Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke on Trent, United Kingdom; Department of Cardiology, University Hospital of North Midlands, Stoke on Trent, United Kingdom.
Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.
Can J Cardiol. 2020 Jun;36(6):868-877. doi: 10.1016/j.cjca.2019.10.010. Epub 2019 Oct 16.
Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown.
We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes.
A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.
This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.
据报道，在设有院内心脏导管实验室（CCL）的医院中，接受侵入性冠状动脉治疗的患者数量有所增加，但根据首诊医院 CCL 设施的类型，以及侵入性冠状动脉治疗策略的应用和临床结局尚不清楚。
我们纳入了 2007 年至 2015 年期间在英格兰和威尔士因非 ST 段抬高型心肌梗死（NSTEMI）入院的 452216 例患者。根据 CCL 设施，将首诊医院分为无实验室、诊断和 PCI 医院。采用多水平逻辑回归模型研究 CCL 设施与院内结局之间的关联。
共有 97777 例（21.6%）患者被收入无实验室医院，134381 例（29.7%）和 220058 例（48.7%）分别被收入诊断和 PCI 医院。与诊断（63.2%）和无实验室（61.4%）医院相比，PCI 医院更常进行冠状动脉造影（77.3%）。经调整后，与无实验室医院相比，诊断（比值比 [OR] 0.93，95%置信区间 [CI] 0.83-1.04）和 PCI 医院（OR 1.09，95% CI 0.96-1.24）的院内死亡率相似。然而，在高危 NSTEMI 亚组（定义为全球急性冠状动脉事件注册评分＞140）中，与无实验室和 PCI 医院相比，诊断医院入院与院内死亡率显著增加相关（OR 1.36，95% CI 1.06-1.75）。
本研究强调了根据首诊医院 CCL 设施，NSTEMI 患者在侵入性冠状动脉治疗策略的应用以及后续管理和结局方面存在重要差异。收入诊断医院的高危 NSTEMI 患者院内死亡率更高，可能是由于 PCI 使用减少所致，这需要加以解决。
