Characteristic and Outcomes of Patients with ST-segment Elevation Myocardial Infarction who have Non-System Reasons for Delay in Treatment: A Report from the AHA GWTG CAD Registry

BackgroundThe past two decades have witnessed reductions in time to diagnosis and reperfusion therapy in patients with ST elevation myocardial infarction (STEMI), largely through improvements in STEMI systems of care. While studies have demonstrated important benefits of timely coronary reperfusion in STEMI patients, those with non-system reasons for delay (NSD) are often excluded from these analyses, limiting insights into the overall quality of care for these patients. MethodsWe analyzed the NSD in patients with STEMI undergoing primary PCI who were enrolled in the GWTD-CAD registry from January 1st, 2019, to December 31st, 2021. We examined the patient-level characteristics and outcomes for patients with and without reported NSD. We performed multivariable logistic regression models to examine the association between NSD and in-hospital mortality, adjusting for patient demographics, clinical variables, and social factors. We then categorized hospitals into four groups based on proportion of STEMI patients with NSD and examined the hospital-level characteristics across the quartiles. We further grouped hospitals by quality metric achievement of timely coronary reperfusion and examined the rates of NSD and treatment times for each category of achievement of the quality metric. Results74,372 patients were included in the study. 17,741 (23.9%) patients were reported to have NSD. Patients with NSD were older, and more likely to be female, of Black race, and have significant comorbidities including higher rates of cardiac arrest, heart failure and cardiogenic shock on presentation. In-hospital mortality rate was significantly higher in patients with NSD (15.4% vs 2.7%), (Adjusted OR 2.78, [95% CI:2.54-3.04]). Although high-achieving hospitals (those meeting the metrics [≥]75%) excluded more patients, they consistently maintained shorter treatment times, even when NSD patients were included in the analysis. ConclusionNSD in STEMI care is prevalent and linked to higher in-hospital mortality. While concerns about selective case exclusion exist, high-achieving hospitals consistently demonstrated excellent time-to-treatment even when patients with NSD are included.