Impact of Patient Unawareness and Socioeconomic Factors on Patient Presentation to Primary Percutaneous Coronary Intervention

Khalfallah, Mohamed; Allaithy, Amany; Maria, Dina A.

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Arquivos Brasileiros de Cardiologia

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Original Article • Arq. Bras. Cardiol. 119 (1) • July 2022 • https://doi.org/10.36660/abc.20210521 copy

Impact of Patient Unawareness and Socioeconomic Factors on Patient Presentation to Primary Percutaneous Coronary Intervention

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Patient unawareness about acute myocardial infarction, its complications and the benefits of early revascularization is a crucial point that determines the outcomes. Moreover, the relationship between socioeconomic factors and patient presentation to primary percutaneous coronary intervention (PPCI) has not been fully studied.

Objectives:

Our objective was to investigate whether or not patient unawareness and other socioeconomic factors impact patient presentation to PPCI.

Methods:

The study comprised 570 patients with ST-segment elevation myocardial infarction (STEMI) revascularized by PPCI. The patients were classified into two groups according to the total ischemia time (the time from STEMI symptom onset to balloon dilatation); group I: Patients with early presentation (1-12 hours). Group II: Patients with late presentation (>12-24 hours). Socioeconomic factors, clinical outcomes including mortality and major adverse cardiac events (MACE) were evaluated in each group. A p-value < 0.05 was considered statistically significant.

Results:

There are different socioeconomic factors affecting patient presentation to PPCI. Multivariate regression analysis identified the independent socioeconomic predictors as following: low educational level - OR 4.357 (CI95% 1.087–17.47, p=0.038), social isolation - OR 4.390 (CI95% 1.158–16.64, p=0.030) and unawareness about the benefits of early revascularization - OR 4.396 (CI95% 1.652–11.69, p=0.003). Mortality and MACE were higher in group II.

Conclusion:

Patient unawareness and low socioeconomic status were associated with late presentation to PPCI with more adverse outcomes.

Keywords:
Socioeconomic Factors; Percutaneous Coronary Intervention; Myocardial Infarction

	Group I (n=280) (1-12 hours)	Group II (n=290) (>12-24 hours)	p-value
Age, years	57.16±12.01	56.60±12.06	0.574
Male gender, n (%)	139 (49.6%)	146 (50.3%)	0.867
Smoking, n (%)	74 (26.4%)	79 (27.2%)	0.827
Hypertension, n (%)	94 (33.6%)	91 (31.4%)	0.576
Diabetes mellitus, n (%)	84 (30.0%)	91 (31.4%)	0.721
Dyslipidemia, n (%)	97 (34.6%)	106 (36.6%)	0.634
Prior MI, n (%)	22 (7.9%)	27 (9.3%)	0.536
Previous stroke, n (%)	9 (3.2%)	8 (2.8%)	0.749
Peripheral vascular disease, n (%)	36 (12.9%)	35 (12.1%)	0.776
Atrial fibrillation, n (%)	24 (8.6%)	41 (14.1%)	0.037^* * significant p-value.
BMI, (kg/m²)	25.26±4.01	25.42±4.36	0.638
Anti-hypertensive medication use, n (%)	84 (30.0%)	76 (26.2%)	0.314
Cholesterol lowering medication use, n (%)	76 (27.1%)	77 (26.6%)	0.873
Anti-platelet medication use, n (%)	97 (34.6%)	89 (30.7%)	0.314
Systolic BP, mmHg	125.3±17.85	124.1±20.9	0.462
Diastolic BP, mmHg	77.50±8.20	76.26±9.50	0.096
LVEF, (%)	47.50±4.65	45.86±6.46	0.001^* * significant p-value.
Hemoglobin, g/dL	11.56±1.48	11.61±1.46	0.646
Random blood glucose, mg/dL	162.5±43.8	160.6±49.9	0.621
Serum creatinine, mg/dL	1.036±0.23	1.093±0.24	0.006^* * significant p-value.
CK-MB, U/L	72.53±33.07	81.98±43.47	0.004^* * significant p-value.
Volume of contrast agent,(mL)	184.2±69.9	182.2±65.3	0.728

