Reperfusion Times and Outcomes in Patients With ST-Elevation Myocardial Infarction Presenting Without Pre-Hospital
Garry W Hamilton1, Julian Yeoh1, Diem Dinh2
1Department of Cardiology, Austin Health, Melbourne, Australia.
Insights
Patients with ST-elevation myocardial infarction (STEMI) without pre-hospital notification (PN) experienced longer ischemic times but had similar long-term outcomes. Optimizing PN systems is crucial for timely reperfusion in STEMI care.
Area of Science:
- Cardiology
- Emergency Medicine
- Public Health
Background:
- Primary percutaneous coronary intervention (PCI) is the recommended treatment for ST-elevation myocardial infarction (STEMI), ideally within 90 minutes of first medical contact.
- Patients without pre-hospital notification (PN) represent an understudied group less likely to achieve reperfusion targets.
Purpose of the Study:
- To evaluate the impact of pre-hospital notification (PN) on reperfusion times and clinical outcomes in STEMI patients undergoing primary PCI.
- To identify disparities in care and outcomes for STEMI patients with and without PN.
Main Methods:
- An observational cohort study analyzed consecutive STEMI patients undergoing primary PCI between 2012 and 2017 from a multicentre PCI registry.
- Patients were categorized into groups with (PN) and without (no-PN) pre-hospital notification, with specific exclusion criteria applied.
Main Results:
- Patients without PN had significantly longer door-to-balloon time (DTBT) and symptom-to-balloon time (STBT) compared to those with PN.
- Despite longer ischemic times, there were no significant differences in 30-day Major Adverse Cardiovascular Events (MACE) or long-term mortality between the no-PN and PN groups.
- The no-PN group showed lower rates of certain interventional procedures, suggesting potentially smaller infarct sizes.
Conclusions:
- Lack of pre-hospital notification in STEMI patients is associated with delayed reperfusion, particularly out-of-hours, but does not independently predict worse long-term mortality.
- Ischemic times may serve as a more sensitive metric for evaluating the efficiency of pre-hospital notification networks than hard clinical outcomes.
- Developing tailored, efficient systems of care is essential for ensuring timely reperfusion for all STEMI patients.
Background:
Primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) is recommended within 90 min of first medical contact. Those without pre-hospital notification (PN) are less likely to meet reperfusion targets and are an understudied subset of the STEMI population.
Methods:
An observational cohort study from a multicentre PCI registry of consecutive patients undergoing primary PCI for STEMI between 2012 and 2017. Exclusion criteria included out-of-hospital cardiac arrest, prior thrombolysis, symptom onset >12 h prior, and cardiogenic shock.
Results:
2519 patients were included: 1392 (55.3%) without PN (no-PN group) and 1127 (44.7%) with PN (PN group). Those without PN had longer median DTBT (78 min vs 51 min, p < 0.001) and STBT (206 min vs 161 min, p < 0.001), with only 55% meeting DTBT targets out-of-hours in the no-PN group. No-PN patients had lower rates of AHA/ACC type B2/C lesions, GP IIb/IIIa use, aspiration thrombectomy and had smaller stent diameter (all p ≤ 0.003), suggesting smaller areas of ischemic myocardium. There were no significant differences in 30-day MACE (no-PN 5.6% vs PN 6.5%, p = 0.36) or long-term National Death Index linked mortality (no-PN 6.2% vs PN 7.9%, p = 0.09). Lack of PN did not independently predict long-term mortality.
Conclusion:
Despite comparably excellent outcomes overall, those without PN had longer ischemic times and were less likely to meet DTBT targets, especially after hours. Ischemic times may be a better evaluation of PN networks than hard clinical outcomes, and efficient systems of care tailored to the individual health service are essential to ensure timely reperfusion of patients with STEMI.
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