Achieving Equitable Access to Acute Myocardial Infarction Therapies for Rural Patients—Is It Possible?

Abstract

Within the United States, rural-urban disparities in cardiovascular disease and resulting mortality have widened over time. 1 When compared with their urban counterparts, rural residents experience higher rates of cardiovascular disease and mortality for acute cardiovascular conditions such as myocardial infarction, heart failure, and stroke. 1,2 These inequities are partly driven by hospital-level differences in quality of care, worse access to emergency services, and barriers to accessing posthospitalization medical services in rural areas. 1,2 Delays in medical care can be particularly devastating, especially for rural residents experiencing ST-segment elevation myocardial infarction (STEMI), which relies on swift detection and timely intervention to improve survival. 3 While patients typically receive greater benefit from rapid reperfusion by primary percutaneous coronary intervention (PCI), rural hospitals often lack these capabilities, and thus instead give thrombolytic therapy with subsequent transfer to a PCIcapable institution. 1 However, substantial variation in achieving guideline-directed medical therapy for STEMI exists among rural hospitals, resulting in delays in reperfusion and increased morbidity and mortality. 1 In this issue of JAMA Cardiology, Hillerson et al 4 examined whether differences in perfusion metrics or clinical outcomes exist among rural vs urban patients presenting with STEMI among 686 US hospitals participating in the Chest Pain-MI National Cardiovascular Data Registry (NCDR). The authors conducted a cross-sectional study of more than 70 000 adult patients presenting with a STEMI from January 1, 2019, to June 30, 2020. Patients residing in a zip code outside of a metropolitan area, defined as having at least 1 urbanized area with a minimum population of 50 000, were classified as rural.Of 70 424 patients presenting with STEMI, 19 722 (28.0%) resided in a rural area. Overall, rural patients were less likely to undergo primary PCI compared with urban patients (73.2% vs 85.1%; P < .001), more likely to receive fibrinolytic therapy (19.7% vs 2.7%; P < .001), and more likely to have door to needle times under 30 minutes (53.1% vs 41.7%; P = .03). Rural patients undergoing primary PCI had longer median time from first medical contact to catheterization laboratory activation (30 minutes vs 22 minutes; P < .001) as well as longer median time from first medical contact to device (99 minutes vs 81 minutes; P < .001) compared with their urban counterparts. Interestingly, despite these differences, unadjusted in-hospital mortality was lower among rural patients compared with urban patients (unadjusted odds ratio, 0.91 [95% CI, 0.84-0.97]; P = .007), with no significant difference in mortality when adjusting for covariates (adjusted odds ratio, 0.97 [95% CI, 0.89-1.06]; P = .49).