Coronary syndrome and other diagnosis result in under reporting of acute myocardial infarction in the Mexico Hospital, Costa Rica

None; None; None

Abstracts

Justification: Acute myocardial infarction is a major public health problem. In Costa Rica, it is necessary to record it accurately in order to handle this problem efficiently. Materials and methods: Descriptive and observational study. Data from patients which were discharged from the Mexico Hospital and diagnosed with acute coronary syndrome, acute myocardial infarction, unstable angina and ischemic heart disease from August 2005 to July 2006 was compiled. The records of the MH- Biostatistics office, as well as those from a series of Units (Coronary, Intensive Care, Hemodynamics and Echocardiograms)- were analyzed. Results: The Mexico Hospital reports 110 patients diagnosed with acute myocardial infarction. This number increased to 172 when patients discharged as cases of ACS, unstable angina or ischemic heart disease were reported also as cases of acute myocardial infarction. The final sample analyzed was 138 patients when some patients were excluded due to incomplete data. This meant that underreporting was at least 36 %. Men represented 78.1 % of the sample; the average age for both sexes was 65.2 years. Troponin was not measured in 49.3% of the patients and a quarter of them were not assessed by a cardiologist. Out of the total of patients discharged with other diagnoses, 20.3% also had AMI. Conclusions: Acute myocardial infarction is under reported in the Mexico Hospital, and in the central offices of the Ministry of Health and of the Costa Rican Social Security System. Findings could be similar in other Costa Rican hospitals.

acute myocardial infarction; acute coronary syndrome; underreport.

Justificación: el infarto agudo del miocardio es un problema mayor de salud pública. Es necesario verificar su adecuado registro en Costa Rica para atender eficientemente su problemática. Materiales y métodos: estudio descriptivo y observacional. Se recopilaron los pacientes egresados del Hospital México con diagnósticos de síndrome coronario agudo, infarto agudo del miocardio, angina inestable y cardiopatía isquémica, de agosto 2005 a julio 2006, analizándose los registros de la oficina de Bioestadística y Unidades (Coronaria, Terapia Intensiva, Hemodinamia y Ecocardiogramas). Resultados: el Hospital México reportó 110 pacientes con el diagnóstico de infarto agudo del miocardio. Al incluir egresados con diagnósticos de síndrome coronario agudo, angor inestable o cardiopatía isquémica y que eran infartos agudos del miocardio, el número aumentó a 172. La muestra analizada finalmente fue de 138 pacientes al eliminar el restante por datos incompletos, significando un subregistro de al menos 36%. El 78.1% fueron hombres y la edad promedio para ambos sexos fue 65.2 años. No se le midió la troponina al 49,3% de la muestra y la cuarta parte no fueron valorados por cardiólogos. El 20.3% de los pacientes que fueron egresados con otros diagnósticos eran portadores también de infarto agudo del miocardio. Conclusiones: existe subregistro de infarto agudo del miocardio en el Hospital México y en oficinas centrales del Ministerio de Salud y la Caja Costarricense de Seguro Social. Este hallazgo también es probable que se presente en otros hospitales costarricenses.existe subregistro de infarto agudo del miocardio en el Hospital México y en oficinas centrales del Ministerio de Salud y la Caja Costarricense de Seguro Social. Este hallazgo también es probable que se presente en otros hospitales costarricenses.

infarto agudo del miocardio; síndrome coronario agudo; subregistro

Justification: Acute myocardial infarction is a major public health problem. In Costa Rica, it is necessary to record it accurately in order to handle this problem efficiently. Materials and methods: Descriptive and observational study. Data from patients which were discharged from the Mexico Hospital and diagnosed with acute coronary syndrome, acute myocardial infarction, unstable angina and ischemic heart disease from August 2005 to July 2006 was compiled. The records of the MH- Biostatistics office, as well as those from a series of Units (Coronary, Intensive Care, Hemodynamics and Echocardiograms)- were analyzed. Results: The Mexico Hospital reports 110 patients diagnosed with acute myocardial infarction. This number increased to 172 when patients discharged as cases of ACS, unstable angina or ischemic heart disease were reported also as cases of acute myocardial infarction. The final sample analyzed was 138 patients when some patients were excluded due to incomplete data. This meant that underreporting was at least 36 %. Men represented 78.1 % of the sample; the average age for both sexes was 65.2 years. Troponin was not measured in 49.3% of the patients and a quarter of them were not assessed by a cardiologist. Out of the total of patients discharged with other diagnoses, 20.3% also had AMI. Conclusions: Acute myocardial infarction is under reported in the Mexico Hospital, and in the central offices of the Ministry of Health and of the Costa Rican Social Security System. Findings could be similar in other Costa Rican hospitals.Acute myocardial infarction is under reported in the Mexico Hospital, and in the central offices of the Ministry of Health and of the Costa Rican Social Security System. Findings could be similar in other Costa Rican hospitals.

acute myocardial infarction; acute coronary syndrome; underreport.

