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Original Investigation |

Outcomes of Myocardial Infarction in Hospitals With Percutaneous Coronary Intervention Facilities FREE

Jose Labarere, MD; Loic Belle, MD; Magali Fourny, MSc; Nathalie Genès, MD; Jean-Marc Lablanche, MD; Didier Blanchard, MD; Jean-Pierre Cambou, MD; Nicolas Danchin, MD; Unité de Soins Intensifs Coronaires 2000 Investigators
[+] Author Affiliations

Author Affiliations: Techniques pour l’Evaluation et la Modélisation des Actions de Santé (ThEMAS, TIMC), National Center for Scientific Research (CNRS 5525), Université Joseph Fourier, Grenoble, France (Dr Labarere); Quality of Care Units, Centre Hospitalier Universitaire, Grenoble (Drs Labarere and Ms Fourny); Department of Cardiology, Centre Hospitalier, Annecy, France (Dr Belle); Intercontinental Medical Affairs, Sanofi-Aventis, Paris, France (Dr Genès); Department of Cardiology, Centre Hospitalier Universitaire, Lille, France (Dr Lablanche); Department of Cardiology, Clinique St Gatien, Tours, France (Dr Blanchard); Unit 558, Institut National de la Santé et de la Recherche Médicale (INSERM), Toulouse, France (Dr Cambou); and Department of Cardiology, Hôpital Européen Georges Pompidou, Paris (Dr Danchin).


Arch Intern Med. 2007;167(9):913-920. doi:10.1001/archinte.167.9.913.
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Published online

Background  Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (hereinafter, PCI hospitals) have improved outcomes in routine practice.

Methods  We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000.

Results  Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P = .75) and reinfarction (1.7% vs 2.5%; P = .25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P = .001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications.

Conclusions  In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Figures in this Article

Percutaneous coronary intervention (PCI) is a proven therapeutic approach for patients with acute ST-segment elevation myocardial infarction. Meta-analyses of randomized controlled trials have shown that primary PCI is associated with improved outcomes compared with thrombolysis,1 even if the patient's transfer to a hospital with PCI facilities (hereinafter, PCI hospital) is needed.2 There is also evidence supporting routine PCI within 24 hours of thrombolysis35 and rescue angioplasty after failed thrombolysis.6

Although promising, the results of these randomized trials have limited generalizability because of the investigators' reluctance to enroll high-risk patients, performance of PCI at tertiary care centers with a high annual volume of procedures, and time delays that were much shorter than in the real world.7,8 In addition, observational studies failed to document any differences in mortality rates for patients presenting at hospitals with vs without on-site catheterization facilities, despite higher rates of PCI use for patients first admitted to hospitals with catheterization facilities.8,9

The aim of this study was to compare processes of care, hospital outcomes, and 1-year mortality rates for patients with acute myocardial infarction who were first admitted to PCI vs non-PCI hospitals.

STUDY DESIGN

The Unité de Soins Intensifs Coronaires (USIC) 2000 study is a prospective cohort study designed to collect complete and representative data on processes of care and clinical outcomes for patients with acute myocardial infarction who were admitted to 316 hospitals with intensive care units (ICUs) over a 1-month period in France. The study design and the primary outcomes of the USIC 2000 study have been reported in detail elsewhere.10,11

STUDY POPULATION

Physicians enrolled patients 24 hours a day, 7 days a week from November 1 to November 30, 2000. Patients were eligible for enrollment if they had (1) an elevated serum marker of myocardial necrosis higher than twice the upper normal limit for creatine kinase, creatine kinase-MB, or troponin and (2) symptoms compatible with acute myocardial infarction for 30 minutes or longer and/or electrocardiographic changes on at least 2 contiguous leads with abnormal Q-waves (≥0.04 seconds) and/or persisting ST-segment elevation or depression greater than 0.1 mV. For the present analysis, we focused on patients with ST-segment elevation, or a presumed new Q-wave or left bundle-branch block on the first electrocardiogram recorded.10

DATA COLLECTION

A physician at each hospital prospectively collected detailed information on demographics, cardiovascular history, risk factors, treatments prior to admission, presenting characteristics, revascularization procedures, medications used within 48 hours of admission, left ventricular ejection fraction assessed within 5 days of admission, and discharge medications. We also documented the characteristics of the hospitals to which patients were first admitted (Table 1). We defined PCI hospitals as hospitals that offered PCI 24 hours a day, 7 days a week.

Table Graphic Jump LocationTable 1. Characteristics of Hospitals With and Without On-site PCI Facilities
OUTCOME MEASURES

Our primary outcome was 1-year all-cause mortality. Death was determined from medical records and follow-up telephone interviews with the patients' relatives or their primary care physician 1 year after index admission. Secondary outcomes included prospectively collected hospital mortality rates, stroke, and reinfarction.

STATISTICAL ANALYSIS

Categorical variables were expressed as frequency and percentage and continuous variables as median and interquartile range (IQR). Differences in characteristics for patients first admitted to PCI vs non-PCI hospitals were compared using the χ2 or Fisher exact tests for categorical variables and the Wilcoxon rank sum test for continuous variables.

