Abstract
Background
Increased use of invasive coronary strategies in patients admitted to hospitals with
on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation
of invasive coronary strategies according to types of CCL facilities at the first
admitting hospital and clinical outcomes is unknown.
Methods
We included 452,216 patients admitted with a diagnosis of non–ST-segment-elevation
myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting
hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according
to CCL facilities. Multilevel logistic regression models were used to study associations
between CCL facilities and in-hospital outcomes.
Results
A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals,
and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals,
respectively. Use of coronary angiography was significantly higher in PCI hospitals
(77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted
odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95%
confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24)
compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined
as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic
hospitals was associated with significantly increased in-hospital mortality (OR 1.36,
95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.
Conclusions
This study highlights important differences in both the utilisation of invasive coronary
strategies and subsequent management and outcomes of NSTEMI patients according to
admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic
hospitals had greater in-hospital mortality, possibly because of reduced PCI use,
which needs to be addressed.
Résumé
Contexte
On a rapporté une utilisation accrue des stratégies coronariennes effractives chez
les patients admis dans les hôpitaux ayant un laboratoire de cathétérisme cardiaque
(LCC), mais on ignore l’utilisation des stratégies coronariennes effractives en fonction
des types de LCC au premier hôpital ayant admis les patients et les résultats cliniques.
Méthodes
Nous avons sélectionné 452 216 patients admis qui avaient un diagnostic d’infarctus
du myocarde sans élévation du segment ST (NSTEMI) en Angleterre et au pays de Galles
de 2007 à 2015. Les hôpitaux ayant admis les patients étaient classés selon les catégories
suivantes : les hôpitaux sans laboratoire, les hôpitaux de diagnostic et les hôpitaux
offrant les ICP en fonction des LCC. Des modèles multiniveaux de régression logistique
étaient utilisés pour étudier les associations entre les LCC et les résultats intrahospitaliers.
Résultats
Un total de 97 777 (21,6 %) patients étaient admis dans des hôpitaux sans laboratoire,
et 134 381 (29,7 %) patients et 220 058 (48,7 %) patients étaient respectivement admis
dans des hôpitaux de diagnostic et dans des hôpitaux offrant les ICP. L’utilisation
de l’angiographie coronarienne était significativement plus élevée dans les hôpitaux
offrant les ICP (77,3 %) que dans les hôpitaux de diagnostic (63,2 %) et les hôpitaux
sans laboratoire (61,4 %). Les probabilités ajustées de mortalité intrahospitalière
étaient similaires dans les hôpitaux de diagnostic (ratio d’incidence approché [RIA]
0,93, intervalle de confiance [IC] à 95 % 0,83-1,04) et les hôpitaux offrant les ICP
(RIA 1,09, IC à 95 % 0,96-1,24) par rapport aux hôpitaux sans laboratoire. Toutefois,
dans le sous-groupe exposé à un risque élevé de NSTEMI (défini selon le score du registre
GRACE [Global Registry of Acute Coronary Events] > 140), une admission dans les hôpitaux
de diagnostic était associée à une mortalité intrahospitalière significativement accrue
(RIA 1,36, IC à 95 % 1,06-1,75) par rapport aux hôpitaux sans laboratoire et aux hôpitaux
offrant les ICP.
Conclusions
Cette étude montre les différences importantes de l’utilisation des stratégies coronariennes
effractives et de la prise en charge subséquente et des résultats cliniques des patients
ayant un NSTEMI en fonction des LCC des hôpitaux ayant admis les patients. Il faut
prendre en considération que les patients exposés à un risque élevé de NSTEMI admis
dans les hôpitaux de diagnostic étaient exposés à un risque plus élevé de mortalité
intrahospitalière, possiblement en raison d’une moindre utilisation de l’ICP.
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Article info
Publication history
Published online: October 16, 2019
Accepted:
October 3,
2019
Received:
July 25,
2019
Footnotes
See editorial by Lambert and Jolicoeur, pages 805-806 of this issue.
See page 875 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Access this article on ScienceDirectLinked Article
- Treatment and Outcomes of Non–ST-Segment-Elevation Myocardial Infarction by Type of Center: A Tale of Patient Pathways, Access, and Clinician AversionCanadian Journal of CardiologyVol. 36Issue 6
- PreviewInformation about patient characteristics, processes of care, and clinical outcomes are essential to optimize decision making for patients and clinicians, as well as for managers of the health care system. In England and Wales, such information for acute coronary events is available through the Myocardial Ischemia National Audit Project (MINAP) and covers the complete system of care, making it all the more valuable.
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