Figure 1
The study flow diagram of patients. ACS QUIK indicates Acute Coronary Syndrome Quality Improvement in Kerala; STEMI, ST-segment myocardial infarction; NSTEMI, non-ST-segment myocardial infarction; PCI, percutaneous coronary intervention; PPCI, primary percutaneous coronary intervention; nPPCI, non-primary percutaneous coronary intervention.
Table 1
Baseline Characteristics of ACS QUIK STEMI Patients Stratified by Reperfusion Strategy.
| All Patients | p-value | Propensity-Matched Patients | p-value | |||
|---|---|---|---|---|---|---|
| Non PPCI (n = 2042) | PPCI (n = 6623) | Non PPCI (n = 1266) | Primary PCI (n = 1266) | |||
| Age (years), mean (SD) | 57.3 (11.0) | 58.1 (11.3) | 0.004 | 57.1 (11.2) | 57.2 (11.5) | 0.796 |
| Female sex, n (%) | 338 (16.6) | 1291 (19.5) | 0.002 | 219 (17.3) | 230 (18.2) | 0.567 |
| Weight (kg), mean (SD) | 66.1 (9.3) | 64.7 (9.5) | <0.001 | 65.4 (10.3) | 65.1 (9.8) | 0.442 |
| Heart Rate (beats/min), mean (SD) | 77.5 (17.6) | 77.1 (16.8) | 0.248 | 78.2 (17.0) | 78.1 (18.0) | 0.891 |
| Systolic BP (mmHg), mean (SD) | 135.1 (26.6) | 136.1 (27.4) | 0.167 | 136.2 (27.4) | 135.4 (27.5) | 0.454 |
| No insurance, n (%) | 1168 (57.2) | 4351 (65.7) | <0.001 | 959 (75.8) | 945 (74.6) | 0.519 |
| Initial troponin (ng/mL), median [IQR] | 1.4 (0.2, 7.7) (n = 570) | 2.4 (0.3, 10.0) (n = 1785) | 0.054 | 2.0 (0.3, 9.4) (n = 486) | 1.9 (0.3, 8.7) (n = 439) | 0.135 |
| LDL (mg/dL), mean (SD) | 121.0 (38.6) (n = 1616) | 127.1 (41.0) (n = 4668) | <0.001 | 122.3 (42.1) (n = 997) | 127.8 (41.4) (n = 974) | 0.003 |
| Triglycerides (mg/dL), mean (SD) | 128.7 (71.9) (n = 1619) | 136.0 (73.7) (n = 4675) | <0.001 | 134.1 (72.5) (n = 1001) | 130.8 (69.2) (n = 974) | 0.300 |
| Fasting glucose (mg/dL), mean (SD) | 157.8 (69.2) (n = 1430) | 151.5 (65.6) (n = 4049) | 0.002 | 155.0 (68.0) (n = 899) | 157.2 (69.0) (n = 864) | 0.506 |
| Creatinine (mg/dl), mean (SD) | 1.1 (0.4) (n = 1309) | 1.0 (0.4) (n = 4489) | <0.001 | 1.1 (0.5) (n = 792) | 1.1 (0.4) (n = 747) | 0.227 |
| Hemoglobin (g/dl), mean (SD) | 13.8 (1.9) (n = 2025) | 13.6 (1.8) (n = 6460) | <0.001 | 13.6 (1.8) (n = 1250) | 13.7 (1.9) (n = 1235) | 0.325 |
| Killip Class, n (%) | ||||||
| 1 | 1862 (91.2) | 5915 (89.3) | 0.005 | 1117 (88.2) | 1150 (90.8) | 0.200 |
| II–IV | 180 (8.8) | 708 (10.7) | 149 (11.8) | 116 (9.2)) | ||
| Time from symptom onset to hospital arrival (min), median [IQR] | 300.0 (135.0, 870.0) (n = 1961) | 159.0 (100.0, 365.0) (n = 6406) | <0.001 | 347.5 (130.0, 1020.0) (n = 1200) | 195.0 (105.0, 510.0) (n = 1226) | <0.001 |
| Risk factors, n (%) | ||||||
| Smoking, n (%) | 693 (33.9) | 2145 (32.4) | 0.191 | 374 (29.5) | 396 (31.3) | 0.341 |
| Hypertension, n (%) | 821 (40.2) | 2580 (39.0) | 0.311 | 529 (41.8) | 504 (39.8) | 0.312 |
| Diabetes mellitus, n (%) | 869 (42.6) | 2652 (40.0) | 0.043 | 576 (45.5) | 553 (43.7) | 0.357 |
| History of cerebrovascular accident, n (%) | 22 (1.1) | 84 (1.3) | 0.49 | 17 (1.3) | 16 (1.3) | 0.860 |
[i] LDL, low-density lipoprotein cholesterol. IQR, interquartile range.
