title: Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry.
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
  
  
  METHODS
  369 intensive care units in France.
  
  
  METHODS
  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).
  
  
  METHODS
  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.
authors.affiliation: Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France. gabriel.steg@bch.ap-hop-paris.fr
authors.forename: P G
authors.initials: PG
authors.lastname: Steg
authors.forename: J-P
authors.initials: JP
authors.lastname: Cambou
authors.forename: P
authors.initials: P
authors.lastname: Goldstein
authors.forename: E
authors.initials: E
authors.lastname: Durand
authors.forename: P
authors.initials: P
authors.lastname: Sauval
authors.forename: Z
authors.initials: Z
authors.lastname: Kadri
authors.forename: D
authors.initials: D
authors.lastname: Blanchard
authors.forename: J-M
authors.initials: JM
authors.lastname: Lablanche
authors.forename: P
authors.initials: P
authors.lastname: Guéret
authors.forename: Y
authors.initials: Y
authors.lastname: Cottin
authors.forename: J-M
authors.initials: JM
authors.lastname: Juliard
authors.forename: G
authors.initials: G
authors.lastname: Hanania
authors.forename: L
authors.initials: L
authors.lastname: Vaur
authors.forename: N
authors.initials: N
authors.lastname: Danchin
mesh_terms: D000368:Aged; D003325:Coronary Care Units / Q000706:statistics & numerical data; D005260:Female; D005602:France / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data; D016017:Odds Ratio; D010343:Patient Admission; D012042:Registries; D013997:Time Factors