Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis

Julia Stehli; Misha Dagan; Diem T Dinh; Jeffrey Lefkovits; Ron Dick; Stephanie Oxley; Angela L Brennan; Stephen J Duffy; Sarah Zaman

doi:10.1136/bmjopen-2021-052000

Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis

BMJ Open. 2022 Mar 7;12(3):e052000. doi: 10.1136/bmjopen-2021-052000.

Authors

Julia Stehli^{1

2}, Misha Dagan³, Diem T Dinh⁴, Jeffrey Lefkovits^{4

5}, Ron Dick², Stephanie Oxley², Angela L Brennan⁴, Stephen J Duffy⁶, Sarah Zaman^{7

8

9}

Affiliations

¹ Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.
² Epworth HealthCare, Richmond, Victoria, Australia.
³ Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia.
⁴ Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.
⁵ Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
⁶ Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.
⁷ School of Clinical Sciences at Monash Health, Monash University, Clayton, VIctoria, Australia sarah.zaman@sydney.edu.au.
⁸ Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.
⁹ Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia.

Abstract

Objectives: Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI.

Design, setting and participants: Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018).

Primary and secondary outcomes: Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding.

Results: Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001).

Conclusions: Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.

Keywords: coronary heart disease; coronary intervention; health & safety; ischaemic heart disease; myocardial infarction; quality in health care.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Female
Hospital Mortality
Hospitals
Humans
Percutaneous Coronary Intervention* / adverse effects
Registries
Risk Factors
ST Elevation Myocardial Infarction* / therapy
Time Factors
Treatment Outcome