Table 2
Hospital of Presentation Characteristics.
| All Patients | p-value | Propensity-Matched Patients | p-value | |||
|---|---|---|---|---|---|---|
| Non PPCI (n = 2042) | PPCI (n = 6623) | Non PPCI (n = 1266) | PPCI (n = 1266) | |||
| Hospital Characteristics | ||||||
| Hospital type, n (%) | ||||||
| Government | 770 (37.7) | 1911 (28.9) | <0.001 | 184 (14.5) | 212 (16.7) | 0.305 |
| Non-profit/Charity | 365 (17.9) | 1993 (30.1) | 296 (23.4) | 285 (22.5) | ||
| Private | 907 (44.4) | 2719 (41.1) | 786 (62.1) | 769 (60.7) | ||
| Catheterization laboratory, n (%) | ||||||
| Installed During Study (n = 3) | 76 (3.7) | 106 (1.6) | <0.001 | 46 (3.6) | 36 (2.8) | 0.472 |
| No (n = 17) | 136 (6.7) | 55 (0.8) | 28 (2.2) | 32 (2.5) | ||
| Yes (n = 43) | 1830 (89.6) | 6462 (97.6) | 1192 (94.2) | 1198 (94.6) | ||
| Hospital size, n (%) | ||||||
| Extra large (>1000) (n = 5) | 689 (33.7) | 1439 (21.7) | <0.001 | 103 (8.1) | 108 (8.5) | 0.672 |
| Large (501–1000) (n = 15) | 658 (32.2) | 3333 (50.3) | 655 (51.7) | 642 (50.7) | ||
| Medium (201–500) (n = 24) | 437 (21.4) | 1580 (23.9) | 387 (30.6) | 408 (32.2) | ||
| Small (≤200) (n = 19) | 258 (12.6) | 271 (4.1) | 121 (9.6) | 108 (8.5) | ||
Table 3
In-hospital and On-discharge Treatment Patterns Stratified by Reperfusion Strategy.
| Non PPCI (n = 2042) | PPCI (n = 6623) | Non PPCI (n = 1266) | PPCI (n = 1266) | |||
|---|---|---|---|---|---|---|
| In-hospital Medications, n (%) | ||||||
| Aspirin | 1998/2041 (97.9) | 6571/6621 (99.2) | <0.001 | 1231/1265 (97.3) | 1251/1266 (98.8) | 0.006 |
| Second antiplatelet | 2012/2042 (98.5) | 6603/6623 (99.7) | <0.001 | 1241/1266 (98.0) | 1261/1266 (99.6) | <0.001 |
| Anticoagulant | 1673/2036 (82.2) | 5452/6615 (82.4) | 0.797 | 947/1261 (75.1) | 986/1264 (78.0) | 0.084 |
| β-blocker | 615/2013 (30.6) | 2658/6519 (40.8) | <0.001 | 519/1249 (41.6) | 433/1263 (35.2) | 0.001 |
| Reperfusion details | ||||||
| Transfer from another facility, n (%) | 1199 (58.7) | 2655 (40.1) | <0.001 | 616 (48.7) | 632 (49.9) | 0.524 |
| Door-to-balloon time (STEMI), median [IQR], min | 90 (60, 212) (N = 1493) | 70 (53, 103) (n = 6168) | <0.001 | 108 (60, 333) (N = 802) | 75 (52, 115) (n = 1165) | <0.001 |
| Echocardiography, n (%) | 1972 (96.6) | 6342 (95.8) | 0.102 | 1202 (94.9) | 1202 (94.9) | 1.000 |
| Stents placed, n (%) | 1854 (90.8) | 6293 (95.0) | <0.001 | 1132 (89.4) | 1203 (95) | <0.001 |
| DES, n (%) | 1696/1845 (91.5) | 6092/6293 (96.8) | <0.001 | 1013/1132 (89.5) | 1136/1203 (94.4) | <0.001 |
| Location of stents | ||||||
| LAD, n (%) | 1015 (54.7) | 3240 (51.5) | 0.013 | 616 (54.4) | 602 (50.0) | 0.034 |
| Discharge treatment and counseling, n (%) | ||||||
| Aspirin | 1981/1994 (99.3) | 6412/6436 (99.6) | 0.099 | 1225/1237 (99.0) | 1227/1238 (99.1) | 0.832 |
| Second antiplatelet | 1958/1994 (98.2) | 6384/6442 (99.1) | <0.001 | 1208/1237 (97.7) | 1219/1240 (98.3) | 0.249 |
| β-blocker | 1140/1968 (57.9) | 4537/6319 (71.8) | <0.001 | 812/1217 (66.7) | 761/1209 (62.9) | 0.051 |
| Statin | 1911/1986 (96.2) | 6287/6438 (97.7) | <0.001 | 1169/1229 (95.1) | 1201/1239 (96.9) | 0.020 |
| ACEi or ARB | 696/1966 (35.4) | 3664/6319 (58.0) | <0.001 | 521/1210 (43.1) | 528/1212 (43.6) | 0.801 |
| Cardiac rehabilitation referral | 251/1911 (13.1) | 2120/6335 (33.5) | <0.001 | 232/1147 (20.2) | 290/1196 (24.2) | 0.019 |
[i] STEMI, ST-segment myocardial infarction; DES, drug-eluting stent; LAD, left anterior descending artery; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.