MexicoHospital, Costa Rica

Manuel Francisco Jiménez-Navarrete,¹ Carlos Arguedas-Chaverri, Luis Romero-Triana

MexicoHospital, Costa Rican Social Security System. San Jose, Costa Rica.

Endocrinology Department¹and Cardiology Department,²Saint Vincent de Paul Hospital.
Abbreviations: CRSSS, Costa Rican Social Security System; MH,Mexico Hospital;AMI,acute myocardial infarction; STEMI, acute myocardial infarction with ST-segment elevation; NSTEMI, acute myocardial infarction without ST-segment elevation; PAHO, Pan American Health Organization; ACS, acute coronary syndrome; CU, Coronary Unit; HU, Hemodynamics Unit; ICU, Intensive Care Unit. mickeymfjn@yahoo.com

Justification: Acute myocardial infarction is a major public health problem. In Costa Rica, it is necessary to record it accurately in order to handle this problem efficiently.

Materials and methods: Descriptive and observational study. Data from patients which were discharged from the MexicoHospital and diagnosed with acute coronary syndrome, acute myocardial infarction, unstable angina and ischemic heart disease from August 2005 to July 2006 was compiled. The records of the MH- Biostatistics office, as well as those from a series of Units (Coronary, Intensive Care, Hemodynamics and Echocardiograms)- were analyzed.

Results: The MexicoHospital reports 110 patients diagnosed with acute myocardial infarction. This number increased to 172 when patients discharged as cases of ACS, unstable angina or ischemic heart disease were reported also as cases of acute myocardial infarction. The final sample analyzed was 138 patients when some patients were excluded due to incomplete data. This meant that underreporting was at least 36 %. Men represented 78.1 % of the sample; the average age for both sexes was 65.2 years. Troponin was not measured in 49.3% of the patients and a quarter of them were not assessed by a cardiologist. Out of the total of patients discharged with other diagnoses, 20.3% also had AMI.

Conclusions: Acute myocardial infarction is under reported in the MexicoHospital, and in the central offices of the Ministry of Health and of the Costa Rican Social Security System. Findings could be similar in other Costa Rican hospitals.

Key words: acute myocardial infarction, acute coronary syndrome, underreport.

¹Modern definitions of the triad of Heberden retain their essential ingredients (retrosternal oppression, worsening with exertion and relieved by rest).

²ACS is an operation term especially useful for the initial evaluation of patients with chest pain, which includes any type of AMI –with or without ST-segment elevation and unstable angina. This syndrome continues “... subject to vertigo research. The inflammatory aspect of the pathophysiology, the diatribe between the pharmacological management and implemented, genetics, even the characterization and classification, are shown as open pathways restless thinking”.³

⁴James Herrick suggested that the presence of coronary artery thrombosis was the mechanism that originated the AMI,⁵and was also the first to propose the electrocardiographic changes in its diagnosis.⁶

⁷

⁸This caused a significant increase in the diagnosis of AMI and helped identify a greater number of patients with ACS who have a lot of comorbidity and worse prognosis at 6 months, rather than the previous criteria of the World Health Organization in 1979 proposed . Investigation is needed to confirm these preliminary findings and to determine the economic implications of the new criteria.⁹

Table 1).¹⁰

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Table 1

United States is 25% in the three years following the event. A significant proportion of heart attack patients develop chronic congestive heart failure, with a mortality of about 20% annually in the symptomatic patients.¹¹In this country, the ACS cause about 1.5 million hospitalizations annually.¹²The AMI without ST segment elevation (NSTEMI) represents a large number of events, which, a year equals, and sometimes exceeds the annual mortality that presents AMI with ST elevation (STEMI).¹²

University of Costa Rica, unpublished), which analyzed the short-and long-term progress of AMI.

¹³

BiostatisticsOfficeMexicoHospital.

¹⁴

MexicoHospital, for the period studied.

MexicoHospital, after analysis of the Local Committee on Bioethics and Investigation (trade-HM CLOBI 009-0407), which endorses from the ethical and methodological development of the proposed study. The authors declare that they have no conflict of interest.

