Shorter waiting times are linked to better outcomes for survivors of myocardial infarction referred for either angioplasty or bypass surgery, according to an article in the Aug. 6th issue of the Journal of the American College of Cardiology.

"Once a decision has been made to revascularize a patient, the answer is, revascularize them as quickly as possible. Delays following that decision will adversely affect outcomes," said David A. Alter, MD, PhD, lead author of the study.

The current study took a new approach to outcome analysis by reviewing registry data on 15,166 Canadian patients who underwent either angioplasty or bypass surgery rather than analyzing data solely by procedure type. Patients who were initially admitted to major hospital centers with facilities for both angioplasty and bypass surgery were more likely to receive angioplasty. However, similar patients who were first admitted to local community hospitals and later referred for revascularization were more likely to undergo bypass surgery than angioplasty.

According to Alter, the most important finding was a dramatic difference between waiting times and outcomes. Patients admitted to major centers waited an average of 12 days for revascularization, whereas patients seen first at community hospitals waited an average of 48 days.

"The earlier referral for angioplasty and the shortened waiting times for patients at tertiary centers did result in significant improvement in their outcomes: fewer heart attacks, fewer readmissions for angina, fewer cases of heart failure," Alter said.

Patients admitted to major centers were less likely than community hospital patients to be readmitted to the hospital with a cardiac problem while waiting for angioplasty procedure or bypass surgery (41.5 versus 68.9 events per 100 patients). These patients also spent fewer days in the hospital (379 days versus 517 days per 100 patients).

After the revascularization procedure was done, there were no differences in outcomes between the two groups of patients (major center and community hospital).

The authors suggested that several steps could be taken to shorten waiting times, including more rapid transfers from community hospitals to major centers, as well as increased capacity at the bigger hospitals.

Alter noted that increasing capacity is likely to lead to increasing use of revascularization procedures: "One challenge is that when capacity for catheterization and revascularization is increased, these interventions will also likely be used more liberally. So, not only will folks get treated sooner, which is good; but individuals who would have otherwise been treated medically now will be referred for revascularization. This may or may not be so good, since such patients may do equally well or better had they been treated with medications alone. The important point here is that most studies have not disentangled waits from rates; that is, 'earlier' versus 'more.' The purpose of this study was to focus in on the relationship between timing and outcomes."

The current study looked only at patients who received follow-up procedures after initial treatment for myocardial infarction, excluding all patients who received primary angioplasty during their primary cardiac event.

Harold L. Dauerman, MD, the author of an accompanying editorial, commented that the study is an important contribution to the understanding of the role for invasive revascularization procedures following myocardial infarction.

"The study by Alter et al. provides a strong argument for considering that earlier is better for the invasive approach. Thus, there appears to be an evolving consistency of evidence that favors an invasive approach that is done during the first hospitalization for heart attack patients. Whether or not all patients require this invasive approach cannot be answered in this study; but if the invasive approach is used, this registry study is another strong argument for applying it in the early period after hospitalization for a heart attack," Dauerman wrote.