Clinical Outcomes of Pharmaco-invasive ST-elevation Myocardial Infarction Management in a Large Australian Regional Centre

Abstract

Background: Primary percutaneous coronary intervention (PCI) is the standard of care for ST-elevation myocardial infarction (STEMI). In rural and remote centres with limited facilities, a pharmaco-invasive approach with thrombolysis followed by transfer of patients to PCI-capable centres remains important. Contemporary Australian data regarding pharmaco-invasive STEMI management are lacking. The primary objective of this study was to examine the clinical outcomes of pharmaco-invasive STEMI management in Bendigo, a large Australian regional centre. Methods: A retrospective analysis was performed for all patients presenting to Bendigo Health with an admission diagnosis of STEMI in the emergency department, between February 2013 and January 2014. During the study period, 68 consecutive patients received an admission diagnosis of STEMI in the emergency department. Of these, 58 patients were actually diagnosed with STEMI due to obstructive coronary artery disease, and received thrombolysis. These patients were divided into two groups: (1) Pharmaco-invasive local (Local) group: thrombolysis with subsequent coronary angiography locally in Bendigo; (2) Pharmaco-invasive transfer (Transfer) group: thrombolysis with immediate transfer for coronary angiography. Door-to-Needle time (DTN), Thrombolysis-to-Angiography time (TTA), transfer cost, and inpatient morbidity and mortality were collected. Results: DTN was more prolonged in the Local group (38 ± 35 minutes versus 25 ± 23 minutes, p=0.135). DTN < 30 minutes was achieved for 71% of patients in the Local group versus 77% in the Transfer group. DTN was significantly prolonged for patients who presented to a peripheral centre first (78 ± 35 minutes, p=0.013). More patients in the Transfer group had TTA ≤ 24 hours (82% vs 60%, p=0.286). Significantly more patients in the Transfer group were managed with PCI (79% vs 53%, p=0.014). In comparison, more patients in the Local group were managed with medical therapy, and surgery, respectively (28%, p<0.05; 20%, p<0.05). Rates of inpatient mortality and total mortality at follow up were higher in the Local group (12% and 20% vs 7% and 10%). The cost of transfer per patient was significantly higher in the Transfer group ($5094.10 vs $1960.90). Conclusion: Locally managed pharmaco-invasive STEMI management in Bendigo, Australia, was associated with a higher proportion of patients waiting > 24 hours for angiography, and a significantly higher proportion of patients being managed by surgery and medical therapy. In a contemporary regional Australian pharmaco-invasive STEMI cohort, significant opportunities existed to improve patient outcomes.