MexicoHospital (before applying criteria used in this study), was not registered with the BiostatisticsOfficeHospital.

Table 2).

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Table 2

Table 3).

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Table 3

Table 4)

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Table 4

^15-17

^19,20

Roughly speaking, about a third of patients admitted with AMI in the Mexico Hospital, not discharged as such, which may even be higher the figure, that shows an underreporting impacting both medically and financially, and is a phenomenon that may occur in other hospitals in the country, although not known whether the same magnitude.

province of San José and 18.3% to the one of Alajuela. ²¹a significant undercount, since only in the Mexico Hospital, main reception center for AMI cases of these provinces, at least 50% of that figure was discharged. AMI cases registered by the Department of Health Statistics (CRSSS) were 1162 (n = 105, 9% of MH), during 2005 and 2006 (n = 88, 7.3% of MH) in 2006. This means that officially, the CRSSS reported between August 2005 and July 2006, less than 60% of patients were hospitalized for AMI in Mexico Hospital Reported cases of AMI by the Ministry of Health (January to November 2006) were 278 at the national level, 28.7% belonged to the province of San José and 18.3% to the foregoing evidence Alajuela. ²¹This represents a significant undercount, since only in the MexicoHospital, main reception center for AMI case of these provinces, at least 50% of that figure was discharged. AMI cases registered by the Department of Health Statistics (CRSSS) were 1162 (n = 105, 9% of MH), during 2005 and 2006 (n = 88, 7.3% of MH) in 2006. This means that officially, the CRSSS reported between August 2005 and July 2006, less than 60% of patients hospitalized for AMI in Mexico Hospital.²²

2003, a decree exists declaring the AMI as an obligated reportable disease (Article 9),²³so it’s necessary to elaborate studies to know the true incidence and prevalence of AMI in Costa Rica. At the moment, any number that is provided implies significant underreporting in both the Ministry of Health as the CRSSS.

Costa Rica, as a first step in the analysis and better patient care with AMI. ^13
24

BiostatisticsOfficeMexicoHospital, the 172 collected later and the 138 finally registered users? In discharge diagnoses, doctors noted “acute coronary syndrome”, “coronary artery disease”, “ischemic heart disease” or other types of angina, in services where these patients were admitted (Cardiology, Internal Medicine, Thoracic Surgery, Intensive Care Unit, etc.).

¹⁴there are no codes to classify “acute coronary syndrome”, as noted mostly within I-20 (angina pectoris) and I-25 (chronic ischemic heart disease). In addition, many doctors do not list “acute myocardial infarction” among discharge diagnoses. The staff of Biostatistics has not been informed that there are patients with AMI under these diagnoses, and are modified, as it must, to that manual.

MexicoHospital, there is no reliable record that specifies how many hospitalizations were due to the event per se, as a result of some of its complications, to subject a user to revascularization surgery (“bypass”), or percutaneous coronary intervention.

²⁵Additionally, troponin T may rise for various cardiovascular, pulmonary, gastrointestinal and kidney causes, as was found in an English study, according to which, 38% corresponded to patients without ACS but with elevated levels of troponin.²⁶

MexicoHospital involved in the clinical management and biostatistics of the AMI analyze and correct these deficiencies, a suggestion which is extensive to the medical and administrative dependencies of the headquarters of the CRSSS and the Ministry of Health. It is essential to coordinate information with the Biostatistics Office and collecting the record books of the thrombolyzed patients in the Emergency Medical Department.

MexicoHospital should be the subject of another study. The number of patients is not large enough sample to obtain statistically significant results in many of the variables and associations studied. The findings in the MexicoHospital do not necessarily reflect the same magnitude of underreporting in other Costa Rican hospitals.

