1
|
Alrumayh AA, Mubarak AM, Almazrua AA, Alharthi MZ, Alatef DF, Albacker TB, Samarkandy FM, Alsofayan YM, Alobaida M. Paramedic Ability in Interpreting Electrocardiogram with ST-segment Elevation Myocardial Infarction (STEMI) in Saudi Arabia. J Multidiscip Healthc 2022; 15:1657-1665. [PMID: 35959233 PMCID: PMC9359379 DOI: 10.2147/jmdh.s371877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/20/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate paramedic ability in recognizing 12-lead Electrocardiogram (ECG) with ST-segment Elevation myocardial infarction (STEMI) in Saudi Arabia. Methods This is a quantitative exploratory cross-sectional study using an electronic survey of paramedics was conducted between June and September 2021. The survey included demographics, educational and clinical experiences, and multiple 12-lead ECG strip questions to assess participants’ ability to recognize STEMI. We reported the overall sensitivity, specificity, and correct proportions with 95% Confidence Intervals (CI). Results Eighty-four paramedics completed the survey, and 65% of them were between 24 and 29 years old, with a median, of three years of field experience. Overall sensitivity and specificity were 58.39% (95% CI, 50.4% to 66.1%) and 29.01% (95% CI, 25.15% to 33.1%), respectively. In total, 67.1% correctly identified inferior STEMI, whereas only 50% correctly identified lateral STEMI. Both STEMIs were correctly identified by 41%, and the majority misinterpreted STEMI mimics (ECG rhythms with similar ECG morphology to STEMI). The proportion who correctly recognized left bundle branch block was 14.8%, pericarditis was 10.9%, and ventricular pacing was 1.4%. However, almost third of participants correctly identified right bundle branch block (32.9%) and left ventricle hypertrophy (30.7%). Overall, there was no correlation between the correct ECG interpretation of STEMIs and educational and clinical experiences. Conclusion Paramedics were able to identify STEMI events in prehospital settings with moderate sensitivity and low specificity with limited ability to differentiate between STEMI and STEMI mimics. Therefore, additional training in ECG interpretation could improve their clinical decision-making, and to ensure that proper care and treatment is provided. Further research on a large, representative sample of paramedics across the country could provide more definitive evidence to establish a greater degree of accuracy in detecting STEMI in prehospital settings.
Collapse
Affiliation(s)
- Abdullah A Alrumayh
- Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah M Mubarak
- Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Abdulkarim A Almazrua
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Musab Z Alharthi
- Department of Accident and Trauma, Prince Sultan Bin AbdulazizCollege for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Deem F Alatef
- Department of Emergency Medical Services and Disaster Management, King Saud Medical City, Riyadh, Saudi Arabia
| | - Turki B Albacker
- Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad M Samarkandy
- Department of Operational Affairs, Saudi Red Crescent Authority, Riyadh, Saudi Arabia
| | - Yousef M Alsofayan
- Executive Directorate of Medical Affairs, Saudi Red Crescent Authority, Riyadh, Saudi Arabia
| | - Muath Alobaida
- Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Muath Alobaida, Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia, Email
| |
Collapse
|
2
|
Tanaka A, Matsuo K, Kikuchi M, Kojima S, Hanada H, Mano T, Nakashima T, Hashiba K, Yamamoto T, Yamaguchi J, Nakayama N, Nomura O, Matoba T, Tahara Y, Nonogi H. Systematic Review and Meta-Analysis of Diagnostic Accuracy to Identify ST-Segment Elevation Myocardial Infarction on Interpretations of Prehospital Electrocardiograms. Circ Rep 2022; 4:289-297. [PMID: 35860351 PMCID: PMC9257459 DOI: 10.1253/circrep.cr-22-0002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/03/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The aim of this study was to assess and discuss the diagnostic accuracy of prehospital ECG interpretation through systematic review and meta-analyses. Methods and Results: Relevant literature published up to July 2020 was identified using PubMed. All human studies of prehospital adult patients suspected of ST-segment elevation myocardial infarction in which prehospital electrocardiogram (ECG) interpretation by paramedics or computers was evaluated and reporting all 4 (true-positive, false-positive, false-negative, and true-negative) values were included. Meta-analyses were conducted separately for the diagnostic accuracy of prehospital ECG interpretation by paramedics (Clinical Question [CQ] 1) and computers (CQ2). After screening, 4 studies for CQ1 and 6 studies for CQ2 were finally included in the meta-analysis. Regarding CQ1, the pooled sensitivity and specificity were 95.5% (95% confidence interval [CI] 82.5–99.0%) and 95.8% (95% CI 82.3–99.1%), respectively. Regarding CQ2, the pooled sensitivity and specificity were 85.4% (95% CI 74.1–92.3%) and 95.4% (95% CI 87.3–98.4%), respectively. Conclusions: This meta-analysis suggests that the diagnostic accuracy of paramedic prehospital ECG interpretations is favorable, with high pooled sensitivity and specificity, with an acceptable estimated number of false positives and false negatives. Computer-assisted ECG interpretation showed high pooled specificity with an acceptable estimated number of false positives, whereas the pooled sensitivity was relatively low.
