title: Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality.
abstract: BACKGROUND
  While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality.
  
  
  METHODS
  The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003-2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: 'early presenters' versus 'late presenters'); and for (b) onset of pain-to-FMC (min) as a continuous variable.
  
  
  RESULTS
  After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013-1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001-1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368-0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex ( p=0.003), anterior infarction ( p=0.004) and diabetes mellitus ( p=0.035) were independently associated with longer delay, while hyperlipidaemia ( p=0.002) and cardiogenic shock ( p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% ( p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999-1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676-1.573; p=0.886).
  
  
  CONCLUSIONS
  In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.
authors.affiliation: 1 Cardiology and Intensive Care Medicine, Wilhelminenhospital, Austria.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Jäger
authors.affiliation: 1 Cardiology and Intensive Care Medicine, Wilhelminenhospital, Austria.
authors.forename: Serdar
authors.initials: S
authors.lastname: Farhan
authors.affiliation: 1 Cardiology and Intensive Care Medicine, Wilhelminenhospital, Austria.
authors.forename: Miklos
authors.initials: M
authors.lastname: Rohla
authors.affiliation: 2 Cardiology, Sozialmedizinsiches Zentrum Süd, Austria.
authors.forename: Günter
authors.initials: G
authors.lastname: Christ
authors.affiliation: 2 Cardiology, Sozialmedizinsiches Zentrum Süd, Austria.
authors.forename: Andrea
authors.initials: A
authors.lastname: Podczeck-Schweighofer
authors.affiliation: 3 Department of Emergency Medicine, University of Medicine, Austria.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Schreiber
authors.affiliation: 3 Department of Emergency Medicine, University of Medicine, Austria.
authors.forename: Anton N
authors.initials: AN
authors.lastname: Laggner
authors.affiliation: 4 Cardiology, Krankenhaus Rudolfstiftung, Austria.
authors.forename: Franz
authors.initials: F
authors.lastname: Weidinger
authors.affiliation: 5 Cardiology, Sozialmedizinisches Zentrum Ost, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Stefenelli
authors.affiliation: 6 Cardiology, Krankenhaus Hietzing, Austria.
authors.forename: Georg
authors.initials: G
authors.lastname: Delle-Karth
authors.affiliation: 7 Ambulance Services Vienna, Austria.
authors.forename: Alfred
authors.initials: A
authors.lastname: Kaff
authors.affiliation: 8 Department of Cardiology, Medical University Vienna, Austria.
authors.forename: Gerald
authors.initials: G
authors.lastname: Maurer
authors.affiliation: 1 Cardiology and Intensive Care Medicine, Wilhelminenhospital, Austria.
authors.forename: Kurt
authors.initials: K
authors.lastname: Huber
mesh_terms: D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention; D016016:Proportional Hazards Models; D012307:Risk Factors; D000072657:ST Elevation Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D012770:Shock, Cardiogenic / Q000453:epidemiology*; D013997:Time Factors
keywords: ST-elevation; all-cause mortality; cardiogenic schock; diabetes mellitus; first medical contact; gender; myocardial infarction; patient-related delay; primary percutaneous coronary intervention; sex