非ST段抬高型急性冠状动脉综合征（NSTE-ACS）患者在基层医院和三级医院的治疗模式及临床结局：来自非ST段抬高型急性冠状动脉综合征早期糖蛋白IIb/IIIa抑制（EARLY-ACS）试验的见解
Practice patterns and clinical outcomes among non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients presenting to primary and tertiary hospitals: insights from the EARLY glycoprotein IIb/IIIa inhibition in NSTE-ACS (EARLY-ACS) trial.
作者信息
Toleva Olga, Westerhout Cynthia M, Senaratne Manohara P J, Bode Christoph, Lindroos Magnus, Sulimov Vitaly A, Montalescot Gilles, Newby L Kristin, Giugliano Robert P, Van de Werf Frans, Armstrong Paul W
机构信息
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
出版信息
Catheter Cardiovasc Interv. 2014 Nov 15;84(6):934-42. doi: 10.1002/ccd.25590. Epub 2014 Jul 9.
OBJECTIVES
We evaluated patients at tertiary [both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) capable] and primary hospitals in the EARLY-ACS trial.
BACKGROUND
Early invasive management is recommended for high-risk non-ST-segment elevation acute coronary syndromes.
METHODS
We evaluated outcomes in 9,204 patients presenting to: tertiary sites, primary sites with transfer to tertiary sites ("transferred") and those who remained at primary sites ("non-transfer").
RESULTS
There were 348 tertiary (n = 7,455 patients) and 89 primary hospitals [n = 1,749 patients (729 transferred; 1,020 non-transfer)]. Significant delays occurred in time from symptom onset to angiography (49 hr), PCI (53h), and CABG (178 hr) for transferred patients (P < 0.001). Non-transfer patients had less 30-day death/myocardial infarction [9.4% vs. 11.7% (tertiary); adjusted odds ratio (OR): 0.78 (0.62-0.97), P = 0.026]; transferred (14.0%) and tertiary patients were similar [adjusted OR: 1.23 (0.98-1.53), P = 0.074]. Non-transfer patients had lower 1-year mortality [4.3% vs. 6.3% (tertiary); adjusted hazard ratio (HR): 0.64 (0.47-0.87), P = 0.005]: there was no difference between transferred and tertiary patients [5.2% vs. 6.3%; adjusted HR: 0.80 (0.58-1.12), P = 0.202]. Despite similar rates of catheterization, GUSTO severe/moderate bleeding within 120 hr was less in non-transfer [3.1% vs. 6.7% (tertiary); adjusted OR: 0.47 (0.32-0.68), P < 0.001], whereas transferred (6.1%) and tertiary patients were similar [adjusted OR: 0.94 (0.68-1.30), P = 0.693]. There was no difference in non-CABG bleeding.
CONCLUSIONS
Timely angiography and revascularization were often not achieved in transferred patients. Non-transferred patients presenting to primary sites had the lowest event rates and the best long-term survival.
目的
在EARLY-ACS试验中，我们评估了三级医院（具备经皮冠状动脉介入治疗[PCI]和冠状动脉旁路移植术[CABG]能力）及基层医院的患者。
背景
对于高危非ST段抬高型急性冠状动脉综合征，推荐早期侵入性治疗。
方法
我们评估了9204例患者的结局，这些患者就诊于：三级医院、转诊至三级医院的基层医院患者（“转诊患者”）以及留在基层医院的患者（“未转诊患者”）。
结果
有348家三级医院（n = 7455例患者）和89家基层医院[n = 1749例患者（729例转诊；1020例未转诊）]。转诊患者从症状发作到血管造影（49小时）、PCI（53小时）和CABG（178小时）存在显著延迟（P < 0.001）。未转诊患者30天死亡/心肌梗死发生率较低[9.4% vs. 11.7%（三级医院）；校正优势比（OR）：0.78（0.62 - 0.97），P = 0.026]；转诊患者（14.0%）与三级医院患者相似[校正OR：1.23（0.98 - 1.53），P = 0.074]。未转诊患者1年死亡率较低[4.3% vs. 6.3%（三级医院）；校正风险比（HR）：0.64（0.47 - 0.87），P = 0.005]：转诊患者与三级医院患者之间无差异[5.2% vs. 6.3%；校正HR：0.80（0.58 - 1.12），P = 0.202]。尽管导管插入率相似，但未转诊患者120小时内GUSTO严重/中度出血发生率较低[3.1% vs. 6.7%（三级医院）；校正OR：0.47（0.32 - 0.68），P < 0.001]，而转诊患者（6.1%）与三级医院患者相似[校正OR：0.94（0.68 - 1.30），P = 0.693]。非CABG出血方面无差异。
结论
转诊患者往往无法及时进行血管造影和血运重建。就诊于基层医院的未转诊患者事件发生率最低，长期生存率最佳。
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