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Published on: May 28, 2019
Outcomes of Patients With ST-Elevation Myocardial Infarction Receiving and Not Receiving Reperfusion Therapy: The
Laurie J Lambert1, James M Brophy2, Normand Racine3
1Unité d'évaluation cardiovasculaire, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Québec, Canada.
Insights
Evaluating all ST-elevation myocardial infarction (STEMI) patients, including those not receiving reperfusion, is crucial for accurate hospital performance assessment. Mixed-care hospitals showed the highest STEMI mortality rates, highlighting the need to consider all patient outcomes.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Hospitals aim for good outcomes in ST-elevation myocardial infarction (STEMI) reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention [PPCI]).
- A comprehensive evaluation must include STEMI patients who do not receive reperfusion.
- Hospital performance varies based on STEMI care models: PPCI-capable centres, fibrinolysis centres, centres transferring for PPCI, and mixed-care centres.
Purpose of the Study:
- To compare outcomes for STEMI patients who received reperfusion versus those who did not, stratified by hospital type.
- To evaluate the overall system performance of different hospital models in STEMI care.
Main Methods:
- A study of 3731 STEMI patients across 82 Quebec hospitals over two 6-month periods.
- Patients were categorized based on receiving reperfusion (PPCI or fibrinolysis) or not.
- Outcomes were analyzed by hospital type: PPCI centres, fibrinolysis centres, transfer PPCI centres, and mixed centres.
Main Results:
- 78.2% of STEMI patients received reperfusion; 21.8% did not.
- 30-day mortality for reperfusion-treated patients ranged from 5.4% to 6.9% across centre types.
- 30-day mortality for untreated patients was significantly higher, ranging from 15.7% to 24.6%.
- Mixed centres exhibited the highest crude and adjusted 30-day STEMI mortality for all patients.
Conclusions:
- Mixed-care centres demonstrated the highest overall STEMI mortality.
- Focusing solely on reperfusion-treated patients can mask a hospital's true performance.
- Comprehensive STEMI care evaluation necessitates including outcomes of all patients, regardless of reperfusion status.
Background:
Hospitals treating patients with ST-elevation myocardial infarction (STEMI) may show good results with reperfusion treatment (fibrinolysis or primary percutaneous coronary intervention [PPCI]), but a comprehensive evaluation should factor in outcomes of patients with STEMI who do not receive reperfusion. We compared outcomes of patients receiving and not receiving reperfusion within a complete system of STEMI care by hospital type: PPCI centres, fibrinolysis centres, centres that only transfer for PPCI, and centres providing a mix of fibrinolysis and PPCI transfer.
Methods:
All patients presenting to 82 Quebec hospitals with characteristic symptoms, a final diagnosis of acute myocardial infarction, and core-laboratory confirmed STEMI over two 6-month periods were studied.
Results:
Of the total 3731 patients with STEMI, 2918 (78.2%) received reperfusion treatment (81% PPCI, 19% fibrinolysis); 813 (21.8%) did not. For reperfusion-treated patients, 30-day mortality was 5.4% in PPCI centres, 5.4% in fibrinolysis centres, 6.9% in transfer PPCI centres, and 6.0% in mixed centres (P = 0.55). For untreated patients, 30-day mortality was 15.7% (PPCI centres), 16.1% (fibrinolysis centres), 21.8% (transfer PPCI), and 24.6% (mixed) (P = 0.08). Adjusted mortality odds ratios for all patients were 1.00 (PPCI centres), 1.50 (95% CI: 0.97-2.32; fibrinolysis centres), 1.30 (0.95-1.78; transfer PPCI centres), and 1.58 (1.09-2.29; mixed centres). PPCI was within recommended delays in 35.4%, 11.9%, and 1.2% of PPCI, transfer, and mixed centres, respectively.
Conclusions:
Mixed centres had the highest crude and adjusted all-patient 30-day STEMI mortality. Relatively good outcomes of reperfusion-treated patients, despite long treatment delays, can misrepresent overall performance if untreated patients are not examined.
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