Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment & outcome.

BACKGROUND: Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS).  We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta. METHODS: Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke. RESULTS: From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001). CONCLUSION: In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.

The effect of a regional care model on cardiac catheterization rates in patients with Acute Coronary Syndromes.

BACKGROUND: Patients with ACS often present to community hospitals without on-site cardiac catheterization and revascularization therapies. Transfer to specialized cardiac procedural centers is necessary to provide access to these procedures. We evaluated process of care within a regional care model by comparing cardiac catheterization and revascularization rates and outcomes in ACS patients presenting to community and interventional hospitals. METHODS: We evaluated a total of 6154 patients with ACS admitted to Southern Alberta hospitals (where a distinct regional care model for ACS exists) between January 1, 2005 and December 31, 2009. We compared cardiac catheterization and revascularization rates during index hospitalization among patients admitted to community and interventional hospitals. Thirty day and 1-year survival were also evaluated. RESULTS: Catheterization was performed more often in patients presenting to community hospitals compared to the interventional facility (respectively 69.5% and 51.4%, p < 0.0001). Catheterization within 72 hours of admission occurred in 48% of patients presenting to the interventional center and in 68.3% of community patients (P < 0.0001). In patients undergoing catheterization, revascularization (PCI and/or CABG) was also performed more frequently in the community group (74.5% vs 56.1%, P < 0.0001). Risk adjusted mortality rates were the same for patients undergoing cardiac catheterization regardless of hospital of initial presentation. CONCLUSION: ACS patients presenting to community centers associated with a regional care model had effective access to cardiac catheterization and revascularization. These findings support the importance of regional initiatives and processes of care that facilitate access to cardiac catheterization for all ACS patients.

Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts.

OBJECTIVE: Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting. METHODS: In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities. RESULTS: In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients. CONCLUSIONS: This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR.