98 Rural Population at Risk of Delayed Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction in North Carolina

Abstract

Emergent reperfusion by percutaneous coronary intervention (PCI) is indicated in patients with ST-elevation myocardial infarction (STEMI) and should be performed within 90-minutes of first medical contact (FMC), although long transport times make meeting this goal difficult in many parts of rural North Carolina (NC). Early fibrinolytic therapy is recommended in cases where PCI is not possible within 120-minutes of FMC and out-of-hospital fibrinolytics may improve outcomes in cases with long transport times. The objectives of this study were to determine the number of NC residents with prolonged transport times to the nearest 24/7 primary PCI (PPCI) center and to map this population. We analyzed transport time to the nearest PPCI center using the ArcGIS Pro geographical information system (GIS). To identify those at risk of a >120-minute FMC-to-device time, a 60-minute transport time cutoff was selected. This cutoff is based on an estimated 15-minute scene time (national median in STEMI) and a 45-minute door-to-device time (NC median with EMS pre-arrival notification). US Census Data (2010) were used to cohort NC residents by time to PPCI. Counties with potential benefit from out-of-hospital fibrinolytics were identified as those with >10% of their population living >60 minutes from PPCI. We identified 28 PPCI centers in NC and 9 in bordering areas of adjacent states. The percentage of NC residents who have greater than a 60-minute transport time to PPCI is 7.5% (718,141/9,535,483). We found that 25 of 100 counties have more than 50% of their population in a long transport area and 15 of those have more than 90% of their population in long transport areas (Figure 1). The longest transport times are found in extreme western and eastern NC. A large percentage of rural NC residents are at risk for delayed PCI. Emergency medical services medical directors should consider these data in conjunction with on-scene times and door-to-device times in their counties to guide decision-making about out-of-hospital fibrinolytic protocols.