Hospital mortality was compared for patients first admitted to PCI vs non-PCI hospitals, using univariable and multivariable logistic regression. Multivariable analysis was adjusted for the patient baseline characteristics listed in Table 2. The confounding effect of age was adjusted using a linear spline with knots at 45, 55, 65, 75, and 85 years. Because of the high correlation between on-site PCI availability at the admitting hospital and the use of PCI, the latter variable was not included in the model.9 All first-order interactions involving on-site PCI availability at the admitting hospital were systematically assessed. The final logistic regression model yielded a C statistic of 0.86, and the corresponding Hosmer-Lemeshow goodness-of-fit χ28 was 5.26 (P = .72).

Table Graphic Jump LocationTable 2. Baseline Characteristics of 1914 Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities*

We also performed a propensity score analysis to adjust for imbalances in measured covariates between patients first admitted to PCI vs non-PCI hospitals.12 Our propensity score analysis attempted to compare outcomes for patients first admitted to PCI vs non-PCI hospitals who had a similar distribution of measured covariates, and in this way approximated the conditions of random site of admission assignment.12 For this purpose, we first developed a full, nonparsimonious logistic regression model to derive a propensity score for admission to PCI hospitals that included the patient baseline characteristics listed in Table 2. Each patient was assigned a propensity score using the logistic regression model. This score ranged from 0.15 to 0.92 and reflected the probability that a patient would be admitted to a PCI hospital. Our propensity score model yielded a C statistic of 0.67, and the corresponding Hosmer-Lemeshow goodness-of-fit χ28 was 7.76 (P = .46). Patients were stratified by quintile of increasing propensity score. We found adequate overlap in propensity score within each quintile and no residual imbalances in covariates for patients admitted to PCI vs non-PCI hospitals after adjusting for quintile. We then used a logistic regression model to estimate the odds ratio for hospital mortality associated with admission to PCI hospitals after adjusting for the quintile of propensity score. Because of the low number of events within comparison groups, adjusted odds ratios for in-hospital stroke and reinfarction could not be estimated in multivariable or propensity analysis.

Hazard ratios for 1-year mortality associated with PCI hospital admission were estimated using Cox proportional hazard models adjusting for baseline characteristics and quintile of propensity score. To determine the role of discharge medications and PCI use within 48 hours of admission in the protective effect of admission to PCI hospitals, these variables were included in separate analyses limited to patients who were discharged alive. The proportional hazard assumption was confirmed by inspection of log(−log [survival]) curves and by examination of Schoenfeld residuals.

Fifty-seven patients (4.8%) admitted to PCI hospitals and 38 patients (5.1%) admitted to non-PCI hospitals had missing data for 1 or more covariates. Exclusion of these patients from the analyses did not modify the estimates of mortality rates or the hazard ratios of mortality associated with admission to PCI hospitals. For all analyses, we used robust estimates of variance to account for patients clustering within hospitals. Two-sided P values of P<.05 were considered statistically significant. Analyses were performed using Stata statistical software (version 9.0; Stata Corp, College Station, Tex).

Of the 2320 patients enrolled in the USIC 2000 study, 1922 had ST-segment elevation, or a presumed new Q-wave or left bundle-branch block. Of these, 8 patients were excluded because of missing information about the hospitals that had first admitted them. Our analytical sample consisted of 1914 patients, with a median number of 4 patients (IQR, 2-8) enrolled per hospital (Table 1). A total of 1176 patients (61%) were first admitted to PCI hospitals and 738 patients (39%) to non-PCI hospitals.

The median age for all patients was 67 years (IQR, 53-76 years), 1393 (73%) were men, 395 (21%) had diabetes mellitus, and 299 (16%) had had a prior myocardial infarction. At presentation, 745 patients (39%) had anterior infarct location, and 426 (22%) presented with a Killip class of II or higher. Patients admitted to PCI hospitals were more likely to be current smokers, to have undergone prior PCI, and to be transported by mobile ICU (Table 2). In contrast, patients admitted to non-PCI hospitals were older and more likely to have hypertension and to present with a Killip class of II or higher.

Patients first admitted to PCI hospitals were more likely to undergo PCI (either primary PCI, within 48 hours of admission, or at anytime during hospital stay) and treatment with an intra-aortic balloon pump, whereas those admitted to non-PCI hospitals were more likely to undergo coronary artery bypass graft surgery and to receive thrombolysis (Table 3). Of patients who were admitted to PCI vs non-PCI hospitals, 58% and 40%, respectively, received reperfusion therapy (ie, thrombolysis [22% and 39%, respectively] or primary PCI [36% and 1%, respectively]). Of the 940 patients who did not receive any reperfusion therapy, 424 (45%) were admitted more than 12 hours after symptom onset, with no difference between PCI and non-PCI hospitals. The median time to intravenous administration of thrombolysis was not different for patients who were admitted to PCI (2 hours; IQR, 2-3 hours) vs non-PCI hospitals (2 hours; IQR, 1-3.3 hours) (P = .33), whereas patients admitted to PCI hospitals had a shorter time to PCI (median, 4.2 hours vs 14 hours; P<.01). Although patients who underwent PCI were healthier than those who did not, the baseline characteristics that were associated with the performance of PCI were similar for both patients admitted to PCI hospitals and those admitted to non-PCI hospitals (data not shown). Compared with those patients admitted to non-PCI hospitals, those admitted to PCI hospitals had shorter lengths of stay and were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications, including low-molecular-weight heparin within 48 hours of admission, and antiplatelet agents, β-blockers, and statins within 48 hours of admission and at discharge (Table 3 and Table 4).

