Access to catheterisation facilities in patients admitted with acute c
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《英国医生杂志》
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
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361: 13-20.
Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Fragmin and fast revascularization during instability in coronary artery disease investigators. Lancet 1999;354: 708-15.
Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344: 1879-87.
Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised intervention trial of unstable angina. Lancet 2002;360: 743-51.
Rogers WJ, Canto JG, Barron HV, Boscarino JA, Shoultz DA, Every NR. Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. Investigators in the national registry of myocardial infarction. J Am Coll Cardiol 2000;35: 371-9.
Topol EJ, Kereiakes DJ. Regionalization of care for acute ischemic heart disease: a call for specialized centers. Circulation 2003;107: 1463-6.
GRACE Investigators. Rationale and design of the GRACE (global registry of acute coronary events) project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 2001;141: 190-9.
Eagle KA, Goodman SG, Avezum A, Budaj A, Sullivan CM, Lopez-Sendon J. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the global registry of acute coronary events (GRACE). Lancet 2002;359: 373-7.
Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, et al. A validated prediction model for all forms of acute coronary syndromes: estimating the risk of 6-month postdischarge death in an international registry. JAMA 2004;291: 2727-33.
Goldberg RJ, Currie K, White K, Brieger D, Steg PG, Goodman SG et al. Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the global registry of acute coronary events (GRACE)). Am J Cardiol 2004;93: 288-93.
Marrugat J, Sanz G, Masia R, Valle V, Molina L, Cardona M, et al. Six-month outcome in patients with myocardial infarction initially admitted to tertiary and nontertiary hospitals. RESCATE investigators. Recursos Empleados en el Sindrome Coronario Agudo y Tiempos de Espera. J Am Coll Cardiol 1997;30: 1187-92.
Feit F, Mueller HS, Braunwald E, Ross R, Hodges M, Herman MV, et al. Thrombolysis in myocardial infarction (TIMI) phase II trial: outcome comparison of a "conservative strategy" in community versus tertiary hospitals. The TIMI research group. J Am Coll Cardiol 1990;16: 1529-34.
Gabriel Steg P, Lung B, Feldman LJ, Maggioni AP, Keil U, Deckers J, et al. Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J 2003;24: 613-22.
Mehta RH, Criger DA, Granger CB, Pieper KK, Califf RM, Topol EJ, et al. Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability. J Am Coll Cardiol 2002;40: 1034-43.
Antman EM, Van de Werf F. Pharmacoinvasive therapy: the future of treatment for ST elevation myocardial infarction. Circulation 2004;109: 2480-6.
Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349: 733-42.
TIMI IIIB Investigators. Effect of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction results of the TIMI IIIB trial. Circulation 1994;89: 1545-56.
Boden WE, O'Rourke RA, Crawford MH, Blaustein AS, Deedwania PC, Zoble RG, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs non-Q-wave infarction strategies in hospital (VANQWISH) trial investigators. N Engl J Med 1998;338: 1785-92.
Yusuf S, Flather M, Pogue J, Hunt D, Varigos J, Piegas L, et al. Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. OASIS (organisation to assess strategies for ischaemic syndromes) registry investigators. Lancet 1998;352: 507-14.
Lupon J, Valle V, Marrugat J, Elosua R, Seres L, Pavesi M, et al. Six-month outcome in unstable angina patients without previous myocardial infarction according to the use of tertiary cardiologic resources. RESCATE Investigators. Recursos Empleados en el Sindrome Coronario Agudo y Tiempos de Espera. J Am Coll Cardiol 1999;34: 1947-53.
Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. Jama 2001;286: 708-13.(Frans Van de Werf, cardiologist1, Joel M)
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
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361: 13-20.
Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Fragmin and fast revascularization during instability in coronary artery disease investigators. Lancet 1999;354: 708-15.
Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344: 1879-87.
Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised intervention trial of unstable angina. Lancet 2002;360: 743-51.
Rogers WJ, Canto JG, Barron HV, Boscarino JA, Shoultz DA, Every NR. Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. Investigators in the national registry of myocardial infarction. J Am Coll Cardiol 2000;35: 371-9.
Topol EJ, Kereiakes DJ. Regionalization of care for acute ischemic heart disease: a call for specialized centers. Circulation 2003;107: 1463-6.
GRACE Investigators. Rationale and design of the GRACE (global registry of acute coronary events) project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 2001;141: 190-9.
Eagle KA, Goodman SG, Avezum A, Budaj A, Sullivan CM, Lopez-Sendon J. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the global registry of acute coronary events (GRACE). Lancet 2002;359: 373-7.
Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, et al. A validated prediction model for all forms of acute coronary syndromes: estimating the risk of 6-month postdischarge death in an international registry. JAMA 2004;291: 2727-33.
Goldberg RJ, Currie K, White K, Brieger D, Steg PG, Goodman SG et al. Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the global registry of acute coronary events (GRACE)). Am J Cardiol 2004;93: 288-93.
Marrugat J, Sanz G, Masia R, Valle V, Molina L, Cardona M, et al. Six-month outcome in patients with myocardial infarction initially admitted to tertiary and nontertiary hospitals. RESCATE investigators. Recursos Empleados en el Sindrome Coronario Agudo y Tiempos de Espera. J Am Coll Cardiol 1997;30: 1187-92.
Feit F, Mueller HS, Braunwald E, Ross R, Hodges M, Herman MV, et al. Thrombolysis in myocardial infarction (TIMI) phase II trial: outcome comparison of a "conservative strategy" in community versus tertiary hospitals. The TIMI research group. J Am Coll Cardiol 1990;16: 1529-34.
Gabriel Steg P, Lung B, Feldman LJ, Maggioni AP, Keil U, Deckers J, et al. Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J 2003;24: 613-22.
Mehta RH, Criger DA, Granger CB, Pieper KK, Califf RM, Topol EJ, et al. Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability. J Am Coll Cardiol 2002;40: 1034-43.
Antman EM, Van de Werf F. Pharmacoinvasive therapy: the future of treatment for ST elevation myocardial infarction. Circulation 2004;109: 2480-6.
Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349: 733-42.
TIMI IIIB Investigators. Effect of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction results of the TIMI IIIB trial. Circulation 1994;89: 1545-56.
Boden WE, O'Rourke RA, Crawford MH, Blaustein AS, Deedwania PC, Zoble RG, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs non-Q-wave infarction strategies in hospital (VANQWISH) trial investigators. N Engl J Med 1998;338: 1785-92.
Yusuf S, Flather M, Pogue J, Hunt D, Varigos J, Piegas L, et al. Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. OASIS (organisation to assess strategies for ischaemic syndromes) registry investigators. Lancet 1998;352: 507-14.
Lupon J, Valle V, Marrugat J, Elosua R, Seres L, Pavesi M, et al. Six-month outcome in unstable angina patients without previous myocardial infarction according to the use of tertiary cardiologic resources. RESCATE Investigators. Recursos Empleados en el Sindrome Coronario Agudo y Tiempos de Espera. J Am Coll Cardiol 1999;34: 1947-53.
Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. Jama 2001;286: 708-13.(Frans Van de Werf, cardiologist1, Joel M)