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Timely and effective treatment is essential for the survival of patients with acute myocardial infarction (AMI). The most critical period in AMI is its earliest phase. The mortality rate for acute heart attacks in the first month is between 30% and 50%, and approximately half of these deaths occur within two hours, usually due to ventricular fibrillation. The high initial mortality rate appears to have changed little over the past 30 years; however, there has been a notable reduction in mortality among cases treated in hospital. From a mean 30-day mortality rate of 18%, as highlighted by a systematic review of mortality studies in the pre-thrombolytic era in the mid-1980s, the mortality rate has dropped, with the widespread use of fibrinolytic drugs, aspirin, and coronary revascularization procedures, to a 6-7% mortality rate, at least in large trials. Reperfusion therapy, if implemented correctly and promptly, leads to both a reduction in mortality and an improvement in short- and long-term prognosis.

Thirty-day mortality after an AMI is considered a valid and reproducible indicator of the appropriateness and effectiveness of the diagnostic-therapeutic process that begins with hospitalization.

However, the choice of therapeutic approach should be made prior to arrival at the hospital, taking into account the characteristics of the available organization and the patient’s clinical status, based on which risk stratification can be performed.

In this context, in order to conduct more in-depth analyses of the healthcare response to a heart attack patient, the following indicators are defined:

1) “Thirty-day mortality from hospitalization for an acute myocardial infarction (AMI)”;

2) “Thirty-day mortality from hospitalization for an acute myocardial infarction (AMI as the primary diagnosis)”.

For these indicators, the outcome is calculated starting from the date of admission for AMI, and exposure is given by
the hospital to which the patient was admitted.
Following verification of associations between outcome trends and new clinical variables introduced in the SDO framework starting in 2018, the following indicator is also defined:

3) “Mortality within thirty days of admission – with new variables”: the outcome is calculated starting from the date of admission for AMI, and exposure is given by the hospital to which the patient was admitted.

This indicator maintains the structure and calculation methodologies previously described, adding the variable related to systolic blood pressure measured at the time of admission as a predictive factor in the outcome rate adjustment model.
Indicators in which mortality is calculated starting from the date of admission are intended to provide information on the functioning of the entire hospital care process starting from the time of admission. Therefore, attributing the outcome to the hospital does not imply an assessment of the quality of care provided by that facility, but rather of the appropriateness and effectiveness of the care process that begins with the patient’s arrival at that facility.

Proper management of patients after hospitalization for myocardial infarction includes a secondary prevention program that must include dietary recommendations, lifestyle changes, and the definition of an appropriate pharmacological strategy. The onset of subsequent cardiovascular or cerebrovascular events, which must be prevented with proper clinical and therapeutic management, can be fatal in these patients. The program should be established during the hospital stay and transmitted to the general practitioner so that patients can follow it indefinitely.

Therefore, the indicators:

4) “12-month mortality of survivors of acute myocardial infarction”;
5) “Major cardiovascular and cerebrovascular events (MACCE) within 12 months of hospitalization for
acute myocardial infarction” were calculated to evaluate the appropriate clinical and therapeutic management of patients in the community.

The values ​​of the indicators may vary between regions and facilities; this phenomenon, in addition to the varying quality of care, may be caused by the heterogeneous distribution, due to case mix, of various risk factors such as age, gender, and the patient’s health conditions.

Scientific literature highlights how the incidence of heart failure in patients who have survived a myocardial infarction does not decrease over time and can significantly impact their prognosis.
The onset of heart failure in patients with AMI can be influenced by various factors (genetics, characteristics of the infarction, clinical risk factors, etc.) and, in part, also by the timeliness of some treatments for acute AMI (procedural such as PCI or pharmacological).

Approximately one-fifth of AMI patients who survive the acute phase develop heart failure during the index hospitalization. Patients with AMI complicated by heart failure, compared to uncomplicated AMI patients, have a poorer prognosis in terms of mortality, MACCE, and rehospitalizations for heart failure in the medium to long term, with rates approximately four times higher.

This prognostic differential requires the development of a specific care plan that provides differentiated and more intensive management for patients with AMI complicated by heart failure (with specific procedural and pharmacological interventions and intensive follow-up), which promotes better
secondary prevention and improved prognosis.

Recent studies demonstrate a reduction in short-term mortality in patients with heart failure following the implementation of integrated care for this condition and the optimization of the use of specific medications.

Volume indicators specific to the subpopulation of patients with AMI complicated by heart failure and long-term outcome can help measure both the burden on the system and the effectiveness of clinical and therapeutic management of these patients, primarily in the community.

In this context, the following indicators are defined:

➢ Volume of hospitalizations for acute myocardial infarction complicated by heart failure;
➢ 12-month mortality in 30-day survivors of acute myocardial infarction complicated by heart failure;
➢ Major cardiovascular and cerebrovascular events (MACCE) within 12 months in 30-day survivors of a hospitalization for acute myocardial infarction complicated by heart failure.

The value of the indicators may vary between regional areas and facilities; This phenomenon, in addition to the varying quality of care, may be caused by the heterogeneous distribution, due to case mix, of various risk factors such as the patient’s age, gender, and health conditions.

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