Table Graphic Jump LocationTable 3. In-Hospital Procedures, Medical Treatments, and Course for 1914 Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities*
Table Graphic Jump LocationTable 4. Discharge Medications for Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities

Although the rates of in-hospital stroke and reinfarction were similar for both groups, patients admitted to PCI hospitals had lower hospital mortality and a nonsignificant trend toward a decreased odds ratio of hospital mortality in multivariable and propensity analyses (Table 5). Patients admitted to PCI hospitals also had a decreased hazard ratio of death within the first year of index admission, which remained significant after adjusting for baseline characteristics and quintile of propensity score (Figure). We did not find any significant first-order interaction involving baseline characteristics (including transport by mobile ICU), which suggests that the effect of admission to a PCI hospital on 1-year mortality rates was homogeneous across baseline characteristics. Among the 1735 patients who were discharged alive, the survival benefit associated with admission to a PCI hospital was explained by performance of PCI within 48 hours of admission and by treatment with evidence-based discharge medications, as illustrated by the attenuated adjusted hazard ratio of death when these variables were added to the multivariable model (Table 6). Although it is a major prognostic factor, adjusting for left ventricular ejection fraction did not alter the independent association between PCI and mortality rate.

Table Graphic Jump LocationTable 5. Comparison of Outcomes for Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities
Place holder to copy figure label and caption
Figure.

Estimates of propensity score–adjusted survival for patients who were admitted to hospitals with and without on-site percutaneous coronary intervention (PCI) facilities (PCI hospitals and non-PCI hospitals, respectively).

Graphic Jump Location
Table Graphic Jump LocationTable 6. Hazard Ratios (HRs) of Death Within the First Year of Index Admission for 1735 Patients Who Were Discharged Alive From Hospital

In this nationwide prospective cohort study of patients with acute myocardial infarction, admission to a PCI hospital was associated with better processes of care and lower 1-year mortality rates than admission to a non-PCI hospital. In addition, this study showed that most of the survival benefit of admission to a PCI hospital was explained by a more frequent use of PCI and evidence-based discharge medications.

These findings are supported by randomized controlled trials that demonstrated the efficacy and safety of primary PCI1 as well as routine and rescue PCI after thrombolysis3,6 for patients with ST-segment elevation myocardial infarction. They are also consistent with the findings of other observational studies. In a prospective cohort study of unselected patients with acute myocardial infarction, primary PCI was associated with shorter length of hospital stay, less frequent readmission and reinfarction, and lower mortality rate than thrombolysis.13 In the Canadian-American Global Use of Strategies to Open Occluded Coronary Arteries IIb14 and the Myocardial Infarction and Triage Intervention15 studies, the presence of on-site catheterization facilities at the admitting hospital was associated with greater use of PCI and lower 1- and 3-year mortality rates for patients with ST-segment elevation myocardial infarction. In contrast, Krumholz et al16 reported comparable short- and long-term mortality rates for Medicare patients who were admitted to hospitals with vs without catheterization facilities. However, in this study, patients originally admitted to hospitals with vs without such facilities had comparable rates of coronary revascularization procedures during the index episode of care (19.5% vs 20.5%).16 The European Network for Acute Coronary Treatment study17 found a more frequent use of PCI in patients with ST-segment elevation myocardial infarction who were admitted to hospitals with on-site catheterization facilities but with no discernible effect on in-hospital mortality. This latter study was underpowered to detect a moderate difference in mortality rates, and a longer follow-up would have been required to demonstrate any survival benefit for patients admitted to hospitals with catheterization facilities. The Global Registry of Acute Coronary Events showed that patients admitted to hospitals with catheterization facilities had no survival benefit by 6 months and an increased risk for major bleeding,8 although there was a potential for overadjustment in this study.18 Indeed, the survival benefit associated with patient admission to hospitals with catheterization facilities may have disappeared after adjusting for PCI as a result of the high correlation between these 2 variables. Actually, our data show that it is the more frequent use of PCI that explains most of the survival benefit of admission to a PCI hospital and not the fact that the hospital is a PCI hospital per se that improves outcomes.

