USA: According to a recent study published in JAMA Cardiology, rural ST-segment elevation myocardial infarction (STEMI) patients experienced longer delays to reperfusion. Also, they were less likely to have primary percutaneous coronary intervention (PPCI) or meet guideline-recommended timings to reperfusion and were more inclined to receive fibrinolytic compared to urban STEMI patients.

PAUSE
Although acute ST-segment elevation myocardial infarction (STEMI) mortality has decreased recently and coronary therapy has improved, STEMI is still one of the deadliest diseases. When compared to their urban counterparts, patients with ST-segment elevation myocardial infarction who live in rural areas frequently experience inferior clinical results. Uncertainty exists on the cause of this disparity, which may be brought on by clinical traits or delays in prompt reperfusion following primary percutaneous coronary intervention (PPCI) or fibrinolysis.

The authors aimed to evaluate process parameters and results for STEMI patients in both urban and rural locations across the US.
For this purpose, a cross-sectional multicenter analysis examined information for 70,424 adult STEMI patients from 686 enrolling US hospitals that participated in the National Cardiovascular Data Registry Chest Pain-MI Registry between January 1, 2019, and June 30, 2020. Patients without a verified zip code were eliminated, and outcome analysis did not include patients who were transferred to another hospital throughout the course of the trial. The primary outcomes were in-hospital mortality and time-to-reperfusion measures.

Findings of the study:
When compared to patients in urban settings, patients from rural settings had a lower likelihood of undergoing PPCI (73.2% vs. 85.1% respectively). They got fibrinolytic more frequently (19.7% vs 2.7%)
The median (IQR) time from first medical contact to catheterization laboratory activation was longer in rural patients undergoing PPCI (30 minutes vs 22 minutes) and the median time from first medical contact to the device was also longer (99 minutes vs 81 minutes).
Individuals from urban settings were much more inclined to suffer an out-of-hospital cardiac arrest (6.1% vs 4.9%) and were also more frequently diagnosed with heart failure (8.1% vs 6.7%).
The in-hospital death rate among rural and urban groups did not significantly vary after multivariable adjustment (adjusted odds ratio, 0.97).
There was no discernible difference in adjusted mortality between patients with STEMI in rural and urban settings, despite variations in risk variables and measures of time to reperfusion, concluded the authors.
REFERENCE:
Hillerson D, Li S, Misumida N, et al. Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry. JAMA Cardiol. Published online August 31, 2022. doi:10.1001/jamacardio.2022.2774