Delayed non-STEMI hospitalization tied to all-cause death, other poor outcomes
Delayed presentation of 24 hours or more after non-STEMI symptom onset was associated with greater risk for all-cause death, recurrent MI and HF hospitalization compared with earlier presentation, researchers reported.
According to data published in the Journal of the American College of Cardiology, researchers in Korea observed that individuals most likely to delay non-STEMI hospitalization were older, were women, had atypical chest pain, had dyspnea, had diabetes and did not utilize emergency medical services (EMS).
“The public's understanding of the correlation between chest pain and MI is still low. Due to COVID-19, it has been reported that patients in England, Italy and the United States have decreased to visit hospitals despite having symptoms due to concerns about nosocomial infection. Interestingly, in the concomitant period, an increase in the mortality rate of non-STEMI patients was also reported,” Jung-Joon Cha, MD, of the department of cardiology at the cardiovascular center at Korea University Anam Hospital, Korea University College of Medicine in Seoul, South Korea, told Healio. “These observations suggest that delayed hospitalization of non-STEMI patients is associated with mortality, and our study showed evidence of the impact of delayed hospitalization on poor clinical outcomes in non-STEMI patients. Therefore, it is expected that reducing delayed hospitalization through continuous societal education on chest pain symptoms will significantly reduce the mortality of non-STEMI patients.”
To evaluate the relationship between delayed hospitalization for non-STEMI and clinical outcomes, researchers assessed 6,544 patients from the Korea Acute Myocardial Infarction Registry-NIH. Patients were classified based on symptom-to-door time, stratified by whether they presented within 24 hours or after 24 hours.
The primary outcome was 3-year all-cause mortality. The secondary outcome was a composite of 3-year all-cause mortality, recurrent MI and HF hospitalization.
Delayed non-STEMI presentation and clinical outcomes
According to the study, 27.9% of patients were classified as presenting 24 hours or more after non-STEMI symptom onset. These patients experienced greater all-cause mortality (17% vs. 10.5%; P < .001) and incidence of secondary outcomes (23.3% vs. 15.7%; P < .001) compared with patients with a symptom-to-door time of less than 24 hours.
The association between all-cause mortality and non-STEMI presentation more than 24 hours after symptom onset was consistent in the subgroup analysis, regardless of age, sex, atypical chest pain, dyspnea, Q-wave on ECG, use of EMS, hypertension, diabetes, chronic kidney disease, left ventricular dysfunction and TIMI flow.
In the subgroup analysis that stratified patients based on the GRACE risk score, researchers observed that patients in the low- to intermediate-risk group (HR = 1.59; 95% CI, 1.19-2.12) experienced greater risk for all-cause mortality compared with the high-risk group (HR = 1.32; 95% CI, 1.12-1.55; P for interaction = .005).
“We observed that delayed hospitalization leads to poor clinical outcomes regardless of history of CVD,” Cha told Healio. “Interestingly, the risk stratification presented by the GRACE risk score showed consistent results that delayed hospitalization had a poor prognosis in both low-intermediate risk and high risk. Moreover, the low-intermediate risk group was worse than the high-risk group. In other words, our report highlights the need to reduce delayed hospitalization even in first-event patients, who may be expected to be at relatively low-to-intermediate risk.”
Moreover, the researchers reported that the following baseline characteristics were associated with likelihood of delay of non-STEMI hospitalization:
- age 75 years or older (OR = 1.44; 95% CI, 1.25-1.65; P < .001);
- female sex (OR = 1.23; 95% CI, 1.09-1.4; P = .001);
- presentation with atypical chest pain (OR = 1.61; 95% CI, 1.39-1.86; P < .001);
- dyspnea (OR = 1.31; 95% CI, 1.15-1.49; P < .001);
- no use of EMS (OR = 3.47; 95% CI, 2.73-4.42; P < .001); and
- diabetes (OR = 1.17; 95% CI, 1.03-1.33; P < .001).
“For the physician, atypical symptoms in non-STEMI patients may lead physicians to underestimate the disease severity,” Cha told Healio. “Thus, we would like to present new insight that physicians may caution for the atypical symptoms, especially in non-STEMI patients, rather than neglect them.”
Possible explanations
In a related editorial, José A. Barrabés, MD, PhD, of the department of cardiology at Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Spain, and colleagues posited several reasons why the prognosis in setting of delayed hospitalization for non-STEMI was so poor in the present analysis.
“Late presenters might have had more frequent recurrent ischemic episodes — which are associated with a worse prognosis — before admission than the remaining patients, but this hypothesis can be neither confirmed nor excluded, because only the time elapsed between the last episode of chest pain and admission was considered,” the authors wrote. “The fact that a prolonged admission delay portended an especially higher risk in patients with lower GRACE scores is noteworthy and suggests that part of these late presenters might originally have had a STEMI, but they no longer had ST-segment elevation on admission.
“Most importantly, non-STEMI patients in this study had longer symptom-to-door times than those reported by other recent registries particularly, those with a symptom-to-door time 24 hours had an extremely prolonged admission delay. This time lag is unusual and reduces the generalizability of the results,” they wrote.
For more information:
Jung-Joon Cha, MD, can be reached at ath3869@naver.com.
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