Practice patterns and clinical outcomes among non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients presenting to primary and tertiary hospitals: Insights from the EARLY glycoprotein IIb/IIIa inhibition in NSTE-ACS (EARLY-ACS) trial. Catheterization Cardiovascular Interventions. July 2014. Olga Toleva MD1, Cynthia M. Westerhout PhD1, Manohara P.J. Senaratne MBBS, PhD2, Christoph Bode MD3, Magnus Lindroos MD, PhD4, Vitaly A. Sulimov MD, PhD5, Gilles Montalescot MD6, L. Kristin Newby MD, MHS7, Robert P. Giugliano MD, SM8, Frans Van de Werf MD, PhD9and Paul W. Armstrong MD1,*
- 1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- 2Coronary Care Unit, Grey Nuns Hospital, Edmonton, Alberta, Canada
- 3Internal Medicine and Cardiology, Universitätsklinikum, Freiburg, Germany
- 4Department of Invasive Cardiology, Jorvi University Hospital, Espoo, Finland
- 5First Moscow State Medical University, Moscow, Russian Federation
- 6Centre Hospitalier Universitaire Pitié–Salpêtrière, Paris, France
- 7Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- 8Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women’s Hospital (RPG), Boston, Massachusetts
- 9Department of Cardiology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
We evaluated patients at tertiary [both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) capable] and primary hospitals in the EARLY-ACS trial.
Early invasive management is recommended for high-risk non-ST-segment elevation acute coronary syndromes.
We evaluated outcomes in 9,204 patients presenting to: tertiary sites, primary sites with transfer to tertiary sites (“transferred”) and those who remained at primary sites (“non-transfer”).
There were 348 tertiary (n = 7,455 patients) and 89 primary hospitals [n = 1,749 patients (729 transferred; 1,020 non-transfer)]. Significant delays occurred in time from symptom onset to angiography (49 hr), PCI (53h), and CABG (178 hr) for transferred patients (P < 0.001). Non-transfer patients had less 30-day death/myocardial infarction [9.4% vs. 11.7% (tertiary); adjusted odds ratio (OR): 0.78 (0.62–0.97), P = 0.026]; transferred (14.0%) and tertiary patients were similar [adjusted OR: 1.23 (0.98–1.53), P = 0.074]. Non-transfer patients had lower 1-year mortality [4.3% vs. 6.3% (tertiary); adjusted hazard ratio (HR): 0.64 (0.47–0.87), P = 0.005]: there was no difference between transferred and tertiary patients [5.2% vs. 6.3%; adjusted HR: 0.80 (0.58–1.12), P = 0.202]. Despite similar rates of catheterization, GUSTO severe/moderate bleeding within 120 hr was less in non-transfer [3.1% vs. 6.7% (tertiary); adjusted OR: 0.47 (0.32–0.68), P < 0.001], whereas transferred (6.1%) and tertiary patients were similar [adjusted OR: 0.94 (0.68–1.30), P = 0.693]. There was no difference in non-CABG bleeding.
Timely angiography and revascularization were often not achieved in transferred patients. Non-transferred patients presenting to primary sites had the lowest event rates and the best long-term survival. © 2014 Wiley Periodicals, Inc.