Culprit Vessel Revascularization Prior to Diagnostic Angiography as a Strategy to Reduce Delays in Primary Percutaneous Coronary Intervention: A Propensity-Matched Analysis.

BACKGROUND: Delays are important markers of quality of care in primary percutaneous coronary intervention. There is scarce data on the impact of obtaining a complete diagnostic angiography before primary percutaneous coronary intervention. METHODS AND RESULTS: Consecutive patients treated with primary percutaneous coronary intervention at our institution between January 2012 and December 2014 were studied. After excluding patients with prior coronary artery bypass surgery, 925 patients were included in the analysis. Patients were classified into 3 groups according to the as-treated revascularization strategy: culprit-vessel revascularization first, contralateral angiography first, or complete angiography first. Propensity score matching was used to minimize difference in clinical characteristics between groups. Predictors of culprit-vessel first revascularization were anterior/lateral infarct location and absence of diabetes mellitus. After propensity score matching, the median vascular access-to-balloon time was 4 to 6 minutes shorter with a culprit-vessel revascularization first strategy. This reduction in time to reperfusion increased the proportion of patients treated within recommended delays. However, there was no significant difference in 30-day clinical outcomes associated with these delays reduction. CONCLUSIONS: Performing culprit-vessel primary percutaneous coronary intervention before contralateral or complete diagnostic angiography is associated with a statistically significant reduction in vascular access-to-balloon time, although the 4- to 6-minute difference is unlikely to be clinically relevant. This small but significant reduction could translate in an augmentation in the proportion of patients treated within recommended delays.

Reduction of delays in primary percutaneous coronary intervention.

BACKGROUND: Acute myocardial infarction is a major health issue. Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction was proved to be superior to fibrinolytic therapy in many randomized trials when done in a timely manner. However, PPCI is associated with delays. Studies have shown that greater delay is associated with increased mortality rate. We applied simple interventions to reduce door-to-balloon time. Our study goal was to evaluate the reduction of delays after our interventions and to monitor 30-day mortality. METHODS: A prospective registry was created to evaluate delays and mortality associated with PPCI. Measures such as annual feedback with suggestions were taken to minimize the delays. Door-to-balloon delays before and after the interventions were compared. RESULTS: A total of 1361 primary PCIs were performed from 2005 to 2008. Of these cases, 1071 patients were transferred from community hospitals. The median door-to-balloon time for transferred patients was 142 minutes for 2005, 138 minutes for 2006, 125 minutes for 2007, and 121 minutes for 2008 (P < 0.001 for 2005 vs. 2008). Door-to-balloon time for patients admitted directly to our centre was 87 minutes in 2005, 74.5 minutes in 2006, 73.5 minutes in 2007, and 74.0 minutes in 2008 (P < 0.001 for 2005 vs. 2008). Thirty-day mortality of these consecutive patients is low (5.2% for 2005 and 3.8% for 2008; P = not significant). CONCLUSIONS: Inexpensive and simple interventions may significantly reduce primary PCI-related delays for transferred cases and patients admitted directly to a centre with PPCI facilities. We also observed a low mortality rate for those consecutive patients.

Same-day transfer of patients with unstable angina and non-ST segment elevation myocardial infarction back to their referring hospital after angioplasty.

BACKGROUND: Recent evidence has shown the advantages of an early invasive strategy for patients with high-risk unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). However, the number of beds available for postangioplasty monitoring limits the use of this approach at the Centre hospitalier universitaire de Sherbrooke (Fleurimont, Quebec). OBJECTIVES: To study the safety of a protocol allowing the same-day return of patients with UA or NSTEMI to their referring hospital after angioplasty at the Centre hospitalier universitaire de Sherbrooke. METHODS: From June 2001 to June 2003, of the 532 patients with UA and NSTEMI who underwent percutaneous coronary intervention with planned same-day transfer back to their referring hospital, 419 consecutive patients who were eligible to return the same day were prospectively followed for 24 h. RESULTS: Stents were used in 94.7% of patients and platelet glycoprotein IIb/IIIa receptor antagonists were used in 34.8% of patients. For 85% of patients, the femoral artery was used as the access route for percutaneous coronary intervention. The mean time that patients stayed in the hospital after angioplasty before returning to their referring centres was 4.4 h. No deaths, life-threatening arrhythmias or urgent revascularizations were reported during the 24 h postangioplasty follow-up period, but one patient had a major bleeding complication. During the study period, the mean angioplasty waiting time decreased from 5.7 days to 2.1 days. CONCLUSIONS: The protocol evaluated in the present article is safe. It frees more beds, thus reducing the waiting list and allowing patients with high-risk acute coronary syndromes without ST segment elevation from community hospitals to benefit from the advantages of an early invasive strategy.