Abstract 185: Outcome Differences Associated With STEMI Diagnostic Delay: Disparities on the Frontlines of STEMI Care

Abstract

Background: AHA/ACC/ESC practice guidelines advise an ECG within 10 minutes for all patients with symptoms suggestive of ST-segment elevation myocardial infarction (STEMI). This facilitates early diagnosis and timely treatment. Earlier treatment, particularly percutaneous coronary intervention (PCI), has been associated with better clinical outcomes. Our objective was to quantify the impact of delayed screening on timely treatment and determine if there may be race, sex or presenting complaint disparities. Methods: We examined the association between time-to-first ECG (door-to-screening, or D2S) and time-to-PCI in a 3-center 1-year retrospective cohort study including all emergency department (ED) patients with acute STEMI per hospital discharge diagnosis who underwent catheterization for PCI. The primary outcome was door-to-balloon time (D2B) and the ED-centric secondary outcome was door-to-cath-lab arrival time (D2CAR). Results: Of 161,920 patients seen in the 3 EDs, 137 (0.08%) were diagnosed with STEMI. Of the 137, 75 (55%) underwent emergent PCI, and 31 (41%) of the ED STEMI PCI patients did not receive an ECG within 10 minutes. These 31 patients were more commonly female (55% vs. 19%, p=0.001), non-white (87% vs. 65%, p =0.028), and reported chest pain or shortness of breath less frequently (55% vs. 94%, p<0.001). In patients with D2S greater than 10 minutes, median D2CAR was longer (159 vs. 50 minutes, p=0.004) as was median D2B time (207 vs. 93 minutes, p=0.048). Conclusion: A significant proportion of ED patients with STEMI did not receive an ECG within 10 minutes of arrival resulting in a 2.2 fold increase in D2B time. They were more likely to be female, non-white, and with atypical chief complaints. Normalizing screening criteria for presentation diversity could improve more equitable access to timely STEMI treatment

Shorter Door-to-ECG Time Is Associated with Improved Mortality in STEMI Patients

“…We used data included in the Emergency STEMI Care Registry (ESC) from 10 PCIcenter associated EDs [18][19][20][21]. The These facilities contributed patient data for all patients with STEMI seen from 1 January 2014-31 December 2016 to the ESC Registry, described below and in prior publications [18][19][20][21][22]. Our description here partly reproduces their wording.…”

“…Our analyses compared differences between those achieving timely diagnosis and those who did not. Timely diagnosis was defined as a D2E ≤ 10 min per international STEMI management guidelines, and untimely diagnosis was a D2E > 10 min [1,2,[18][19][20][21].…”

“…The ESC Registry is an emergency care delivery-focused data registry [19][20][21][22]. We acquired the cohort of potentially eligible patients using electronic health record (EHR) data abstraction of ED STEMI patients seen during the study period using ICD-coded final hospital diagnoses consistent with acute STEMI.…”

“…This begins with early diagnosis upon first medical contact [16,17]. Our prior work has shown that STEMI patients with a delayed acquisition of a diagnostic electrocardiogram (ECG) have a longer door-to-balloon (D2B) time [18][19][20]. We have also observed how the individuals and care teams making the diagnosis vary depending on the location of diagnosis with emergency department (ED) diagnosed patients being the least studied [21].…”

Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients

“…We included demographic subgroups for which the literature has previously described variation in the timeliness of care [ 4 , 8 , 9 , 10 , 11 , 22 , 23 ]. These include sex (male or female), age (18–29, 30–49, 50–64, 65–80, and >80), race (Asian, Black/African American, Native American, Alaskan, or Hawaiian/Pacific Islander, White, other race, and unknown/refused), ethnicity (Hispanic or Non-Hispanic), and language (English, Spanish, or other language).…”