24 The impact of a PPCI programme on time to treatment and on outcomes following STEMI. A rural based population study. (16th October 2019)

• Record Type: Journal Article
• Authors: Cronin, M; Murphy, R; Teehan, S; Shiels, P; Fleming, S
• Is Part Of: Heart. Volume 105(2019)Supplement 7
• Page Start: A20
• Page End: A20
• Publication Date: 2019-10-16
• Subjects: Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2019-ICS.24
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Background: In 2013, PPCI was implemented as the reperfusion strategy for STEMI in Ireland. A PPCI strategy may result in increased delays to treatment, which may negate the anticipated benefit of PPCI over fibrinolysis provided in a local hospital. We wished to explore the real world effect of a PPCI strategy on clinical outcomes for a cohort of rural based patients distant from their designated PPCI centre (at a projected 60–90 min transfer time). Methods: We conducted this retrospective cohort study at 2 rural hospitals and at a PPCI centre. We identified 2 cohorts of patients with STEMI. The first comprised all patients presenting to the rural hospitals between 01/01/2011 to 31/12/2012 with STEMI (Pre-PPCI cohort). The second comprised all patients from the catchment area of these hospitals presenting with STEMI to the PPCI centre between 01/01/2015 to 31/12/2016 (PPCI cohort). For each cohort we compared baseline characteristics, timeliness of initiation of reperfusion therapy, in hospital mortality, and for patients who survived to discharge the prevalence of LV dysfunction at 180 days. We tested for significance using chi square test. Results: We identified 127 STEMI patients (97 M/30F), median age 60.6 (Range 31–94). A door to needle time of less than 30 minutes was achieved in the Pre-PPCI cohort in 68% of eligible patients (n=73) (median 21 mins (IQR 13–31 mins)) and a reperfusion time <120 minutes in the PPCI cohort in 44% (n=54) (median 139 mins (IQR 114–165 mins)). These results can be seen in figure 1 . Application of OMT was similar in both cohorts. In-hospital mortality was 2.7% (2/73) in the Pre-PPCI and 3.7% (2/54) in the PPCI cohort P=NS. There was a non-significant trend towards better LV function among survivors at 6 months. For the Pre-PPCI cohort survivors (n=71), 56% had normal LVEF, 24% LVEF 41–49%, 10% LVEF 31- 40%, and 10% LVEF ≤ 30%. Whereas, for the PPCI cohort (n=52) 64% had normal LVEF, 26% LVEF 41–49%, 8% LVEF 31–40%, and 2% LVEF ≤ 30% (p=0.2). These results can be seen in Image 1 . Considering the PPCI cohort in isolation, 35% (19) patients were transferred direct from the field to the PPCI hospital, the remainder 65% (35) by interhospital transfer. The observed reperfusion time for directly transferred patients was shorter (Median 123 mins (IQR 94–149) vs 145 mins (IQR 120–180)), survival to discharge was better (100% vs 94% p=NS), and the proportion of patients with normal LV function at 180 days was higher (74% vs 51% p=0.1). These results can be seen in figure 2 . Conclusions: Projected patient transfer times utilised by healthcare planners may underestimate the challenges faced in delivering optimal reperfusion times for rural patients in clinical practice. We found delays to PPCI were commonplace, and overall we did not demonstrate a superiority for PPCI over fibrinolysis in this setting. In light of the trend towards better outcomes for patients directly transferred from the community to the PPCI hospital, a comprehensive strategy of direct transfer needs to be rigorously pursued.