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Canadian Journal of Cardiology

Outcomes of Patients With ST-Elevation Myocardial Infarction Receiving and Not Receiving Reperfusion Therapy: The Importance of Examining All Patients

Published:March 03, 2016DOI:https://doi.org/10.1016/j.cjca.2016.02.073

      Abstract

      Background

      Hospitals treating patients with ST-elevation myocardial infarction (STEMI) may show good results with reperfusion treatment (fibrinolysis or primary percutaneous coronary intervention [PPCI]), but a comprehensive evaluation should factor in outcomes of patients with STEMI who do not receive reperfusion. We compared outcomes of patients receiving and not receiving reperfusion within a complete system of STEMI care by hospital type: PPCI centres, fibrinolysis centres, centres that only transfer for PPCI, and centres providing a mix of fibrinolysis and PPCI transfer.

      Methods

      All patients presenting to 82 Quebec hospitals with characteristic symptoms, a final diagnosis of acute myocardial infarction, and core-laboratory confirmed STEMI over two 6-month periods were studied.

      Results

      Of the total 3731 patients with STEMI, 2918 (78.2%) received reperfusion treatment (81% PPCI, 19% fibrinolysis); 813 (21.8%) did not. For reperfusion-treated patients, 30-day mortality was 5.4% in PPCI centres, 5.4% in fibrinolysis centres, 6.9% in transfer PPCI centres, and 6.0% in mixed centres (P = 0.55). For untreated patients, 30-day mortality was 15.7% (PPCI centres), 16.1% (fibrinolysis centres), 21.8% (transfer PPCI), and 24.6% (mixed) (P = 0.08). Adjusted mortality odds ratios for all patients were 1.00 (PPCI centres), 1.50 (95% CI: 0.97-2.32; fibrinolysis centres), 1.30 (0.95-1.78; transfer PPCI centres), and 1.58 (1.09-2.29; mixed centres). PPCI was within recommended delays in 35.4%, 11.9%, and 1.2% of PPCI, transfer, and mixed centres, respectively.

      Conclusions

      Mixed centres had the highest crude and adjusted all-patient 30-day STEMI mortality. Relatively good outcomes of reperfusion-treated patients, despite long treatment delays, can misrepresent overall performance if untreated patients are not examined.

      Résumé

      Introduction

      Les hôpitaux qui traitent les patients atteints d’un infarctus du myocarde (IM) avec sus-décalage du segment ST montrent de bons résultats avec le traitement par reperfusion (fibrinolyse ou intervention coronarienne percutanée primaire [ICPP]), mais une évaluation exhaustive devrait prendre en compte les résultats cliniques des patients atteints d’un IM avec sus-décalage du segment ST qui ne reçoivent pas la reperfusion. Nous avons comparé les résultats cliniques des patients qui reçoivent ou non la reperfusion dans un programme complet de soins de l’IM avec sus-décalage du segment ST par type d’hôpitaux : les centres d’ICPP, les centres de fibrinolyse, les centres qui transfèrent seulement pour les ICPP, et les centres mixtes qui proposent la fibrinolyse et le transfert pour ICPP.

      Méthodes

      Nous avons étudié tous les patients admis dans les 82 hôpitaux du Québec qui présentaient des symptômes caractéristiques, un diagnostic final d’infarctus aigu du myocarde et d’IM avec sus-décalage du segment ST confirmé par un laboratoire central au cours de 2 périodes de 6 mois.

      Résultats

      Parmi les 3731 patients atteints d’un IM avec sus-décalage du segment ST, 2918 (78,2 %) ont reçu un traitement de reperfusion (81 % l’ICPP, 19 % la fibrinolyse); 813 (21,8 %) n’en ont pas reçu. Pour les patients traités par reperfusion, la mortalité à 30 jours était de 5,4 % dans les centres d’ICPP, de 5,4 % dans les centres de fibrinolyse, de 6,9 % dans les centres de transfert pour l’ICPP et de 6,0 % dans les centres mixtes (P = 0,55). Pour les patients non traités, la mortalité à 30 jours était de 15,7 % dans les centres d’ICPP, de 16,1 % dans les centres de fibrinolyse, de 21,8 % dans les centres de transfert pour l’ICPP et de 24,6 % dans les centres mixtes (P = 0,08). Les rapports de cotes de mortalité ajustés de tous les patients étaient de 1,00 (centres d’ICPP), de 1,50 (IC à 95 % : 0,97-2,32; centres de fibrinolyse), de 1,30 (0,95-1,78; centres de transfert pour l’ICPP) et de 1,58 (1,09-2,29; centres mixtes). L’ICPP était réalisée dans les délais recommandés dans les centres d’ICPP, de transfert et mixtes à 35,4 %, 11,9 % et 1,2 % respectivement.

      Conclusions

      Les centres mixtes avaient les taux bruts et ajustés de mortalité à 30 jours de tous les patients atteints d’IM avec sus-décalage du segment ST les plus élevés. En dépit des longs délais de traitement, les résultats cliniques relativement bons des patients traités par reperfusion peuvent faussement représenter la performance globale si les patients non traités ne sont pas examinés.
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