Practice patterns and clinical outcomes among non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients presenting to primary and tertiary hospitals: Insights from the EARLY glycoprotein IIb/IIIa inhibition in NSTE-ACS (EARLY-ACS) trial

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.

Management and Outcomes in the Elderly with Non-ST-Elevation Acute Coronary Syndromes Admitted to Spoke Hospitals with No Catheterization Laboratory Facility

Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational−retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82−89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25−87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7−27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0−4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.

Antiplatelet agents for chronic kidney disease

BACKGROUND

Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013.

OBJECTIVES

To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost.

AUTHORS' CONCLUSIONS

Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.

Cardiac mortality benefit of direct admission to percutaneous coronary intervention-capable hospital in acute myocardial infarction: Community registry-based study

Appropriate risk stratification and timely revascularization of acute myocardial infarction (AMI) are available in percutaneous coronary intervention (PCI) - capable hospitals (PCHs). This study evaluated whether direct admission vs inter-hospital transfer influences cardiac mortality in patients with AMI. This study was conducted in the PCH where the patients were able to arrive within an hour. The inclusion criteria were AMI with a symptom onset time within 24 hours and having undergone PCI within 24 hours after admission. The cumulative incidence of cardiac death after percutaneous coronary intervention was evaluated in the direct admission versus inter-hospital transfer groups. Among the 3178 patients, 2165 (68.1%) were admitted via inter-hospital transfer. Patients with ST-segment elevation myocardial infarction (STEMI) in the direct admission group had a reduced symptom onset-to-balloon time (121 minutes, P < .001). With a median period of 28.4 (interquartile range, 12.0-45.6) months, the cumulative incidence of 2-year cardiac death was lower in the direct admission group (NSTEMI, 9.0% vs 11.0%, P = .136; STEMI, 9.7% vs 13.7%, P = .040; AMI, 9.3% vs 12.3%, P = .014, respectively). After the adjustment for clinical variables, inter-hospital transfer was the determinant of cardiac death (hazard ratio, 1.59; 95% confidence interval, 1.08-2.33; P = .016). Direct PCH admission should be recommended for patients with suspected AMI and could be a target for reducing cardiac mortality.

Outcome of emergency coronary artery bypass grafting

OBJECTIVES

The aim of this study was to evaluate the immediate and late outcome of emergency coronary artery bypass grafting (CABG) in a multicenter setting.

DESIGN

Multicenter, retrospective study.

SETTING

Four university hospitals.

PARTICIPANTS

596 patients were included in this study.

INTERVENTIONS

Included patients underwent isolated, emergency CABG.

MEASUREMENTS AND MAIN RESULTS

Sixty patients (absolute rate: 10.1%, pooled rate: 8.7%) died during the in-hospital stay period. Increasing emergency CABG classes (p<0.0001), recent myocardial infarction (p=0.019), left ventricular ejection fraction≤30% (p=0.034), on-pump surgery (p=0.012), and participating centers (p<0.0001) were independent predictors of in-hospital mortality. Survival rates at 1, 3, and 5 years were 86.4%, 81.6%, and 76.1%, respectively. Extracorporeal membrane oxygenation was used in 6 patients and 3 of them (50.0%) survived the immediate postoperative period. Patient populations of participating centers differed significantly in most of baseline characteristics. The preoperative use of intra-aortic balloon pump (8% to 51%) and off-pump surgery (2.8% to 56.3%) varied significantly between institutions. In-hospital mortality (2.8%, 5.9%, 7.7% and 19.8%, p<0.0001), as well as midterm survival, significantly differed between institutions (at 3 years, 90.6%, 89.8%, 81.2%, and 67.2%, p<0.0001).

CONCLUSIONS

The outcome after emergency CABG is satisfactory despite a significant operative risk. However, the results of emergency CABG significantly differed between the participating institutions, likely due to differences in the referral pathways and perioperative treatment strategies. Evaluation of these factors is crucial for implementation of treatment in centers with suboptimal results.