Mortality differences among patients with in-hospital ST-elevation myocardial infarction
Negeen Shahandeh1, Xuming Dai2, Brian Jaski3
1University of California Los Angeles, Los Angeles, California, USA.
Insights
In-hospital ST-elevation myocardial infarction (STEMI) patients not related to cardiac issues or procedures had longer treatment delays and higher mortality. Developing quality metrics is crucial for improving outcomes in these critical cases.
Area of Science:
- Cardiology
- Hospital Medicine
- Quality Improvement
Background:
- In-hospital ST-elevation myocardial infarction (STEMI) carries a higher mortality risk than out-of-hospital STEMI.
- Lack of standardized quality measures and protocols contributes to delayed recognition and treatment of in-hospital STEMI.
Purpose of the Study:
- To investigate and compare mortality rates among distinct patient subgroups experiencing in-hospital STEMI.
- To analyze the impact of STEMI's context (cardiac, periprocedure, noncardiac) on patient outcomes.
Main Methods:
- A multicenter, retrospective observational study was conducted across six US medical centers from 2008 to 2017.
- Patients were categorized into three groups: cardiac, periprocedure, and noncardiac/nonpostprocedure STEMI.
- Key outcomes included electrocardiogram (ECG)-to-cardiac catheterization lab arrival (ECG-to-CCL) time and survival to discharge.
Main Results:
- 184 patients with in-hospital STEMI were identified.
- Periprocedure and noncardiac/nonpostprocedure STEMI groups exhibited significantly longer ECG-to-CCL times compared to the cardiac group.
- While not statistically significant after adjustment, survival to discharge was lower in the periprocedure and noncardiac/nonpostprocedure groups.
Conclusions:
- In-hospital STEMI arising from noncardiac conditions or procedures is associated with delayed reperfusion and increased mortality.
- Further research with larger cohorts is needed to validate these findings.
- Health systems must prioritize developing quality metrics and improvement initiatives for in-hospital STEMI care.
Background:
In-hospital ST-elevation myocardial infarction (STEMI) is associated with a higher mortality rate than out-of-hospital STEMI. Quality measures and universal protocols for treatment of in-hospital STEMI do not exist, likely contributing to delays in recognition and treatment.
Hypothesis:
To analyze differences in mortality among three subsets of patients who develop in-hospital STEMI.
Methods:
This was a multicenter, retrospective observational study of patients who developed in-hospital STEMI at six United States medical centers between 2008 and 2017. Patients were stratified into three groups: (1) cardiac, (2) periprocedure, or (3) noncardiac/nonpostprocedure. Outcomes examined include time from electrocardiogram (ECG) acquisition to cardiac catheterization lab arrival (ECG-to-CCL) and survival to discharge.
Results:
We identified 184 patients with in-hospital STEMI (mean age 68.7 years, 58.7% male). Group 1 (cardiac) patients had a shorter average ECG-to-CCL time (69 minutes) than group 2 (periprocedure, 215 minutes) and group 3 (noncardiac/nonpostprocedure, 199 minutes). Compared to group 1, survival to discharge was lower for group 2 (OR 0.33, P = .102) and group 3 (OR 0.20, P = .016). After adjusting for prespecified covariates, the relationship between group and survival showed a similar trend but did not reach statistical significance.
Conclusions:
Patients who develop in-hospital STEMI in the context of a preceding procedure or noncardiac illness appear to have longer reperfusion times and higher in-hospital mortality than patients admitted with cardiac diagnoses. Larger studies are warranted to further investigate these observations. Health systems should place an increased emphasis on developing quality metrics and implementing quality improvement initiatives to improve outcomes for in-hospital STEMI.
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