Collapse
Affiliation(s)
- Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kunihiro Matsuo
- Department of Acute Care Medicine, Fukuoka University Chikushi Hospital
| | - Migaku Kikuchi
- Department of Cardiovascular Medicine, Emergency and Critical Care Center, Dokkyo Medical University
| | - Sunao Kojima
- Department of Internal Medicine, Sakurajyuji Yatsushiro Rehabilitation Hospital
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University
| | | | - Takahiro Nakashima
- Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care, University of Michigan
| | | | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | | | - Naoki Nakayama
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Faculty of Medical Sciences
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | |
Collapse
|
3
|
Fakhri Y, Andersson H, Gregg RE, Babaeizadeh S, Kastrup J, Holmvang L, Clemmensen P. Diagnostic performance of a new ECG algorithm for reducing false positive cases in patients suspected acute coronary syndrome. J Electrocardiol 2021; 69:60-64. [PMID: 34571467 DOI: 10.1016/j.jelectrocard.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/03/2021] [Accepted: 07/04/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Early and correct diagnosis of ST-segment elevation myocardial infarction (STEMI) is crucial for providing timely reperfusion therapy. Patients with ischemic symptoms presenting with ST-segment elevation on the electrocardiogram (ECG) are preferably transported directly to a catheterization laboratory (Cath-lab) for primary percutaneous coronary intervention (PPCI). However, the ECG often contains confounding factors making the STEMI diagnosis challenging leading to false positive Cath-lab activation. The objective of this study was to test the performance of a standard automated algorithm against an additional high specificity setting developed for reducing the false positive STEMI calls. METHODS We included consecutive patients with an available digital prehospital ECG triaged directly to Cath-lab for acute coronary angiography between 2009 and 2012. An adjudicated discharge diagnosis of STEMI or no myocardial infarction (no-MI) was assigned for each patient. The new automatic algorithm contains a feature to reduce false positive STEMI interpretation. The STEMI performance with the standard setting (STD) and the high specificity setting (HiSpec) was tested against the adjudicated discharge diagnosis in a retrospective manner. RESULTS In total, 2256 patients with an available digital prehospital ECG (mean age 63 ± 13 years, male gender 71%) were included in the analysis. The discharge diagnosis of STEMI was assigned in 1885 (84%) patients. The STD identified 165 true negative and 1457 true positive (206 false positive and 428 false negative) cases (77.3%, 44.5%, 87.6% and 17.3% for sensitivity, specificity, PPV and NPV, respectively). The HiSpec identified 191 true negative and 1316 true positive (180 false positive and 569 false negative) cases (69.8%, 51.5%, 88.0% and 25.1% for sensitivity, specificity, PPV and NPV, respectively). From STD to HiSpec, false positive cases were reduced by 26 (12,6%), but false negative results were increased by 33%. CONCLUSIONS Implementing an automated ECG algorithm with a high specificity setting was able to reduce the number of false positive STEMI cases. However, the predictive values for both positive and negative STEMI identification were moderate in this highly selected STEMI population. Finally, due the reduced sensitivity/increased false negatives, a negative AMI statement should not be solely based on the automated ECG statement.
