Abstract
Background
Because of limitations on hospital resources, patients with ST-elevation myocardial
infarction (STEMI) who undergo successful primary percutaneous coronary intervention
(PCI) are often repatriated to non-PCI centres. However, the safety of this practice
is not clear. Our objective was to evaluate the safety of early repatriation of STEMI
patients after PCI to a non-PCI centre, compared with ongoing treatment at the PCI
centre.
Methods
Consecutive STEMI patients, who received primary PCI at 1 of 4 PCI hospitals in Toronto,
Canada between 2010 and 2012 were identified. Patients with shock or who died within
24 hours of presentation were excluded. Outcomes of interest were all-cause mortality
and readmission for recurrent myocardial infarction (MI) at 1 year. To account for
confounding because of the observational nature of our data, propensity score-matched
pairs of patients who were repatriated vs nonrepatriated were identified.
Results
Using the propensity score, 430 well matched pairs were identified, representing our
cohort. There was no significant difference between repatriated and nonrepatriated
groups in 1-year mortality (repatriated: 6.7%, nonrepatriated: 5.6%, hazard ratio,
1.18; 95% confidence interval, 0.69-2.03; P = 0.545). The 1-year readmission rates for MI were significantly greater for the
repatriated group compared with the nonrepatriated group (repatriated: 12.1%; nonrepatriated:
5.8%; hazard ratio, 2.09; 95% confidence interval, 1.30-3.36; P = 0.002).
Conclusions
A strategy of early repatriation of STEMI patients was associated with a greater rate
of readmission for MI. Our study raises questions regarding the safety of an early
repatriation strategy that merit further research.
Résumé
Introduction
Puisque les ressources hospitalières sont limitées, les patients souffrant d’infarctus
du myocarde avec sus-décalage du segment ST (IM avec sus-décalage du segment ST) chez
qui l’intervention coronarienne percutanée (ICP) primaire est réussie sont souvent
orientés vers des centres n’offrant pas de services d’ICP. Cependant, l’innocuité
de cette pratique n’est pas clairement démontrée. Notre objectif était d’évaluer l’innocuité
de l’orientation précoce des patients souffrant d’IM avec sus-décalage du segment
ST après l’ICP vers un centre n’offrant pas de services d’ICP par rapport au traitement
en cours au centre offrant des services d’ICP.
Méthodes
Nous avons identifié les patients consécutifs souffrant d’IM avec sus-décalage du
segment ST qui ont subi l’ICP primaire dans 1 des 4 hôpitaux offrant des services
d’ICP de Toronto, au Canada, entre 2010 et 2012. Nous avons exclu les patients souffrant
de choc ou qui sont morts dans les 24 heures de l’admission. Les résultats d’intérêt
ont été la mortalité toutes causes confondues et la réadmission en raison d’un infarctus
du myocarde (IM) récurrent à 1 an. Pour tenir compte des facteurs de confusion, du
fait de la nature observationnelle de nos données, nous avons identifié les patients
appariés par score de propension qui étaient orientés vs les patients qui n’étaient pas orientés.
Résultats
À l’aide du score de propension, nous avons identifié 430 « paires bien appariées
» pour représenter notre cohorte. Nous n’avons observé aucune différence significative
dans la mortalité à 1 an entre les groupes orientés et non orientés (orientés : 6,7
%, non orientés : 5,6 %, rapport de risque, 1,18; intervalle de confiance à 95 %,
0,69-2,03; P = 0,545). Les taux de réadmission à 1 an en raison d’IM ont été significativement
plus élevés chez le groupe orienté que chez le groupe non orienté (orienté : 12,1
%; non orienté : 5,8 %; rapport de risque, 2,09; intervalle de confiance à 95 %, 1,30-3,36;
P = 0,002).
Conclusions
Une stratégie d’orientation précoce des patients souffrant d’IM avec sus-décalage
du segment ST a été associée à un taux plus élevé de réadmission en raison d’un IM.
Notre étude concernant l’innocuité d’une stratégie d’orientation précoce soulève des
questions qui méritent de faire l’objet de futures recherches.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review [erratum in JAMA 1998;279:1876].JAMA. 1997; 278: 2093-2098
- Strategies for reducing the door-to-balloon time in acute myocardial infarction.N Engl J Med. 2006; 355: 2308-2320
- Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction.J Am Coll Cardiol. 1998; 32: 1312-1319
- The 2004 ACC/AHA guidelines: a perspective and adaptation for Canada by the Canadian Cardiovascular Society Working Group.Can J Cardiol. 2004; 20: 1075-1079
- Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis.Circulation. 2003; 108: 1809-1814
- Delivery of primary percutaneous coronary intervention for the management of acute ST segment elevation myocardial infarction: summary of the Cardiac Care Network of Ontario Consensus Report.Can J Cardiol. 2006; 22: 243-250
- Transfer for urgent percutaneous coronary intervention early after thrombolysis for ST-elevation myocardial infarction: the TRANSFER-AMI pilot feasibility study.Can J Cardiol. 2006; 22: 1121-1126
- In-hospital outcomes of a regional ST-segment elevation myocardial infarction acute transfer and repatriation program.Can J Cardiol. 2011; 27: 664.e1-664.e8
Ontario Ministry of Health and Long-Term Care. Critical Care Strategy. Provincial Life or Limb Policy. Available at: http://www.health.gov.on.ca/en/pro/programs/criticalcare/life.aspx. Accessed November 12, 2014.
- Secular trends in acute coronary syndrome hospitalization from 1994 to 2005.Can J Cardiol. 2010; 26: 129-134
- Coding accuracy of administrative drug claims in the Ontario Drug Benefit database.Can J Clin Pharmacol. 2003; 10: 67-71
- 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: e78-140
- Development and validation of the Ontario acute myocardial infarction mortality prediction rules.J Am Coll Cardiol. 2001; 37: 992-997
- Comparative-effectiveness of revascularization versus routine medical therapy for stable ischemic heart disease: a population-based study.J Gen Intern Med. 2014; 29: 1031-1039
- Propensity scores: help or hype?.Nephrol Dial Transplant. 2004; 19: 1671-1673
- An introduction to propensity score methods for reducing the effects of confounding in observational studies.Multivariate Behav Res. 2011; 46: 399-424
- Thirty-day rehospitalizations after acute myocardial infarction: a cohort study.Ann Intern Med. 2012; 157: 11-18
- Repatriation after reperfusion of STEMI patients transferred for primary percutaneous coronary intervention: insights of a regionalized STEMI care system.Can J Cardiol. 2012; 28: S210
- Excess morbidity associated with interhospital transport.Pediatrics. 1992; 90: 893-898
- The impact of intrainstitutional relocation on morbidity in an acute care setting.Gerontologist. 1995; 35: 217-224
- Gaps in the continuity of care and progress on patient safety.BMJ (Clin Res Ed). 2000; 320: 791-794
- Consequences of inadequate sign-out for patient care.Arch Intern Med. 2008; 168: 1755-1760
- Medical errors related to discontinuity of care from an inpatient to an outpatient setting.J Gen Intern Med. 2003; 18: 646-651
- Medical errors involving trainees: a study of closed malpractice claims from 5 insurers.Arch Intern Med. 2007; 167: 2030-2036
- Discontinuity of chronic medications in patients discharged from the intensive care unit.J Gen Intern Med. 2006; 21: 937-941
Article info
Publication history
Published online: February 05, 2015
Accepted:
January 30,
2015
Received:
November 12,
2014
Footnotes
See editorial by Knudtson, pages 1219-1220 of this issue.
See page 1230 for disclosure information.
Identification
Copyright
© 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
