Abstract 153: Rural Systems of Care: Real World Observations and Trends in ST Elevation Myocardial Infarction Patient Characteristics, and Correlations of Arrival Mode to Outcomes

Abstract

Background: Minnesota, North Dakota and South Dakota have been enhancing statewide systems through infrastructure and clinical education regarding ST-elevation myocardial infarction (STEMI) since 2010 in an attempt to equalize access to timely reperfusion in rural areas. A trend in faster time to reperfusion has been observed for STEMI patients who transfer directly to Percutaneous Coronary Intervention (PCI) capable facilities via Emergency Medical Services (EMS) and receive a pre-hospital 12-lead ECG in comparison to those who first present to a non PCI capable facility. This improved time to STEMI recognition and reperfusion may be associated with improved outcomes. Methods: Data was collected via ACTION Registry-GWTG from 2012-2015. The cohort was defined as STEMI patients who received PPCI with interfacility transfer (n=1010) and without (n=376) and who receive a pre-hospital 12-lead ECG (n=1078) and do not (n=308). The association between mode of transport, time to PPCI, and outcomes including LV function, in hospital clinical events, and in-hospital mortality were analyzed by unadjusted association. Multivariable adjustment was performed using covariates from the previously developed and validated ACTION mortality model to determine the independent association between arrival mode and outcomes. Results: The direct transfer group demonstrated shorter cumulative times (79 vs. 145 min., p=<0.001) to coronary reperfusion as compared to the interfacility transfer group. The pre-hospital ECG group experienced a shorter time to transfer (40 vs. 55 min., p=<0.001) to a PPCI center consistent with earlier system recognition and activation for a STEMI patient. The direct transfer and pre-hospital ECG groups had a statistically significant less risk of in-hospital cardiogenic shock, congestive heart failure, cardiac arrest and death as a composite end-point, p=0.011 & <0.001 respectively. During the years of 2012 to 2015, the performance of pre-hospital ECGs has increased. Conclusion: Implementation of Mission Lifeline programming was associated with significantly lower risk of in-hospital shock, congestive heart failure, cardiac arrest and death in STEMI patients presenting via EMS through increased utilization of pre hospital ECG, education, and hospital triage and procedural PPCI streamlining.