STEMI Management and Outcomes at a Regional Hospital in Guatemala
BACKGROUND: ST-elevation myocardial infarction (STEMI) is a leading cause of cardiovascular mortality worldwide, with a growing burden in low- and middle-income countries (LMICs). In Guatemala, in-hospital mortality from acute coronary syndromes markedly exceeds global averages due to delayed presentation, limited reperfusion access, and systemic resource constraints. Hospital Nacional de San Benito (HNSB), the main public referral hospital for rural Petén, operates without percutaneous coronary intervention (PCI) and with severely restricted fibrinolytic supply, providing a critical setting to examine evidence-practice gaps in STEMI care. METHODS: A retrospective chart review was conducted of all adults (≥18 years) with ECG-confirmed STEMI presenting to HNSB between January 2019 and April 2025. Patients with revised non‑STEMI diagnoses or insufficient documentation were excluded. Demographic, clinical, geographic, and process‑of‑care variables were abstracted from paper medical records using a standardized form. The primary outcome was in‑hospital mortality. Survivors and non‑survivors were compared using chi‑square or Fisher's exact tests for categorical variables and two‑sample or Welch's t‑tests for continuous variables. RESULTS: Of 112 patients, 62 (55.4%) survived to discharge and 50 (44.6%) died in‑hospital. Mortality was numerically higher among women, older patients, and those residing farther from HNSB, though these differences did not reach statistical significance. Documented dyslipidemia and diabetes were highly prevalent overall and more often recorded in survivors (92.0% vs 70.0%, p < 0.023 and 87.2% vs 53.3%, p < 0.001, respectively, while prior TIA/stroke showed a trend toward higher prevalence in non‑survivors (34.45% vs 11.5%, p = 0.035), patterns suggesting substantial documentation and survivorship bias rather than true protective effects of chronic conditions. Overall, care‑process intervals and treatment patterns revealed large deviations from guideline‑recommended STEMI management in both groups with survivors showing longer symptom-onset-to-door and door-to-ECG time intervals. Survivors had markedly longer symptom‑onset‑to‑door times than non‑survivors (23.96 ± 27.11 vs 1.27 ± 0.70 hours), whereas non‑survivors received faster in‑hospital ECGs (21.36 ± 10.82 vs 46.8 ± 10.82 minutes), a pattern consistent with severity‑driven presentation and triage (both p < 0.001). Aspirin and streptokinase use were significantly more frequent among survivors (aspirin 83.9% vs 40.0%, p < 0.001; streptokinase 19.4% vs 4.0%, p = 0.03). CONCLUSIONS: In this rural, resource‑limited referral hospital, in‑hospital STEMI mortality approached 50%, far exceeding global benchmarks. Gaps between evidence‑based recommendations and real‑world practice were associated with geographic barriers, profound prehospital and in‑hospital delays, constrained fibrinolytic supply, and inconsistent delivery of basic therapies such as aspirin and streptokinase. These findings provide a site‑specific baseline assessment of STEMI care at HNSB and highlight specific, context‑appropriate targets (e.g., early ECG acquisition, protocolized fibrinolysis, and improved documentation) for future quality‑improvement interventions and prospective risk modeling in Petén and similar LMIC settings.
Guatemala, Hospital Mortality, Myocardial Infarction, Quality of Health Care, ST Elevation Myocardial Infarction, Thrombolytic Therapy, Time-to-Treatment
University of Texas Southwestern Medical Center
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