Evaluating clinical reason and rationale for not delivering reperfusion therapy in ST elevation myocardial infarction patients: Insights from a comprehensive cohort.

BACKGROUND: In ST elevation myocardial infarction (STEMI), reperfusion therapy is lifesaving but is not delivered in approximately one quarter of patients. To address this care gap, we reviewed all STEMI patients that did not receive reperfusion to identify patient characteristics, in-hospital outcomes and the clinical reason or rationale for withholding reperfusion therapy.
METHODS: A prospective chart review identified a consecutive cohort of STEMI patients over one-year within a defined health care region with independent data abstraction. Subsequently a trained nurse completed retrospective chart review and categorized patients by rationale for failure to receive reperfusion.
RESULTS: Of 745 STEMI patients, 181 (24.3%) did not receive reperfusion. Compared to those receiving reperfusion, they were older (67.5 vs. 58.0years, p=0.001) with more comorbidities and higher in-hospital mortality (15.5% vs. 3.5% p=<0.0001). After excluding 35 patients (unavailable data) there were 146 STEMI patients for qualitative determination. Patient delay greater than 12hours from symptom onset accounted for the majority of patients (56/146, 38.4%). In 19.9% (29/146), conservative medical management with documented rationale occurred. Following angiography, primary PCI was attempted but was unsuccessful or no culprit lesion identified in 19.2% (28/146). The diagnosis of STEMI was missed or no rationale for failure to deliver therapy identified in 8.2% (12/146). Death prior to planned reperfusion occurred in 8 (8/146, 5.5%).
CONCLUSIONS: Legitimate rationale exists for the majority of STEMI patients not receiving reperfusion. Ultimately, only 1.6% (12/745) of consecutive STEMI patients failed to receive reperfusion without documented rationale or due to missed diagnosis.