Prehospital and hospital delays and ambulance use in foreign-born versus native-born patients with ST-elevation myocardial infarction – a nationwide SWEDEHEART study

Background

Ambulance use and delay times are critical components of ST-elevation myocardial infarction (STEMI) care. Delays in managing STEMI patients are associated with increased morbidity and mortality. Foreign-born patients may face unique challenges in seeking timely care. Whether prehospital and hospital delays differ between foreign-born and native-born patients remains understudied.

Purpose

To assess possible disparities in ambulance use and delays in STEMI care, comparing foreign-born and native-born patients.

Methods

This retrospective study included all STEMI patients recorded in the SWEDEHEART MI registry in Sweden from 2008-2022. The exposure was country or region of birth, categorised into seven groups (Figure 1). Outcomes were: 1) ambulance use; 2) prehospital delay time (PHDT, defined as time from symptom onset to hospital admission) <120 min; 3) hospital delay time (HDT, defined as time from hospital admission to initiation of reperfusion therapy) <30 min; and 4) total ischaemic time (defined as time from symptom onset to initiation of reperfusion therapy) <150 min. In crude and adjusted (age, sex, comorbidities, and socioeconomic variables) logistic regression models, the association between country or region of birth and outcomes was assessed.

Results

Of the 78,298 patients, 65,328 (83.4%) were native-born, and 12,970 (16.6%) were foreign-born. Patients born in the Nordic countries outside of Sweden comprised the largest group (n=3,823, 4.9%), whereas those born in the Americas comprised the smallest (n=475, 0.6%). The median age was 70 years (IQR 60–79); patients born in Africa were the youngest (56 y [IQR 50–65] ), and native-born patients were the oldest (71 y [IQR 62–79]).

Compared with native-born patients, ambulance use was lower among patients born in non-EU countries (0.81 [0.73–0.90]) (Figure 1). Achieving PHDT <120 minutes was more likely among patients born in non-Nordic EU countries (1.14 [1.03–1.26]), non-EU countries (1.19 [1.08–1.32]), Asia (1.21 [1.10–1.32]), and the Americas (1.45 [1.17–1.80]). Patients born in non-EU European countries were less likely to achieve HDT <30 minutes (0.78 [0.70–0.87]). Total ischaemic time was shortest among patients born in the Americas (167 min [IQR 100–347]), with patients from the non-Nordic EU (1.14 [1.03–1.26]), Asia (1.20 [1.10–1.32]), and the Americas (1.31 [1.05–1.63) more likely to achieve the total ischemic time <150 minutes.

Conclusions

We observed small differences in delay times and ambulance use between foreign-born and native-born patients. Some foreign-born groups had lower ambulance use or longer hospital delays, whereas prehospital delays were not prolonged and were shorter in several groups. Our findings suggest limited disparities in acute STEMI care.Main analysisTable 1.Ambulance use and delay times