First medical contact place determines prognosis in a regional STEMI network. Is time the most important factor?

Funding Acknowledgements Type of funding sources: None. OnBehalf Codi IAM investigators Background Long revascularization times have been associated with worse prognosis in PCI-treated STEMI patients. Thus, efforts have been focused in optimizing revascularization times. In Catalonia, the different first medical contact (FMC) points with the regional STEMI network CODI IAM have been associated with different degrees of delay in reperfusion. Purpose we aim to determine if our regional STEMI network achieves better mortality rates in the fastest circuits than in slower ones by optimizing revascularization times. Methods since CODI IAM network was launched in June 2009, a prospective registry of all attended cases is conducted. We included in the study all patients with final STEMI diagnosis treated with primary PCI from January 2010 to December 2016. Patients were divided in 4 different groups regarding FMC point: primary care center (PCC), community hospital (CH), PCI-hospital (PCI-H), emergency medical services (EMS)). Clinical data, reperfusion times and 30-day and 1-year mortality were analyzed. Results a total of 14,483 patients (PCC 19%, CH 35,7%, PCI-H 12,5%; EMS 32,7%) were included in the analysis. Women proportion was higher in hospital-attended cases (p < 0,001), and so was diabetes (p < 0,001). Previous history of MI, PCI and CABG were more frequent in both EMS and PCI-H groups (p < 0,001). Killip-Kimball Classes III-IV were more frequent in PCI-H and EMS groups (EMS 12,5%, PCI-H 10,4%, CH 7%, PCC 4,6%; p < 0,001). All complications (intubation, ventricular fibrillation, ventricular tachycardia, atrial fibrillation, AV block) in first medical assistance were more frequent in EMS group (p < 0,001). Median time from ECG to reperfusion was shorter in the PCI-H group (74 min (IQR 56-110), p < 0,001) but the shortest median ischaemic time was achieved by EMS group (155 min (IQR 120-215), p < 0,001). Global 30-day and 1-year mortality were 5,8% and 9,4% respectively, significantly higher in PCI-H and EMS groups than in CH and PCC groups (30-day m. CH 4,9%, PCC 3,3%, PCI-H 7%, EMS 7,8%), p < 0,001). After Cox regression adjusted analysis including sex, age, diabetes, anterior STEMI, Killip-Kimball Class and primary VF, 30-day and 1-year mortality remained higher in PCI-H and EMS groups compared to CH group, both without adjusting by time (HR 1,31 (1,01-1,69), p = 0,04 for PCI-H 30-day mortality; HR 1,25 (1,03-1,51), p = 0,025 for EMS 30-day mortality), and after adjusting by time ECG-reperfusion >120 min (HR 1,56 (1,20-2,03), p = 0,001 for PCI-H 30-day mortality and HR 1,48 (1,21-1,82), p < 0,001 for EMS 30-day mortality). Conclusions considering that reperfusion time intervals favour EMS and PCI-H groups, crude between-groups mortality differences might be justified by a selection bias rather than by the pathway itself. Despite this probable selection bias, the STEMI network achieves a reduction of these differences by shortening reperfusion times in EMS and PCI-H groups. Abstract Figure. 1-year mortality curves

Distance-related Differences in Critical Times, Protocol Activation and Mortality in a Regional STEMI Network

Introduction: The aim of the study was to assess the differences in critical network times and mortality in STEMI patients presenting to hospitals in the same STEMI network, but located at different distances from the pPCI center. Methods: Four-hundreed sixteen patients with STEMI were studied. Group 1: 101 patients presenting to any of the six regional hospitals in the network located at less than 70 km from the pPCI center, with a maximum transport time of 30 minutes. Group 2: 81 patients presenting to any of the three territorial hospitals in the network located at 70–150 km from the pPCI center, with a transport time between 30 and 70 minutes. Group 3: 93 patients presenting to any of the four territorial hospitals in the network located at 150–250 km from the pPCI center, with a transport time between 70 and 150 minutes. Group 4: 141 patients presenting directly to the emergency room of the pPCI center. The following time intervals were recorded: presentation time (PT), from the onset of symptoms to arrival at the pPCI center; protocol initiation time (PIT), from arrival at the pPCI center to STEMI protocol initiation; ischemic time (IT), from the onset of symptoms to repermeabilisation; door to balloon time (DTB), from arrival in the pPCI center to balloon. Results: PT showed no significant difference between the groups – 183.08 ± 25.2 minutes vs. 199.1 ± 32.4 minutes vs. 166.7 ± 42.5 minutes vs. 161.91 ± 36.8 minutes, respectively (p=0.4). PIT was significantly lower in Group 3 (61.66 ± 15.4 minutes in Group 3 vs. 92 ± 11.5 minutes in Group 2 vs. 107.4 ± 12.5 minutes in Group 1, p = 0.002). DTB time was significantly longer for patients presenting directly to the pPCI center compared to those arriving from Zone 1, 2 or 3 hospitals, 86.96 ± 11.6 minutes vs. 52.27 ± 11.2 minutes vs. 39.94 ± 10.3 minutes vs. 43.9 ± 5.3 minutes, p <0.001). Despite the differences in distance to the pPCI center, there was no significant difference in total IT between the groups (Group 1, 344.6 ± 53.4 minutes; Group 2, 369.3 ± 42.6 minutes; Group 3, 366.65 ± 36.4 minutes; and 340.2 ± 26.9 minutes in the pPCIcenter, p = 0.2), and this was reflected in similar rates of mortality (Group 1, 3.9%; Group 2, 3.7%; Group 3, 3.2%; and 3.5% in the pPCI center). Conclusion: A well organized STEMI network can shorten protocol initiation and DTB times, achieving similar ischemic times and resulting in similar mortality rates with the centers located closer to the pPCI center. Early activation of the STEMI protocol could lead to superior results even in areas situated at longer distances from the pPCI center.