Analysis of Potential Factors Contributing to Refusal of Invasive Strategy After ST-Segment Elevation Myocardial Infarction in China
ST-segment elevation myocardial infarction (STEMI) is a severe and life-threatening condition that requires immediate medical intervention to restore blood flow to the heart. Percutaneous coronary intervention (PCI) is a widely accepted and effective treatment for STEMI, significantly reducing mortality rates when applied promptly. However, despite its proven benefits, a substantial proportion of eligible patients in China refuse to undergo PCI, leading to poorer outcomes. This study aims to identify the potential factors contributing to the refusal of PCI among STEMI patients in China and to explore sex differences in these factors.
Introduction
Reperfusion therapy, particularly PCI, is the cornerstone of treatment for STEMI, as it restores blood flow to the occluded coronary artery, reducing myocardial damage and improving survival rates. Despite advancements in medical technology and increased awareness, many patients in China still do not receive timely reperfusion therapy, even when they have no absolute contraindications. This phenomenon raises concerns about the barriers to PCI acceptance and the factors influencing patients’ decisions. Understanding these factors is crucial for developing targeted interventions to improve the uptake of PCI and, consequently, patient outcomes.
Methods
This study was conducted as a retrospective analysis of data from a prospective cohort study. The primary data were collected from a multicenter registry of STEMI patients presenting to the emergency departments (EDs) of six public hospitals in China between August 24, 2015, and September 30, 2017. All participating hospitals were equipped with catheterization centers capable of providing 24-hour interventional therapy, including four tertiary and two secondary hospitals.
A total of 1061 patients were diagnosed with STEMI during the study period. After excluding patients who did not meet the inclusion criteria, 957 patients (260 women and 697 men) were included in the final analysis. Patients were divided into two groups: those who refused PCI (n=98) and those who underwent PCI (n=859). Baseline characteristics, medical history, clinical status at presentation, and 30-day outcomes were compared between the two groups. Multivariable logistic regression analysis was used to identify potential factors associated with the refusal of PCI.
Results
The study revealed several significant differences between patients who refused PCI and those who underwent the procedure. Patients who refused PCI were more likely to be older than 65 years (odds ratio [OR] 2.66, 95% confidence interval [CI] 1.56–4.52, P < 0.001), have a lower body mass index (BMI) (OR 0.91, 95% CI 0.84–0.98, P = 0.013), and be unmarried (OR 0.29, 95% CI 0.17–0.49, P < 0.001). Additionally, a history of myocardial infarction (MI) (OR 2.59, 95% CI 1.33–5.04, P = 0.005), higher heart rate (HR) at presentation (OR 1.02, 95% CI 1.01–1.03, P = 0.002), and the presence of cardiac shock in the ED (OR 5.03, 95% CI 1.48–17.08, P = 0.010) were associated with a higher likelihood of refusing PCI.
Pre-hospital delay, defined as the time from symptom onset to arrival at the ED exceeding 12 hours, was another significant factor (OR 3.31, 95% CI 1.83–6.02, P < 0.001). Patients who were not hospitalized in tertiary hospitals were also more likely to refuse PCI (OR 0.45, 95% CI 0.27–0.75, P = 0.002). Furthermore, women were found to be older, less often married, had a lower BMI, and were less likely to be hospitalized in tertiary hospitals compared to men.
Discussion
The findings of this study highlight several key factors that contribute to the refusal of PCI among STEMI patients in China. Older age emerged as a significant predictor, with patients over 65 years being more than twice as likely to refuse PCI. This may be due to a combination of factors, including a higher prevalence of comorbidities, reduced perceived benefit of invasive procedures, and potential financial constraints. The lower BMI observed in the refusal group may reflect a population with poorer overall health status, which could influence their decision to avoid invasive treatments.
Marital status also played a role, with unmarried patients being less likely to undergo PCI. This could be attributed to the lack of social support, which is often provided by a spouse, influencing both the decision-making process and the ability to manage the logistical aspects of receiving timely medical care. The higher prevalence of pre-hospital delay in the refusal group underscores the importance of timely medical intervention and suggests that delayed presentation may be associated with a lower likelihood of accepting PCI.
Cardiac shock at presentation was a strong predictor of PCI refusal, possibly due to the critical condition of these patients, which may lead to a more conservative approach by both patients and healthcare providers. However, it is important to note that even in patients with cardiogenic shock, aggressive PCI treatment has been shown to improve outcomes. The lower likelihood of PCI acceptance in non-tertiary hospitals may reflect disparities in the availability of resources, expertise, and patient education between hospital levels.
Sex Differences in PCI Refusal
The study also explored sex differences in the factors associated with PCI refusal. Women were found to be older, had a lower BMI, and were less often married compared to men. These factors may contribute to the higher refusal rates observed among women. Additionally, women were less likely to be hospitalized in tertiary hospitals, which may further limit their access to PCI.
Multivariable analysis revealed that BMI, marital status, history of MI, HR, cardiac shock in the ED, pre-hospital delay, and tertiary hospital status were significant predictors of PCI refusal in women. In contrast, only age, marital status, and pre-hospital delay were significant predictors in men. These findings suggest that women face unique barriers to PCI acceptance, which may require targeted interventions to address.
Implications for Clinical Practice
The results of this study have important implications for clinical practice and public health interventions. Efforts to improve the acceptance of PCI among STEMI patients should focus on addressing the identified barriers, particularly for older patients, those with lower socioeconomic status, and women. Educational campaigns aimed at increasing awareness of the benefits of PCI and reducing pre-hospital delays could play a crucial role in improving outcomes. Additionally, healthcare providers should be encouraged to offer more aggressive treatment recommendations, especially in patients with critical conditions such as cardiac shock.
Conclusion
In conclusion, this study identified several factors contributing to the refusal of PCI among STEMI patients in China, including older age, lower BMI, unmarried status, history of MI, higher HR, cardiac shock in the ED, pre-hospital delay, and treatment at non-tertiary hospitals. Sex differences in these factors highlight the need for targeted interventions to improve PCI acceptance, particularly among women. By addressing these barriers, healthcare providers can improve the uptake of PCI and, ultimately, patient outcomes.
doi.org/10.1097/CM9.0000000000001171
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