Study Suggests ICU Care May Be Overutilized in Stable STEMI Patients

A study led by Dr. Jay S. Shavadia published in JACC: Cardiovascular Interventions showed that although more than 80% of stable patients with an ST-elevation myocardial infarction (STEMI) were treated in the intensive care unit (ICU), the risk of developing a complication requiring ICU care was around 16%. These findings suggest that implementing a risk-based triage strategy could be a better alternative to the current strategy where patients with STEMI are typically admitted to the ICU.

Due to the risk of ventricular arrhythmias in an era prior to primary percutaneous coronary intervention (PCI), many guidelines have endorsed an initial ICU admission for all patients with STEMI. However, advancements in PCI have led to a decrease in the risk of acute cardiovascular complications requiring ICU care. The National Cardiovascular Data Registry Chest-Pain MI Registry is a large quality improvement initiative that includes 34,623 patients with myocardial infarction. Using the data from the registry, the authors aimed to identify the proportion of stable patients with STEMI admitted to the ICU, assess the rate of complications requiring ICU care and identify factors associated with an increased risk of in-hospital complications requiring ICU care. These complications included death, cardiac arrest, post-admission shock, stroke, high-grade atrioventricular (AV) block requiring treatment or post-admission respiratory failure.

Out of the 34,623 patients in the registry, 19,507 patients with STEMI and an uncomplicated primary PCI were included in the study. Around 82% (16,047 patients) were admitted to the ICU after PCI. Compared to the patients not admitted to the ICU, patients admitted to the ICU were more likely to be female, have signs of heart failure, present during work hours, and present to larger hospitals. Of all the patients in the study, 16% (3,159 patients) developed a complication requiring ICU care. Out of the patients admitted to the ICU, 18% (2,889 patients) required ICU care. Of the patients admitted to the ICU, 4.1% died, 4.1% developed a cardiac arrest, 9.8% developed shock, 4.6% had a high-grade AV block requiring treatment and 6.4% developed respiratory failure. Among patients with STEMI not admitted to the ICU, 7.8% (270 patients) developed a complication requiring ICU care, with the most common complication being shock (3.6%, 123 patients). The authors found that patients with longer time from first medical contact to device (FTD) had higher rates of in-hospital death, cardiac arrest, shock, and respiratory failure. Factors associated with an increased risk of developing a complication requiring ICU care included lower systolic blood pressure, heart rate on first medical contact, heart failure, initial serum creatinine, female sex, increasing age and time from first medical contact to PCI.

The authors concluded that although a majority of patients in the study did not develop ICU-requiring complications, a considerable portion did. The results of the study highlight the need to develop an ICU triage system so that patients at a higher risk of complications can be monitored in the ICU while those at lower risk can be safely monitored at a lower intensity unit such as a telemetry ward. When discussing the study, Dr. Shavadia wrote, “ICU resources are finite, and the costs of ICU care are substantial. In current clinical practice, the majority of eligible patients with STEMI receive timely reperfusion; in this STEMI population, our study provides a contemporary quantification of risk aimed at leveraging a safe, risk-based ICU utilization strategy rather than the current universal ICU utilization strategy.” In an editorial published with the article, Dr. Ahmed Abdel-Latif echoes the study’s message and said, “The high ICU utilization pattern, despite declining complications following PPCI, calls for a new approach. This is particularly important because the overall health care cost continues to grow and calls for optimal resource utilization to prevail. Despite the assertion that FTD time is an important outcome predictor in elderly STEMI patients, studies challenging the outdated system-based practice with a more comprehensive, yet simple-to-follow, algorithm for risk stratification of STEMI patients are imperative.”