title: 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.
abstract: OBJECTIVE
  We evaluated patients at tertiary [both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) capable] and primary hospitals in the EARLY-ACS trial.
  
  
  BACKGROUND
  Early invasive management is recommended for high-risk non-ST-segment elevation acute coronary syndromes.
  
  
  METHODS
  We evaluated outcomes in 9,204 patients presenting to: tertiary sites, primary sites with transfer to tertiary sites ("transferred") and those who remained at primary sites ("non-transfer").
  
  
  RESULTS
  There were 348 tertiary (n = 7,455 patients) and 89 primary hospitals [n = 1,749 patients (729 transferred; 1,020 non-transfer)]. Significant delays occurred in time from symptom onset to angiography (49 hr), PCI (53h), and CABG (178 hr) for transferred patients (P < 0.001). Non-transfer patients had less 30-day death/myocardial infarction [9.4% vs. 11.7% (tertiary); adjusted odds ratio (OR): 0.78 (0.62-0.97), P = 0.026]; transferred (14.0%) and tertiary patients were similar [adjusted OR: 1.23 (0.98-1.53), P = 0.074]. Non-transfer patients had lower 1-year mortality [4.3% vs. 6.3% (tertiary); adjusted hazard ratio (HR): 0.64 (0.47-0.87), P = 0.005]: there was no difference between transferred and tertiary patients [5.2% vs. 6.3%; adjusted HR: 0.80 (0.58-1.12), P = 0.202]. Despite similar rates of catheterization, GUSTO severe/moderate bleeding within 120 hr was less in non-transfer [3.1% vs. 6.7% (tertiary); adjusted OR: 0.47 (0.32-0.68), P < 0.001], whereas transferred (6.1%) and tertiary patients were similar [adjusted OR: 0.94 (0.68-1.30), P = 0.693]. There was no difference in non-CABG bleeding.
  
  
  CONCLUSIONS
  Timely angiography and revascularization were often not achieved in transferred patients. Non-transferred patients presenting to primary sites had the lowest event rates and the best long-term survival.
authors: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors: Olga
authors: O
authors: Toleva
authors: Cynthia M
authors: CM
authors: Westerhout
authors: Manohara P J
authors: MP
authors: Senaratne
authors: Christoph
authors: C
authors: Bode
authors: Magnus
authors: M
authors: Lindroos
authors: Vitaly A
authors: VA
authors: Sulimov
authors: Gilles
authors: G
authors: Montalescot
authors: L Kristin
authors: LK
authors: Newby
authors: Robert P
authors: RP
authors: Giugliano
authors: Frans
authors: F
authors: Van de Werf
authors: Paul W
authors: PW
authors: Armstrong
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000368:Aged; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D004334:Drug Administration Schedule; D000077542:Eptifibatide; D005260:Female; D019983:Guideline Adherence; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010360:Patient Transfer; D010455:Peptides / Q000008:administration & dosage* / Q000009:adverse effects; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors* / Q000378:metabolism; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011320:Primary Health Care; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D000077542:Eptifibatide
keywords: acute coronary syndrome; bleeding; mortality; practice patterns; revascularization; transfer