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Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry
  1. P G Steg1,
  2. J-P Cambou2,
  3. P Goldstein3,
  4. E Durand4,
  5. P Sauval5,
  6. Z Kadri4,
  7. D Blanchard4,*,
  8. J-M Lablanche6,
  9. P Guéret7,
  10. Y Cottin8,
  11. J-M Juliard1,
  12. G Hanania9,
  13. L Vaur10,
  14. N Danchin4,
  15. for the USIC 2000 Investigators
  1. 1Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique–Hôpitaux de Paris, Paris, France
  2. 2Department of Epidemiology, INSERM U558, Toulouse, France
  3. 3SAMU Régional de Lille, Centre Hospitalier de Lille, Lille, France
  4. 4Cardiology, Hôpital Européen Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
  5. 5SAMU de Paris, Hôpital Necker, Assistance Publique–Hôpitaux de Paris, Paris, France
  6. 6Department of Cardiology, Centre Hospitalier de Lille, Lille, France
  7. 7Department of Cardiology, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil, France
  8. 8CHU du Bocage, Dijon
  9. 9Centre Hospitalier Robert Ballanger, Aulnay sous Bois, France
  10. 10Sanofi-aventis, Paris, France
  1. Correspondence to:
    Professor Philippe Gabriel Steg
    Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75877 Paris Cedex 18, France; gabriel.steg{at}bch.ap-hop-paris.fr

Abstract

Objective: To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI)

Design: Nationwide observational registry of STEMI patients

Setting: 369 intensive care units in France.

Interventions: Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).

Main outcome measures: Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.

Results: Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p  =  0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p  =  0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p  =  0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).

Conclusions: In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

  • ASSENT-3 PLUS, Assessment of the Safety and Efficacy of a New Thrombolytic-3 Plus
  • CABG, coronary artery bypass grafting
  • CCU, coronary care unit
  • CI, confidence interval
  • ER, emergency room
  • HR, hazard ratio
  • OR, odds ratio
  • PCI, percutaneous coronary intervention
  • STEMI, ST-segment elevation myocardial infarction
  • TIMI, Thrombolysis In Myocardial Infarction
  • acute myocardial infarction
  • emergency room
  • reperfusion therapy
  • percutaneous coronary intervention

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Footnotes

  • * Also Clinique Saint-Gatien, Tours, France

  • Published Online First 16 August 2006

  • This study was supported by an unrestricted educational grant from Aventis Pharma France (now sanofi-aventis). One of the co-authors is an employee of Aventis (now sanofi-aventis). The study was, however, planned, organised and analysed, and this report was written and submitted, independently of Aventis Pharma.

  • Competing interests: PGS: Consultant and speaker for sanofi-aventis. Institution receives a research grant from sanofi-aventis. J-PC: Consultant and speaker for sanofi-aventis. P Goldstein: Speaker for Boehringer Ingelheim and sanofi-aventis. P Guéret: Consultant for sanofi-aventis. J-MJ: Speaker and consultant for sanofi-aventis and Boehringer Ingelheim. GH: Consultant for sanofi-aventis. LV: Full-time employee of sanofi-aventis. ND: speaker for sanofi-aventis. Chair of the USIC 2000 registry Steering Committee. ED, PS, ZK, DB, J-ML, YC, SRS: None.

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