Comparing ST-segment elevation myocardial infarction care between patients residing in central vs remote locations: a retrospective case series

Introduction: Patients who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RT) and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality.In remote areas, a number of geographical and organisational barriers may influence access to ORT. However, these are not well understood and the exact proportion of patients who receive ORT and the relationship to time of day and remoteness from the cardiac cath lab is unknown. Aims: To compare thecharacteristics of ORT delivery in central and remote locations in the North of Scotland and to identify potential barriers to optimal care with a view to service redesign. Methods: The study was set in the North of Scotland. All patients who attended hospital with a ST elevation myocardial infarction between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters.Data included treatment location, date of admission, distance to the cath lab, route of access to health care, left ventricular function and RT received. Patients were described as remote if > 90 minutes driving time from the cardiac cath lab and central if ≤90 min drive time. For patients who made contact in a pre-hospital setting ORT was defined as pre-hospital TL or pPCI. For patients who self-presented to the hospital first, ORT was defined as inhospital TL or pPCI. Data were described as mean (SD) as appropriate. Chi-squared and Student’s t-test were used as appropriate. Each case was reviewed to determine if ORT was received and if not, the reasons for this were recorded to identify potentially modifiable barriers. The study was approved by the ethical review panel of the School of Pharmacy and Life Sciences at Robert Gordon University (06/04/16/S17). Approval from the Caldecott guardian and NHS Highland Research and Development office were also obtained. Results: Of 627 acute myocardial infarction patients initially identified, 131 had a STEMI, the others were a non-STEMI. From this STEMI cohort,82 (62%) patients were classed as central and 49 (38%) were remote.In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received pre-hospital TLs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; Chi-square = 7.05, DF =130, p < 0.01).Several recurring barriers were identified. Conclusion: This study has demonstrated a significant health inequality between the treatment of STEMI in remote compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the North of Scotland.