Collapse
Affiliation(s)
- Yama Fakhri
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark; Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark; Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.
| | - Hedvig Andersson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Richard E Gregg
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
| | - Saeed Babaeizadeh
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
| | - Jens Kastrup
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
4
|
Derivation and validation of the Montreal prehospital ST-elevation myocardial infarction activation rule. J Electrocardiol 2020; 59:10-16. [DOI: 10.1016/j.jelectrocard.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/19/2019] [Accepted: 12/03/2019] [Indexed: 12/31/2022]
|
5
|
Żurowska-Wolak M, Piekos P, Jąkała J, Mikos M. The effects of prehospital system delays on the treatment efficacy of STEMI patients. Scand J Trauma Resusc Emerg Med 2019; 27:39. [PMID: 30961648 PMCID: PMC6454716 DOI: 10.1186/s13049-019-0616-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/15/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiovascular disease accounts for nearly half of all deaths in Poland. The aim of this study was to assess both the duration and the delays of prehospital treatment in ST-segment elevation myocardial infarction (STEMI) patients and how it impacts left ventricle ejection fraction (LVEF) measured at the time of discharge and the frequency of in-hospital patient mortality. METHODS This study retrospectively analyzed medical records from January 2011 to December 2015 (excluding the year 2013) of 573 patients who were transported to a hospital with a diagnosis of STEMI. RESULTS The mean time of prehospital system delays was 59 min with a maximum time of 152 min and a minimum time of 23 min. The relationship between reduced LVEF (< 55%) and in-hospital patient mortality and the relationship between length of time from first medical contact (FMC) to hospital admission was analysed in 515 respondents. Extending the time of FMC to hospital admission by 1 min increased the chances of lowering LVEF by 2% (95% CI: 1.004-1.041) and increased the chances of death by 2% (95% CI: 1.002-1.04) in STEMI patients. CONCLUSIONS This study emphasised how vital it is to minimise time spent with STEMI patients at the scene of their cardiovascular event by performing an ECG as quickly as possible and by immediately transporting the patient to the hospital with the targeted treatment. This may lead to the implementation of additional training in the field of ECG interpretation, increase the prevalence of teletransmission systems, and improve communication between Emergency Medical Services (EMS) and catheterization laboratories ultimately reducing patient mortality.
Collapse
Affiliation(s)
- Magdalena Żurowska-Wolak
- Jagiellonian University Medical College, Faculty of Health Sciences, Division of Emergency Medical Services, Kraków, Poland
| | - Patryk Piekos
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek Jąkała
- Cracow Center of Invasive Cardiology, Electrotherapy and Angiology, Scanmed, Kraków, Poland
| | - Marcin Mikos
- Department of Emergency Medical Services, Faculty of Medicine and Health Sciences Andrzej Frycz Modrzewski Krakow University, Gustawa Herlinga-Grudzińskiego 1, 30-705 Kraków, Poland
| |
Collapse
|
6
|
Improving Electrocardiography Diagnostic Accuracy in Emergency Medical Services Personnel. CJC Open 2019; 1:28-34. [PMID: 32159079 PMCID: PMC7063641 DOI: 10.1016/j.cjco.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/29/2018] [Indexed: 01/06/2023] Open
Abstract
Background Accuracy of electrocardiogram (ECG) interpretation is important for identification of ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) personnel who recognize STEMI in the field and activate the coronary catheterization laboratory. According to previous research, there is improvement in diagnosis of STEMIs for healthcare providers who read an average of > 20 ECGs per week. This study evaluated the effectiveness of online ECG modules on improving diagnostic accuracy. Methods EMS personnel received 25 ECGs per week to interpret via an online program. Diagnostic accuracy was assessed for improvement via completion of an ECG evaluation package before and after the intervention. Job satisfaction data were collected to determine the impact of the educational initiative. Results A total of 64 participants completed the study. Overall, there was an improvement in ECG diagnostic accuracy from 50.8% to 61.2% (95% confidence interval [CI], 7.7-13.2; P < 0.0001). Specifically, there was significant improvement in the diagnosis of STEMI (8.5%; 95% CI, 4.9-12.3; P < 0.003) and supraventricular tachycardia (39.0%; 95% CI, 17.2-60.8; P < 0.008), with a trend toward improvement in all other diagnoses. These effects were sustained to 3 months (9.6%; 95% CI, 6.4-12.7; P < 0.0001). Improvement was seen regardless of employment experience and training. There was no significant impact on job satisfaction. Conclusions ECG exposure remains an important factor in improving the accuracy of ECG diagnosis in EMS personnel. Online education modules provide an easily accessible way of improving ECG interpretation with the opportunity for positive downstream effects on patient outcomes and resource use.
