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Canadian Journal of Cardiology

Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI

Published:October 16, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.010

      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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