICU) as place of death. On the other hand, those who died in the Internal Medicine wards presented high percentages of no CPC. When the all the 460 cases were analyzed, also a greater no CPC was observed in diabetics and in patients died in the Intermediate Care Unit (IMCU). (Table 2, Table 3, Table 4)

Table 2. Main characteristics of the died patients
with Acute Myocardial Infarction, according to clinic-pathologic correlation.
"Dr. Gustavo Aldereguía Lima" Hospital. (Series I: 1985-1987; n=257)

*p=0.0000001.

 

Table 3. Main characteristics of the died patients
with Acute Myocardial Infarction, according to clinic-pathologic correlation.
"Dr. Gustavo Aldereguía Lima" Hospital. (Series II: 1991-1993; n=203)

*p=0.002 **** p=0.000003. ** p=0.01. ***** p=0.000001. *** p=0.0000001.

 

Table 4.Main characteristics of the died patients
with Acute Myocardial Infarction, according to clinic-pathologic correlation.
"Dr. Gustavo Aldereguía Lima" Hospital.
Both series ; n=460: (Series I: 1985-1987; n=257) + (Series II: 1991-1993; n=203).

*p=0.04. ** p=0.0000001. *** p=0.008

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Discussion

It was found a number of patients who died with AMI, without a correct pre-mortem diagnosis. In this study, two classical variables, referred as basic ones in the diagnostic data of AMI, were consistently associated with a high percentages of a complete CPC: a) chest pain, and b) unequivocal changes in the ECG. In other words, the higher risks for clinical misdiagnosis, were in the patients who did not suffer chest pain –painless and silent clinical forms, sometimes called as "atypical" ones -, or in those with a normal 12-lead ECG, or with equivocal changes. These results have to be not overlooked, if we know that only 237 (51.5%) of all deceased patients referred chest pain before their deaths, and the ECG findings were unequivocal in 294 (66.4%) of 443 patients with ECG performed. In this study, biochemical markers were useful tools in the diagnosis of AMI.

A greater possibility of misdiagnosis was confirmed, as the age of the patients was increasing, probably due to often atypical clinical onset of AMI in these groups. The difficulties for obtaining a good anamnesis in the elderly, and their usual polimorbidity, are other two factors involved in the explanation of a greater no CPC in these cases.

It was also evident in this research, the association of the antecedents of diabetes mellitus and the no CPC, as it has been referred in medical literature, where the diagnosis of AMI in a diabetic patient is emphasized as one of the challengers to clinical expertise of the physicians, especially because of the frequent painless clinical onset in them.

As expected, the higher percentages of died patients with a complete CPC occurred in the ICU, following by the IMCU, and the wards of Internal Medicine. In those with partial or none CPC, the other way around occurred. However, only 37.8% of our 460 patients died in the ICU, 38.7% died in IMCU, and 23.5% in other wards. In this last group, the majority showed a partial or none CPC.

These are logical results, because a high qualified personnel in the care of critical patients work in the ICU and in the IMCU. Furthermore, because the characteristics of these units, the patients that are admitted there are generally selected from the Emergency Department or other wards, among those with high suspicion of AMI, in order to justify their hospitalization for intensive surveillance and/or treatment. Therefore, if the possibility of AMI is not thought, because the clinical picture is unclear, or the ECG is normal, or there are equivocal changes, or it was not indicated, the install care system for the assistance of these patients is not activated.

In order to solve the dramatic situation of a misdiagnosis in a patient with AMI, different ways have been proposed, especially based on the edition of different types of guidelines for diagnosis and treatment, with the inclusion of algorithms which facilitate the transit of the patients through the complicated net of emergency services. This is the aim of the Guidelines published in our Hospital in 1994, and reviewed in 1998.

The AMI of posterior and/or lower walls was less detected from the clinical point of view, because it can be associated to different types of pain, like: epigastric, abdominal, or thoracic ones. Medical doctors can be deceived by this situation.

Finally, it is necessary to emphasize that increasing number of patients with AMI could be benefit with the modern and powerful therapeutic approaches that now exist.

Conclusions

In our study, the diagnosis of AMI constituted a necropsy finding in one out of three died patients with AMI. A group of risk factors were associated to the complete, partial or none CPC. Necropsy performance and the study of CPC are yet, two important tools in the evaluation of the quality of medical care offer in hospitals, and in its improvement.

 

Questions, contributions and commentaries to the Authors: send an e-mail message (up to 15 lines, without attachments) to coronary-pcvc@pcvc.sminter.com.ar , written either in English, Spanish, or Portuguese.

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