439 Impact of the type and timeliness of reperfusion on left ventricular dysfunction amongst survivors of ST elevation myocardial infarction (STEMI) within a regional model of stemi care: Insights from the vancouver coastal health authority STEMI initiative

Abstract

BackgroundLeft ventricular dysfunction (LVD) after STEMI is a strong predictor of future adverse cardiac events. The impact of reperfusion with primary percutaneous coronary intervention (PPCI) versus fibrinolysis (FL) on LVD within the context of a regional model of STEMI reperfusion utilizing both modes of reperfusion has not been well studied.ObjectivesTo determine the proportion of STEMI patients with LVD, defined as a left ventricular ejection fraction (LVEF) <40%, in a regional model of STEMI care utilizing both PCI and FL, and to explore any association between LVD and the type and timeliness of reperfusion strategy used.MethodsThis was a retrospective cohort study of all STEMI patients treated in the Vancouver Coastal Health Authority between May 21, 2007 and May 20, 2009 who received either PPCI or FL, survived through to hospital discharge and who had an evaluable EF. The association of the type and timeliness of both reperfusion strategies with LVD was explored with multivariable logistic regression.Results436 STEMI patients met the inclusion criteria. 311 patients underwent PPCI and 125 patients underwent FL. Recommended reperfusion times [door to balloon <90 min and door to needle <30 min] were achieved in 48% of PPCI treated patients compared to 37.6% of FL treated patients. Absolute reperfusion times for PPCI were longer than with FL (Table I). The mean LVEF in PPCI treated patients was similar to FL treated patients (48.6% vs 50.9%, P = NS). Overall, 18.3% of patients (80 patients) had an LVEF <40%. An LVEF <40% was seen in 20.6% of PPCI treated patients and 12.8% of FL treated patients (P = 0.06). However, rates of LVD were similar between PPCI and FL treated patients who received reperfusion within recommended time frames (16.0% vs 12.8%, P = NS). In contrast, rates of LVD were significantly higher amongst PPCI treated patients compared to FL treated patients when reperfusion times were prolonged (24.8% vs. 12.8% P = 0.03). The adjusted OR for LVD with delayed PPCI was 2.80 (95% C.I. 1.20-6.52) compared with delayed FL.Tabled 1ConclusionLVD was present in 18.3% of STEMI patients treated with either PPCI or FL. Rates of LVD were similar between PPCI and FL treated patients when both were administered within recommended times. However, delayed PPCI was associated with higher rates of LVD compared to delayed FL. Delayed PPCI may be more detrimental for the treatment of STEMI than delayed FL in a mixed reperfusion model of STEMI care.Vancouver Coastal Health Authority Innovation Fund BackgroundLeft ventricular dysfunction (LVD) after STEMI is a strong predictor of future adverse cardiac events. The impact of reperfusion with primary percutaneous coronary intervention (PPCI) versus fibrinolysis (FL) on LVD within the context of a regional model of STEMI reperfusion utilizing both modes of reperfusion has not been well studied. Left ventricular dysfunction (LVD) after STEMI is a strong predictor of future adverse cardiac events. The impact of reperfusion with primary percutaneous coronary intervention (PPCI) versus fibrinolysis (FL) on LVD within the context of a regional model of STEMI reperfusion utilizing both modes of reperfusion has not been well studied. ObjectivesTo determine the proportion of STEMI patients with LVD, defined as a left ventricular ejection fraction (LVEF) <40%, in a regional model of STEMI care utilizing both PCI and FL, and to explore any association between LVD and the type and timeliness of reperfusion strategy used. To determine the proportion of STEMI patients with LVD, defined as a left ventricular ejection fraction (LVEF) <40%, in a regional model of STEMI care utilizing both PCI and FL, and to explore any association between LVD and the type and timeliness of reperfusion strategy used. MethodsThis was a retrospective cohort study of all STEMI patients treated in the Vancouver Coastal Health Authority between May 21, 2007 and May 20, 2009 who received either PPCI or FL, survived through to hospital discharge and who had an evaluable EF. The association of the type and timeliness of both reperfusion strategies with LVD was explored with multivariable logistic regression. This was a retrospective cohort study of all STEMI patients treated in the Vancouver Coastal Health Authority between May 21, 2007 and May 20, 2009 who received either PPCI or FL, survived through to hospital discharge and who had an evaluable EF. The association of the type and timeliness of both reperfusion strategies with LVD was explored with multivariable logistic regression. Results436 STEMI patients met the inclusion criteria. 311 patients underwent PPCI and 125 patients underwent FL. Recommended reperfusion times [door to balloon <90 min and door to needle <30 min] were achieved in 48% of PPCI treated patients compared to 37.6% of FL treated patients. Absolute reperfusion times for PPCI were longer than with FL (Table I). The mean LVEF in PPCI treated patients was similar to FL treated patients (48.6% vs 50.9%, P = NS). Overall, 18.3% of patients (80 patients) had an LVEF <40%. An LVEF <40% was seen in 20.6% of PPCI treated patients and 12.8% of FL treated patients (P = 0.06). However, rates of LVD were similar between PPCI and FL treated patients who received reperfusion within recommended time frames (16.0% vs 12.8%, P = NS). In contrast, rates of LVD were significantly higher amongst PPCI treated patients compared to FL treated patients when reperfusion times were prolonged (24.8% vs. 12.8% P = 0.03). The adjusted OR for LVD with delayed PPCI was 2.80 (95% C.I. 1.20-6.52) compared with delayed FL.Tabled 1 436 STEMI patients met the inclusion criteria. 311 patients underwent PPCI and 125 patients underwent FL. Recommended reperfusion times [door to balloon <90 min and door to needle <30 min] were achieved in 48% of PPCI treated patients compared to 37.6% of FL treated patients. Absolute reperfusion times for PPCI were longer than with FL (Table I). The mean LVEF in PPCI treated patients was similar to FL treated patients (48.6% vs 50.9%, P = NS). Overall, 18.3% of patients (80 patients) had an LVEF <40%. An LVEF <40% was seen in 20.6% of PPCI treated patients and 12.8% of FL treated patients (P = 0.06). However, rates of LVD were similar between PPCI and FL treated patients who received reperfusion within recommended time frames (16.0% vs 12.8%, P = NS). In contrast, rates of LVD were significantly higher amongst PPCI treated patients compared to FL treated patients when reperfusion times were prolonged (24.8% vs. 12.8% P = 0.03). The adjusted OR for LVD with delayed PPCI was 2.80 (95% C.I. 1.20-6.52) compared with delayed FL. ConclusionLVD was present in 18.3% of STEMI patients treated with either PPCI or FL. Rates of LVD were similar between PPCI and FL treated patients when both were administered within recommended times. However, delayed PPCI was associated with higher rates of LVD compared to delayed FL. Delayed PPCI may be more detrimental for the treatment of STEMI than delayed FL in a mixed reperfusion model of STEMI care.Vancouver Coastal Health Authority Innovation Fund LVD was present in 18.3% of STEMI patients treated with either PPCI or FL. Rates of LVD were similar between PPCI and FL treated patients when both were administered within recommended times. However, delayed PPCI was associated with higher rates of LVD compared to delayed FL. Delayed PPCI may be more detrimental for the treatment of STEMI than delayed FL in a mixed reperfusion model of STEMI care.