Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study
Frans Van de Werf1, Joel M Gore, Alvaro Avezum
1Universitair Ziekenhuis Gasthuisberg, Herestraat 49, Leuven, Belgium 3000. frans.vandewerf@uz.kuleuven.ac.be
Insights
Access to cardiac catheterisation labs did not improve early survival for acute coronary syndrome patients. However, it increased risks of bleeding and stroke, suggesting local care is often best.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Acute coronary syndrome (ACS) management guidelines often recommend timely revascularization.
- The impact of immediate access to cardiac catheterisation laboratories on ACS patient outcomes remains a critical research question.
- Patient transfer protocols to specialized centers are debated.
Purpose of the Study:
- To investigate the association between cardiac catheterisation laboratory availability and clinical outcomes in patients hospitalized with suspected ACS.
- To evaluate the impact of hospital catheterisation facilities on treatment strategies and patient prognosis.
- To inform clinical practice regarding patient disposition for ACS.
Main Methods:
- Prospective, multinational, observational registry.
- 28,825 adult patients admitted with suspected ACS across 106 hospitals in 14 countries (1999-2003).
- Outcomes assessed included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, death, myocardial infarction, stroke, and major bleeding.
Main Results:
- Hospitals with catheterisation labs facilitated higher rates of PCI (41% vs 3.9%) and CABG (7.1% vs 0.7%).
- No significant difference in early in-hospital or 30-day mortality was observed between hospitals with and without catheterisation facilities after adjustment.
- Patients initially admitted to hospitals with catheterisation labs had a higher risk of 6-month mortality (HR 1.14), in-hospital bleeding (OR 1.94), and stroke (OR 1.53).
Conclusions:
- Directing ACS patients to the nearest hospital with acute care facilities, regardless of catheterisation lab availability, aligns with current strategies.
- Routine early transfer of ACS patients to tertiary centers with interventional facilities is not supported by these findings.
- The study suggests potential harms associated with immediate transfer, including increased bleeding and stroke risks.
Objective:
To investigate the relation between access to a cardiac catheterisation laboratory and clinical outcomes in patients admitted to hospital with suspected acute coronary syndrome.
Design:
Prospective, multinational, observational registry.
Setting:
Patients enrolled in 106 hospitals in 14 countries between April 1999 and March 2003.
Participants:
28,825 patients aged > or = 18 years.
Main Outcome Measures:
Use of percutaneous coronary intervention or coronary artery bypass graft surgery, death, infarction after discharge, stroke, or major bleeding.
Results:
Most patients (77%) across all regions (United States, Europe, Argentina and Brazil, Australia, New Zealand, and Canada) were admitted to hospitals with catheterisation facilities. As expected, the availability of a catheterisation laboratory was associated with more frequent use of percutaneous coronary intervention (41% v 3.9%, P < 0.001) and coronary artery bypass graft (7.1% v 0.7%, P < 0.001). After adjustment for baseline characteristics, medical history, and geographical region there were no significant differences in the risk of early death between patients in hospitals with or without catheterisation facilities (odds ratio 1.13, 95% confidence interval 0.98 to 1.30, for death in hospital; hazard ratio 1.05, 0.93 to 1.18, for death at 30 days). The risk of death at six months was significantly higher in patients first admitted to hospitals with catheterisation facilities (hazard ratio 1.14, 1.03 to 1.26), as was the risk of bleeding complications in hospital (odds ratio 1.94, 1.57 to 2.39) and stroke (odds ratio 1.53, 1.10 to 2.14).
Conclusions:
These findings support the current strategy of directing patients with suspected acute coronary syndrome to the nearest hospital with acute care facilities, irrespective of the availability of a catheterisation laboratory, and argue against early routine transfer of these patients to tertiary care hospitals with interventional facilities.
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