title: Evaluating clinical reason and rationale for not delivering reperfusion therapy in ST elevation myocardial infarction patients: Insights from a comprehensive cohort.
abstract: BACKGROUND
  In ST elevation myocardial infarction (STEMI), reperfusion therapy is lifesaving but is not delivered in approximately one quarter of patients. To address this care gap, we reviewed all STEMI patients that did not receive reperfusion to identify patient characteristics, in-hospital outcomes and the clinical reason or rationale for withholding reperfusion therapy.
  
  
  METHODS
  A prospective chart review identified a consecutive cohort of STEMI patients over one-year within a defined health care region with independent data abstraction. Subsequently a trained nurse completed retrospective chart review and categorized patients by rationale for failure to receive reperfusion.
  
  
  RESULTS
  Of 745 STEMI patients, 181 (24.3%) did not receive reperfusion. Compared to those receiving reperfusion, they were older (67.5 vs. 58.0years, p=0.001) with more comorbidities and higher in-hospital mortality (15.5% vs. 3.5% p=<0.0001). After excluding 35 patients (unavailable data) there were 146 STEMI patients for qualitative determination. Patient delay greater than 12hours from symptom onset accounted for the majority of patients (56/146, 38.4%). In 19.9% (29/146), conservative medical management with documented rationale occurred. Following angiography, primary PCI was attempted but was unsuccessful or no culprit lesion identified in 19.2% (28/146). The diagnosis of STEMI was missed or no rationale for failure to deliver therapy identified in 8.2% (12/146). Death prior to planned reperfusion occurred in 8 (8/146, 5.5%).
  
  
  CONCLUSIONS
  Legitimate rationale exists for the majority of STEMI patients not receiving reperfusion. Ultimately, only 1.6% (12/745) of consecutive STEMI patients failed to receive reperfusion without documented rationale or due to missed diagnosis.
authors.affiliation: University of Alberta, Canada; Mazankowski Alberta Heart Institute, Canada. Electronic address: Robert.Welsh@albertahealthservices.ca.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.affiliation: Alberta Health Services, Canada.
authors.forename: Jessica
authors.initials: J
authors.lastname: Deckert-Sookram
authors.affiliation: University of Alberta, Canada.
authors.forename: Sunil
authors.initials: S
authors.lastname: Sookram
authors.affiliation: Alberta Health Services, Canada.
authors.forename: Shelley
authors.initials: S
authors.lastname: Valaire
authors.affiliation: University of Alberta, Canada; Royal Alexandra Hospital, Canada.
authors.forename: Neil
authors.initials: N
authors.lastname: Brass
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D000072700:Conservative Treatment; D019468:Disease Management; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D000072657:ST Elevation Myocardial Infarction / Q000453:epidemiology* / Q000628:therapy*
keywords: Qualitative research; Reperfusion; STEMI