Independent Predictors of Late Presentation in Patients with ST-Segment Elevation Myocardial Infarction

Abstract

BackgroundIn patients with acute ST-segment elevation myocardial infarction (STEMI), the time elapsed from symptom onset to receiving medical care is one of the main mortality predictors.ObjectiveTo identify independent predictors of late presentation in patients STEMI representative of daily clinical practice.MethodsAll patients admitted with a diagnosis of STEMI in a reference center between December 2009 and November 2014 were evaluated and prospectively followed during hospitalization and for 30 days after discharge. Late presentation was defined as a time interval > 6 hours from chest pain onset until hospital arrival. Multiple logistic regression analysis was used to identify independent predictors of late presentation. Values of p < 0.05 were considered statistically significant.ResultsA total of 1,297 patients were included, with a mean age of 60.7 ± 11.6 years, of which 71% were males, 85% Caucasians, 72% had a mean income lower than five minimum wages and 66% had systemic arterial hypertension. The median time of clinical presentation was 3.00 [1.40-5.48] hours, and approximately one-quarter of the patients had a late presentation, with their mortality being significantly higher. The independent predictors of late presentation were Black ethnicity, low income and diabetes mellitus, and a history of previous heart disease was a protective factor.ConclusionBlack ethnicity, low income and diabetes mellitus are independent predictors of late presentation in STEMI. The identification of subgroups of patients prone to late presentation may help to stimulate prevention policies for these high-risk individuals.

The Importance of the Prehospital Phase in ST Elevation Myocardial Infarction

“…A recent study carried out in Japan showed that patients who were men, were elderly, had lower levels of schooling and had lower self-confidence regarding their understanding of AMI would present delays in seeking medical treatment. 11 These patient-related factors were also absent from Rodrigues et al 9 …”

“…In Brazil, Rodrigues et al published a study on predictors of late presentation in 1,297 patients with AMI in a referral center in the country’s South Region, which is able to perform primary angioplasty 24 hours a day, seven days a week. 9 Approximately 25% (n = 302) of the total patients attended between December 2009 and November 2014 presented a delay of more than six hours, with a significantly higher mortality rate. The independent predictors of late presentation were: black ethnicity, low income level (less than five times minimum wage), and diabetes mellitus.…”

“…Patients with all of the independent predictors of late presentation took twice as long to reach the hospital as other patients. History of previous heart disease, AMI, or myocardial revascularization were protective factors, 9 likely owing to the early recognition of a new event and, thus, to reduced delays in seeking medical treatment.…”

“…Unfortunately, the authors of this study did not record the distance between the place where symptoms onset and the referral center; they also excluded transfer patients in order to evaluate spontaneous demand. 9 These two factors also influence mortality related to the pre-hospital phase, even though they are dependent on the healthcare system. On the other hand, they also did not analyze the following confounding factors which are related both to distance between place of symptoms onset and referral center and to transfer patients: ventricular function, time taken to implement mechanical or drug reperfusion therapy, reperfusion therapy success rate, associated procedures, and implementation of adjuvant therapy recommended in the guidelines.…”

“…In the study carried out by Rodrigues et al, these patients were excluded, thus making it impossible to establish a comparison. 9 …”