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Published on: September 3, 2020
Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without
Andrew Kochan1, Terry Lee2, Nima Moghaddam3
1Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada.
Insights
Delays in reperfusion therapy for ST-elevation myocardial infarction (STEMI) with cardiogenic shock (CS) significantly increase mortality. Reducing first medical contact-to-device time is crucial for improving outcomes in these high-risk patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Research
Background:
- High mortality persists in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock (CS).
- Early reperfusion therapy is vital for improving outcomes in STEMI patients.
- The association between reperfusion time and adverse events in STEMI with and without CS requires further investigation.
Purpose of the Study:
- To analyze the relationship between first medical contact (FMC)-to-percutaneous coronary angiography (device) time and mortality.
- To evaluate the association between FMC-to-device time and major adverse cardiovascular events (MACE) in STEMI patients with and without CS.
- To identify the impact of reperfusion delays on outcomes in STEMI patients complicated by CS.
Main Methods:
- Retrospective analysis of the Vancouver Coastal Health Authority STEMI registry (2010-2020).
- Inclusion of STEMI patients undergoing primary percutaneous coronary angiography, stratified by presence or absence of CS.
- Mixed effects logistic regression with restricted cubic splines to model FMC-to-device time and outcomes.
Main Results:
- 9.4% of 2929 STEMI patients presented with CS.
- Patients with CS experienced longer median FMC-to-device times (113.5 min) compared to those without CS (103.0 min).
- For each 10-minute delay in FMC-to-device time (60-90 min), mortality increased by 4-7% in CS patients versus <0.5% in non-CS patients.
Conclusions:
- Reperfusion delays are significantly associated with worse outcomes in STEMI patients with CS undergoing primary PCI.
- Urgent strategies are needed to shorten FMC-to-device times for STEMI patients presenting with CS.
- Reducing reperfusion times is critical for mitigating mortality and MACE in this vulnerable population.
Background:
Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS.
Methods:
We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups.
Results:
2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%.
Conclusions:
Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.
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