ACS patients do better when first taken to closest hospital and not hospitals with angio capabilities

[Guest guest]

Kind of interesting to see a large study that makes a strong case against a

practice we think intuitively is correct.

Frans Van de Werf, M Gore, Ãlvaro Avezum, Dietrich C Gulba, Shaun G

Goodman, Andrzej Budaj, Brieger, Kami White, A A Fox, Kim A Eagle,

M Kennelly for the GRACE Investigators. Access to catheterisation

facilities in patients admitted with acute coronary syndrome: multinational

registry study. BMJ 2005;330:441,

Abstract

Objective To investigate the relation between access to a cardiac

catheterisation laboratory and clinical outcomes in patients admitted to

hospital with suspected acute coronary syndrome.

Design Prospective, multinational, observational registry.

Setting Patients enrolled in 106 hospitals in 14 countries between April 1999

and March 2003.

Participants 28 825 patients aged ≥ 18 years.

Main outcome measures Use of percutaneous coronary intervention or coronary

artery bypass graft surgery, death,

infarction after discharge, stroke, or major bleeding.

Results Most patients (77%) across all regions (United States, Europe, Argentina

and Brazil, Australia, New Zealand, and Canada) were admitted to hospitals with

catheterisation facilities. As expected, the availability of a catheterisation

laboratory was associated with more frequent use of percutaneous coronary

intervention (41% v 3.9%, P < 0.001) and coronary artery bypass graft (7.1% v

0.7%, P < 0.001). After adjustment for baseline characteristics, medical

history, and geographical region there were no significant differences in the

risk of early death between patients in hospitals with or without

catheterisation facilities (odds ratio 1.13, 95% confidence interval 0.98 to

1.30, for death in hospital; hazard ratio 1.05, 0.93 to 1.18, for death at 30

days). The risk of death at six months was significantly higher in patients

first admitted to hospitals with catheterisation facilities (hazard ratio 1.14,

1.03 to 1.26), as was the risk of bleeding complications in hospital (odds ratio

1.94, 1.57 to 2.39) and stroke (odds ratio 1.53, 1.10 to 2.14).

Conclusions These findings support the current strategy of directing patients

with suspected acute coronary syndrome to the nearest hospital with acute care

facilities, irrespective of the availability of a catheterisation laboratory,

and argue against early routine transfer of these patients to tertiary care

hospitals with interventional facilities.

Original Article at: http://bmj.bmjjournals.com/cgi/reprint/330/7489/441