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CLINICAL STUDY: ACUTE CORONARY SYNDROMES

Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability

Rajendra H. Mehta, MD, FACC^*,*, Douglas A. Criger, MPH, Christopher B. Granger, MD, FACC, Karen K. Pieper, MS, Robert M. Califf, MD, FACC, Eric J. Topol, MD, FACC and Eric R. Bates, MD, FACC^*

^* From the University of Michigan, Ann Arbor, Michigan, USA
Duke Clinical Research Institute, Durham, North Carolina, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA

^* Reprint requests and correspondence: Dr. Rajendra H. Mehta, University of Michigan and VA Ann Arbor Health System, Cardiology, 111A VAMC 2399, 2215 Fuller Road, Ann Arbor, Michigan 48109, USA.
rmehta{at}umich.edu

OBJECTIVES: This study evaluated clinical outcomes in patients with acute myocardial infarction (MI) treated with fibrinolytic therapy in hospitals with and without coronary revascularization capability.

BACKGROUND: Patients with MI may have better outcomes when admitted to certain hospitals with coronary revascularization capability. Development of regional heart care centers for the treatment of MI has been proposed.

METHODS: We performed a retrospective analysis of 25,515 U.S. patients enrolled in the Global Use of Streptokinase and TPA (alteplase) for Occluded Coronary arteries (GUSTO)-I trial. Outcomes of patients admitted to hospitals with and without coronary revascularization capability were analyzed. We also analyzed patients who remained in hospitals without coronary revascularization capability compared with those transferred to hospitals with revascularization capability.

RESULTS: Baseline characteristics and complications were similar between patients in the two hospital types. Patients in hospitals with coronary revascularization capability more often underwent cardiac catheterization (78.1% vs. 59.2%; p < 0.001), angioplasty (34.6% vs. 22.6%; p < 0.001), or bypass surgery (14.1% vs. 10.4%; p < 0.001) but had a similar adjusted 30-day (odds ratio [OR] 0.91, 95% confidence interval [CI] 82 to 1.02) and one-year (OR 0.98, 95% CI 0.90 to 1.07) mortality. Forty percent of patients admitted to hospitals without revascularization capability were transferred, with 94% of transfer patients undergoing angiography. Almost 80% of transfers occurred >48 h after hospital admission.

CONCLUSIONS: Patients receiving fibrinolytic therapy for acute MI admitted to hospitals without coronary revascularization capability appear to have outcomes similar to those of patients admitted to hospitals with such capability when aspirin and beta-adrenergic blocking agents are given appropriately and transfer is available for angiography and angioplasty as needed.

Abbreviations and Acronyms   ACE   angiotensin-converting enzyme   CABG   coronary artery bypass grafting   CI   confidence interval   GUSTO-I   Global Utilization of Streptokinase and TPA (alteplase) for Occluded coronary arteries   GUSTO-IIb   Global Use of Strategies To Open occluded arteries in acute coronary syndromes   MI   myocardial infarction   NRMI   National Registry of Myocardial Infarction   OR   odds ratio   PTCA   percutaneous transluminal coronary angioplasty

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