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Am Fam Physician. 2000;61(12):3724

Over the past few years, a significant shift in the treatment of patients with acute myocardial infarctions (MIs) has occurred. Recent management includes thrombolysis with early interventions based on cardiac catheterization results. These interventions include percutaneous transluminal coronary artery angioplasty (PTCA) or coronary artery bypass grafting (CABG). However, relatively few hospitals are equipped to provide this type of aggressive and early intervention. If this intervention provides patients with better outcomes, patients may be better served by regionalization of acute MI care. Rogers and colleagues studied the ability of a hospital to perform invasive cardiac diagnostic testing and interventions on the outcomes of patients admitted with acute MI.

The 1,506 hospitals (representing 26 percent of the acute care hospitals in the United States) that participated in the National Registry of Myocardial Infarction 2 study were classified according to their highest level of intervention: (1) none—28.1 percent, (2) coronary arteriography—25.2 percent, (3) PTCA–capable—7.4 percent and (4) CABG–capable—39.2 percent. Treatment and inhospital outcomes were measured for 305,812 patients admitted with acute MI. A subset of 30,402 patients was reassessed through a 90-day follow-up period.

The number of patients who received initial reperfusion therapy was only slightly higher at the hospitals that were equipped to perform PTCA and CABG. However, the median time for door-to-drug thrombolytic treatment was no different among the institutions. The number of patients who underwent cardiac catheterization and PTCA was higher at the institutions that were equipped to perform the more invasive procedures. The percentage of patients who were transferred from a facility was higher at the hospitals that were not invasive cardiac facilities. The 90-day patient survival rates were the same among all the hospitals.

The authors conclude that although patients who were admitted to hospitals without invasive cardiac facilities had a higher transfer rate, the percentage of patients who received reperfusion therapy, the door-to-drug time interval and the 90-day survival rates were similar to those in hospitals with more invasive cardiac capabilities. The data support the policy of initially treating patients with acute MI at the nearest hospital.

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