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Acute Myocardial Infarction: Setting Priorities for Effectiveness Research Report of a Study by a Committee of the INS TllrUTE OF MEDICINE Division of Health Care Services Patrick H. Mattingly and Kathleen N. Lohr, editors NATIONAL ACADEMY PRESS Washington, D.C. 1990

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NOTICE: The project that is He subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. The report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Astute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertairung to He health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibil- ity to be an adviser to the federal government and its own initiative in identify- ing issues of medical care, research, and education. This workshop was supported by the Health Care Financing Administration, U.S. Department of Health and Human Services, under Basic Ordering Agreement Contract No. 500-89-0008. Library of Congress Catalog Card No. 90-63449 International Standard Book No. 0-309-04380-8 Publication IOM-90-07 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Washington, DC 20418. S250 Printed in the United States of America

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INSTITUTE 017 MEDICINE Division of Health Care Services HCFA Effectiveness Initiative Acute Myocard~al Infarction Workshop Committee KENNETH I. SHINE, Chair, Dean, School of Medicine, University of California, Los Angeles HOOSHANG BOLOOKI, Jackson Memorial Hospital, Miami, Florida WILLIAM H. CARTER, The Charleston Cardiology Group, Charleston, West Virginia KATHLEEN DRACUP, Professor of Nursing, School of Nursing, University of California, Los Angeles MAUREEN M. HENDERSON, Head, Cancer Prevention Research Center, Fred Hutchinson Cancer Research Center, Seattle, Washington EMMETT B. KEELER, Senior Mathematician, Economics Department, The RAND Corporation, Santa Monica, California KENNETH M. KENT, Director, Cardiac Catheterization Laboratory, Georgetown University School of Medicine, Washington, D.C. BARBARA J. McNEIL, Head, Department of Heals Care Policy, Harvard Medical School, Boston, Massachusetts DAVID G. MURRAY, Professor, Department of Orthopedic Surgery, Health Services Center, State University of New York, Syracuse ALAN R. NELSON, Associate, Memorial Medical Center, Salt Lake City, Utah BRUCE PATON, Arapahoe Cardiovascular Surgeons, Denver, Colorado GERALD M. POHOST, Director, Division of Cardiovascular Disease, University of Alabama, Birmingham JOHN V. RUSSO, John Russo ~ Shellee Nolan, Washington, D.C. THOMAS J. RYAN, Chief of Cardiology, Boston University School of Medicine, Massachusetts J. SANFORD SCHWARTZ, Professor, General Internal Medicine, Hospitals of die University of Pennsylvania, Philadelphia HARRY P. SELKER, Director, Center for Cardiovascular Health Services Research, New England Medical Center Hospital, Boston, Massachusetts G. RICHARD SMITH, Associate Professor of Psychiatry, Department of Psychiatry, University of Arkansas for the Medical Sciences, Little Rock HAROLD G. SOX, Professor and Chairman, Department of Medicine, Damnouth Medical School, Hanover, New Hampshire . . . us

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GEORGE T. THIBAULT, Chief, Medical Service, VA Medical Center, West Roxbury, Massachusetts W. DOUGLAS WEAVER, Director, Cardiovascular Critical Care, University of Washington, Seattle MYRON WEISFELDT, Director of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland NANETTE K. WENGER, Professor of Medicine (Cardiology), Emory University School of Medicine, Atlanta, Georgia STUDY STAFF Division of Health Care Services KARL D. YORDY, Director KATHLEEN N. LOHR, Deputy Director RICHARD A. RE'l l IG, Senior Staff Officer KIM A. HEITHOFF, Research Assistant Division of Health Promotion and Disease Prevention MARIE ELENA LARA, Program Officer PATRICK H. MATIINGLY, Scholar in Residence lV

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Acknowledgments lithe contributions of several members of the Institute of Medicine staff deserve special mention. Among them are H. Donald Tiller, a~ninis- traiive assistant, and Theresa Nally, senior secretary. Maria Elena Lara reviewed workshop materials and earlier drafts of this report, and Kim Heithoff contributed greatly to the smooth logistics of the committee's homework exercise and the workshop meeting. Richard A. Rettig and Karl D. Yordy provided steady support and leadership throughout the entire pro- ject. Funding for this study was provided by the U.S. Department of Health and Human Services, Health Care Financing Administration. We particu- larly wish to acknowledge the cheerful support of the government's project officer, John Spiegel, of the Health Standards and Quality Bureau, through- out the entire project.

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Contents ACKNOWLEDGMENTS SUMMARY ............. 1NTR()DIJ[-I ION Effectiveness lhiiiaiive, 5 The IOM Clinical Workshop, 6 Condiiion-specific Research Workshops, 7 THE KNOWLEDGE BASE FOR KEY CLINICAL ISSUES IN ACUTE MYOCARDLAL INFARC-l'lON............ Etiology and Epidemiology, 10 Diagnosis and Management, 12 Therapeutic Options, 19 FACTORS IMPORTANT FOR THE SELECTION OF KEY PATIENT MANAGEMENT ISSUES AND RELATED RESEARCH ACTIVITIESeeeeeeeeeeeeeee..eeeeeeeeee~eeeeeeeeeeeeaee.~.e Selecting Patient Management Issues, 25 Selecting Research Topics and Activities, 26 KEY PA'l'~NT MANAGEMENT TOPICS FOR EF'L'EC~VENESS RESEARCH IN ACIJ7rE MYOCARDIAL INFARe'l'lON........................................... Preliminary Discussion and Selection of Major Topics, 29 SummaIy of Recommendations, 32 Methods Issues, 33 Patient Management Topics, 39 CONCLUSIONS . e e e ~ - e e e e e e e e e e e e e - ~ e e ~ e e e e e e e e ~ e e e e e BIBLIOGRAPHY e ~ e ~ APPENDIX A: Background and Conduct of the Workshop . . . vu ..25 .29 .43 ..45 .49

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