Abstract 1758: Impact of Clinical Risk and Prehospital Delay on 1 Year Outcome in STEMI Patients Treated with Reperfusion Therapy in a Context of Interhospital Network
Prehospital delay and clinical risk are major predictors of outcome in STEMI patients treated with primary angioplasty (pPCI) or thrombolytic therapy (TT). The impact of prehospital delay-risk interaction to the effectiveness of pPCI in decreasing 1 year death/MI compared to TT is little known. We analyzed the data of all consecutive STEMI prospectically recordered over a 6-month period (Dec/2002–May/2003) in the VENEto acute myocardial infarction Registry (VENERE). The registry was developed and shared by the cardiology department in the Veneto region to assess the outcome of patients with STEMI as function of the therapeutic strategy applied. Data were managed according to the intention to treat principle. 999 STEMI patients with symptom onset < 12 hours were admitted to 28 participating hospitals: 860 were treated on site and 139 were transferred from the admitting hospital to and interventional center for pPCI. Overall, 81% of patients were treated with reperfusion therapy: 512 (median age 65 years, interquartile range [IQR] 54, 74 years) were treated with pPCI, 302 (median age 64 years, IQR 54, 75) with TT. The median TIMI risk index (heart rate x [age/10]2/systolic blood pressure) was 25 in both pPCI and TT groups. High risk patients (TIMI risk index ≥ 30) were 28% in pPCI gruop and 25% in TT group. Prehospital delay (symptom onset to hospital admission) was 90 (IQR 55, 180) in TT group and 97 (IQR 54, 185) in TT group (p 0.2). Median time from admission to needle was 31 (19, 57); median time from admission to balloon was 71 (45, 112) (p = 0.001). The covariate-adjusted odds ratio (OR) for the 1 year death/MI after TT relative to pPCI was: 2.25 (95% CI 1.12–2.78) for high risk patients; 1.49 (95% CI 0.8–2.78) for low risk patients; 2.18 (95% CI 1.18 – 4.04) for patients with prehospital delay < 121 minutes, 1.28 (95% CI 0.6 –2.5) for those with delay ≥ 121 minutes. The adjusted more favourable interaction between risk-delay and the effectiveness of pPCI in decreasing 1-year death/MI compared to TT was observed in STEMI patients at high risk, with prehospital delay < 121 minutes (OR 0.25; 95% CI 0.1– 0.7). In the VENERE registry, a strategy of pPCI seems to be particularly effective in reducing 1-year death/MI compared to TT in high risk patients with prehospital delay less than 2 hours.