In-hospital STEMI may carry worse outcomes

Patients who develop STEMI in the hospital may fare considerably worse than patients who experience one outside the hospital and arrive via ambulance or get driven, a study published online Jan. 3 in Circulation found. Treatment time and length of stay (LOS) after an in-hospital STEMI are longer and mortality is higher, the authors found.

Ross F. Garberich, MS, and colleagues from the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital in Minneapolis, used a regional STEMI database to evaluate 3,795 consecutive patients between March 2003 and January 2013. They compared how patients arrived to the PCI-capable hospital (EMS, self/family driven, or in-hospital) for length of time to procedure, length of stay and outcomes. For patients who arrived from outside the hospital, they calculated door-to-balloon times. For in-hospital STEMI patients, they calculated diagnostic electrocardiogram (EKG)-to-balloon times. They defined LOS as date of STEMI onset to discharge.

Patients whose STEMI occurred in the hospital were older, had higher body mass indexes, were more likely to have high blood pressure and have a pre-PCI history of cardiac arrest and cardiogenic shock.

EKG-to-balloon times were higher among in-hospital STEMI patients compared with door-to-balloon times of patients who arrived via ambulance (76 minutes vs. 51 minutes), but were similar to arrival via self/family (76 minutes vs. 66 minutes). In-hospital STEMI patients also had longer LOS compared with the other two groups (five days vs. three days for the other groups). Mortality at one year was also higher in in-hospital patients compared with the others (16.9 percent vs. 10.3 percent for EMS arrivals vs. 7.1 percent for self/family arrivals).

In-hospital STEMI patients were also high risk on admission. Thirty percent had acute coronary syndrome, 24 percent were post-operative, 12 percent had respiratory failure and 8.4 percent were in ventricular fibrillation.

The authors noted that in-hospital STEMI protocols that utilize a rapid response team and adjuvant medications have led to better outcomes, and argued that their findings suggest such protocols should be in place for these patients.

“Our results suggest the implementation of a standardized protocol for patients who develop STEMI after admission to the hospital may improve recognition, decrease time to reperfusion and subsequently improve clinical outcomes including mortality,” wrote the authors.