Late Outcomes of Patients With Prehospital ST-Segment Elevation and Appropriate Cardiac Catheterization Laboratory
Amir Faour1,2, Reece Pahn2, Callum Cherrett1
1Department of Cardiology, Liverpool Hospital Sydney New South Wales.
Insights
Patients with nonactivated cardiac catheterization labs (CCL-NA) after suspected ST-segment-elevation myocardial infarction (STEMI) had higher death risks, mainly from noncardiovascular causes. This was due to misdiagnoses like non-STEMI and myocardial injury, not missed STEMI.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Research
Background:
- Patients with suspected ST-segment-elevation myocardial infarction (STEMI) experiencing cardiac catheterization laboratory nonactivation (CCL-NA) have higher mortality risks.
- The underlying reasons for increased mortality in CCL-NA patients compared to those with CCL activation remain unclear.
- Understanding outcomes in STEMI patients with CCL-NA is crucial for improving care pathways.
Purpose of the Study:
- To determine the late clinical outcomes of patients with prehospital ECG criteria for STEMI who underwent CCL-NA versus CCL activation.
- To investigate the diagnostic profiles and causes of death in patients with CCL-NA.
- To compare the risks of all-cause death, cardiovascular death/MI/stroke, and noncardiovascular death between the two groups.
Main Methods:
- Retrospective analysis of 1033 consecutive prehospital ECG transmissions between June 2010 and October 2016.
- Adjudication of diagnoses based on the Fourth Universal Definition of Myocardial Infarction (MI), including myocardial injury.
- Comparison of primary outcome (all-cause death) and secondary outcomes (cardiovascular death/MI/stroke, noncardiovascular death) using cause-specific hazard ratios.
Main Results:
- Of 1033 patients, 55% had CCL activation and 45% had CCL-NA.
- In CCL-NA patients, only 37% had MI (61% non-STEMI, 39% STEMI), with significant rates of acute (10%) and chronic (23%) myocardial injury.
- At 2 years, CCL-NA was associated with higher all-cause death risk (23% vs 7.9%), driven by noncardiovascular deaths (adjusted HR 3.56), with no significant difference in cardiovascular death/MI/stroke risk.
Conclusions:
- CCL-NA in suspected STEMI patients is often due to conditions other than missed STEMI, including non-STEMI and myocardial injury.
- Patients experiencing CCL-NA face significantly worse late clinical outcomes, primarily due to increased noncardiovascular mortality.
- These findings highlight the need for careful diagnostic evaluation in patients with nonactivated cardiac catheterization labs.
Abstract:
Background Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.
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