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Access to catheterisation facilities in patients admitted with acute c
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     1 Universitair Ziekenhuis Gasthuisberg, Herestraat 49, Leuven, Belgium 3000, 2 University of Massachusetts Memorial Health Care, Worcester, MA 01655, USA, 3 University of Massachusetts Medical School, Worcester, MA 01604, USA, 4 Research Division, Dante Pazzanese Institute of Cardiology, 04012-909, San Paulo, Brazil, 5 Krankenhaus Düren, Düren, NRW Germany 52351, 6 Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada M5B 1W8, 7 Postgraduate Medical School, Grochowski Hospital, Centrum Medycznego Ksztalcenia Podyplomowego, Warsaw, Poland 04-073, 8 Concord Repatriation General Hospital, Coronary Care Unit, Concord, NSW, Australia 2139, 9 Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh EH16 4SB, 10 University of Michigan Cardiovascular Center, Ann Arbor, MI 48109-0477, USA, 11 Hoag Memorial Hospital Presbyterian, Newport Beach, CA 92658-6100, USA

    Correspondence to: F Van de Werf frans.vandewerf@uz.kuleuven.ac.be

    Abstract

    The optimal early management of patients presenting to hospital with acute coronary syndrome has been studied extensively over the past 10 years. Recent randomised trials and meta-analyses have shown better clinical outcomes in patients assigned to an early invasive strategy, including primary percutaneous coronary intervention for those with persistent ST segment elevation,1 or early revascularisation with percutaneous coronary intervention or coronary artery bypass grafting in those with non-ST segment elevation acute coronary syndrome.2-4 In these randomised trials a reduction in recurrent ischaemic events was consistently associated with the invasive strategy, while significant reductions in mortality were rarely observed. For example, in the latest study—the randomised intervention trial of unstable angina (RITA-3)—there was a 34% reduction in the risk of death, reinfarction, or refractory angina in the invasive group at four months, mainly due to a halving of the rise of refractory angina but without any survival benefit.4

    In the "real world" the choice of a management strategy is often governed by the facilities available at the hospital at which patients initially present. Though thrombolytic and antithrombotic therapies are widely available, only 20% of emergency care departments have access to a catheterisation laboratory, and still fewer hospitals have the capability to perform immediate percutaneous coronary intervention or coronary artery bypass grafting.5 The issue of whether access to interventional facilities affects clinical outcomes in patients admitted with acute coronary syndrome is under scrutiny. A positive association between the availability of a catheterisation laboratory and improved outcomes would argue for a change in the routing of patients with acute coronary syndrome from the nearest community hospital to a regional specialised tertiary care hospital with immediate access to a catheterisation laboratory (similar to the handling of acute trauma cases).6

    The global registry of acute coronary events (GRACE) is an ongoing, multinational, prospective registry of patients with the entire spectrum of acute coronary syndrome. The registry collects data on baseline characteristics, management, and clinical outcomes. We investigated the relation between access to a cardiac catheterisation laboratory and the use of percutaneous coronary intervention or coronary artery bypass grafting and clinical outcomes in patients admitted with suspected acute coronary syndrome.

    Methods

    Study population

    We analysed data from 28 825 patients with acute coronary syndrome enrolled between April 1999 and March 2003 from 106 hospitals in 14 countries. Baseline risk factors, use of percutaneous coronary intervention and coronary artery bypass graft, and clinical outcomes were stratified according to the presence or absence of a catheterisation laboratory. The crude model for death at 30 days and at six months was based on data from 28 371 (98%) patients, while the adjusted model was based on data from 25 402 (88%) patients. We collected data on myocardial infarction after discharge up to six months as of June 2000 and in 15 205 patients.

    Baseline clinical characteristics and revascularisation procedures

    We analysed baseline characteristics of the patient cohort according to the capability of the admitting hospital to carry out cardiac catheterisation (table 1). Most patients in this analysis (77%) were admitted to hospitals with catheterisation facilities with a consistent pattern across different regions (79% in the United States, 76% in Europe, 66% in Australia/New Zealand/Canada, and 83% in Argentina/Brazil). The median age of admitted patients was 66 years in units with catheterisation facilities and 68 years in units without such facilities. Overall, most patients admitted were male, but more female patients were admitted to hospitals without catheterisation facilities (32% v 37%). More patients who were first admitted to hospitals without catheterisation facilities were in a poor haemodynamic state (that is, Killip class > I).

    Table 1 Key baseline characteristics and revascularisation procedures by type of hospital (n=28 825)

    Table 1 also shows the medical history of patients in each type of hospital facility. A history of previous myocardial infarction and hypertension was equally prevalent in the two groups. A history of diabetes mellitus was more common in patients admitted to hospitals with catheterisation facilities (25% v 23%), as was the previous use of invasive procedures.

    In patients admitted to hospitals with catheterisation facilities, percutaneous coronary intervention procedures and coronary artery bypass graft during the index admission were significantly more common than in patients first admitted to hospitals without facilities: 41% v 4% for percutaneous coronary intervention and 7% v < 1% for coronary artery bypass graft (table 1). The largest difference in percutaneous coronary intervention was found in Europe, with 48% in hospitals with and 2% in hospitals without catheterisation facilities, respectively. For coronary artery bypass graft the largest differences between hospitals with and without facilities were found in the United States (11% v 1.6%) and Argentina/Brazil (10% v 1%).

    Clinical outcomes

    The figure shows the observed clinical outcomes, the absolute differences in outcome between patients first admitted to hospitals with or without catheterisation facilities, and the unadjusted and adjusted odds ratios/hazard ratios in the total acute coronary syndrome population. Tables 2 and 3 show the results for the diagnostic subgroups of patients with acute coronary syndrome.

    Clinical outcomes for all patients with acute coronary syndrome, for patients admitted to hospitals with or without catheterisation laboratory (open squares are unadjusted ratios and closed squares are adjusted ratios)

    Table 2 Clinical outcomes by final diagnosis of acute coronary syndrome and access to catheterisation facility. Figures are numbers (percentages) of patients

    Table 3 Adjusted odds or hazard ratios (95% confidence intervals) for patients first admitted to hospitals with or without catheterisation facilities according to final diagnosis of acute coronary syndrome

    In the total population of patients with acute coronary syndrome, and after adjustment for baseline characteristics, medical history, and geographical region, patients first admitted to hospitals with catheterisation facilities were at a 14% increased risk of death at six months. The risk of in hospital stroke or major bleeding was also higher (53% and 94% respectively). There was, however, a trend towards a lower risk of reinfarction after discharge in such patients (hazard ratio 0.86, 0.69 to 1.08).

    The pattern of increased risk of death at six months and increased risk of major bleeding or stroke in hospitals with catheterisation facilities remained consistent across the three subgroups. There was a significant reduction in the risk of reinfarction after discharge in the patients with non-ST segment elevation myocardial infarction (tables 2 and 3). In all hospitals, the highest rates of stroke were observed in patients with ST segment elevation myocardial infarction, while major bleeding complications were less common in patients with unstable angina.

    Discussion

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