		Group I (n=280) (1-12 hours)	Group II (n=290) (>12-24 hours)	p-value
Has seen a medical specialist in the previous year, n (%)		193 (68.9%)	113 (39.0%)	0.001^* * significant p value.
Compliance with medical treatment, n (%)		159 (56.8%)	121 (41.7%)	0.001^* * significant p value.
Income category
	High income, n (%)	88 (31.4%)	77 (26.6%)	0.199
	Low income, n (%)	192 (68.6%)	213(73.4%)	0.199
Level of schooling
	Bachelor's degree or higher, n (%)	119 (42.5%)	88 (30.3%)	0.003^* * significant p value.
	High school or less, n (%)	161 (57.5%)	202 (69.7%)	0.003^* * significant p value.
Social isolation
	Lives with others, n (%)	248 (88.6%)	228 (78.6%)	0.001^* * significant p value.
	Lives alone, n (%)	32 (11.4%)	62 (21.4%)	0.001^* * significant p value.
Beck Depression Inventory
	Normal, n (%)	247 (88.2%)	250 (86.2%)	0.473
	Abnormal, n (%)	33 (11.8%)	40 (13.8%)	0.473
Marital Status
	Married, n (%)	188 (67.1%)	177 (61.0%)	0.129
	Separated/Divorced/Single/	92 (32.9%)	113 (39.0%)
	Widow/Widower, n (%)	92 (32.9%)	113 (39.0%)
Employment status
	Employed, n (%)	173 (61.8%)	170 (58.6%)	0.718
	Retired, n (%)	50 (17.9%)	54 (18.6%)
	Unemployed, n (%)	57 (20.4%)	66 (22.8%)
Awareness about the benefits of early revascularization, n (%)		179(63.9%)	103 (35.5%)	0.001^* * significant p value.
Onset of chest pain during night hours, n (%)		112 (40.0%)	148 (51.0%)	0.008^* * significant p value.
Health insurance, n (%)		89 (31.8%)	81 (27.9%)	0.315
Living away from health care providers, n (%)		33 (11.8%)	52 (17.9%)	0.039^* * significant p value.

		Group I (n=280) (1-12 hours)	Group II (n=290)(>12-24 hours)	p-value
Interval from symptom onset to FMC, (hours)		7.61±2.71	18.34±3.41	0.001^* * significant p value.
Interval from FMC to balloon dilation, (minutes)		63.98±19.50	64.04±19.45	0.971
Initial TIMI flow
	0-2	246 (87.9%)	265 (91.4%)	0.168
	3	34 (12.1%)	25 (8.6%)	0.168
Post-procedural TIMI flow
	0	2 (0.7%)	7 (2.4%)	0.027^* * significant p value.
	1	8 (2.9%)	18 (6.2%)
	2	13 (4.6%)	22 (7.6%)
	3	257 (91.8%)	243(83.8%)
Thrombus burden
	Low	147 (52.5%)	116 (40.0%)	0.010^* * significant p value.
	Moderate	85 (30.4%)	106 (36.6%)
	High	48 (17.1%)	68 (23.4%)
Aspiration catheter		22 (7.9%)	39 (13.4%)	0.031^* * significant p value.
Glycoprotein IIb/IIIa inhibitors		26 (9.3%)	48 (16.6%)	0.010^* * significant p value.
Reperfusion type
	Balloon angioplasty	8 (2.9%)	14 (4.8%)	0.466
	Direct stenting	56 (20.0%)	55 (19.0%)
	Stenting after pre-dilation	216 (77.1%)	221 (76.2%)
Length of the lesion, mm		21.39±5.40	20.73±5.25	0.143
Culprit vessel
LM coronary artery, n (%)		6 (2.1%)	7 (2.4%)	0.829
LAD coronary artery, n (%)		111 (39.6%)	121 (41.7%)	0.613
	CX coronary artery, n (%)	85 (30.4%)	90 (31.0%)	0.861
Right coronary artery, n (%)		78 (27.9%)	72 (24.8%)	0.412

	Group I (n=280) (1-12 hours)	Group II (n=290) (>12-24 hours)	p-value
Mortality, n (%)	7 (2.5%)	17 (5.9%)	0.046^* * significant p value.
Cardiogenic shock, n (%)	15 (5.4%)	30 (10.3%)	0.027^* * significant p value.
Cardiac arrest, n (%)	16 (5.7%)	12 (4.1%)	0.384
Contrast-induced nephropathy, n (%)	26 (9.3%)	34 (11.7%)	0.343
Heart failure, n (%)	23 (8.2%)	42 (14.5%)	0.019^* * significant p value.
Major bleeding, n (%)	2 (0.7%)	5 (1.7%)	0.274
Reinfarction, n (%)	4 (1.4%)	6 (2.1%)	0.560
Repeat revascularization, n (%)	4 (1.4%)	7 (2.4%)	0.393
Cerebral stroke, n (%)	2 (0.7%)	3 (1.0%)	0.682
No-reflow phenomenon, n (%)	25 (8.9%)	47 (16.2%)	0.009^* * significant p value.

	Multivariate analysis		value-p
	OR	(95% CI)	value-p
Has seen a medical specialist in the previous year	2.364	0.866–6.450	0.093
Compliance with medical treatment	1.237	0.436–3.511	0.689
Level of schooling	4.357	1.087–17.47	0.038^* * significant p value.
Social isolation	4.390	1.158–16.64	0.030^* * significant p value.
Awareness about the benefit of early revascularization	4.396	1.652–11.69	0.003^* * significant p value.
Chest pain onset during the night hours	1.707	0.493–5.909	0.398
Living away from health care providers	1.001	0.279–3.598	0.999

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[1] Correspondência: Mohamed Khalfallah • Faculdade de Medicina, Tanta University – 31Elgeish street, Tanta – Egito. E-mail: khalfallah@yahoo.com