Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000
P G Steg1, J-P Cambou, P Goldstein
1Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France. gabriel.steg@bch.ap-hop-paris.fr
Insights
Direct admission for ST-segment elevation myocardial infarction (STEMI) patients bypasses the emergency room (ER), leading to faster reperfusion therapy and improved survival rates. This approach significantly reduces mortality compared to ER admission.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- ST-segment elevation myocardial infarction (STEMI) requires rapid reperfusion therapy for optimal outcomes.
- The pathway of patient admission, either directly to a specialized unit or via the emergency room (ER), may influence treatment timeliness and patient survival.
Purpose of the Study:
- To compare the clinical outcomes of direct admission versus emergency room (ER) admission in patients diagnosed with ST-segment elevation myocardial infarction (STEMI).
- To evaluate the impact of admission pathway on the timeliness of reperfusion therapy and short-term mortality in STEMI patients.
Main Methods:
- A nationwide observational registry of 1204 STEMI patients admitted to 369 intensive care units in France was analyzed.
- Patients were categorized based on their initial management pathway: direct transfer to the coronary care unit/catheterisation laboratory or transfer via the ER.
- Key outcome measures included delays from symptom onset to admission and reperfusion, and mortality at five days and one year.
Main Results:
- Direct admission (66.9% of patients) was associated with more frequent reperfusion therapy (61.7% vs. 53.1%) and significantly shorter delays for admission, thrombolysis, and primary percutaneous coronary intervention.
- Five-day mortality rates were lower in patients admitted directly, bypassing the ER (4.9% vs. 8.6%).
- Admission via the ER was identified as an independent predictor of five-day mortality after adjusting for the TIMI risk score.
Conclusions:
- Bypassing the emergency room for STEMI patients is associated with more frequent and earlier administration of reperfusion therapy.
- Direct admission appears to confer a survival benefit compared to admission via the ER in STEMI patients.
- Optimizing patient flow to specialized cardiac units may improve outcomes for STEMI.
Objective:
To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients
Setting:
369 intensive care units in France.
Interventions:
Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).
Main Outcome Measures:
Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.
Results:
Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).
Conclusions:
In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.
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