Healthcare system performance, as well as patient education and behavior, are the cornerstone in the management of STEMI and improving clinical outcomes. The emerging need to conduct this study is clear with the lack of a STEMI network in Alexandria. Reperfusion delays are the most easily audited index in STEMI management of quality care. A patient’s delay or a healthcare system’s delay is what delays the reperfusion strategy. Delay in the healthcare system is the period between FMC and reperfusion. A delay in the healthcare system can occur at many stages: Emergency Medical Services (EMS) delay, ER delay and CCU delay.
As regarding baseline characteristics, Zeymer et al. [7] described reperfusion strategy and in-hospital outcomes for STEMI patients based on 11,462 patients in Association for Acute Cardiovascular Care (ACVC)- European Association of Percutaneous Coronary Intervention (EAPCI) EurObservational programme (EORP) STEMI registry. The mean age was 61.0 year. The majority were males (76.9%), smoking and diabetes were less in percentage than our study 45.7% and 26.7%, respectively, while hypertension (47.9%), hyperlipidemia (38.5%) were higher in percentage than in our study. In a meta-analysis studying STEMI epidemiology, management, and outcomes in five Asian-Pacific countries, twenty studies, including 158 420 patients, were under investigation. Tern et al. [8] stated that 78.7% of them were males, 30.5% were diabetic, 36.7% had Hyperlipidemia. Those results are similar to demographic data in our study except for the mean age of STEMI patients that was higher (61.6 years), hypertension as risk factor was higher (53.7%) and smoking was less (53.0%) (Table 4).
The mean value of pre-hospital delay in our study was 629.0 ± 796.7 min (10.4 h) (Table 5). The main cause of Pre-hospital delay was a delay in seeking medical care (45.6%), which indicates the poor application of medical education to the general population. 17.9% of the patients had been missed diagnosed, which on the other hand, indicates deficient medical training for ER physicians and General practitioners. Lack of PCI capable facilities led to long distance and difficult transportation for 16.7% of the patients. Zeymer et al. [7] reported that average time from symptoms onset to first medical contact was 221.6 ± 460.6 min which is significantly lower than in our study. Shaheen et al. [9] studied the current practice of STEMI management in Egypt and reported that delay in seeking medical advice is the main cause of pre-hospital delay and 24% of patients presenting to PPCI hospitals arrive to the hospital within 2 h of chest pain which is significantly higher than in our study.
ER delay was appointed as the time from ER admission to CCU admission. Upon analysis, the main factor of delay was transfer delay (61.5%) due to deficient numbers of transporting equipment and personnel. ER high volume admissions with the lack of ER beds and equipment also play an important role as it delays reaching to diagnosis. Steg et al. [10] studied a total of 1204 patients, 33.1% of them were taken to the ER before being admitted to the CCU, whereas 66.9% were admitted immediately to the CCU laboratory. Direct transfer to the CCU was linked to a quicker time between the onset of symptoms and admission to the CCU (244 vs. 292 min; P < 0.001) and a higher reperfusion rate (61.7% vs. 53.1%; P = 0.001). Choosing not to use the ER also decreased five-day mortality rates (4.9% v 8.6%; P = 0.01).
As the primary PCI center, Door to balloon was calculated from the first medical contact in our emergency department through CCU to Cath lab. Mean door to crossing time was 92.86 ± 54.66 min, and the median time was 70.0 (60.0–110.0). ESC latest guidelines for the management of STEMI described Timely PPCI in PPCI capable hospital as less than 60 min from door to balloon, Zeymer et al. [7] reported 54.4% of the studied population had timely reperfusion, while in our center as PPCI capable center had 35% timely reperfusion. Tern et al. [8] stated that the median door to balloon time was 63.5 (39.7–87.2), which was consistent with our study.
In-hospital mortality, in our study was 5.5% (n = 436) irrespective of the type of management, while in the PPCI group, 2.9% (n = 280), and 12.9% (n = 124) in the conservative management group, with a statistically significant difference (P < 0.001). Within one-month mortality rate was 3.4% irrespective of the type of management, with the highest in the conservative group, 8.2%, with a statistically significant difference from other groups (MCp = 0.001). MACE rate was 27.3% (n = 436) irrespective of the type of management, while the MACE rate was 15% in the PPCI group, 28.1% in the thrombolytic group, and 54.8 in the conservative group with a statistically significant difference (P < 0.001). One month follow-up MACE rate was 17.9% irrespective of the type of management, with the highest in the conservative group at 34.1%, with a statistically significant difference from other groups (P = 0.001) (Table 6). Song et al. [11] reported an in-hospital mortality rate in primary PCI-treated patients of 3.2%, a heart failure rate of 11.3%, and MACE rate of 16.9%, which is consistent with our study in mortality but less in heart failure rate and higher in MACE rate. Zeymer et al. [7] reported in-hospital mortality of 4.4% (n = 11,462) irrespective of the type of management, while mortality occurred in 3.1% of the PPCI group (n = 8275), 4.4% (n = 2160) in thrombolytic group and 14.1% (n = 1027) conservative management group, which is consistent with our study.
In-hospital mortality was observed by Shaheen et al. [12] to be 4.65% in Egypt, 2.10% in primary PCI, 4.97% in thrombolysis, and 18.87% in no-reperfusion patients, which was higher than our study in no-reperfusion group.