Another important finding of our study was the greater use of guidelines-recommended medications for patients who were admitted to PCI hospitals. The Intravenous nPA for Treatment of Infarcting Myocardium Early II study19 reported concordant results with a more common use of β-blockers for patients admitted to hospitals with 24-hour PCI facilities. Our findings are also supported by previous studies20,21 showing that patients undergoing PCI were more likely to receive guidelines-recommended therapies. Secondary prevention therapy with antiplatelet agents, β-blockers, and statins has been shown to be associated with a decreased 1-year mortality rate in patients with acute myocardial infarction.22,23 Although not recommended as an ancillary therapy to PCI, low-molecular-weight heparin was used more frequently within 48 hours of admission in patients admitted to PCI hospitals in our study. A potential explanation for this discrepancy may be that low-molecular-weight heparin was used for the prevention of venous thromboembolism,24 as suggested by the overlap of unfractionated and low-molecular-weight heparin use within 48 hours of admission.

Only 40% of the patients who were admitted to non-PCI hospitals received reperfusion therapy (ie, thrombolysis [39%] or primary PCI [1.2%]). Although 45% of the patients who did not receive any reperfusion therapy were admitted more than 12 hours after symptom onset, the lack of cardiac catheterization facilities was probably a key determinant for nonperformance of PCI for the remaining 55% of patients.25 Regional initiatives have been launched to improve processes of care for patients with ST-segment elevation myocardial infarction since the USIC 2000 study was conducted. These initiatives include dissemination of evidence-based guidelines, use of an algorithm for guiding the initial reperfusion therapy decision (ie, thrombolysis performed before hospital admission, direct transport to a facility capable of primary PCI, or conservative treatment), and transferring patients from hospitals without PCI capability to specialized regional primary PCI hospitals. A recent study26 showed that regionalization of care for acute myocardial infarction in the Alps area in France was followed by an increasing use of thrombolysis performed before hospital admission for patients transported by mobile ICUs (49%, 67%, and 68% in 2002, 2003, and 2004, respectively) and PCI (either primary or routine/rescue PCI within 24 hours of thrombolysis) for patients who presented to non-PCI hospitals (48%, 59%, and 72% in 2002, 2003, and 2004, respectively).

The limitations of our study should be acknowledged. First, admission to PCI hospitals was not based on random assignment, and therefore our results may be confounded by other factors.12 Although we performed multivariable and propensity score analyses to adjust for imbalances in measured covariates, unmeasured covariates that we did not account for may exist and could explain the survival benefit of admission to PCI hospitals. For the same reason, comparisons of mortality rates for patients who had or did not have PCI should be interpreted with caution because some patients might have died before undergoing this procedure. However, our observational study addresses an important question that is unlikely to be studied by large randomized controlled trials because the initial site of admission for patients with acute myocardial infarction depends on many factors, including distance to PCI facilities and patient preferences. Second, we cannot exclude the possibility that some mobile ICUs might have used protocols for guiding the initial site of admission decision at the time that the USIC 2000 study was conducted. However, baseline characteristics associated with admission to PCI hospitals were not different for patients who were transported by mobile ICU and those who were not (data not shown). Moreover, we did not find a significant interaction between transport by mobile ICU and admission to PCI hospital for the hazard ratio of mortality. Third, the 5-year difference in median age between the 2 groups of patients was unexpected, although this finding was consistent with other studies showing that patients admitted to hospitals without catheterization facilities were significantly older than those admitted to hospitals with on-site catheterization facilities.8,9 To adjust for imbalances in age for patients admitted to PCI vs non-PCI hospitals, we used a linear spline in multivariable and propensity score analyses. Fourth, physicians were not asked for their reasons for conservative treatment of the 267 patients who did not receive any reperfusion therapy despite admission to PCI hospital less than 12 hours after symptom onset. Fifth, our study was conducted in France, and our findings may not extend to patients treated in other geographic locations because processes of care for patients with acute coronary syndrome have been shown to vary across countries.17 Sixth, the potential for a selection bias was real because participation in the USIC 2000 study was voluntary. However, 83% of the French ICUs that treated patients with acute myocardial infarction participated in the USIC 2000 study independently of the region and teaching or private status.10

In conclusion, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidenced-based therapies and with lower 1-year mortality rate in this observational study. These findings provide additional support for recommending PCI, either primary PCI or after failed thrombolysis, and secondary prevention with evidence-based therapies for these patients.

Correspondence: Jose Labarere, MD, Unité d’Evaluation Médicale, Pavillon Taillefer, Centre Hospitalier Universitaire BP 217, 38043 Grenoble CEDEX 9, France (JLabarere@chu-grenoble.fr or jose.labarere@laposte.net).

Accepted for Publication: December 22, 2006.

Author Contributions:Study concept and design: Genès, Blanchard, Cambou, and Danchin. Acquisition of data: Genès, Lablanche, Blanchard, Cambou, and Danchin. Analysis and interpretation of data: Labarere, Belle, and Fourny. Drafting of the manuscript: Labarere. Critical revision of the manuscript for important intellectual content: Belle, Fourny, Genès, Lablanche, Cambou, and Danchin. Statistical analysis: Labarere and Fourny. Obtained funding: Genès and Danchin. Study supervision: Blanchard, Cambou, and Danchin.

