Management of high-risk non-ST elevation myocardial infarction in the UK: need for alternative models of care to reduce length of stay and admission to angiography times

Direct admission versus interhospital transfer for revascularisation in non-ST-segment elevation myocardial infarction

BACKGROUND

The differences in outcomes and process parameters for NSTEMI patients who are directly admitted to an intervention centre and patients who are first admitted to a general centre are largely unknown.

HYPOTHESIS

There are differences in process indicators, but not for clinical outcomes, for NSTEMI who are directly admitted to an intervention centre and patients who are first admitted to a general centre.

METHODS

We aim to compare process indicators, costs and clinical outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients stratified by center of first presentation and revascularisation strategy. Hospital claim data from patients admitted with a NSTEMI between 2017 and 2019 were used for this study. Included patients were stratified by center of admission (intervention vs. general center) and subdivided by revascularisation strategy (PCI, CABG, or no revascularisation [noRevasc]). The primary outcome was length of hospital stay. Secondary outcomes included: duration between admission and diagnostic angiography and revascularisation, number of intracoronary procedures, clinical outcomes at 30 days (MACE: all-cause mortality, recurrent myocardial infarction and cardiac readmission) and total costs (accumulation of costs for hospital claims and interhospital ambulance rides).

RESULTS

A total of 9641 NSTEMI events (9167 unique patients) were analyzed of which 5399 patients (56%) were admitted at an intervention center and 4242 patients to a general center. Duration of hospitalization was significantly shorter at direct presentation at an intervention centre for all study groups (5 days [2-11] vs. 7 days [4-12], p < 0.001). For PCI, direct presentation at an intervention center yielded shorter time to diagnostic angiography (1 day [0-2] vs. 1 day [1-2], p < 0.01) and revascularisation (1 day [0-3] vs. 4 days [1-7], p < 0.001) and less intracoronary procedures per patient (2 [1-2] vs. 2 [2-2], p < 0.001). For CABG, time to revascularisation was shorter (8 days [5-12] vs. 10 days [7-14], p < 0.001). Total costs were significantly lower in case of direct presentation in an intervention center for all treatment groups €10.211 (8750-18.192) versus €13.741 (11.588-19.381), p < 0.001) while MACE was similar 11.8% versus 12.4%, p = 0.344).

CONCLUSION

NSTEMI patients who were directly presented to an intervention center account for shorter duration of hospitalization, less time to revascularisation, less interhospital transfers, less intracoronary procedures and lower costs compared to patients who present at a general center.

Association of admitting physician specialty and care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI): insights from a national registry

AIM

Little is known about the association between admitting physician specialty and care quality and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS AND RESULTS

We identified 288 420 patients hospitalized with NSTEMI between 2010 and 2017 in the UK Myocardial Infarction National Audit Project database. The cohort was dichotomized according to care under a non-cardiologist (n = 146 722) and care under a cardiologist (n = 141 698) within the first 24 h of admission to hospital. Patients admitted under a cardiologist were significantly younger (70 vs. 75 years, P < 0.001), and less likely to be female (32% vs. 39%, P < 0.001). Independent factors associated with admission under a cardiologist included prior history of percutaneous coronary intervention (PCI) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07; P = 0.04], hypercholesterolaemia (OR 1.17, 95% CI 1.15-1.20; P < 0.001), hypertension (OR 1.03, 95% CI 1.01-1.04; P = 0.01), and admission to an interventional centre (OR 3.90, 95% CI 3.79-4.00; P < 0.001). Patients admitted under cardiology were more likely to receive optimal pharmacotherapy, undergo invasive coronary angiography (79% vs. 60%, P < 0.001), and receive revascularization in the form of PCI (52% vs. 36%, P < 0.001). Following propensity score matching, odds of in-hospital all-cause mortality (OR 0.81, 95% CI 0.79-0.85; P < 0.001), re-infarction (OR 0.78, 95% CI 0.66-0.91; P = 0.001), and major adverse cardiovascular events (OR 0.81, 95% CI 0.78-0.84; P < 0.001) were lower in patients admitted under a cardiologist.

CONCLUSION

Patients with NSTEMI admitted under a cardiologist within 24 h of hospital admission were more likely to receive guideline-directed management and had better clinical outcomes.

Drug-eluting balloon: is it useful?

Background

Coronary artery disease is one of the major issues in the medical world around the globe. The prevalence tends to increase. The use of coronary intervention is one of the ways often used in the management of coronary artery disease due to its satisfying result from earlier studies. Nowadays, there are several different techniques in coronary intervention: balloon vs stent.

Main body

The stent-based vascular interventions are increasingly being used over balloon-based coronary intervention. However, revascularization intervention using stent often have undesirable long-term effects compared to balloon. Besides, stent-based interventions are also considered more expensive, use more complicated techniques, and use more drug regimens. On the other hand, percutaneous coronary intervention techniques using balloons coated by anti-proliferation drugs have begun to be glimpsed by many interventionists. Studies have found many benefits that cannot be given by stent-based intervention therapy.

Conclusions

Angioplasty using percutaneous coronary intervention techniques reveals satisfying result compared to conservative medical treatment. The indication and technique of percutaneous coronary intervention is still evolving until now. Currently, percutaneous coronary intervention using stent, either bare-metal stent or drug-eluting stent, is preferred by interventionist. Nevertheless, recent clinical trial favors the using of drug-eluting balloon for percutaneous coronary intervention in terms of both clinical outcome and complication in several scenarios.

Acute coronary syndromes

In the UK, there are over 80,000 admissions annually with acute coronary syndromes (ACS). Management of ST-elevation myocardial infarction (STEMI) involves primary percutaneous coronary intervention (PCI), which is delivered via dedicated heart attack centres. Non-ST elevation-ACS (NSTE-ACS) accounts for two-thirds of ACS presentations, affecting an older cohort of patients - often with more complex comorbidities. Initial management is with anti-thrombotic therapy with a view to PCI within 24 hours for the most acute cases and within 72 hours for all others. However, varying management pathways and access to specialist cardiology services results in variable times to definitive treatment. Advances in the sensitivity of cardiac biomarkers and the use of risk assessment tools now enable rapid diagnosis within a few hours of symptom onset. Advances in invasive management and drug therapy have resulted in improved clinical outcomes with resultant decline in mortality associated with ACS.

Acute coronary syndromes

In the UK, there are over 80,000 admissions annually with acute coronary syndromes (ACS). Management of ST-elevation myocardial infarction (STEMI) involves primary percutaneous coronary intervention (PCI), which is delivered via dedicated heart attack centres. Non-ST elevation-ACS (NSTE-ACS) accounts for two-thirds of ACS presentations, affecting an older cohort of patients - often with more complex comorbidities. Initial management is with anti-thrombotic therapy with a view to PCI within 24 hours for the most acute cases and within 72 hours for all others. However, varying management pathways and access to specialist cardiology services results in variable times to definitive treatment. Advances in the sensitivity of cardiac biomarkers and the use of risk assessment tools now enable rapid diagnosis within a few hours of symptom onset. Advances in invasive management and drug therapy have resulted in improved clinical outcomes with resultant decline in mortality associated with ACS.