Abstract 18419: Evolution of a Regional STEMI Reperfusion Model: More and Earlier Reperfusion but No Improvement in Clinical Outcomes
Introduction: Guidelines strongly recommend that regional systems of STEMI care include the assessment and continuous quality improvement of emergency medical services and hospital-based activities.
Hypothesis: Within a mixed reperfusion model of STEMI care, the introduction of individual care components will improve reperfusion times and clinical outcomes.
Methods: All patients with confirmed STEMI presenting within the Vancouver Coastal Health Authority from June 2007 to September 2013 were included (n = 2041). Primary analysis was performed by care component phase: Phase 1, regionalization of the STEMI program (n = 278, June 2007 to May 2008); Phase 2, introduction of pre-hospital ECGs (n = 979, May 2008 to May 2011); and Phase 3, implementation of an inter-facility transfer protocol for primary PCI (pPCI) (n = 784, May 2011 to September 2013). Secondary analysis compared PCI capable vs. PCI non-capable hospitals.
Results: Clinical characteristics were similar across phases. Median first medical contact-to-device times for pPCI decreased over the three phases, whether at a PCI capable hospital (116 min, 92 min, 95 min; p<0.001) or PCI non-capable hospital (174 min, 146 min, 123 min; p<0.001). The proportion of STEMI patients receiving successful pPCI increased over the three phases (44.2%, 63.8%, 74.5%; p<0.001). However, overall in-hospital mortality was unchanged (9.4%, 8.8%, 10.6%; p=0.44) and rates of in-hospital CHF (15.8%, 19.7%, 23.9%; p=0.008) and major bleeding (9.0%, 16.0%, 14.8%; p=0.014) increased over the three phases. When stratified by presenting hospital, a trend of increased in-hospital mortality was observed at PCI capable hospitals (8.9%, 9.3%, 13.4%; p=0.069), while the opposite was observed at PCI non-capable hospitals (9.9%, 7.9%, 5.5%; p=0.234).
Conclusions: Within a geographically defined STEMI cohort, a phased rollout of regional pPCI reduced reperfusion times and increased pPCI uptake over a 6-year period. However, no reduction in either overall in-hospital mortality or complications was observed over the three phases, with a trend towards increased mortality at PCI capable sites. Further understanding and optimization of those variables beyond receiving timely PCI will be critical to improve STEMI outcomes.
- Myocardial infarction, STEMI
- Systems of care
- Quality improvement
- Percutaneous coronary intervention (PCI)
Author Disclosures: C.B. Fordyce: None. K. Ramanathan: None. J.E. Park: None. R.A. Vandegriend: None. J.A. Cairns: None. M. Perry: None. M. Gao: None. G.C. Wong: None.
- © 2014 by American Heart Association, Inc.