Group Members: The USIC 2000 investigators are as follow: K. Abolmaali, MD; P. Admant, MD; N. Afchar, MD; B. Agier, MD; B. Agraou, MD; M. Ain Fares, MD; P. Airaud, MD; Z. Alagha, MD; B. Aljouma, MD; S. Allam, MD; G. Allard Latour, MD; S. Anieu, MD; A. Anzid, MD; B. Assoun, MD; K. Aswad, MD; J. P. Auloge, MD; B. Baala, MD; F. Baget, MD; J. M. Baisset, MD; C. Baixas, MD; J. Ballout, MD; G. Baradat, MD; H. Barake, MD; M. Barboteu, MD; C. Barjhoux, MD; F. Barthes, MD; J. Bauchart, MD; M. Baudet, MD; N. Bayo, MD; B. Beaudet, MD; V. Bechet, MD; P. Bechetoille, MD; A. Belabbas, MD; H. Belfaqih, MD; M. Belhameche, MD; R. Benderbous, MD; K. Benia, MD; L. Bensaad, MD; A. J. Benslimane, MD; J. Bera, MD; A. Bereski, MD; J. Berland, MD; F. Bernard, MD; J. D. Berthou, MD; P. Bickert, MD; M. P. Bienvenu, MD; J. P. Binon, MD; J. P. Biou, MD; J. J Blanc, MD; J. C. Bodart, MD; E. Bonnefoy, MD; L. Bonnefoy, MD; J. L. Bonnet, MD; P. Bonnet, MD; L. Bonnevie, MD; D. Bouchayer, MD; S. E. Bouchemal, MD; C. Boukerche, MD; J. L. Bourdon, MD; C. Boureux, MD; P. Boulard, MD; S. Boutalba, MD; C. Bouteau, MD; J. L. Bouvier, MD; J. M. Bouvier, MD; M. Brami, MD; P. Brandstatt, MD; P. Broin, MD; P. Buttard, MD; E. Caillou, MD; I. Canavy, MD; B. Carette, MD; C. Carville, MD; J. Cassagnes, MD; C. Cassat, MD; P. Cazaux, MD; P. Cazenave, MD; S. Champagne, MD; S. Chaouche, MD; L. Chapoutot, MD; J. Charles, MD; S. Chassaing, MD; A. Chassing, MD; P. Chavernac, MD; S. Chayeb, MD; N. Cheu, MD; J. Cheikel, MD; P. Chenevez, MD; I. Cheradame, MD; J. M. Chevalier, MD; J. Chevrier, MD; C. Choffe, MD; M. Clavier, MD; J. P. Colin, MD; G. Convert, MD; I. Cornuejols, MD; Y. Cottin, MD; G. Courdier, MD; A. Courtault, MD; B. Crousillat, MD; Y. Cuisinier, MD; A. Dabboura, MD; P. Dambrine, MD; J. P. Darracq, MD; P. Dary, MD; J. M. Davy, MD; B. De Breyne, MD; E. Decoulx, MD; B. Degand, MD; N. Delarche, MD; P. Delebarre, MD; M. Delomez, MD; C. Deramchi, MD; E. Desjoyaux, MD; J. Deyrolle, MD; A. Dibie, MD; M. C. Dickele, MD; C. Dieux, MD; F. Digne, MD; J. P. Doazan; G. Doll, MD; R. Douillet, MD; F. Duclos, MD; D. Ducos, MD; P. Dugrand, MD; X. Dujardin, MD; E. Durand, MD; G. V. Dussarat, MD; A. Dutoit, MD; N. El Hajjaji, MD; N. El Mansour, MD; J. Elaerts, MD; N. Elbaz, MD; M. Eldakdouki, MD; D. Elharrar Raufast, MD; J. P. Elkaim, MD; D. Ennouchi, MD; J. Fabre, MD; R. Faitg, MD; R. Faivre, MD; L. Favreau, MD; D. Fedaoui Delalou, MD; E. Ferrari, MD; M. Ferriere, MD; B. Ferron, MD; M. Font, MD; M. Fourdilis, MD; P. Y. Fournier, MD; P. Fournier, MD; P. Fromage, MD; C. Gaillemin, MD; E. Galland, MD; T. Gandon, MD; A. J. Garcia, MD; L. F. Garnier, MD; H. Garnier, MD; P. Gaudel, MD; O. Gauffre, MD; B. Gauthier, MD; J. Gerard, MD; N. Ghanem, MD; J. P. Godenir, MD; M. Gofard, MD; A. Goguey, MD; A. Gommeaux, MD; Y. Gottwalles, MD; P. Goube, MD; M. Gourdon, MD; G. Gournay, MD; J. Y. Grall, MD; G. Grollier, MD; A. Guignier, MD; J. P. Guillot, MD; J. P. Hacot, MD; G. Haddad, MD; J. Haddad, MD; V. Haddad, MD; J. J. Halary, MD; P. Hallali, MD; D. Hamani, MD; G. Hannebicque, MD; F. Haziza, MD; F. Heuon, MD; P. Houplon, MD; A. Huyghe