Abstract 14166: Predictors of Mortality in Patients With In-Hospital STEMI After Implementation of a Comprehensive STEMI Protocol

Abstract

Introduction Patients who experience in-hospital ST-elevation myocardial infarction (iSTEMI) comprise a uniquely high-risk cohort owing to multiple factors including delays in diagnosis and treatment. Improvements in quality care metrics are needed to more fully understand the reasons for the poor outcomes, including high mortality, in this population. Methods Consecutive patients with iSTEMI who were treated with percutaneous coronary intervention (PCI) between 01/01/2011-07/15/2019 at a single, tertiary referral center were included. A comprehensive iSTEMI protocol (CSP) was implemented on 7/15/2014, incorporating: (1) nursing chest pain protocol, (2) improved electronic access to electrocardiographic studies, (3) checklist for initial triage and management, (4) 24/7/365 catheterization lab readiness, and (5) radial-first PCI approach. Process metrics and clinical outcomes were compared pre- and post-CSP implementation, and multivariable logistic regression analysis was performed to assess for predictors of in-hospital mortality. Results Among 125 iSTEMI patients, the post-CSP group (n=81) were younger with more active smoking and heart failure relative to the pre-CSP group (n=44). CSP implementation resulted in an increased use of trans-radial PCI (14.6 vs. 70.4%, p<0.001), greater rate of ECG-to-first device activation < 90 minutes (36.4% vs. 76.5%, p<0.001), and decreased median ECG-to-first device activation time (114 vs. 64 minutes, p<0.001). In-hospital mortality was numerically lower in the post-CSP group (18.2% vs. 9.9%, p=0.295). On multivariable analysis, the presence of shock was the only independent predictor of in-hospital mortality (OR: 26.05, 95% CI [5.5-211.6], p<0.001). Conclusions The adoption of a CSP conferred marked improvements in key care metrics in patients with iSTEMI. Its use holds promise in reducing mortality among a vulnerable population at high risk of death owing to underlying shock.