The stay-at-home STEMI – does location of emergency medical service contact impact care and prognosis?

Sascha Macherey-Meyer (Köln)1, S. Heyne (Köln)2, M. Meertens (Mainz)3, S. Braumann (Köln)2, I. Ahrens (Köln)4, F. M. Baer (Köln)5, F. Eberhardt (Köln)6, M. Horlitz (Köln)7, J.-M. Sinning (Köln)8, A. Meissner (Köln)9, S. Baldus (Köln)1, C. Adler (Köln)10, S. Lee (Köln)10

1Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 2Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 4Krankenhaus der Augustinerinnen, Akademisches Lehrkrankenhaus Klinik für Kardiologie und internistische Intensivmedizin Köln, Deutschland; 5St. Antonius Krankenhaus Medizinische Klinik & Kardio-Diabetes-Zentrum Köln Köln, Deutschland; 6Ev. Krankenhaus Köln-Kalk Kardiologie & Internistische Intensivmedizin Köln, Deutschland; 7Krankenhaus Porz am Rhein gGmbH Klinik für Kardiologie, Elektrophysiologie u. Rhythmologie Köln, Deutschland; 8St. Vinzenz-Hospital Innere Medizin III - Kardiologie Köln, Deutschland; 9Kliniken der Stadt Köln gGmbH, Krankenhaus Merheim Medizinische Klinik II Köln, Deutschland; 10Universitätsklinikum Köln Klinik III für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland


Background: ST-segment myocardial infarction (STEMI) requires immediate and standardized treatment to overcome the high morbidity and mortality rates. First medical contact (FMC) was described as prognostic indicator in STEMI before, and treatment and transport by emergency medical service (EMS) represents FMC in the majority of patients. Little is known about the prognostic implications of the location of EMS contact and further analysis is reasonable.


Objective: This study evaluated the impact of location of EMS-FMC (public place vs. home) in a STEMI cohort in a metropolitan infarction network.


Methods: The STEMI registry includes patients treated between January 2005 and December 2020. Patients were divided in public (street, work place, restaurant, doctor’s practice) and home cohort. Primary outcome was in-hospital all-cause mortality. Data were analyzed using Student’s t- and Chi square test. 


Results: 3280 patients including 1919 treated at home (58.5%) and 1361 treated in public (41.5%) were eligible. The latter were significantly younger (61.0 vs. 65.5 years, mean, p<0.001) and had a lower proportion of women (21.4 vs. 28.8%, p<0.001).

During the prehospital course, the public cohort had a higher prevalence of resuscitation (16.6 vs. 13.6%, p=0.022), but intubation (13.2 vs. 13.3%) and use of vasopressors (11.9 vs. 13.5%) did not significantly differ. Cardiogenic shock had a similar prevalence (17.0 vs. 16.8%, p<0.901), but pulmonary oedema more frequently occurred in home group (5.8 vs. 9.3%, p<0.001). Prehospital mortality was 0.4% vs. 0.1% (p=0.249), respectively. Both groups were equally referred for angiography (99.5 vs. 99.0%, p=0.08). The public group had a lower rate of TIMI 0 flow (11.8 vs. 14.3%, p=0.038), and they were more often treated with stent implantation (85.4 vs. 81.9%, p=0.008). Anterior infarction was more common in public group (40.5 vs. 37.0% p=0.039). Symptom-to-FMC time was significantly increased in public cohort (365.0 [±740.9] vs. 216.6 [±472.3], mean, p<0.001), while door-to-balloon time (60.4 [±79.0] vs. 63.4 [±77.2], mean, p<0.333) and contact-to-balloon time (99.4 [±91.6] vs. 103.6 [±73.5], mean, p<0.263) were comparable between the groups.

Procedure-related complications, periinterventional resuscitation, access-site bleeding and stroke rates did not differ between the groups (see figure). The home group had significantly higher rates of re-infarction (0.8 vs. 1.8% p=0.022) and in-hospital mortality (7.3 vs. 11.9% p<0.001). 


Conclusion: The present study demonstrated a relevant patient-related delay in patients with STEMI in public. Complications and outcome were more favorable in public cohort despite higher prehospital resuscitation rates and this delay. The home cohort group had significantly increased in-hospital mortality. Contributing factors for this worse outcome might be disparities regarding pulmonary oedema, infarct-related artery characteristics, invasive management, age and gender. Further prospective analyses of underlying conditions are needed, but EMS personnel should be aware of potential differences in these cohorts. Strategies to minimize patient-related delay are still warranted.

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