Dear Sirs,
We read with interest the article by Kam et al. describing delays to invasive coronary angiography for patients with non-ST-elevation myocardial infarction (NSTEMI) admitted to hospitals without on-site catheterisation facilities in Southeast Scotland.1 Their findings reflect important logistical challenges in delivering timely care, particularly when inter-hospital transfer is required. However, such pressures are not exclusive to non-percutaneous coronary intervention (PCI) hospitals.
At our tertiary PCI centre in London, we conducted a retrospective audit of all patients admitted under the acute medical take with a diagnosis of non-ST-elevation – acute coronary syndrome (NSTE-ACS) between October 2023 and October 2024. As per our Trust pathway, patients with NSTE-ACS were admitted under acute medicine, rather than cardiology, if they did not have significant dynamic electrocardiogram (ECG) changes, ongoing chest pain, pulmonary oedema, cardiogenic shock, ventricular arrhythmias or a history of coronary intervention in the preceding 30 days. In total, 74 patients underwent coronary angiography with a mean age of 64.2 ± 9.8 years, and 63.5% were male.
Among those with a GRACE (Global Registry of Acute Coronary Events) score ≥3% (n=56), 44.6% underwent PCI within 72 hours. The mean time from admission to PCI was 3.81 days, despite patients already being at a PCI centre. This suggests that capacity and scheduling restraints on the treating cardiac catherisation laboratory, rather than solely delays related to transferring patients from their initial point of care, may represent a significant limiting factor in timely access to revascularisation for this patient group. Furthermore, for patients admitted locally at a PCI centre, the time to coronary angiography may be prolonged by constraints placed on the cath lab by patients being treated through an inter-hospital transfer system.
We agree with the authors’ concerns about the discomfort experienced by patients delayed in acute hospital beds. While National Institute for Health and Care Excellence (NICE) guidelines advocate for PCI within 72 hours for all patients with a GRACE score ≥3%, recent European Society of Cardiology (ESC) guidance encourages a more nuanced, risk-stratified approach.2,3 The findings from Kam et al. and our centre underscore the need to re-evaluate a universal early invasive approach for all patients with NSTE-ACS. In this context, we considered an alternative care pathway: early discharge to a ‘virtual ward’ for selected low-risk NSTE-ACS patients, as pioneered by our colleagues at Barts Health NHS Trust, London.
Box 1. Proposed eligibility criteria for discharge to an outpatient ‘virtual ward’ for patients with low-risk non-ST-elevation – acute coronary syndrome (NSTE-ACS)
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| Key: GRACE = Global Registry of Acute Coronary Events |
We applied their proposed criteria for discharge to a ‘virtual ward’ (box 1), finding that 71.6% of our patients were eligible, with a mean length of stay in this group of 9.2 days. Their early discharge and subsequent outpatient angiography could save a significant number of bed-days, and by scheduling the expected number of cases into elective cath lab lists, would improve capacity for emergent PCI in higher-risk cases. Although there is, as yet, no large body of peer-reviewed safety data on this approach, preliminary data from Barts Health NHS Trust, who have cared for 1,000 patients with NSTEMI through their ATLAS (AT home Low risk Acute coronary Syndrome) virtual ward, demonstrates zero 30-day readmissions or major adverse cardiovascular events.4
We support the authors’ call for the development of new treatment pathways in NSTE-ACS, improving the quality of care for those with low-risk NSTE-ACS and ensuring that emergent cath lab capacity exists for those that need it most.
Hugh Lurcott
Internal Medicine Trainee
([email protected])
Sarah O’Connell
Foundation Year 1
Lynn Almasri
Medical Student
Asma Khan
Consultant in Acute & General Internal Medicine
Michael Dodkin
ACS Specialist Nurse
M Zeeshan Khawaja
Consultant Interventional Cardiologist
King’s College Hospital NHS Foundation Trust, London
Conflicts of interest
None declared.
Funding
None.
References
1. Kam MM, Lee R, Ng BZ et al. Delay to ICA for patients with NSTEMI admitted to hospitals without cardiac catheterisation facilities in SE Scotland. Br J Cardiol 2025;32:63–7. https://doi.org/10.5837/bjc.2025.022
2. National Institute for Health and Care Excellence. Acute coronary syndromes. NG185. London: NICE, 2020. Available from: https://www.nice.org.uk/guidance/ng185/chapter/Recommendations
3. Collet JP, Thiele H, Barbato E et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021;42:1289–367. https://doi.org/10.1093/eurheartj/ehab696
4. Ortis-iHealth. Virtual ward case studies. AT Home Low Risk Acute Coronary Syndrome (ATLAS) Virtual Ward. Stockport: Convenzis, 2024 [accessed 18 July 2025]. Available at: https://www.convenzis.co.uk/uploads/pdfs/OnePageCaseStudies-66f66118b6647.pdf
