Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis

Abstract

ObjectivesPatients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital (‘in-hospital STEMI’) face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI.Design, Setting and ParticipantsConsecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013–2018).Primary and secondary outcomesPatients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding.ResultsOf 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001).ConclusionsPatients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.

Impact of Gender, Race, and Insurance Status on Inhospital Management and Outcomes in Patients With COVID-19 and ST-Elevation Myocardial Infarction (a Nationwide Analysis)

“…We also investigated patterns of outcomes for STEMI in patients with COVID-19 based on whether the STEMI event occurred outside or inside the hospital. Our results are consistent with preCOVID-19 trends, 34 whereby patients with inhospital STEMI have a significantly greater mortality rate and compromised revascularization than those getting admitted with out-of-hospital STEMI. This may be explained by the fact that patients developing STEMI while in the hospital were quite ill because of COVID-19 and thus might have been poor candidates for an invasive work-up/revascularization and thus are inherently at a higher risk for mortality.…”

“…The results from our study, though, show even worse mortality outcomes for inhospital STEMI than previously reported. 34 This possibly reflects the impact of COVID-19 and related restrictions in preparing patients for timely revascularization because inhospital patients are more likely to have a known COVID-19 status and any additional risk for clinical decompensation with COVID-19 and related co-morbidities.…”

Comparison between Invasive Intervention and Conservative Treatment in Patients with In-Hospital Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study

“…Acute myocardial infractions (AMIs) occurring among patients hospitalized for other conditions, otherwise known as in-hospital AMIs, constitute between 1 and 11% of the total AMI cases managed in hospitals [1][2][3]. Compared to patients with out-of-hospital AMIs, those with in-hospital AMIs have a higher risk of in-hospital complications, as well as short-and long-term mortality [1][2][3][4][5][6][7][8][9]. Lower rates of invasive intervention (percutaneous coronary intervention and/or bypass surgery) in patients with in-hospital AMIs may be associated with the worse clinical outcomes observed in this group [1,4,8].…”

“…Compared to patients with out-of-hospital AMIs, those with in-hospital AMIs have a higher risk of in-hospital complications, as well as short-and long-term mortality [1][2][3][4][5][6][7][8][9]. Lower rates of invasive intervention (percutaneous coronary intervention and/or bypass surgery) in patients with in-hospital AMIs may be associated with the worse clinical outcomes observed in this group [1,4,8].…”

“…In contrast, less is known about the determinants of invasive intervention in patients with in-hospital AMIs specifically. Since in-hospital AMIs differ from their out-of-hospital counterpart in terms of associated risk factors, treatments, and consequently outcomes [1][2][3][4][5][6][7][8][9], it is important to identify the specific patterns of utilization and determinants of invasive intervention in patients with in-hospital AMIs.…”