Reperfusion for STEMI in current Canadian Practice: are we closing the care gap?

The current standard of care for patients presenting with acute ST-segment Elevation Myocardial Infarction (STEMI) includes early reperfusion therapy with either fibrinolytics or primary percutaneous coronary intervention (primary PCI).Previous registry data has shown that 30% of patients with STEMI receive neither form of reperfusion (1,2,3).Furthermore, untreated patients have 30-day mortality rates that are 2-3 times higher than those who are treated (3,4).The goal of the present study is to document the current prevalence of reperfusion therapy at three Canadian teaching hospitals and to identify underlying demographic and clinical factors that correlate with rates of reperfusion in these patients. METHOdSPatients were identified from a prospectively collected database of all STEMI patients presenting to three teaching hospitals in Hamilton, Ontario, between April 2004 and July 2006.This institutional database contains clinical, angiographic, and outcome variables collected by individuals using standardized criteria.One of the three hospitals is equipped with cardiac catheterization facilities.Patients presenting to the other two sites had to be transferred if cardiac catheterization was required.Thirteen clinical and demographic variables were compared in order to identify predictors of not receiving reperfusion.Variables were selected based on both their proven significance in previous studies (age, sex, time from symptom onset to presentation, history of congestive heart failure, and history of diabetes) and the possibility that they might be specifically clinically relevant (history of hypertension, stroke, peripheral vascular disease, coronary artery disease, myocardial infarction, previous angioplasty, coronary artery bypass surgery and presentation during regular working hours).Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for each of the variables.Multiple logistic regression using a forward selection model was used to identify independent predictors of not receiving reperfusion.Statistical analyses were performed with SAS version 9.1 (SAS Institute Inc, Cary, NC).In patients who did not receive reperfusion, a retrospective chart review was done to identify any and all reasons that treatment was withheld.Each chart was reviewed by two of the authors (M.K. and D.Y.) and any differences were resolved by consensus.