Background:
Late presentation after ST-elevation myocardial infarction (STEMI) is associated with poor outcomes. However, contemporary data regarding management and outcomes of such patients are lacking.
Methods:
Using data from the ACTION Registry-GWTG, we identified 170,247 patients who presented with STEMI to 688 US sites, between 7/08 and 12/13. Patients were stratified according to time from symptom onset to presentation as timely presenters (<12 hours) and late presenters (≥12 hours). Baseline characteristics, management and in-hospital outcomes were compared between the groups. Among late presenters, temporal trends in reperfusion strategy were also examined.
Results:
A total of 9389 patients (5.5%) had late presentation and 160,858 (94.5%) had timely presentation. Late presenters were more frequently elderly, female and of non-White ethnicity (Table). Late presenters were less likely to have prior MI or prior revascularization, but more likely to have diabetes. Compared with timely presenters, late presenters had worse in-hospital outcomes including mortality (6.3% vs. 5.2%; p<0.0001). Over the 6-year study period, the proportion of late presenters decreased slightly (5.8 vs. 5.4% respectively; p=0.03), while the proportion of late presenters undergoing primary PCI increased from 65% to 71% (p<0.001). Over the same time-period, among late presenters, median time from symptom onset to presentation increased slightly, door to balloon time decreased, and in-hospital mortality remained unchanged (6.0% vs. 6.0%).
Conclusions:
In contemporary practice, a modest proportion of STEMI patients continue to present >12 hours after symptom onset. Despite increased use of primary PCI and reduction in door-to-balloon times, the unadjusted mortality remains high among late presenters. Continued efforts to educate the public in order to reduce the proportion of late presenters remains warranted.