title: Bypassing the emergency room to reduce door-to-balloon time and improve outcomes of ST elevation myocardial infarction patients: analysis of data from 2004-2010 ACSIS registry.
abstract: OBJECTIVE
  Our objective was to assess whether bypassing the emergency room (ER) is associated with meaningful reduction in Major Adverse Cardiac and Cerebrovascular Event (MACCE) or mortality in a large cohort of ST Elevation Myocardial Infarction (STEMI) patients.
  
  
  BACKGROUND
  Prior studies suggest that bypassing the emergency room reduces door-to-balloon time (DBT). However, it is not clear whether this translates into reduced mortality.
  
  
  METHODS
  We analyzed data of 1,552 consecutive patients with STEMI treated by primary percutaneous coronary intervention (PCI) and enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) registry. Thirty percent of patients (n = 459) arrived directly to the Intensive Cardiac Care Unit or catheterization laboratory and 70% (n = 1093) were assessed first in the ER. Our primary end points were DBT, 30-day MACCE, and 30-day and 1-year mortality. Our secondary end points were pre-discharge ejection fraction less than 40%, in-hospital pulmonary edema, in-hospital cardiogenic shock, ST resolution, and duration of hospitalization.
  
  
  RESULTS
  Bypassing the ER was associated with signficantly shorter DBT (59 vs. 97 minutes, P = 0.001). There was no difference in 30-day MACCE and 30-day or 1-year mortality between the 2 study groups. The findings were consistent in multiple subgroups, including women, anterior STEMI, off hours PCI, and patients with pain-to-door (PDT) time of less than 120 minutes.
  
  
  CONCLUSIONS
  Bypassing the ER is associated with significant shortening of DBT. This reduction, however, is not associated with any change in 30-day MACCE and 30-day or 1-year mortality.
authors.affiliation: Department of Cardiology, Bnai Zion Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute ofTechnology, Haifa, Israel.
authors.forename: Alla
authors.initials: A
authors.lastname: Lubovich
authors.forename: Idit
authors.initials: I
authors.lastname: Dobrecky-Mery
authors.forename: Eugeny
authors.initials: E
authors.lastname: Radzishevski
authors.forename: Neemer
authors.initials: N
authors.lastname: Samnia
authors.forename: Shlomi
authors.initials: S
authors.lastname: Matetzky
authors.forename: Rafael
authors.initials: R
authors.lastname: Nagler
authors.forename: Uri
authors.initials: U
authors.lastname: Rosenschein
mesh_terms: D054058:Acute Coronary Syndrome; D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D004636:Emergency Service, Hospital; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D012042:Registries; D013997:Time Factors; D061665:Time-to-Treatment