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CLINICAL GUIDELINE: PART I: Guidelines for Risk Stratification after Myocardial Infarction
- American College of Physicians* *This paper, written by Eric D. Peterson, MD, Leslee J. Shaw, PhD, and Robert M. Califf, MD, was developed for the Health and Public Policy Committee by the Clinical Efficacy Assessment Subcommittee: George E. Thibault, MD, Chair; John R. Feussner, MD, Co-Chair; Anne-Marie J. Audet, MD; Gottlieb C. Friesinger Jr., MD; Daniel L. Kent, MD; Keith I. Marton, MD; Valerie Anne Palda, MD; John J. Whyte, MD; and Preston L. Winters, MD. This paper was approved by the Board of Regents on 22 April 1996. Note: The Clinical Efficacy Assessment Project (CEAP) of the American College of Physicians is designed to evaluate and inform College members and others about the safety and efficacy of diagnostic and therapeutic methods. Acknowledgment: The authors thank Patricia Williams for editorial assistance. Requests for Reprints: Customer Service Representative, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572.
The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, “Risk Stratification after Myocardial Infarction,” which is part II of this Guideline (see pages 561-582).
In the 6 years since the publication of the previous American College of Physicians guidelines on risk stratification after myocardial infarction [1], the management of patients who have myocardial infarction has changed dramatically. Three major factors have prompted this change: the increased availability of empirical data from randomized clinical trials, the proliferation of diagnostic and interventional technologies, and the growth of managed care organizations.
The recent completion of several large clinical trials has not only shown the efficacy of many new therapeutic agents but has supplied rich clinical databases for use in outcomes research. The dramatic spread of diagnostic and therapeutic technologies has also influenced acute coronary care in the United States. For example, the use of cardiac catheterization and revascularization in Medicare patients presenting with acute infarction increased by 45% and 70%, respectively, between 1987 and 1992 [2, 3]. Among 350 775 patients in the United States who were enrolled in the National Registry of Myocardial Infarction between 1990 and 1994, overall rates of catheterization, angioplasty, and bypass surgery were 56%, 20%, and 12%, respectively [4]. The counterbalance to this increase in technology-based medicine has been a growing, nationwide concern about the escalating cost of medical care. In the managed care settings of the 1990s, providers have been encouraged to shorten hospital stays and limit resource utilization.
To continue to provide high-quality care while controlling medical costs in today's health care environment, providers must use an evidence-based strategy to quantify a patient's overall short- and long-term risk. In this position paper, we highlight the four major phases of the hospitalization of a patient with acute …