de Mahenge, MD; E. Illouz, MD; A. Issa, MD; A. Jacquot, MD; C. Jais, MD; D. Janody, MD; H. Jeanvoine, MD; P. Jouffroy, MD; G. Kai, MD; B. Keravec, MD; A. Kermarrec, MD; R. Ketelers, MD; J. Y. Ketelers, MD; P. Khanoyan, MD; P. Kieffer, MD; M. Kolb, MD; R. Kraft, MD; G. Kruszynski, MD; M. Lang, MD; P. Lantelme, MD; B. Lascar, MD; L. Lattes, MD; J. M. Laudinat, MD; Y. Laurent, MD; M. Le Blainvaux, MD; D. Le Carreres, MD; C. Le Ray, MD; D. Lecuyer, MD; L. Ledain, MD; C. Ledieu, MD; E. Lefebvre, MD; P. Legalery, MD; N. Lemaire, MD; R. Lepori, MD; J. Levy, MD; G. Levy, MD; J. L. Leymarie, MD; N. Lhoest, MD; J. Lipiecki, MD; D. Logeart, MD; M. Lopez, MD; O. Lozinguez, MD; B. Maalouf, MD; J. Machecourt, MD; B. Maitre, MD; J. Manaffino, MD; H. Mann, MD; F. Marco, MD; A. Marek, MD; P. Maribas, MD; M. Marinov, MD; J. P. Maroni, MD; M. Martelet, MD; J. Martelli, MD; D. Martin, MD; E. Martin, MD; D. Martin, MD; S. Masson, MD; C. Mathurin, MD; D. Matina, MD; G. Mayoux, MD; D. Medekour, MD; B. Mentre, MD; D. Mery, MD; F. Michel, MD; D. Milhau, MD; C. Milon, MD; C. Moini, MD; G. Montalescot, MD; D. Morizot, MD; R. Mossaz, MD; J. Mouallem, MD; I. Mouhoub, MD; F. Moulin, MD; K. E. Mpolesha, MD; A. H. N. Guyen, MD; M. Naisseh, MD; F. Nassar, MD; G. Nedelec, MD; T. Olive, MD; A. Ould Silmane, MD; A. Page, MD; M. C. Palcoux, N. Paquet, MD; M. Pathe, MD; M. Peignon, MD; D. Peltier, MD; J. M. Peltier, MD; H. Perchet, MD; G. Perrard, MD; J. P. Peyre, MD; A. Philias, MD; E. Pierre Justin, MD; D. Pinaud, MD; G. Piszker, MD; M. Placente, MD; O. Poitrineau, MD; F. Poquet, MD; C. Portier, MD; F. Pouillart, MD; N. Poulos, MD; M. A. Preiss, MD; Y. Protin, MD; A. Proton, MD; P. Quandalle, MD; V. Quillasi, MD; J. C. Quiret, MD; J. Rabarjoelina, MD; J. Rabatel, MD; D. Raguin, MD; D. Rakotoarimanana, MD; X. Ranouil, MD; J. P. Ray, MD; C. Richard, MD; M. Ricoux, MD; P. Riviere, MD; D. Roiguez, MD; D. Rondepierre, MD; P. Rosak, MD; P. Rougier, MD; G. Roul, MD; F. Rouleau, MD; J. J. Roux, MD; O. Roux, MD; D. Saadoun, MD; F. Saint-Cricq, MD; D. San German, MD; A. Sangare, MD; A. Sbaiti, MD; P. Schue, MD; J. Schwob, MD; B. Segrestin, MD; P. Sosner, MD; F. X. Soto, MD; V. Stratiev, MD; P. Sultan, MD; M. Sunda, MD; M. Teche, MD; M. Thomas, MD; M. Tissot, MD; X. Tran Thanh, MD; J. P. Usdin, MD; A. C. Vanconi, MD; F. Vayre, MD; B. Veyre, MD; H. Vial, MD; J. Villedary, MD; O. Wittenberg, MD; A. Zabel, MD; M. Zaehringer, MD; H. Zaouali, MD; H. Zemir, MD; G. Zemour, MD; Z.E. Zerrouk, MD; M. Zupan, MD. For a complete list of the departments and institutions that participated in the USIC 2000 study, please contact the authors.

