Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.
Epworth HealthCare, Richmond, Victoria, Australia.
BMJ Open. 2022 Mar 7;12(3):e052000. doi: 10.1136/bmjopen-2021-052000.
Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI.
DESIGN, SETTING AND PARTICIPANTS: Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018).
Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding.
Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001).
Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.
已经在医院（“院内 ST 段抬高型心肌梗死（STEMI）”）发生的 ST 段抬高型心肌梗死（STEMI）患者死亡率较高。然而，关于该患者人群的数据很少。我们旨在研究院内 STEMI 与院外 STEMI 的再灌注和结局差异。
设计、地点和参与者：连续 30 个中心接受经皮冠状动脉介入治疗（PCI）的 STEMI 患者均前瞻性纳入维多利亚心脏结局登记处（2013-2018 年）。
将院内 STEMI 患者与院外 STEMI 患者进行比较，主要终点为 30 天主要不良心血管事件（MACE）。次要终点包括缺血时间、全因死亡率和大出血。
在接受 PCI 治疗的 7493 例 STEMI 患者中，494 例（6.6%）为院内 STEMI。院内 STEMI 患者年龄更大（67.1 岁 vs 62.4 岁，p<0.001），女性更多（32% vs 19.9%，p<0.001），合并症更多。与院外 STEMI 患者相比，院内 STEMI 患者 30 天 MACE（20.4% vs 9.8%，p<0.001）、死亡率（12.1% vs 6.9%，p<0.001）和大出血（4.9% vs 2.3%，p<0.001）发生率更高。根据指南标准，院内 STEMI 患者的症状至器械时间分别为≤70 分钟和≤90 分钟的比例分别为 29%和 47%。院外 STEMI 患者门至器械时间≤90 分钟的比例为 71%。住院期间 STEMI 的发生独立预测更高的 MACE（调整后的 OR 1.77，95%CI 1.33 至 2.36，p<0.001）和 12 个月死亡率（调整后的 OR 1.49，95%CI 1.08 至 2.07，p<0.001）。
在校正混杂因素后，与院外 STEMI 患者相比，院内 STEMI 患者的再灌注时间延迟，且 MACE 和死亡率明显更高。在这一高危且研究不足的人群中，需要有针对性的策略来提高对该疾病的认识并改善结局。