Collapse
|
7
|
Swenne CA, Pahlm O, Atwater BD, Bacharova L. Galen Wagner, M.D., Ph.D. (1939–2016) as international mentor of young investigators in electrocardiology. J Electrocardiol 2017; 50:21-46. [DOI: 10.1016/j.jelectrocard.2016.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
8
|
Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications. J Electrocardiol 2017; 50:47-73. [DOI: 10.1016/j.jelectrocard.2016.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
9
|
de Champlain F, Boothroyd LJ, Vadeboncoeur A, Huynh T, Nguyen V, Eisenberg MJ, Joseph L, Boivin JF, Segal E. Computerized interpretation of the prehospital electrocardiogram: predictive value for ST segment elevation myocardial infarction and impact on on-scene time. CAN J EMERG MED 2015; 16:94-105. [DOI: 10.2310/8000.2013.131031] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACTIntroduction:Computerized interpretation of the prehospital electrocardiogram (ECG) is increasingly being used in the basic life support (BLS) ambulance setting to reduce delays to treatment for patients suspected of ST segment elevation myocardial infarction (STEMI).Objectives:To estimate 1) predictive values of computerized prehospital 12-lead ECG interpretation for STEMI and 2) additional on-scene time for 12-lead ECG acquisition.Methods:Over a 2-year period, 1,247 ECGs acquired by primary care paramedics for suspected STEMI were collected. ECGs were interpreted in real time by the GEMarquette 12SL ECG analysis program. Predictive values were estimated with a bayesian latent class model incorporating the computerized ECG interpretations, consensus ECG interpretations by study cardiologists, and hospital diagnosis. On-scene time was compared for ambulance-transported patients with (n 5 985) and without (n 5 5,056) prehospital ECGs who received prehospital aspirin and/or nitroglycerin.Results:The computer's positive and negative predictive values for STEMI were 74.0% (95% credible interval [CrI] 69.6–75.6) and 98.1% (95% CrI 97.8–98.4), respectively. The sensitivity and specificity were 69.2% (95% CrI 59.0–78.5) and 98.9% (95% CrI 98.1–99.4), respectively. Prehospital ECGs were associated with a mean increase in on-scene time of 5.9 minutes (95% confidence interval 5.5–6.3).Conclusions:The predictive values of the computerized prehospital ECG interpretation appear to be adequate for diversion programs that direct patients with a positive result to hospitals with angioplasty facilities. The estimated 26.0% chance that a positive interpretation is false is likely too high for activation of a catheterization laboratory from the field. Acquiring prehospital ECGs does not substantially increase on-scene time in the BLS setting.
Collapse
|
10
|
Huitema AA, Zhu T, Alemayehu M, Lavi S. Diagnostic accuracy of ST-segment elevation myocardial infarction by various healthcare providers. Int J Cardiol 2014; 177:825-9. [PMID: 25465827 DOI: 10.1016/j.ijcard.2014.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aimed to compare the accuracy of ECG interpretation for diagnosis of STEMI by different groups of healthcare professionals involved in the STEMI program at our institution. METHODS We selected 21 ECGs from patients with typical symptoms of MI that were diagnosed with STEMI, and 10 ECGs of STEMI mimics. STEMI mimic ECGs were repeated in the package with a story of typical and atypical chest pain. ECGs were interpreted to diagnose STEMI and identify need for initiation of the cardiac catheterization lab (CCL). Participants identified confidence in STEMI recognition, and average number of ECGs read per week. RESULTS A total of 64 participants completed the study package. Cardiologists were more likely to provide correct interpretation compared to other groups. False positive diagnoses were more likely made by paramedics when compared to cardiologists (p < 0.01). There was a positive correlation between increased exposure to ECGs and accurate STEMI diagnosis (r = 0.482, p < 0.001). A threshold of ≥ 20 ECGs read per week showed a statistically significant improvement in accuracy (p < 0.001). Self-reported confidence correlated positively with accuracy (r = 0.402, p =< 0.001). Changing the ECG narrative of the STEMI mimic ECGs had a significant effect on interpretation between groups (p = 0.043). CONCLUSIONS Our study showed that healthcare profession and number of ECGs reviewed per week are predictive of the accuracy of ECG interpretation of STEMI. Cardiologists are the most accurate diagnosticians, and are the least likely to falsely activate the CCL. Weekly exposure of ≥ 20 ECGs may improve diagnostic accuracy regardless of underlying experience.