Financial Disclosure: Drs Lablanche, Blanchard, Cambou, and Danchin were compensated by Sanofi-Aventis France for their participation in the steering committee of the USIC 2000 registry. Dr Genès is an employee of Sanofi-Aventis France.

Funding/Support: This study was supported by an unrestricted grant from Sanofi-Aventis France. Dr Labarere was supported by a grant from the Egide Foundation (Programme Lavoisier, French Foreign office).

Acknowledgment: We are indebted to the physicians who participated in the study.

Keeley  ECBoura  JAGrines  CL Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;36113- 20
PubMed Link to Article
Dalby  MBouzamondo  ALechat  PMontalescot  G Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation 2003;1081809- 1814
PubMed Link to Article
Fernandez-Avilés  FAlonso  JJCastro-Beiras  A  et al.  Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial. Lancet 2004;3641045- 1053
PubMed Link to Article
Le May  MRWells  GALabinaz  M  et al.  Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study). J Am Coll Cardiol 2005;46417- 424
PubMed Link to Article
Scheller  BHennen  BHammer  B  et al.  Beneficial effects of immediate stenting after thrombolysis in acute myocardial infarction. J Am Coll Cardiol 2003;42634- 641
PubMed Link to Article
Gershlick  AHStephens-Lloyd  AHughes  S  et al.  Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;3532758- 2768
PubMed Link to Article
Brophy  JMBogaty  P Primary angioplasty and thrombolysis are both reasonable options in acute myocardial infarction. Ann Intern Med 2004;141292- 297
PubMed Link to Article
Van de Werf  FGore  JMAvezum  A  et al.  Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005;330441
PubMed Link to Article
Every  NRLarson  EBLitwin  PE  et al. Myocardial Infarction Triage and Intervention Project Investigators, The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med 1993;329546- 551
PubMed Link to Article
Danchin  NBlanchard  DSteg  PG  et al.  Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry. Circulation 2004;1101909- 1915
PubMed Link to Article
Hanania  GCambou  JPGueret  P  et al.  Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: results from the French nationwide USIC 2000 registry. Heart 2004;901404- 1410
PubMed Link to Article
Joffe  MMRosenbaum  PR Invited commentary: propensity scores. Am J Epidemiol 1999;150327- 333
PubMed Link to Article
Stenestrand  ULindback  JWallentin  L Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction. JAMA 2006;2961749- 1756
PubMed Link to Article
Khadour  FHFu  YChang  WC  et al.  Impact of on-site cardiac interventional facilities on management and outcome of patients with acute coronary syndromes. Can J Cardiol 2003;19257- 263
PubMed
Every  NRParsons  LSFihn  SD  et al. Myocardial Infarction Triage and Intervention (MITI) Investigators, Long-term outcome in acute myocardial infarction patients admitted to hospitals with and without on-site cardiac catheterization facilities. Circulation 1997;961770- 1775
PubMed Link to Article
Krumholz  HMChen  JMurillo  JECohen  DJRadford  MJ Admission to hospitals with on-site cardiac catheterization facilities: impact on long-term costs and outcomes. Circulation 1998;982010- 2016
PubMed Link to Article
Steg  PGIung  BFeldman  LJ  et al. ENACT Investigators, Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J 2003;24613- 622
PubMed Link to Article
Stenestrand  U Improper statistical explanation for surprising outcome in the GRACE-study of access to catheterisation facilities in patients admitted with ACS? http://bmj.bmjjournals.com/cgi/eletters/330/7489/441#100753. Accessed June 7, 2006
Llevadot  JGiugliano  RPAntman  EM  et al.  Availability of on-site catheterization and clinical outcomes in patients receiving fibrinolysis for ST-elevation myocardial infarction. Eur Heart J 2001;222104- 2115
PubMed Link to Article
Danchin  NGrenier  OFerrieres  JCantet  CCambou  JP Use of secondary preventive drugs in patients with acute coronary syndromes treated medically or with coronary angioplasty: results from the nationwide French PREVENIR survey. Heart 2002;88159- 162
PubMed Link to Article
Mehta  RHMontoye  CKFaul  J  et al.  Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use: the American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion. J Am Coll Cardiol 2004;432166- 2173
PubMed Link to Article
Danchin  NCambou  JPHanania  G  et al.  Impact of combined secondary prevention therapy after myocardial infarction: data from a nationwide French registry. Am Heart J 2005;1501147- 1153
PubMed Link to Article
Ho  PMSpertus  JAMasoudi  FA  et al.  Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med 2006;1661842- 1847
PubMed Link to Article
Antman  EMAnbe  DTArmstrong  PW  et al.  ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44E1- E211
PubMed Link to Article
Belle  LLabarere  JFourny  MCambou  JPDanchin  N Variations in the management of patients with acute myocardial infarction in Alps hospitals and other French hospitals: secondary analysis of the USIC 2000 study data. Ann Cardiol Angeiol (Paris) 2005;54310- 316
PubMed Link to Article
Debaty  GBelle  LLabarere  J  et al.  Evolution of strategies of revascularization in acute coronary syndrome with ST elevation: analysis of the RESURCOR. Arch Mal Coeur Vaiss 2007;100105- 111
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Estimates of propensity score–adjusted survival for patients who were admitted to hospitals with and without on-site percutaneous coronary intervention (PCI) facilities (PCI hospitals and non-PCI hospitals, respectively).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of Hospitals With and Without On-site PCI Facilities
Table Graphic Jump LocationTable 2. Baseline Characteristics of 1914 Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities*
Table Graphic Jump LocationTable 3. In-Hospital Procedures, Medical Treatments, and Course for 1914 Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities*
Table Graphic Jump LocationTable 4. Discharge Medications for Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities
Table Graphic Jump LocationTable 5. Comparison of Outcomes for Patients Who Were First Admitted to Hospitals With and Without On-site PCI Facilities
Table Graphic Jump LocationTable 6. Hazard Ratios (HRs) of Death Within the First Year of Index Admission for 1735 Patients Who Were Discharged Alive From Hospital

