Inpatient-Onset Versus Outpatient-Onset ST-Segment-Elevation Myocardial Infarction in Patients With Percutaneous
Hon Jen Wong1, Chen Ee Low1, Chun En Yau1
1Department of Medicine Yong Loo Lin School of Medicine, National University of Singapore Singapore.
Insights
Patients with inpatient-onset ST-elevation myocardial infarction (STEMI) face higher long-term mortality risks than those with outpatient-onset STEMI. This occurs despite faster treatment times, highlighting the need for better inpatient care strategies.
Area of Science:
- Cardiology
- Public Health
Background:
- Inpatient-onset ST-elevation myocardial infarction (STEMI) may paradoxically have worse outcomes than outpatient-onset STEMI.
- This poorer prognosis in hospitalized patients might stem from underlying conditions despite immediate healthcare access.
Purpose of the Study:
- To compare the prognosis and treatment times of inpatient-onset STEMI versus outpatient-onset STEMI.
- To identify factors associated with delayed percutaneous coronary intervention (PCI) in inpatient-onset STEMI cases.
Main Methods:
- Analysis of the Singapore Myocardial Infarction Registry (2007-2020) for first-onset STEMI patients undergoing PCI.
- Measurement of recognition-to-balloon time for both inpatient and outpatient STEMI.
- Logistic and Cox regression analyses to determine predictors of delayed PCI and mortality.
Main Results:
- Inpatient-onset STEMI patients were older, had more comorbidities, and experienced delays in PCI.
- Independent predictors for delayed PCI included age ≥65, diabetes, and breathlessness.
- Inpatient-onset STEMI was associated with significantly higher 1-, 5-, and 10-year all-cause mortality.
Conclusions:
- Inpatient-onset STEMI is linked to increased long-term all-cause mortality compared to outpatient-onset STEMI.
- Despite shorter recognition-to-balloon times, inpatient-onset STEMI patients have a worse long-term survival outlook.
Background:
Compared with patients who develop ST-segment-elevation myocardial infarction (STEMI) outside the hospital and present at the emergency department (outpatient-onset), patients with inpatient-onset STEMI may paradoxically experience a poorer prognosis due to underlying disease, despite the apparent immediate access to acute health care services.
Methods:
Patients with first-onset STEMI who underwent percutaneous coronary intervention (PCI) in the Singapore Myocardial Infarction Registry (2007-2020) were included. For patients with inpatient-onset STEMI, the recognition-to-balloon time was measured from symptom onset to PCI. For outpatient-onset STEMI, the recognition-to-balloon time was defined as the sum of the symptom-to-door and door-to-balloon time. Logistic regression was used to identify factors associated with delayed PCI after inpatient-onset STEMI. Cox regression was used to assess 30-day, 1-year, 5-year, and 10-year all-cause and cardiovascular mortality.
Results:
A total of 19 149 patients, 17 659 (92.2%) outpatient-onset and 1595 (7.8%) inpatient-onset, were included. The median follow-up duration was 6.91 years. Patients with inpatient-onset STEMI were older, more frequently women, nonsmokers, more likely to have comorbidities, less likely to present with typical STEMI symptoms, and more likely to experience delays in PCI than patients with outpatient-onset STEMI within the hospital setting. The independent predictors of delayed PCI for inpatient-onset STEMI were age ≥65 years, diabetes, breathlessness at presentation, and Killip class III. After adjustment for differences in baseline and clinical characteristics, inpatient-onset STEMI was associated with significantly greater 1-year, 5-year, and 10-year all-cause mortality (1-year hazard ratio [HR], 1.27 [95% CI, 1.13-1.43]; 5-year HR, 1.27 [95% CI, 1.13-1.43]). There was no difference in 30-day all-cause or short-/long-term cardiovascular mortality.
Conclusions:
Inpatient-onset STEMI was linked to an increased long-term risk of all-cause mortality compared with outpatient-onset STEMI despite a shorter recognition-to-balloon time.
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