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Diagnostic uncertainty may cause delays in reperfusion
New findings suggest that reperfusion delays in primary PCI due to interhospital transfer are not always the result of system failure and may be due to diagnostic uncertainty.
The aim of the retrospective stratified case analysis was to determine the reason or reasons why some patients with STEMI present to hospitals equipped for non-primary PCI in regions that provide a heart attack center on a 24-hour basis.
The analysis included 180 interhospital transfer patients and 201 individuals who underwent direct access non-primary PCI.
Patients in both groups were similar in terms of age, male to female ratio, and CV risk profile. For example, hypertension was reported in 53% of transfer patients and 46% of PCI patients (P=.64), hypercholesterolemia was reported in 32% of transfer patients and 25% of the PCI group (P=.22), and 38% of transfer patients and 35% of non-primary PCI patients were smokers (P=.56). Fifteen percent of patients in the transfer group had diabetes compared with 8% in the PCI group (P<.05).
Symptom call times were 104 minutes (42-195 minutes) for the interhospital transfer group and 46 minutes (19-114) for the PCI group (P<.0001). ECG ST-elevation scores were also lower in the transfer group (3 mm [1-6] vs. 5 mm [3-9]; P<.0001). There were more protocol-negative ECGs at presentation in the transfer group (31.6% vs. 9.4%; P<.0001).
Peak creatine kinase was 628 IU/L (191-1,144) for the transfer group and 603 IU/L (280-1,238) for the PCI group, which the researchers noted was similar (P=.61). In-hospital mortality (1.7% vs. 1.5%; P=.89) and 30-day mortality (2.8% vs. 2.0%; P=.61) also were similar between the two groups.
Reperfusion delays in non-primary PCI due to transfer from hospital to hospital are not always the result of failures within the system, according to the researchers. They suggested that transfer patients could be a different patient cohort altogether due to the fact that ECG symptoms may be less clear.
“In many cases, initial triage to a non-primary PCI center may be justifiable due to diagnostic uncertainty, and guideline time metrics should be amended appropriately,” they concluded.
Disclosure: The researchers report no relevant financial disclosures.