References

1. Akita A and McGee SR. Bedside Diagnosis of Coronary Artery Disease: A Systematic Review. AmJ Med 2004; 117: 334-343.
2. Fuster V, Steele PM and Chesebro JH. Role of platelets and thrombosis in coronary atherosclerotic disease and sudden death. J Am Coll Cardiol1985; 5: 175B- 184B.
3. Albalá N y Ancillo P.El síndrome coronario agudo en su clasificación actual. MedIntensiva 2006; 30: 74-76.
4. López- Sendón J. y López de Sá. Nuevos criterios de diagnóstico de infarto de miocardio: orden en el caos. Rev Esp Cardiol2001; 54: 669-674.
5. Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015-19.Reproducido en JAMA 1983; 250: 1757-65.
6. Herrick JB. Concerning thrombosis of the coronary arteries. Trans Assoc Am Phys 1918; 33: 408-15.
7. Wang K, A singer RW and Marriott HJL.ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. NEnglJ Med 2003; 349: 2128-35.
8. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol2000; 36:959-69.
9. Meier MA, Al-Badr WH, Cooper JV, Kline-Rogers EM, Smith DE, Eagle KM, et al. The New Definition of Myocardial Infarction.Arch Intern Med 2002; 162: 1585-1589.
10. Roger VL. Epidemiology of Myocardial Infarction. Med ClinN Am 2007; 91: 541-544.
11. 2004 Chartbook on cardiovascular lung and blood diseases. Bethesda, MD: National Heart, Lung, and Blood Institute. En: National Heart, Lung, and Blood Institute MorbMortal; 2004: 2-53.
12. Singh M and Holmes DR. Acute Myocardial Infarction. Med ClinN Am 2007; 91:684 y 729.
13. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am CollCardiol2000; 36:959-69.
14. Organización Panamericana de la Salud. Clasificación Estadística Internacional de Enfermedades y Problemas relacionados con la Salud. X revisión, volumen 1. Publicación científica No. 554. Organización Panamericana de la Salud. WashingtonDC, EUA, 1995. 455-461.
15. Reeder GS y GershBJ. Modern Management of Acute Myocardial Infarction.Current Problems in Cardiology 2000; 25: 689-690.
16. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WE, Rich M, et al. Acute Coronary Care in the Eldery, Part II.ST-Segment-Elevation Myocardial Infarction. A Scientific Statement for Healthcare Professionals Fromthe American Heart Association Council on Clinical Cardiology. Circulation 2007; 115: 2570-2589.
17. Shah R, Selter J, Wang Y, Greenspan M, Foody JM. Association of troponin status with guideline-based management of acute myocardial infarction in older persons.Arch Intern Med 2007; 167: 1621-1628.
18. Sheifer SE, Manolio TA and Gersh BJ. Unrecognized Myocardial Infarction.Ann Intern Med 2001; 135: 801-811.
19. Schelbert EB, Rumsfeld JS, Krumholz HM, Canto JG, Magid DJ, Masoudi FA et al. Ischaemic Symptoms, Quality of Care, and Mortality during Myocardial Infarction. Heart 2008;94: 2 Publicado en línea el 16 julio2007.
20. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM. Challenges and Opportunities in Quantifying the Quality of Care for Acute Myocardial Infarction. Circulation2003; 107: 1681-1691.
21. Ministerio de Salud. Unidad de Información Bioestadística. Registro de Pacientes con Infarto Agudo del Miocardio. San José, Costa Rica, enero 2007.
22. Caja Costarricense de Seguro Social. Departamento Estadística de Salud. Registro de pacientes egresados con el diagnóstico de infarto agudo del miocardio. Años 2005 y 2006. Oficinas Centrales. San José, Costa Rica.
23. Presidencia de la República de Costa Rica y Ministerio de Salud. Decreto No. 30945-d. Artículo 9, II. Otros subsistemas de vigilancia. La Gaceta No. 18 del 27/01/03.
24. ThygesenK, Alpert JS, White HD. Universal definition of myocardial infarction. Circulation, 2007; 116: 2634-2653.
25. Jaffe AS. Use of Biomarkers in the Emergency Department and Chest Pain Unit. Cardiol Clin2005; 23: 453-465.
26. Wong P, Murray S, Ramsewak A, Robinson A, Van Heyningen C, Rodrigues E. Raised cardiac troponin T levels in patients without acute coronary syndrome. Postgrad MedJ 2007; 83: 200-205.

