The FAST-STEMI Network in Biella From 2013 to 2019: Impact of the Delocalization of the Hospital Facilities on Ischemia Time and In-hospital Outcomes

Abstract

Background:The optimization of the strategies for myocardial revascularization has improved the outcomes of patients with ST-segment elevation myocardial infarction. In Piedmont, the FAST-STEMI regional network was created for improving the management and transportation of ST-segment elevation (STEMI) patients to primary percutaneous coronary intervention facilities, reducing the time to reperfusion. Within this network, the Hospital of Biella was delocalized in December 2014 to a new suburban structure designed for an easier access, which might have shortened the duration of patients' transportation and ischemia, with potential positive prognostic effects. The aim of the present study was to define the impact of the decentralization of the hospital structure on the time to reperfusion and in-hospital outcomes among STEMI patients admitted to the Hospital of Biella. Methods: We included STEMI patients admitted to our urban hospital between 2013 and 2019 and included in the FAST-STEMI database. The primary endpoint was the duration of ischemia, defined as pain to balloon (PTB). The primary outcome endpoint (PE) was in-hospital mortality. Results: We included 276 consecutive patients with STEMI undergoing primary percutaneous coronary intervention between 2016 and 2019 in the new hospital facility, which were compared with 170 patients treated between 2013 and June 2014 in the prior structure. Patients' characteristics included a mean age of 67.5 ± 12.5 years, 72.1% males and 18.7% patients with diabetes. In the new facility, the median PTB was 188 minutes [interquartile range: 125-340 min], reduced as compared with the period 2013-2014 [215 (128.5-352 min), P = 0.002]. The median in-hospital stay was also shorter (P = 0.004), whereas a nonsignificant improvement was noted for ejection fraction (EF) at discharge (P = 0.14). A linear relationship was demonstrated between PTB and the EF (r = −0.183, P = 0.003) in patients treated between 2016 and 2019 while not affecting the length of hospitalization or in-hospital outcomes. In fact, in-hospital death occurred in 36 patients, 8% in the new structure versus 7.7% in 2013-2014 [hazard ratio (HR) (95% confidence interval [CI]) = 1.20 (0.59-2.42), P = 0.62]. The independent predictors of mortality were patients' age and EF at discharge (age ≥ 75 y: adjusted HR [95% CI] = 6.75 [1.51-30.1], P = 0.01; EF: adjusted HR [95% CI] = 0.91 [0.88-0.95], P < 0.001). Conclusions: The present study shows that, among the STEMI patients treated in our center, the delocalization of the hospital facilities and the optimization of the FAST-STEMI network reduced the duration of ischemia, with positive effects on left ventricular function at discharge. However, this did not translate into a significant benefit in survival, which was instead conditioned by the aging of the population.

Impact of age on pre-procedural TIMI flow in STEMI patients undergoing primary percutaneous coronary intervention

“…Similarly, Verdoia et al documented that age ≥75 years was associated with a more than six-fold increased risk of in-hospital death in a recent cohort of consecutive patients being treated with the current best standard of care for pPCI 25 …”

“…Previous studies have linked more advanced age with the achievement of a suboptimal TIMI flow after pPCI, being the consequence of longer time-to-treatment, 25 more frequent procedural complications and more complex clinical and anatomical presentation 26–28 …”

“…11 Similarly, Verdoia et al documented that age !75 years was associated with a more than six-fold increased risk of in-hospital death in a recent cohort of consecutive patients being treated with the current best standard of care for pPCI. 25 In a pooled analysis of 3032 patients from the Primary Angioplasty in Myocardial Infarction (PAMI)-2, Stent-PAMI, and PAMI-No Surgery On Site trials, among the 452 elderly patients, lower ejection fraction, lower final TIMI flow and hemodynamic or electrical instability predicted the short-term outcomes. 29 However, elderly patients with STEMI have been associated with impaired outcomes even despite epicardial reperfusion.…”

“…21 Shorter time-to-treatment and more aggressive preprocedural antiplatelet strategies have been shown to favour spontaneous reperfusion in large cohorts of patients with STEMI, 22,23 although opposite conclusions have been reached in other dedicated studies. 24 Previous studies have linked more advanced age with the achievement of a suboptimal TIMI flow after pPCI, being the consequence of longer time-to-treatment, 25 more frequent procedural complications and more complex clinical and anatomical presentation. [26][27][28] In a large sub-analysis of the EGYPT study, De Luca et al reported an increased mortality among the 231 patients aged >75 years, despite the use of GPIIbIIIa inhibitors in the whole cohort of patients, as a consequence of higher rates of distal embolization, poor myocardial perfusion and in addition to the worse risk profile of the elderly cohort.…”

Updates on the Management of STEMI in 2021

“…These data stress the importance of maintaining an efficient STEMI network to warrant prompt access of patients to primary PCI, allowing improvement in the success of recanalization, myocardial salvage, and the outcomes. 3 , 4 , 5 This conclusion was also supported by the Task Force of the European Society of Cardiology, who recommended that the COVID-19 pandemic should not compromise timely reperfusion of STEMI patients. 6 The data from the NACMI registry 1 , 2 suggest that in the initial phases of the COVID-19 pandemic, the need to assess positivity and to implement protective measures for health care personnel could have delayed access to reperfusion strategies in positive or suspected positive patients, increasing mortality ( P = 0.008 vs control population).…”