Direct Admission vs. Interhospital Transfer for PCI in STEMI

Study Questions:

What is the influence of direct admission versus transfer via regional hospital to a percutaneous coronary intervention (PCI) center on time delays and 12-month mortality in ST-segment elevation myocardial infarction (STEMI) patients?

Methods:

The analysis used prospective nationwide registry data of STEMI patients admitted to PCI centers within 12 hours of symptom onset and treated with PCI between 2006 and 2013. Patients admitted directly were compared with patients transferred to a PCI center via a regional non–PCI-capable facility in terms of time delays, left ventricular ejection fraction (LVEF), and 12-month mortality. Data were adjusted using propensity-matched and multivariate Cox analyses.

Results:

Of the 70,093 patients eligible for analysis, 39,144 (56%) were admitted directly to a PCI center. Direct admission was associated with a shorter median symptom-to-admission time (by 44 minutes; p < 0.001) and total ischemic time (228 vs. 270 minutes; p < 0.001), higher LVEF (47.5% vs. 46.3%; p < 0.001), and lower propensity-matched 12-month mortality (9.6% vs. 10.4%; p < 0.001). In propensity-matched multivariate Cox analysis, direct admission (hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.01-1.11) and shorter symptom-to-admission time (HR, 1.03; 95% CI, 1.01-1.06) were significant predictors of lower 12-month mortality.

Conclusions:

The authors concluded that among patients with STEMI treated by PCI, direct admission to a primary PCI center was associated with lower 12-month mortality.

Perspective:

This study reports a 12-month mortality benefit after direct admission to a PCI center as compared with interhospital transfer in an unselected cohort of STEMI patients undergoing primary PCI. Furthermore, interhospital transfer to PCI was identified as a predictor of higher 12-month mortality after adjustment for baseline characteristics and time from onset of symptoms to reperfusion in the entire cohort and additionally after propensity-score matching. Since it may not be feasible to eliminate transfer for primary PCI from regional hospitals, we need to focus on opportunities for minimizing delays at the level of regional hospitals and transport services.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Mortality, Myocardial Infarction, Patient Admission, Patient Transfer, Percutaneous Coronary Intervention, Stroke Volume


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