Figure 2
Relative Risk (RR) for in-hospital major adverse cardiac events in propensity-matched cohort according to subgroup. Onset refers to the time from symptom onset to hospital presentation. CI indicates confidence interval; LAD, left anterior descending artery; HTN, hypertension; DM, diabetes mellitus.
Table 4
Risk of adverse clinical outcomes among STEMI patients comparing non-PPCI to PCI.
| All Patients | p-value | Propensity-Matched Patients | p-value | |||||
|---|---|---|---|---|---|---|---|---|
| Non PPCI (n = 2042) | PPCI (n = 6623) | Unadjusted RR (95% CI) | Non PPCI (n = 1266) | PPCI (n = 1266) | Adjusted RR (95% CI) | |||
| In-hospital outcomes | ||||||||
| MACE | 56 (2.7) | 207 (3.1) | 0.88 (0.66, 1.17) | 0.377 | 45 (3.6) | 42 (3.3) | 1.07 (0.71, 1.62) | 0.74 |
| Mortality | 32 (1.6) | 156 (2.4) | 0.67 (0.46, 0.97) | 0.032 | 24 (1.9) | 23 (1.8) | 1.043 (0.59, 1.84) | 0.882 |
| Shock | 53 (2.6) | 101 (1.5) | 1.70 (1.23, 2.36) | 0.001 | 16 (1.3) | 12 (0.9) | 1.333 (0.63, 2.81) | 0.447 |
| Heart failure | 35 (1.7) | 132 (2.0) | 0.86 (0.59, 1.24) | 0.422 | 24 (1.9) | 22 (1.7) | 1.091 (0.62, 1.94) | 0.766 |
| Cardiac arrest | 31 (1.5) | 129 (1.9) | 0.78 (0.53, 1.15) | 0.207 | 20 (1.6) | 29 (2.3) | 0.69 (0.39, 1.21) | 0.194 |
| Reinfarction | 26 (1.3) | 40 (0.6) | 2.11 (1.29, 3.45) | 0.002 | 24 (1.9) | 14 (1.1) | 2.43 (1.31, 4.503) | 0.102 |
| Stroke | 4 (0.2) | 18 (0.3) | 0.72 (0.24, 2.13) | 0.551 | 3 (0.2) | 6 (0.5) | 0.50 (0.13, 2.00) | 0.507 |
| Major bleeding | 3 (0.1) | 9 (0.1) | 1.08 (0.29, 3.99) | 0.99 | 2 (0.2) | 1 (0.1) | 2.0 (0.182, 22.03) | 0.99 |
| Post-STEMI LVEF (%), median [IQR] | 50 (45, 60) | 53 (45, 59) | 1.01 (1.01, 1.02) | <0.001 | 52 (45, 60) | 52 (45, 60) | 1.00 (0.99, 1.02) | 0.727 |
| 30-day outcomes | ||||||||
| 30-d MACE | 69/2025 (3.4) | 266/6562 (4.1) | 0.84 (0.65, 1.09) | 0.189 | 55/1252 (4.4) | 58/1252 (4.6) | 0.948 (0.661, 1.36) | 0.772 |
| 30-d mortality | 41/2025 (2.0) | 200/6562 (3.0) | 0.67 (0.48, 0.93) | 0.014 | 30/1252 (2.4) | 32/1252 (2.6) | 0.938 (0.573, 1.533) | 0.797 |
| 30-d CVD mortality | 40/2025 (2.0) | 195/6562 (3.0) | 0.67 (0.48, 0.93) | 0.016 | 29/1252 (2.3) | 31/1252 (2.5) | 0.935 (0.567, 1.543) | 0.793 |
| Stroke | 7/2025 (0.3) | 36/6563 (0.5) | 0.63 (0.28, 1.42) | 0.258 | 5/1252 (0.4) | 11/1252 (0.9) | 0.455 (0.158, 1.304) | 0.132 |
| 30-d major GUSTO bleeding | 3/2025 (0.1) | 15/6623 (0.2) | 0.65 (0.19, 2.24) | 0.591 | 2/1252 (0.2) | 3/1252 (0.2) | 0.667 (0.112, 3.983) | 1.000 |
| Reinfarction | 29/2025 (1.4) | 50/6563 (0.8) | 1.88 (1.19, 2.96) | 0.005 | 27/1252 (2.2) | 18/1252 (1.4) | 1.5 (0.83, 2.71) | 0.175 |
[i] MACE: death, reinfarction, stroke or major bleeding. Values are n (%).
STEMI, ST-segment myocardial infarction; LVEF, left ventricular ejection fraction; IQR, interquartile range; CVD, cardiovascular disease; Global Utilization Of Streptokinase And Tpa For Occluded Arteries (GUSTO).