Abstract 13594: Impact on Clinical Outcomes of Randomization at Community Hospitals Versus Pre-hospital location in STEMI Patients: Insights From the STREAM Study

Abstract

Objectives: The STREAM study randomized STEMI pts <3 hrs from symptom onset to primary PCI (pPCI) or a fibrinolysis pharmacoinvasive approach (PI) with rescue for failed fibrinolysis and scheduled angiography for the remainder within 24h. Although most pts were randomized pre-hospital (PH) and admitted to pPCI centres, selected community hospitals (CH) within STEMI networks also participated. Given the inherent delays with inter-hospital transfer, we examined outcomes accordingly to randomization location. Methods: CH pts 358/1866 (19.2%) were compared to PH pts. Results are further categorized according to pts receiving pPCI, PI rescue, PI with scheduled angiography (%’s and medians with 25th-75th percentiles). Results: Overall compared to PH, CH pts had more diabetes (17.8% vs. 11.5%, p=0.001), higher Killip Class >1 (9.4% vs. 5.0%, p=0.002) and TIMI Risk Score ≥5 (18.2% vs. 12.4%, p=0.005). 30-day primary composite endpoint (death, CHF, shock, re-infarction) for CH was 14.9% vs. PH 13.2% (p=0.403). PI pts within CH received less rescue PCI than PH pts (35.1% vs. 42.8%, p=0.062) (table) and it was delayed by approximately 43 min. CH pts undergoing pPCI also had an approximate 31 min delay. After adjusting for TIMI risk score and time from symptom onset, CH pts requiring rescue had worse outcomes compared to PH (OR 2.3, 95% CI, 1.2-4.6); However no difference in outcomes existed between CH and PH pts in those undergoing pPCI (p interaction=0.027). PI pts receiving scheduled cath from CH and PH had comparable times to cath (17.7 vs. 18.7 hours) and low primary composite event rates (6.2% vs 8.0%). Conclusion: Within STREAM CH pts had higher baseline risk but overall similar outcomes to those randomized PH. Despite higher baseline risk, CH pts with successful fibrinolysis and scheduled angiography or those who underwent primary PCI had similar outcomes to PH. The worse outcomes in CH rescue pts emphasizes the need to identify and expeditiously treat those pts needing rescue PCI.