In-Hospital Outcomes Associated With Initial Fibrinolysis Versus Primary Percutaneous Coronary Intervention Among Patients Residing in Rural Areas Presenting With ST-Segment Elevation Myocardial Infarction

Background: Fibrinolysis is more commonly used to manage ST-segment elevation myocardial infarction (STEMI) in rural versus urban areas. However, little is known about the outcomes associated with this treatment strategy in rural individuals. We sought to compare in-hospital outcomes associated with the use of fibrinolysis versus primary percutaneous coronary intervention (PCI) among patients residing in rural areas presenting with STEMI. Methods: We identified adult patients with STEMI between 2016 and 2021 using the United States National Inpatient Sample. The cohort was restricted to individuals residing in rural areas. Patients were divided into 2 cohorts based on the receipt of initial fibrinolysis versus primary PCI. In-hospital outcomes were compared between cohorts, with in-hospital mortality serving as the primary outcome and length of stay (LOS) serving as a secondary outcome. Results: We identified 13 475 rural STEMI encounters receiving either initial fibrinolytic therapy (n = 1095) or primary PCI (n = 12 380). The average age and number of comorbidities were similar between cohorts. In-hospital mortality occurred in 5.2% of patients, and mean LOS for initial fibrinolysis and primary PCI patients was 3.73 ± 3.739 days and 3.45 ± 3.974 days, respectively. After adjusting for covariates, initial fibrinolysis was not associated with higher in-hospital mortality (odds ratio [OR] = 0.913; 95% confidence interval [CI] = 0.679-1.228). Initial fibrinolysis was associated with a small increase in LOS compared to primary PCI (Mean difference = 0.079 days; 95%CI = 0.035-0.123). Conclusions: In this analysis of approximately 13 000 STEMI encounters among rural individuals, patient characteristics between those treated with initial fibrinolysis versus primary PCI were similar. Observed outcomes were not meaningfully different between cohorts. Fibrinolytic therapy should not be an overlooked treatment strategy in rural STEMI patients facing delays in receipt of primary PCI.