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Gabriel I. Barbash, MD, MPH; Harvey D. White, MB; Michaela Modan, PhD; Rafael Diaz, MD; John R. Hampton, MD; Juhani Heikkila, MD; Arni Kristinsson, MD; Spiros Moulopoulos, MD; Ernesto A. C. Paolasso, MD; Tyeerd Van der Werf, MD; Kenneth Pehrsson, MD; Eric Sandoe, MD; John Simes, MD; Robert G. Wilcox, MD; Marc Verstraete, MD; Gerhard von der Lippe, MD; Frans Van de Werf, MD

Arch Intern Med. 1994;154(19):2237-2242.

Abstract
Objective
The outcome of patients with acute myocardial infarction who received thrombolytic therapy was assessed in relation to the size and comprehensiveness of cardiovascular services in the admitting hospitals.

Methods
Two characteristics were obtained for each of the 438 hospitals: number of beds and in-house availability of cardiovascular services (coronary catheterization laboratory and coronary angioplasty or bypass surgery). Hospitals were grouped into four categories on the basis of size (300 vs >300 beds) and availability of cardiovascular services. Baseline and outcome variables were compared by ² analysis and logistic regression. Patients were followed up for 6 months.

Results
Baseline variables were comparable among hospital categories except for significant differences in the distribution of antecedent angina and time to treatment. Significantly more coronary angioplasties and bypass surgeries were performed in patients first treated in hospitals with coronary revascularization services (4.1% and 4.2% vs 1.0% and 1.9%, P<.0001). Rates of strokes (1.9% vs 1.3% and 1.6%, P=.54 hospital mortality (11.9% vs 8.5%, (P=.11), and 6-month mortality (17.0% vs 11.8% and 12.3%, P=.03) were highest among patients treated in small hospitals that had coronary revascularization facilities. The rate of invasive procedures was higher in the smaller hospitals (odds ratio [OR], 1.44; 95% confidence limits [CL], 1.11 and 1.87; P=.006) and in hospitals with coronary revascularization services (OR, 4.05; 95% CL, 3.14 and 5.22; P<.0001); hemorrhage was more frequent in centers with coronary revascularization facilities (OR, 1.39; 95% CL, 1.13 and 1.71; P=.002). Rates of hospital mortality and 6-month mortality were similar.

Conclusions
Patients with acute myocardial infarction treated with thrombolytic therapy have the same mortality in small centers without in-house coronary revascularization services as in larger centers with such services.

(Arch Intern Med. 1994;154:2237-2242)

Footnotes
A list of the affiliations of the Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Trial who participated in this study is given on page 2238. Deceased.

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