Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol.
Background We evaluated whether a comprehensive STEMI protocol (CSP) focusing on guideline-directed medical therapy, trans-radial percutaneous coronary intervention (PCI), and rapid door to balloon time (D2BT) improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with STEMI treated with PCI at a single hospital before (1/1/2011-7/14/2014) and after (7/15/2014-7/15/2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤ 50th percentile; 29.0%), moderate (51-90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was D2BT. Achievement of guideline-recommend D2BT goals improved in all deprivation groups pre- vs. post-CSP (low: 67.8% vs. 88.5%; moderate: 50.7% vs. 77.6%; high: 65.5% vs. 85.6%; all p<0.001). Median D2BT among ED/in-hospital patients was significantly non-inferior in higher vs. lower deprivation groups post-CSP (non-inferiority limit = 5 minutes, p non-inferiority high vs. moderate 0.002, high vs. low <0.001, moderate vs. low 0.02). In-hospital mortality, the primary clinical outcome, was significantly lower post-CSP in patients with moderate / high deprivation in unadjusted (pre-CSP 7.0% vs. post-CSP 3.1%, OR 0.42 [95% CI 0.25, 0.72], p=0.002) and risk-adjusted (OR 0.42 [0.23, 0.77], p=0.005) models. Conclusions A CSP was associated with improved STEMI care across all deprivation groups and reduced mortality in those with moderate or high deprivation. Standardized initiatives to reduce care variability may mitigate social determinants of health in time-sensitive conditions such as STEMI.
['Huded|Chetan P|CP|', 'Dalton|Jarrod E|JE|', 'Kumar|Anirudh|A|', 'Krieger|Nikolas I|NI|', 'Kassis|Nicholas|N|', 'Phelan|Michael|M|', 'Kravitz|Kathleen|K|', 'Reed|Grant W|GW|', 'Krishnaswamy|Amar|A|', 'Kapadia|Samir R|SR|', 'Khot|Umesh|U|']
myocardial infarction STEMI door to balloon time disparities socioeconomic position