Study: STEMI network outcomes comparable to PCI-capable hospitals
“The current guidelines for the management of STEMI recommend primary PCI (pPCI) as the preferred treatment strategy if it can be conducted in a timely fashion by an experienced catheterization team,” wrote Marc J. Claeys, MD, of the University Hospital Antwerp in Edegem, Belgium, and colleagues. “However, because of logistical restraints, PCI can only be offered in less than 50 percent of European and U.S. hospitals.”
Due to these constraints, policy has focused on extending PCI access to patients who present at community-based hospitals that may not have these types of interventional capabilities.
To better understand the interworking of STEMI networks and their outcomes in a real-world setting, Claeys et al evaluated reperfusion strategies and in-hospital mortality in 8,500 STEMI patients who presented at 47 community-based hospitals and 25 PCI-capable hospitals. The patients were part of a nationwide STEMI network program initiated in Belgium in 2007.
The distance between hospitals included in the study ranged from 2.2 to 47 km (median 15 km). The researchers used a propensity score to adjust for the differences in baseline characteristics. While patients presenting to community-based hospitals were more likely to be older, be female and have longer total ischemic time delays, they also were more likely to be hemodynamically stable compared with patients admitted to PCI-capable hospitals.
Treatment strategies differed significantly between the two groups. For PCI-capable hospitals, primary PCI was used in the majority of cases (93.3 percent). Community-based hospitals used both transfer for primary PCI (70.7 percent) and thrombolytic therapy (20 percent). Fibrinolysis was given to patients prior to arriving at the hospitals in 16.6 percent of cases.
The authors reported that more community-based hospitals utilized more conservative therapy strategies compared with PCI-capable hospitals, 9.4 percent vs. 3.7 percent, respectively. This was mostly related to a late hospital presentation or severe comorbidities, 78 percent and 14 percent, respectively. Patients who presented to community-based hospitals had lower TIMI risk scores compared to those who presented at PCI-capable hospitals.
Claeys et al also reported door-to-balloon (D2B) times to be comparable between the two hospitals subsets; however, longer D2B times at community hospitals were related to longer transfer times. D2B times of less than 120 minutes were reported at 83 percent of community-based hospitals and 91 percent of PCI-capable hospitals.
In-hospitals mortality rates were reported to be 6.8 percent for the total patient population. These rates were 7 percent in community hospitals vs. 6.7 percent at PCI-capable hospitals. While outcomes were similar, researchers noted that mortality rates were higher for thrombolysed patients who were admitted to PCI hospitals.
The researchers wrote that older age, Killip Class greater than 1, low blood pressure, high heart rate, cardiac arrest and a history of peripheral disease, among other factors, were independent risk factors for in-hospital death.
Between 2007 and 2008, and 2009 and 2010, there was a shift toward the use of more primary PCI, especially in community-based hospitals. Primary PCI increased from a rate of 60 percent to 80 percent at the cost of less thrombolysis and less conservative treatment strategies.
Researchers called the present study “reassuring” due to the narrowed outcomes gap shown between community hospitals and PCI-capable hospitals.
“The findings of the present study may help policy makers identify the optimal number of PCI centres needed to provide high quality care to a region’s inhabitants,” the authors wrote. “Our data do not support a further increase in the number of PCI centers in urban regions in Belgium, as PCI centers with a reasonable PCI-related time delay are already widely available in these regions.
“Our data may foster the debate on whether treatment of STEMI patients should be restricted only to PCI-capable centers, thereby bypassing community hospitals through direct pre-hospital triage and transfer protocols to the nearest PCI capable hospitals,” according to the authors.
The authors summed that data point to the fact that STEMI networks should be implemented in areas with limited access to PCI-capable hospitals.