Prehospital Delay Among Patients With NSTEMI

Quick Takes

  • A retrospective analysis from this large Korean cohort showed significantly higher in-hospital and 3-year mortality among patients with NSTEMI and delayed hospitalization (≥24 hours of symptoms) compared to patients presenting with <24 hours of symptoms.
  • This finding persisted regardless of baseline clinical risk.
  • Age >75 years, female sex, atypical chest pain, and absence of using EMS were predictors of prehospital delay in care.

Study Questions:

What is the association between prehospital delay and clinical outcomes among patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI)?

Methods:

Among 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry–National Institutes of Health, the authors evaluated 6,544 patients with NSTEMI. Study patients were categorized into two groups according to symptom-to-door (StD) time (<24 or ≥24 hours). The primary outcome was 3-year all-cause mortality, and the secondary outcome was 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure.

Results:

Overall, 1,827 (27.9%) patients were classified into the StD time ≥24 hours group. The StD time ≥24 hours group had higher all-cause mortality (17.0% vs. 10.5%; p < 0.001) and incidence of secondary outcomes (23.3% vs. 15.7%; p < 0.001) than the StD time <24 hours group. The higher all-cause mortality in the StD time ≥24 hours group was observed consistently in the subgroup analysis regarding age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services (EMS), hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score. In the multivariable analysis, independent predictors of prehospital delay were the elderly, women, nonspecific symptoms such as atypical chest pain or dyspnea, diabetes, and no use of EMS.

Conclusions:

Prehospital delay is associated with an increased risk of 3-year all-cause mortality in patients with NSTEMI.

Perspective:

Findings from this study lend support to the theory that time is muscle not only among patients with STEMI but also with NSTEMI presentations. A retrospective analysis from this large Korean cohort showed significantly higher in-hospital and 3-year mortality among patients with NSTEMI and delayed hospitalization (≥24 hours of symptoms) compared to patients with <24 hours of symptoms. This finding persisted regardless of baseline clinical risk. Age >75 years, women, patients with atypical chest pain, and those not using EMS services were more likely to have prehospital delay in care. The findings highlight the importance of addressing factors and vulnerable populations that are most affected by prehospital delay in care. The importance of these results is further elevated given the 40-60% decline in acute myocardial infarction presentations to the hospital during the current pandemic.

Keywords: Acute Coronary Syndrome, Catheters, Chest Pain, Diabetes Mellitus, Dyspnea, Electrocardiography, Emergency Medical Services, Geriatrics, Heart Failure, Hypertension, Myocardial Infarction, Non-ST Elevated Myocardial Infarction, Renal Insufficiency, Chronic, Risk Factors, Thrombolytic Therapy, Ventricular Dysfunction, Left


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