Treatment Delay and Mortality in STEMI With Shock

Study Questions:

What is the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without hemodynamic instability?

Methods:

The investigators used data from the prospective, multicenter FITT-STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial. They assessed the prognostic relevance of first medical contact-to-balloon time in n = 1,2675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). Logistic regression models were calculated to identify independent predictors of in-hospital mortality using either dichotomized or continuous data for contact-to-balloon time as the independent variable.

Results:

For patients treated within 60-180 minutes from the first medical contact, the authors found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-minute treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to hemodynamically stable patients (0.34, p < 0.0001).

Conclusions:

The authors concluded that in patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome.

Perspective:

This study reports that in STEMI patients, reduced contact-to-balloon time is associated with better survival, regardless of the adverse hemodynamic consequences of acute ischemia-induced systolic dysfunction and cardiac arrest. Furthermore, in CS and in OHCA patients, shorter times to reperfusion considerably improved the outcome, with surprisingly low mortality in OHCA patients in this study. These and other data suggest that efforts to shorten the time to PCI therapy should be applied to all STEMI patients, and patients with hemodynamic instability may particularly benefit most from improvements in STEMI treatment protocols.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, SCD/Ventricular Arrhythmias, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, Emergency Medical Services, Hemodynamics, Hospital Mortality, Out-of-Hospital Cardiac Arrest, Myocardial Infarction, Percutaneous Coronary Intervention, Shock, Cardiogenic, Treatment Outcome


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