Collapse
Affiliation(s)
- Ashlay A Huitema
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Tina Zhu
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Shahar Lavi
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| |
Collapse
|
11
|
Abstract
AbstractIntroduction:Correct identification of the J-Point and ST-segment on an electrocardiograph (ECG) is an important clinical skill for paramedics working in acute healthcare settings. The skill of ECG analysis and interpretation is known to be challenging to learn and often is a difficult concept to teach.Objectives:The objective of the study was to determine if undergraduate paramedic students could accurately identify ECG ST-segment elevation and J-Point location.Methods:A convenience sample of undergraduate paramedic students (n = 148) was provided with four enlarged ECGs (ECG1–4) that illustrated different levels, patterns, and characteristics of ST-segment elevation. Participants were asked to identify whether ST-elevation was present, and if so, height in millimeters (mm) and the correct location of the J-Point.Results:There were significant variations in students'accuracy with both J-Point and ST-segment determination. Eleven (10%) students correctly identified the ST-segment being present in all ECGs. Also, ECG 2 reflected 6 mm of ST-elevation; however, only one student correctly identified this. Overall the students were 0.55 mm (95% CI = 0.29–0.81 mm, range = -6.5–5.8 mm) from the J-point on the horizontal and -0.18 mm (95% CI = -0.31–0.04 mm, range = -2.8–2.3 mm) on the vertical axis.Conclusions:Undergraduate paramedic students recognize ST-segment elevation. However, inaccuracies occurred with measurements of ST-segment and precise location of J-Points. Errors in ECG analysis may reflect weaknesses in teaching this skill. Consideration should be given to the design of an educational program that can reliably improve performance of this skill.
Collapse
|
12
|
Young DR, Murinson M, Wilson C, Hammond B, Welch M, Block V, Booth S, Tedder W, Dolby K, Roh J, Beaton R, Edmunds J, Young M, Rice V, Somers C, Edwards R, Maynard C, Wagner GS. Paramedics as decision makers on the activation of the catheterization laboratory in the presence of acute ST-elevation myocardial infarction. J Electrocardiol 2011; 44:18-22. [DOI: 10.1016/j.jelectrocard.2010.06.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Indexed: 10/19/2022]
|
13
|
Barbagelata A, Perna ER, Clemmensen P, Uretsky BF, Canella JPC, Califf RM, Granger CB, Adams GL, Merla R, Birnbaum Y. Time to reperfusion in acute myocardial infarction. It is time to reduce it! J Electrocardiol 2007; 40:257-64. [PMID: 17478179 DOI: 10.1016/j.jelectrocard.2007.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 01/26/2007] [Accepted: 01/30/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials. METHODS All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment. RESULTS In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11). CONCLUSION Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.