en_bart05v55n1

Received: November 30, 2011 Accepted: November 8, 2012

References

1. Akita A and McGee SR. Bedside Diagnosis of Coronary Artery Disease: A Systematic Review. AmJ Med 2004; 117: 334-343.
2. Fuster V, Steele PM and Chesebro JH. Role of platelets and thrombosis in coronary atherosclerotic disease and sudden death. J Am Coll Cardiol1985; 5: 175B- 184B.
3. Albalá N y Ancillo P.El síndrome coronario agudo en su clasificación actual. MedIntensiva 2006; 30: 74-76.
4. López- Sendón J. y López de Sá. Nuevos criterios de diagnóstico de infarto de miocardio: orden en el caos. Rev Esp Cardiol2001; 54: 669-674.
5. Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015-19.Reproducido en JAMA 1983; 250: 1757-65.
6. Herrick JB. Concerning thrombosis of the coronary arteries. Trans Assoc Am Phys 1918; 33: 408-15.
7. Wang K, A singer RW and Marriott HJL.ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. NEnglJ Med 2003; 349: 2128-35.
8. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol2000; 36:959-69.
9. Meier MA, Al-Badr WH, Cooper JV, Kline-Rogers EM, Smith DE, Eagle KM, et al. The New Definition of Myocardial Infarction.Arch Intern Med 2002; 162: 1585-1589.
10. Roger VL. Epidemiology of Myocardial Infarction. Med ClinN Am 2007; 91: 541-544.
11. 2004 Chartbook on cardiovascular lung and blood diseases. Bethesda, MD: National Heart, Lung, and Blood Institute. En: National Heart, Lung, and Blood Institute MorbMortal; 2004: 2-53.
12. Singh M and Holmes DR. Acute Myocardial Infarction. Med ClinN Am 2007; 91:684 y 729.
13. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am CollCardiol2000; 36:959-69.
14. Organización Panamericana de la Salud. Clasificación Estadística Internacional de Enfermedades y Problemas relacionados con la Salud. X revisión, volumen 1. Publicación científica No. 554. Organización Panamericana de la Salud. WashingtonDC, EUA, 1995. 455-461.
15. Reeder GS y GershBJ. Modern Management of Acute Myocardial Infarction.Current Problems in Cardiology 2000; 25: 689-690.
16. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WE, Rich M, et al. Acute Coronary Care in the Eldery, Part II.ST-Segment-Elevation Myocardial Infarction. A Scientific Statement for Healthcare Professionals Fromthe American Heart Association Council on Clinical Cardiology. Circulation 2007; 115: 2570-2589.
17. Shah R, Selter J, Wang Y, Greenspan M, Foody JM. Association of troponin status with guideline-based management of acute myocardial infarction in older persons.Arch Intern Med 2007; 167: 1621-1628.
18. Sheifer SE, Manolio TA and Gersh BJ. Unrecognized Myocardial Infarction.Ann Intern Med 2001; 135: 801-811.
19. Schelbert EB, Rumsfeld JS, Krumholz HM, Canto JG, Magid DJ, Masoudi FA et al. Ischaemic Symptoms, Quality of Care, and Mortality during Myocardial Infarction. Heart 2008;94: 2 Publicado en línea el 16 julio2007.
20. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM. Challenges and Opportunities in Quantifying the Quality of Care for Acute Myocardial Infarction. Circulation2003; 107: 1681-1691.
21. Ministerio de Salud. Unidad de Información Bioestadística. Registro de Pacientes con Infarto Agudo del Miocardio. San José, Costa Rica, enero 2007.
22. Caja Costarricense de Seguro Social. Departamento Estadística de Salud. Registro de pacientes egresados con el diagnóstico de infarto agudo del miocardio. Años 2005 y 2006. Oficinas Centrales. San José, Costa Rica.
23. Presidencia de la República de Costa Rica y Ministerio de Salud. Decreto No. 30945-d. Artículo 9, II. Otros subsistemas de vigilancia. La Gaceta No. 18 del 27/01/03.
24. ThygesenK, Alpert JS, White HD. Universal definition of myocardial infarction. Circulation, 2007; 116: 2634-2653.
25. Jaffe AS. Use of Biomarkers in the Emergency Department and Chest Pain Unit. Cardiol Clin2005; 23: 453-465.
26. Wong P, Murray S, Ramsewak A, Robinson A, Van Heyningen C, Rodrigues E. Raised cardiac troponin T levels in patients without acute coronary syndrome. Postgrad MedJ 2007; 83: 200-205.

en_bart05v55n1

Received: November 30, 2011 Accepted: November 8, 2012

Publication Dates

Publication in this collection
01 Aug 2013
Date of issue
Mar 2013

History

Received
30 Nov 2011
Accepted
08 Nov 2012

[1] 1. Akita A and McGee SR. Bedside Diagnosis of Coronary Artery Disease: A Systematic Review. AmJ Med 2004; 117: 334-343.

[2] 2. Fuster V, Steele PM and Chesebro JH. Role of platelets and thrombosis in coronary atherosclerotic disease and sudden death. J Am Coll Cardiol1985; 5: 175B- 184B.

