Is coronary angiography in unstable patients safe in district general hospitals without any on-site...

Patients admitted to hospital with unstable angina or non-ST segment elevation myocardial infarction have a high risk of death, re-infarction or re-hospitalisation within the next 6 months. International guidelines recommend an early interventional strategy in moderate- to high-risk patients with pre-discharge coronary angiography. In the UK, such patients admitted to district hospitals have traditionally been transferred to tertiary centres for investigation and treatment. Due to the large numbers involved and scarcity of tertiary centre beds, this results in long delays before transfer. The objective of this study was to determine whether diagnostic cardiac catheterisation in moderate- to high-risk patients could be safely performed in hospitals without on-site revascularisation and whether this strategy led to earlier discharge times.

A retrospective audit was undertaken of all patients undergoing inpatient coronary angiography to a large district general hospital (DGH) after admission with a clinical diagnosis of unstable angina or non-ST elevation myocardial infarction over a 12-month period from April 2002 to March 2003. The main outcome measures were complications arising from coronary angiography and number of bed-days saved by allowing earlier discharge.

142 patients with non-ST elevation ACS who met 'high risk' criteria underwent inpatient angiography locally. Significant luminal coronary disease was present in 76% of patients but 49% were treated medically and discharged early. 32% of patients required transfer for percutaneous intervention (PCI) and 19% were referred directly for surgery. There was a high revascularisation rate (43%) even in patients who did not have elevated troponin levels on admission. No patients died or sustained a myocardial infarction as a result of angiography, and morbidity was minimal. Patients waited an average of 3 days for an angiogram locally, but transfer time to a tertiary centre was 9 days for PCI and 12 days for surgery. As almost half of all patients were discharged without requiring transfer for revascularisation, we estimate a total of 490 bed-days were saved over 12 months.

Cardiac catheterisation in most 'high-risk' patients with non-ST elevation ACS is safe in DGHs without on-site PCI or surgery and frees up large numbers of acute medical beds by selecting out only those patients requiring onward referral for revascularisation.