Collapse
|
14
|
Strauss DG, Sprague PQ, Underhill K, Maynard C, Adams GL, Kessenich A, Sketch MH, Berger PB, Marcozzi D, Granger CB, Wagner GS. Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction. J Electrocardiol 2007; 40:265-70. [PMID: 17292381 DOI: 10.1016/j.jelectrocard.2006.11.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 11/27/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE We tested the hypothesis that paramedic recognition of ST-elevation myocardial infarction (STEMI) and cardiologist activation of the cardiac catheterization laboratory without transmission of the electrocardiogram reduces door-to-balloon times. METHODS We studied a consecutive series of patients suspected to have STEMI who were taken to the cardiac catheterization laboratory in the 6-month period before hotline implementation (historical controls) and during the first year of hotline use (intervention group, hotline; emergency medical service patients without hotline, concurrent controls). RESULTS Emergency medical services activated the hotline 47 times, and 25 patients were subsequently taken to the catheterization laboratory. Patients who received PCI involving hotline use (n = 20) had significantly shorter door-to-balloon times (58 minutes; 25th-75th percentile, 52-73 minutes) than historical controls (n = 15) (112 minutes; 25th-75th percentile, 81-137; P < .0001) and concurrent controls (n = 15) (92 minutes; 25th-75th percentile, 76-112; P = .019). CONCLUSIONS Paramedic transtelephonic communication to cardiologist of clinical and electrocardiogram assessment resulted in a 54-minute reduction in door-to-balloon time for patients with STEMI.
Collapse
|
15
|
Le May MR, Dionne R, Maloney J, Trickett J, Watpool I, Ruest M, Stiell I, Ryan S, Davies RF. Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. CAN J EMERG MED 2007; 8:401-7. [PMID: 17209489 DOI: 10.1017/s1481803500014196] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Most studies of pre-hospital management of ST-elevation myocardial infarction (STEMI) have involved physicians accompanying the ambulance crew, or electrocardiogram (ECG) transmission to a physician at the base hospital. We sought to determine if Advanced Care Paramedics (ACPs) could accurately identify STEMI on the pre-hospital ECG and contribute to strategies that shorten time to reperfusion. METHODS A STEMI tool was developed to: 1) measure the accuracy of the ACPs at diagnosing STEMI; and 2) determine the potential time saved if ACPs were to independently administer thrombolytic therapy. Using registry data, we subsequently estimated the time saved by initiating thrombolytic therapy in the field compared with in-hospital administration by a physician. RESULTS Between August 2003 and July 2004, a correct diagnosis of STEMI on the pre-hospital ECG was confirmed in 63 patients. The performance of the ACPs in identifying STEMI on the ECG resulted in a sensitivity of 95% (95% confidence interval [CI] 86%-99%), a specificity of 96% (95% CI 94%-98%), a positive predictive value (PPV) of 82% (95% CI 71%-90%), and a negative predictive value (NPV) of 99% (95% CI 97%-100%). ACP performance for appropriately using thrombolytic therapy resulted in a sensitivity of 92% (95% CI 78%-98%), a specificity of 97% (95% CI 94%-98%), a PPV of 73% (95% CI 59%-85%) and an NPV of 99% (95% CI 97%-100%). We estimated that the median time saved by ACP administration of thrombolytic therapy would have been 44 minutes. CONCLUSIONS ACPs can be trained to accurately interpret the pre-hospital ECG for the diagnosis of STEMI. These results are important for the design of regional integrated programs aimed at reducing delays to reperfusion.
Collapse
|
16
|
Wireless electrocardiogram in early diagnosis and triaging of ST-elevation myocardial infarction: The TIME Study. J Electrocardiol 2007. [DOI: 10.1016/j.jelectrocard.2006.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
17
|
Adams GL, Campbell PT, Adams JM, Strauss DG, Wall K, Patterson J, Shuping KB, Maynard C, Young D, Corey C, Thompson A, Lee BA, Wagner GS. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from the Timely Intervention in Myocardial Emergency, NorthEast Experience [TIME-NE]). Am J Cardiol 2006; 98:1160-4. [PMID: 17056318 DOI: 10.1016/j.amjcard.2006.05.042] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 05/14/2006] [Accepted: 05/14/2006] [Indexed: 10/24/2022]
Abstract
Percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) decreases morbidity and mortality if performed within the first 2 hours of symptom onset. However, the American College of Cardiology/American Heart Association guideline for percutaneous coronary intervention door-to-balloon time (<90 minutes) in patients with STEMI is a infrequently accomplished goal. This study enrolled 277 patients with STEMI who were self-transported or transported by emergency medical services to NorthEast Medical Center for primary percutaneous coronary intervention. This study tested the hypothesis that prehospital wireless transmission of an electrocardiogram to a cardiologist's hand-held device results in shorter emergency department door-to-reperfusion time. A comparison was made between patients whose electrocardiogram was successfully transmitted during the intervention phase with (1) patients transported by the emergency medical services in the preintervention, (2) patients self-transported in the intervention phase, and (3) patients whose wireless transmission failed in the intervention phase. During the preintervention phase (2001 to 2003), 48 patients were enrolled. During the intervention phase (2003 to 2005), the following patients were enrolled: 101 self-transported patients, 24 patients with successful electrocardiographic transmission, and 19 patients for whom transmission failed. The median door-to-reperfusion time for patients with successful electrocardiographic transmission was 50 minutes, which was significantly shorter than a preintervention time of 101 minutes (p <0.0001), an intervention phase self-transport time of 96 minutes (p <0.0001), and a failed transmission time of 78 minutes (p <0.0001). In conclusion, prehospital wireless electrocardiographic transmission to a cardiologist's hand-held device significantly decreased emergency department door-to-reperfusion time, thus achieving the American College of Cardiology/American Heart Association guideline for patients with STEMI.