[3] 3. Albalá N y Ancillo P.El síndrome coronario agudo en su clasificación actual. MedIntensiva 2006; 30: 74-76.

[4] 4. López- Sendón J. y López de Sá. Nuevos criterios de diagnóstico de infarto de miocardio: orden en el caos. Rev Esp Cardiol2001; 54: 669-674.

[5] 5. Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015-19.Reproducido en JAMA 1983; 250: 1757-65.

[6] 6. Herrick JB. Concerning thrombosis of the coronary arteries. Trans Assoc Am Phys 1918; 33: 408-15.

[7] 7. Wang K, A singer RW and Marriott HJL.ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. NEnglJ Med 2003; 349: 2128-35.

[8] 8. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol2000; 36:959-69.

[9] 9. Meier MA, Al-Badr WH, Cooper JV, Kline-Rogers EM, Smith DE, Eagle KM, et al. The New Definition of Myocardial Infarction.Arch Intern Med 2002; 162: 1585-1589.

[10] 10. Roger VL. Epidemiology of Myocardial Infarction. Med ClinN Am 2007; 91: 541-544.

[11] 11. 2004 Chartbook on cardiovascular lung and blood diseases. Bethesda, MD: National Heart, Lung, and Blood Institute. En: National Heart, Lung, and Blood Institute MorbMortal; 2004: 2-53.

[12] 12. Singh M and Holmes DR. Acute Myocardial Infarction. Med ClinN Am 2007; 91:684 y 729.

[13] 13. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined –a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am CollCardiol2000; 36:959-69.

[14] 14. Organización Panamericana de la Salud. Clasificación Estadística Internacional de Enfermedades y Problemas relacionados con la Salud. X revisión, volumen 1. Publicación científica No. 554. Organización Panamericana de la Salud. WashingtonDC, EUA, 1995. 455-461.

[15] 15. Reeder GS y GershBJ. Modern Management of Acute Myocardial Infarction.Current Problems in Cardiology 2000; 25: 689-690.

[16] 16. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WE, Rich M, et al. Acute Coronary Care in the Eldery, Part II.ST-Segment-Elevation Myocardial Infarction. A Scientific Statement for Healthcare Professionals Fromthe American Heart Association Council on Clinical Cardiology. Circulation 2007; 115: 2570-2589.

[17] 17. Shah R, Selter J, Wang Y, Greenspan M, Foody JM. Association of troponin status with guideline-based management of acute myocardial infarction in older persons.Arch Intern Med 2007; 167: 1621-1628.

[18] 18. Sheifer SE, Manolio TA and Gersh BJ. Unrecognized Myocardial Infarction.Ann Intern Med 2001; 135: 801-811.

[19] 19. Schelbert EB, Rumsfeld JS, Krumholz HM, Canto JG, Magid DJ, Masoudi FA et al. Ischaemic Symptoms, Quality of Care, and Mortality during Myocardial Infarction. Heart 2008;94: 2 Publicado en línea el 16 julio2007.

[20] 20. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM. Challenges and Opportunities in Quantifying the Quality of Care for Acute Myocardial Infarction. Circulation2003; 107: 1681-1691.

[21] 21. Ministerio de Salud. Unidad de Información Bioestadística. Registro de Pacientes con Infarto Agudo del Miocardio. San José, Costa Rica, enero 2007.

[22] 22. Caja Costarricense de Seguro Social. Departamento Estadística de Salud. Registro de pacientes egresados con el diagnóstico de infarto agudo del miocardio. Años 2005 y 2006. Oficinas Centrales. San José, Costa Rica.

[23] 23. Presidencia de la República de Costa Rica y Ministerio de Salud. Decreto No. 30945-d. Artículo 9, II. Otros subsistemas de vigilancia. La Gaceta No. 18 del 27/01/03.

[24] 24. ThygesenK, Alpert JS, White HD. Universal definition of myocardial infarction. Circulation, 2007; 116: 2634-2653.

[25] 25. Jaffe AS. Use of Biomarkers in the Emergency Department and Chest Pain Unit. Cardiol Clin2005; 23: 453-465.

[26] 26. Wong P, Murray S, Ramsewak A, Robinson A, Van Heyningen C, Rodrigues E. Raised cardiac troponin T levels in patients without acute coronary syndrome. Postgrad MedJ 2007; 83: 200-205.

<b>Coronary syndrome and other diagnosis result in under reporting of acute myocardial infarction in the Mexico Hospital, Costa Rica</b>

Abstracts

References

References

Publication Dates

History