title: High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients.
abstract: OBJECTIVE
  To evaluate reduction of door-to-balloon (DTB) time and its impact on in-hospital mortality of high-risk infarct patients in a collaboration of district general hospitals (DGH) with a physician-to-patient model.
  
  
  METHODS
  Primary percutaneous coronary interventions (PPCI) with short DTB time offer mortality benefit for ST-segment elevation myocardial infarction but literatures are conflicting on this benefit for high- vs. low-risk patients. In a unique model at Sandwell and West Birmingham Hospitals, five interventional cardiologists provide 24-h PPCI at whichever one of its two DGH that patients present to. A retrospective audit was performed on 3 years (July 2005-June 2008) of PPCI data in the British Cardiovascular Intervention Society database. Data were analysed in four periods corresponding to change from daytime-only to 24-h PPCI. DTB time and in-hospital mortality were the main outcome measures.
  
  
  RESULTS
  Of the 459 patients, median DTB time improved from 89 min (interquartile range: 49-120) to 68 min (50-91) (p = 0.005) and proportion of patients achieving target 90-min DTB time increased from 53% (21/40) to 75% (93/124) (p = 0.005). In-hospital mortality was less for short DTB time [4.6% (13/284) vs. 11.5% (20/174); odds ratio (OR) 0.37, 95% confidence interval (CI): 0.18-0.75; p = 0.008]. With the proviso that our study was limited in power, long DTB time (> 90 min vs. < or = 90 min) was associated with higher in-hospital mortality in high-risk patients [15.6% (20/128) vs. 7.1% (12/168); OR 2.41, 95% CI: 1.14-5.06; p = 0.024] and not in low-risk patients [0% (0/46) vs. 0.9% (1/117); OR 0, 95% CI: 0-9.88; p = 1.000].
  
  
  CONCLUSIONS
  A collaboration of DGH with a physician-to-patient model can deliver timely PPCI that appear to translate into mortality benefit more so in high-risk patients. Low-risk patients would therefore probably tolerate delays associated with transfer to large centres while high-risk patients would not and need alternative strategy. A collaboration of smaller hospitals with a pool of mobile interventional cardiologists could be such an alternative.
authors.affiliation: Department of Cardiology, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK. pkdd210@yahoo.co.uk
authors.forename: P K
authors.initials: PK
authors.lastname: Kong
authors.forename: D
authors.initials: D
authors.lastname: Connolly
authors.forename: C
authors.initials: C
authors.lastname: Varma
authors.forename: G
authors.initials: G
authors.lastname: Lip
authors.forename: T
authors.initials: T
authors.lastname: Millane
authors.forename: R
authors.initials: R
authors.lastname: Davis
authors.forename: R
authors.initials: R
authors.lastname: Ahmad
mesh_terms: D000077284:Abciximab; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D004739:England; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000911:Antibodies, Monoclonal; D007140:Immunoglobulin Fab Fragments; D010975:Platelet Aggregation Inhibitors; D000077284:Abciximab