Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Presenting With Cardiogenic Shock

Abstract

Objectives: This study sought to examine whether quality improvement initiatives across multiple ST-segment elevation myocardial infarction (STEMI) systems translated to faster first medical contact (FMC)-to-device times for patients presenting with cardiogenic shock (CS).

Background: There are limited data describing contemporary rates of achieving guideline-directed FMC-to-device times for STEMI patients with CS.

Methods: From 2012 to 2014, the American Heart Association Mission: Lifeline STEMI Systems Accelerator project established a protocol-guided approach to STEMI reperfusion systems in 484 U.S. hospitals. The study was stratified by CS versus no CS at presentation and performed Cochrane-Armitage tests to evaluate trends of achieving FMC-to-device time targets. A multivariable logistic regression model assessed the association between achieving guideline-directed FMC-to-device times and mortality.

Results: Among 23,785 STEMI patients, 1,993 (8.4%) experienced CS at presentation. For direct presenters, patients with CS were less likely to achieve the 90-min FMC-to-device time compared with no-CS patients (37% vs. 54%; p < 0.001). For transferred patients, CS patients were even less likely to reach the 120-min FMC-to-device time compared with no-CS patients (34% vs. 47%; p < 0.0001). The Accelerator intervention did not result in improvements in the FMC-to-device times for direct-presenting CS patients (p for trend = 0.53), although there was an improvement for transferred patients (p for trend = 0.04). Direct-presenting patients arriving within 90 min had lower mortality rates compared with patients who reached after 90 min (20.49% vs. 39.12%; p < 0.001).

Conclusions: Fewer than 40% of STEMI patients presenting with CS achieved guideline-directed FMC-to-device targets; delays in reperfusion for direct-presenting patients were associated with higher mortality.

Keywords: STEMI; cardiac arrest; cardiogenic shock; first-medical-contact to device; mortality; regional systems of care; treatment delays.