High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients

Poi Keong Kong (1) , Derek Connolly (1) , Chetan Varma (2) , Gregory Lip (2) , Teri Millane (2) , Russell Davis (1) , Rajai Ahmad (1)

1 Department of Cardiology
2 Department of Cardiology

Objectives: 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 STEMI but literatures are conflicting on this benefit for high-risk versus low-risk patients. In a unique model at Sandwell and West Birmingham Hospitals, 5 interventional cardiologists provide 24-hour PPCI at whichever one of its 2 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 4 periods corresponding to change from daytime-only to 24-hour PPCI. DTB time and in-hospital mortality were the main outcome measures. Results: Of the 459 patients, median DTB time improved from 89 minutes (interquartile range 49-120) to 68 minutes (50-91) (P=0.005) and proportion of patients achieving target 90-minute 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]; OR 0.37, 95%CI 0.18-0.75; P=0.008). With the proviso that our study was limited in power, long DTB time (>90 minutes vs. ≤90 minutes) 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.

Mots clés: Medicine

Poi Keong Kong, Derek Connolly, Chetan Varma, Gregory Lip, Teri Millane, et al.. High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients. International Journal of Clinical Practice, 2009, 63 (12), pp.1693. ⟨10.1111/j.1742-1241.2009.02122.x⟩. ⟨hal-00510620⟩