Reperfusion times and outcomes in patients with ST-elevation myocardial infarction presenting without pre-hospital notification

• Published in: Cardiovascular revascularization medicine 2022-08, Vol.41, p.136-141
• Main Authors: Hamilton, Garry W., Yeoh, Julian, Dinh, Diem, Brennan, Angela, Yudi, Matias B., Freeman, Melanie, Horrigan, Mark, Martin, Lorelle, Reid, Christopher M., Yip, Thomas, Picardo, Sandra, Sharma, Anand, Duffy, Stephen J., Farouque, Omar, Clark, David J., Ajani, Andrew E.
• Format: Article
• Language: English
• Subjects: Door-to-balloon time; Ischemic time; Outcomes; Pre-hospital notification; STEMI
• ISSN: 1553-8389; 1878-0938
• DOI: 10.1016/j.carrev.2022.01.024

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. 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. 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. 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. •Patients without pre-hospital notification (PN) were found to make up more then half of those presenting with STEMI.•A lack of PN was associated with longer ischemic times, especially after hours, however this did not translate to inferior clinical outcomes compared to those with PN.•Ischemic times may be a better metric then hard clinical outcomes when evaluating PN networks, and streamlined systems of care for all patients presenting with STEMI are vital.