Rural urban differences in management and outcomes of patients with ST-segment elevation myocardial infarction; insights from SCALIM a french regional registry

Abstract

Abstract Background The prognostic disparities among rural and urban patients experiencing ST-segment elevation myocardial infarction (STEMI) is debated. While access to primary percutaneous coronary intervention (PPCI) facilities, and speed of initial management is of a paramount importance, the long-term outcome depends also on the quality of secondary prevention. Few studies address the prognostic parameters during the acute phase and long-term management simultaneously. Purpose We aimed to assess differences in the short- and long-term management of urban and rural patients experiencing STEMI in the predominantly rural region of Limousin, France. Methods From 05/2015 to 05/2019, all consecutive patients residing in the Limousin region and experiencing STEMI were included. The cohort was subdivided into 2 groups according to residential zipcodes: rural vs. urban. The primary outcome was major adverse cardiac and cerebrovascular (MACCE) (composite of cardiovascular mortality, myocardial infarction, coronary revascularization, ischemic stroke, peripheral vascular events and cardiovascular rehospitalization). The quality of secondary prevention was also assessed. Results A total of 705 patients (449 (63.7%) rural and 256 (36.8%) urban) were included. Patient delay (from symptom onset to first medical contact) and total delay (from symptom onset to coronary guidewire) were higher in the rural patients (Figure 1). No difference was found in in-hospital outcomes between the two groups. After STEMI, access to cardiac rehabilitation was similar between rural and urban populations (70.6% vs. 66.5%; p=0.502). Smoking cessation at 1 year was more often achieved in rural patients (68.6% vs. 51.7% in urban patients; p = 0.003). At follow up, the prescription of antithrombotic and lipid-lowering agents in rural patients was maintained in 92.8% and 85.6%, respectively with no difference observed in comparison with urban patients (93.8% and 86%, respectively; all p >0.05). The mean follow-up time was 54.7 ± 22.7 months. Five-year MACCE-free survival was similar in the rural and urban groups (75.3% vs. 73.8% respectively; p= 0.812). Conclusions Our study contradicts most studies performed elsewhere, and this might be related to overall shorter distances from rural zones to PCI in France, higher rehabilitation rates than elsewhere, as well as a full insurance coverage without residential disparity in secondary prevention.Figure 1