Outcomes Among Patients With Non–ST-Segment Elevation Myocardial Infarction Presenting to Interventional Hospitals With and Without On-Site Cardiac Surgery
Yuri B. Pride, MD*,
John G. Canto, MD, MSPH ,
Paul D. Frederick, MPH, MBA ,
C. Michael Gibson, MS, MD ,* for the NRMI Investigators
* Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Center for Cardiovascular Prevention, Research & Education, Watson Clinic, Lakeland, Florida
ICON Lifecycle Sciences Group, San Francisco, California
* Reprint requests and correspondence: Dr. C. Michael Gibson, 350 Longwood Avenue, 1st Floor, Boston Massachusetts 02115 (Email: mgibson{at}perfuse.org).
Objectives: The goals of this analysis were: 1) to evaluate outcomes among non–ST-segment elevation myocardial infarction (NSTEMI) patients presenting to hospitals with on-site cardiac surgery (OHS hospitals) and without on-site cardiac surgery (No-OHS hospitals); and 2) to specifically examine outcomes among the subset of NSTEMI patients undergoing percutaneous coronary intervention (PCI).
Background: Whether backup cardiac surgery improves outcomes among NSTEMI patients or is simply a marker of better adherence to guideline recommendations is unknown.
Methods: The NRMI (National Registry of Myocardial Infarction) enrolled 100,071 NSTEMI patients from 2004 to 2006. Outcomes were evaluated in the population as a whole and in propensity-matched analyses in the entire population and in the subset of patients undergoing PCI.
Results: In-hospital mortality was significantly lower at OHS hospitals (5.0% vs. 8.8%, p < 0.001). Patients presenting to OHS hospitals were significantly more likely to receive aspirin, beta-blockers, and statins (p < 0.05 for all) and to undergo PCI (38.4% vs. 14.1%, p < 0.001). In the propensity-matched model, the difference in mortality remained significant (5.9% vs. 8.5%, p < 0.001). After adjusting for differences in medications administered within 24 h of arrival and hospital characteristics, the difference in mortality was nearly attenuated (hazard ratio: 0.89, 95% confidence interval: 0.79 to 1.00, p = 0.050). When the propensity-matched model was restricted to patients undergoing PCI, there was no significant difference in mortality (1.3% vs. 1.0%, p = 0.51).
Conclusions: NSTEMI patients presenting to No-OHS hospitals have significantly higher mortality. This appears to be due to both modifiable (lower use of guideline-recommended medications) and nonmodifiable factors (hospital size, myocardial infarction volume). In a propensity-matched analysis of patients undergoing PCI for NSTEMI, there was no significant difference in mortality.
Key Words: percutaneous coronary intervention • non–ST-segment elevation myocardial infarction • backup cardiac surgery
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Abbreviations and Acronyms
| | CHF = congestive heart failure | | GP = glycoprotein | | MI = myocardial infarction | | No-OHS = hospitals without on-site open heart surgery | | NSTEMI = non–ST-segment elevation myocardial infarction | | OHS = hospitals with on-site open heart surgery | | PCI = percutaneous coronary intervention |
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G. J. Dehmer and R. G. Brindis
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