The management of acute coronary syndrome (ACS) complicated with out-of-hospital cardiac arrest (OHCA) remains challenging, particularly in non-city areas (Figure 1). The implementation of appropriate treatment strategies for improving pre-hospital emergency care is fundamental. Little is known about the resuscitation performances of emergency medical service (EMS) teams in sparsely populated areas. Built at the top of a hill, the location of our institution consists of rural areas with a low population density. Established in 1903, the hospital was initially founded to treat patients suffering from tuberculosis.

To identify parameters influencing the 30-day outcome after sudden coronary death in non-city areas.

Retrospective single-centre study including 40 patients resuscitated from OHCA after ACS. Resuscitation settings, time intervals, blood samples, cardiac findings and clinical outcomes at 30 days were analyzed.

30-day mortality was more likely associated with the following parameters: unwitnessed collapse, km, NF/LF duration, epinephrine dose, time to cath lab, gender, asystole, recurrent cardiac arrest, shock, lactate level, LVEF and LAD culprit lesion. Particularly, remoteness from hospital and prolonged pre-hospital management (duration of CPR, delayed cath lab admission) were predictors of early mortality (Table 1).

Remoteness from hospital, duration of resuscitation on-site and time to cath lab admission may represent major determinants of clinical outcomes beyond the usual prognostic factors. The relationship between early mortality and duration of NF, non-shockable rhythm, hemodynamic instability and lactate level may reflect the impact of prolonged time intervals during the pre-hospital phase of management. EMS teams should focus on improving pre-hospital response times and optimizing cardiac cath lab activation. Further RCTs should evaluate the impact of the ‘scoop and run’ approach versus the ‘stay and play’ approach in this setting.