Rural EMS STEMI Patients – Why the Delay to PCI?

Abstract

Background

The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI).

Methods

We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency.

Results

Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7–19) in the group that received PCI within the time goal compared to 21 min (IQR 10–37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11–4.10) compared to the female sex.

Conclusion

Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.

Acknowledgments

The authors would like to thank David Herrington MD, Doug Easterling PhD, Ralph D’Agostino, E. Brooke Lerner PhD, Scott Rhodes PhD, Kathryn Weaver, PhD, David Miller MD, Brennan E. Paradee MS, Claudia Olivier PhD, Indra Newman PhD, and Tom Roth for their assistance with this project.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Dr. Stopyra receives research funding from HRSA (H2ARH39976-01-00), AHRQ (R01HS029017), AHRQ (1R21HS029234-01A1), The Duke Endowment, Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Ashburn receives funding from AHRQ (R01HS029017). Dr. Snavely receives funding from Abbott Laboratories, AHRQ (R01HS029017), and HRSA (1H2ARH399760100). Dr. Supples receives funding from the NIH (UL1TR001420), HRSA (1H2ARH399760100), and the National Foundation of Emergency Medicine. Dr. Miller receives research funding from Siemens, Abbott Point of Care, Creavo Medical Technologies, Grifols, and NHLBI (5U01HL123027). He has a US Patent on cardiac biomarkers for coronary artery disease related to cholesterol esters. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Ortho, Siemens, Grifols, Pathfast, Genetesis, Cytovale, Beckman Coulter, AHRQ (R01HS029017), AHRQ (1R21HS029234-01A1), The Duke Endowment, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Siemens, Genetesis, Inflammatix, Radiometer, and Amgen and the Chief Medical Officer for Impathiq Inc. Research reported in this publication was supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number KL2TR001421. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.