An Evaluation of the Use of Fibrinolytic Therapy for Treatment of STEMI in Northern New England Over Two Decades.

Background: Geographic challenges complicate treatment of rural patients with ST-elevation myocardial infarction (STEMI), and many undergo a pharmacoinvasive (PI) strategy for optimal STEMI management. The PI population remains vastly understudied in contemporary interventional cardiology practice. This study sought to evaluate the changing comorbidities, clinical characteristics, treatment strategies and in-hospital outcomes over a twenty-year period between the premodern era (2001-2012) and the modern era (2013-2020) of patients who underwent a PI strategy for STEMI. Methods: All patients presenting with a STEMI and treated with a PI strategy within the Dartmouth-Health regional STEMI network over a 20-year period were retrospectively analyzed. Patients were stratified to the premodern era (2000-2012) or the modern era (2013-2020), and patient-level data were compared between eras. Two coprimary outcomes of in-hospital major adverse cardiac events (death, recurrent myocardial infarction, ischemic stroke, and hemorrhagic stroke) and bleeding complications were compared between eras. Results: Despite an increase in the global burden of cardiovascular comorbidities over the past 2 decades, comorbidities remained constant in this patient population over time. In contrast with the observed temporal improvements in STEMI outcomes in urban populations, adjusted in-hospital MACE (7.2% vs 6.9%, Conclusions: In a large cohort of rural STEMI patients treated with a PI strategy over the past 20 years, care delivery metrics improved, while in-hospital outcomes remained largely unchanged over time. This presents a target for future strategies to improve cardiovascular care in rural patient populations.