References

Keeley  ECBoura  JAGrines  CL Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;36113- 20
PubMed Link to Article
Dalby  MBouzamondo  ALechat  PMontalescot  G Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation 2003;1081809- 1814
PubMed Link to Article
Fernandez-Avilés  FAlonso  JJCastro-Beiras  A  et al.  Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial. Lancet 2004;3641045- 1053
PubMed Link to Article
Le May  MRWells  GALabinaz  M  et al.  Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study). J Am Coll Cardiol 2005;46417- 424
PubMed Link to Article
Scheller  BHennen  BHammer  B  et al.  Beneficial effects of immediate stenting after thrombolysis in acute myocardial infarction. J Am Coll Cardiol 2003;42634- 641
PubMed Link to Article
Gershlick  AHStephens-Lloyd  AHughes  S  et al.  Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;3532758- 2768
PubMed Link to Article
Brophy  JMBogaty  P Primary angioplasty and thrombolysis are both reasonable options in acute myocardial infarction. Ann Intern Med 2004;141292- 297
PubMed Link to Article
Van de Werf  FGore  JMAvezum  A  et al.  Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005;330441
PubMed Link to Article
Every  NRLarson  EBLitwin  PE  et al. Myocardial Infarction Triage and Intervention Project Investigators, The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med 1993;329546- 551
PubMed Link to Article
Danchin  NBlanchard  DSteg  PG  et al.  Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry. Circulation 2004;1101909- 1915
PubMed Link to Article
Hanania  GCambou  JPGueret  P  et al.  Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: results from the French nationwide USIC 2000 registry. Heart 2004;901404- 1410
PubMed Link to Article
Joffe  MMRosenbaum  PR Invited commentary: propensity scores. Am J Epidemiol 1999;150327- 333
PubMed Link to Article
Stenestrand  ULindback  JWallentin  L Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction. JAMA 2006;2961749- 1756
PubMed Link to Article
Khadour  FHFu  YChang  WC  et al.  Impact of on-site cardiac interventional facilities on management and outcome of patients with acute coronary syndromes. Can J Cardiol 2003;19257- 263
PubMed
Every  NRParsons  LSFihn  SD  et al. Myocardial Infarction Triage and Intervention (MITI) Investigators, Long-term outcome in acute myocardial infarction patients admitted to hospitals with and without on-site cardiac catheterization facilities. Circulation 1997;961770- 1775
PubMed Link to Article
Krumholz  HMChen  JMurillo  JECohen  DJRadford  MJ Admission to hospitals with on-site cardiac catheterization facilities: impact on long-term costs and outcomes. Circulation 1998;982010- 2016
PubMed Link to Article
Steg  PGIung  BFeldman  LJ  et al. ENACT Investigators, Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J 2003;24613- 622
PubMed Link to Article
Stenestrand  U Improper statistical explanation for surprising outcome in the GRACE-study of access to catheterisation facilities in patients admitted with ACS? http://bmj.bmjjournals.com/cgi/eletters/330/7489/441#100753. Accessed June 7, 2006
Llevadot  JGiugliano  RPAntman  EM  et al.  Availability of on-site catheterization and clinical outcomes in patients receiving fibrinolysis for ST-elevation myocardial infarction. Eur Heart J 2001;222104- 2115
PubMed Link to Article
Danchin  NGrenier  OFerrieres  JCantet  CCambou  JP Use of secondary preventive drugs in patients with acute coronary syndromes treated medically or with coronary angioplasty: results from the nationwide French PREVENIR survey. Heart 2002;88159- 162
PubMed Link to Article
Mehta  RHMontoye  CKFaul  J  et al.  Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use: the American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion. J Am Coll Cardiol 2004;432166- 2173
PubMed Link to Article
Danchin  NCambou  JPHanania  G  et al.  Impact of combined secondary prevention therapy after myocardial infarction: data from a nationwide French registry. Am Heart J 2005;1501147- 1153
PubMed Link to Article
Ho  PMSpertus  JAMasoudi  FA  et al.  Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med 2006;1661842- 1847
PubMed Link to Article
Antman  EMAnbe  DTArmstrong  PW  et al.  ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44E1- E211
PubMed Link to Article
Belle  LLabarere  JFourny  MCambou  JPDanchin  N Variations in the management of patients with acute myocardial infarction in Alps hospitals and other French hospitals: secondary analysis of the USIC 2000 study data. Ann Cardiol Angeiol (Paris) 2005;54310- 316
PubMed Link to Article
Debaty  GBelle  LLabarere  J  et al.  Evolution of strategies of revascularization in acute coronary syndrome with ST elevation: analysis of the RESURCOR. Arch Mal Coeur Vaiss 2007;100105- 111
PubMed

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