Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction

Abstract

Background: The aim of this study was a) To identify predictors of the use of aspirin in the pre-hospital setting in acute myocardial infarction (AMI) and b) To analyze whether the use of any of the recommended medications was associated with outcome. Methods: All patients with a final diagnosis of AMI, transported by the Emergency Medical Services (EMS) and admitted to the coronary care unit at Sahlgrenska University Hospital in Gothenburg, Sweden, in 2009-2011, were included. Results: 1,726 patients were included. 58% received aspirin by the EMS. Ischemic heart disease (IHD) was suspected in 84%. Among patients who did not receive aspirin IHD was still suspected in 67%. Among patients in whom IHD was suspected, and who were not on chronic treatment with aspirin the following predicted its pre-hospital use: a) age (odds ratio 0.98; 95% confidence interval (CI) 0.96-0.99); b) a history of myocardial infarction (2.21; 1.21-4.04); c) priority given by EMS (8.07; 5.42-12.02); d) ST-elevation on ECG on admission to hospital (2.22; 1.50-3.29); e) oxygen saturation > 90% (3.37; 1.81-6.27). After adjusting for confounders among patients who were not on chronic aspirin, only nitroglycerin of the recommended medications was associated with a reduced risk of death within 1year (hazard ratio 0.40; 95% CI 0.23-0.70). Conclusions: Less than six out of ten patients with AMI received pre-hospital aspirin. Five clinical factors were independently associated with the pre-hospital administration of aspirin. This suggests that the decision to treat is multifactorial, and it highlights the lack of accurate diagnostic tools in the pre-hospital environment. Nitroglycerin was independently associated with a reduced risk of death, suggesting that we select the use for a low-risk cohort.