Reasons for reperfusion delay in ST-elevation myocardial infarction and their impact on mortality
Paolo Rubartelli1, Davide Bartolini1, Sandro Bellotti1
1Cardiology Unit, Ospedale Villa Scassi.
Insights
Delays in reperfusion therapy for ST-elevation myocardial infarction (STEMI) significantly increase mortality. Patient-related factors like comorbidities and hemodynamic instability are key independent risk factors for death after primary percutaneous coronary intervention (pPCI).
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Reperfusion delay in ST-elevation myocardial infarction (STEMI) negatively impacts patient outcomes.
- Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy for STEMI.
- Understanding specific causes of delay is crucial for improving treatment efficacy.
Purpose of the Study:
- To identify specific reasons for delays in primary percutaneous coronary intervention (pPCI) for STEMI patients.
- To assess the impact of these delays on 1-year all-cause mortality, adjusting for confounders.
- To differentiate the impact of system-related versus patient-related delays on mortality.
Main Methods:
- Retrospective analysis of 2149 STEMI patients undergoing pPCI between 2006 and 2019.
- Definition of delayed pPCI based on first-medical-contact-to-device (FMCTD) time (>90 min or >120 min for inter-hospital transfers).
- Multivariable Cox-regression models used to identify independent risk factors for mortality, adjusting for established risk scores and procedural success.
Main Results:
- pPCI was timely in 69.9% of patients; delays occurred in 16.4% (system-related) and 13.7% (patient-related).
- Patient-related delays, particularly due to comorbidities (HR 2.19) and hemodynamic instability (HR 2.05), were significant independent predictors of 1-year mortality.
- The increased mortality risk associated with these delays persisted across the time spectrum from symptom onset.
Conclusions:
- Specific causes of delay, especially patient-related factors like comorbidities and hemodynamic instability, have a greater impact on mortality than the duration of delay alone.
- Targeted performance improvement programs should address these specific patient-related causes of delay.
- Prompt reperfusion, including timely pPCI, remains critical for improving prognosis even in patients presenting later after symptom onset.
Aims:
The impact of reperfusion delay in ST-elevation myocardial infarction (STEMI) is well known. We aimed to describe the specific reasons for delay to primary percutaneous coronary intervention (pPCI), and their impact on mortality after adjusting for confounders, using the first-medical-contact-to-device (FMCTD) time to measure the delay.
Methods:
Between January 2006 and December 2019, 2149 STEMI patients underwent pPCI at our centre. Delayed pPCI was defined as FMCTD > 90 min or > 120 min in the case of inter-hospital transfer. The causes of delay were classified as system-related (related to the network organization) or patient-related (related to the clinical condition of the patient). Primary outcome was 1-year all-cause mortality.
Results:
The pPCI was timely in 69.9% of patients, delayed for system-related causes in 16.4% or for patient-related causes in 13.7%. Different patient-related causes induced variable median FMCTD time (from 114 min for technically difficult pPCI to 159 min for ECG and/or symptom resolution). By multivariable Cox-regression models, the main independent risk factors for mortality were delay due to comorbidities [hazard ratio (HR) 2.19 (1.22-3.91)], or hemodynamic instability [HR 2.05 (1.25-3.38)], after adjusting for Global Registry of Acute Coronary Events risk score tertiles and angiographic success. The difference in risk of mortality is maintained over the entire spectrum of time from symptom onset.
Conclusions:
Different causes of delay had different impacts on mortality, generally more important than the length of the delay. Causes of delay such as hemodynamic instability and comorbidities should prompt specific programs of performance improvement. Timely pPCI maintains prognostic advantages after several hours from symptom onset, mandating prompt reperfusion also in late-presenter patients.
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