Collapse
Affiliation(s)
- George L Adams
- Duke University Medical Center, Durham, North Carolina, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Vaught C, Young DR, Bell SJ, Maynard C, Gentry M, Jacubowitz S, Leibrandt PN, Munsey D, Savona MR, Wall TC, Wagner GS. The failure of years of experience with electrocardiographic transmission from paramedics to the hospital emergency department to reduce the delay from door to primary coronary intervention below the 90-minute threshold during acute myocardial infarction. J Electrocardiol 2006; 39:136-41. [PMID: 16580408 DOI: 10.1016/j.jelectrocard.2005.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2004] [Accepted: 12/12/2005] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Emergency medical services (EMS), hospital emergency departments, and cardiologists have taken steps to reduce time to reperfusion therapy by implementation of aggressive acute myocardial infarction treatment and triage protocols. Data indicate that significant myocardial salvage requires reperfusion within 2 hours, and the current American College of Cardiology guideline is 90 minutes after hospital emergency department admission. MATERIALS AND METHODS To minimize delays in time to reperfusion in an urban-rural North Carolina County, Guilford County EMS and the Moses Cone Hospital have collaborated to implement transmission of EMS electrocardiographs (ECGs) to the emergency department. The study population included 92 patients who were transported by EMS and received primary coronary intervention during the second, third, and fourth years after initiation of this intervention in 1993. RESULTS The median time from symptom onset to the initial ECG was 77 minutes. There was an additional 23 minutes between the availability of this ECG and the arrival of the patient at the emergency department. In the first year of the intervention, the time from hospital arrival to percutaneous coronary intervention was 80 minutes. In years 2 through 4, they were 93, 85, and 94 minutes, respectively. In 2003, 10 years after the intervention, the time from hospital arrival to percutaneous coronary intervention was 113 minutes. CONCLUSION Initial gains in the time from hospital arrival to percutaneous coronary intervention, attributed to acquisition of the ECG in the prehospital setting, were not sustained over 10 years.
Collapse
Affiliation(s)
- Creighton Vaught
- Department of medicine, Duke University Medical Center, Durham, NC 27705, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Johanson P, Armstrong PW, Barbagelata NA, Chaitman BR, Clemmensen P, Dellborg M, French J, Goodman SG, Green CL, Krucoff MW, Langer A, Pahlm O, Reilly P, Wagner GS. An Academic ECG Core Lab Perspective of the FDA Initiative for Digital ECG Capture and Data Management in Large-Scale Clinical Trials. ACTA ACUST UNITED AC 2005. [DOI: 10.1177/009286150503900402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
20
|
Young D, Barbagelata A, Wagner G. Have we made progress in reducing time to reperfusion in the management of acute myocardial infarction? A last decade overview. J Electrocardiol 2005; 38:94-5. [PMID: 16226081 DOI: 10.1016/j.jelectrocard.2005.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/21/2022]
|
21
|
Dowdy L, Wagner GS, Birnbaum Y, Clemmensen P, Fu Y, Maynard C, Menown I, Sejersten M, Young D, Johanson P, Barbagelata A. Aborted infarction: the ultimate myocardial salvage. Am Heart J 2004; 147:390-4. [PMID: 14999184 DOI: 10.1016/j.ahj.2003.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|