Six-month outcome in patients with myocardial infarction initially admitted to tertiary and nontertiary hospitals

Objectives. The aim of the present study was to ascertain whether the degree of accessibility to coronary angiography and revascularization results in differing usages or outcomes, or both, in the setting of a high coverage national health system. Background. The selective use of coronary angiography and revascularization procedures in the management of acute myocardial infarction (MI) remains controversial. Methods. A cohort of 1,460 consecutive patients with a first MI admitted to four referral teaching hospitals (one with tertiary facilities) were followed up for 6 months after admission. Only patients initially admitted to each of the study hospitals were retained for analysis in the original hospital's cohort. End points mere 6-month mortality and readmission for reinfarction, unstable angina, heart failure or severe ventricular arrhythmia. Results. Patients admitted to the tertiary hospital were more likely to undergo coronary angiography (adjusted relative risk 4.22, 95% confidence interval [CI] 3.37 to 5.45) than those admitted to the nontertiary sites (use rate: 22.1% for nontertiary care, 55.5% for tertiary care). Revascularization procedures mere performed in 21.2% of patients in the tertiary hospital and in 8.3% in the nontertiary hospitals (p < 0.0001). Median delay for emergency coronary angiography mas shorter in the tertiary hospital (within 1 vs. 2 days, p < 0.0001). Six-month mortality or readmission rates mere similar (23.7% and 24.7% for tertiary and nontertiary care, respectively), After adjustment for comorbidity and disease severity, the relative risk of death or readmission for the tertiary hospital was 1.03 (95% CI 0.69 to 1.53) times that of the nontertiary hospitals. Conclusions. Selective use of coronary angiography and revascularization procedures may be as effective as less restricted use in the management of acute MI. (C) 1997 by the American College of Cardiology.