Present and Future Status of Cardiovascular Emergency Care System in Urban Areas of Japan - Importance of Prehospital 12-Lead Electrocardiogram

Benefit of prehospital electrocardiogram on door-to-device time in ST-segment elevation myocardial infarction with cardiogenic shock: Data from the Kanagawa Acute Cardiovascular Registry

BACKGROUND

The benefit of prehospital 12‑lead electrocardiogram (PH-ECG) performed by emergency medical service personnel at the site of first medical contact (FMC) in patients with ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock (CS-STEMI) remains unclear. This study aimed to investigate the effect of PH-ECG on door-to-device time in patients with CS-STEMI.

METHODS

This study enrolled CS-STEMI (Killip class IV) patients who were transferred directly to hospitals by ambulance (n = 517) from the Kanagawa Acute Cardiovascular Registry database. Patients were divided into PH-ECG (+) (n = 270) and PH-ECG (-) (n = 247) groups. Patients who experienced out-of-hospital cardiac arrest, who did not undergo emergent coronary intervention, or whose data were missing were excluded. Patient characteristics, FMC-to-door time, door-to-device time, and in-hospital mortality were compared between the groups.

RESULTS

The patient backgrounds of the PH-ECG (+) and PH-ECG (-) groups were comparable. The peak creatinine kinase level was greater in the PH-ECG (+) group than in the PH-ECG (-) group [2756 (1292-6009) IU/ml vs. 2270 (957-5258) IU/ml, p = 0.048]. The FMC-to-door time was similar between the two groups [25 (20-33) min vs. 27 (20-35) min, p = 0.530], while the door-to-device time was significantly shorter in the PH-ECG group [74 (52-103) min vs. 83 (62-111) min, p = 0.007]. In-hospital mortality did not differ between the two groups (18 % vs. 21 %, p = 0.405). Multivariable logistic regression analyses revealed that PH-ECG (+) was independently associated with a door-to-device time < 60 min [odds ratio (95 % confidence intervals): 1.88 (1.24-2.83), p = 0.003].

CONCLUSIONS

PH-ECG was significantly associated with shorter door-to-device times in patients with CS-STEMI. Further studies with larger populations and more defined protocols are required to evaluate the utility of PH-ECG in patients with CS-STEMI.

Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Artificial intelligence-assisted remote detection of ST-elevation myocardial infarction using a mini-12-lead electrocardiogram device in prehospital ambulance care

Objective

To implement an all-day online artificial intelligence (AI)-assisted detection of ST-elevation myocardial infarction (STEMI) by prehospital 12-lead electrocardiograms (ECGs) to facilitate patient triage for timely reperfusion therapy.

Methods

The proposed AI model combines a convolutional neural network and long short-term memory (CNN-LSTM) to predict STEMI on prehospital 12-lead ECGs obtained from mini-12-lead ECG devices equipped in ambulance vehicles in Central Taiwan. Emergency medical technicians (EMTs) from the 14 AI-implemented fire stations performed the on-site 12-lead ECG examinations using the mini portable device. The 12-lead ECG signals were transmitted to the AI center of China Medical University Hospital to classify the recordings as "STEMI" or "Not STEMI". In 11 non-AI fire stations, the ECG data were transmitted to a secure network and read by available on-line emergency physicians. The response time was defined as the time interval between the ECG transmission and ECG interpretation feedback.

Results

Between July 17, 2021, and March 26, 2022, the AI model classified 362 prehospital 12-lead ECGs obtained from 275 consecutive patients who had called the 119 dispatch centers of fire stations in Central Taiwan for symptoms of chest pain or shortness of breath. The AI's response time to the EMTs in ambulance vehicles was 37.2 ± 11.3 s, which was shorter than the online physicians' response time from 11 other fire stations with no AI implementation (113.2 ± 369.4 s, P < 0.001) after analyzing another set of 335 prehospital 12-lead ECGs. The evaluation metrics including accuracy, precision, specificity, recall, area under the receiver operating characteristic curve, and F1 score to assess the overall AI performance in the remote detection of STEMI were 0.992, 0.889, 0.994, 0.941, 0.997, and 0.914, respectively. During the study period, the AI model promptly identified 10 STEMI patients who underwent primary percutaneous coronary intervention (PPCI) with a median contact-to-door time of 18.5 (IQR: 16-20.8) minutes.

Conclusion

Implementation of an all-day real-time AI-assisted remote detection of STEMI on prehospital 12-lead ECGs in the field is feasible with a high diagnostic accuracy rate. This approach may help minimize preventable delays in contact-to-treatment times for STEMI patients who require PPCI.

Prehospital Administration of Aspirin and Nitroglycerin for Patients With Suspected Acute Coronary Syndrome ― A Systematic Review ―

Background: Recent guidelines for acute coronary syndrome (ACS) recommend prehospital administration of aspirin and nitroglycerin for ACS patients. However, there is no clear evidence to support this. We investigated the benefits and harms of prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals in patients with suspected ACS.

Methods and Results: We searched the PubMed database and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence. Three retrospective studies for aspirin and 1 for nitroglycerin administered in the prehospital setting to patients with acute myocardial infarction were included. Prehospital aspirin administration was associated with significantly lower 30-day and 1-year mortality compared with aspirin administration after arrival at hospital, with odds ratios (OR) of 0.59 (95% confidence interval [CI] 0.35–0.99) and 0.47 (95% CI 0.36–0.62), respectively. Prehospital nitroglycerin administration was also associated with significantly lower 30-day and 1-year mortality compared with no prehospital administration (OR 0.34 [95% CI 0.24–0.50] and 0.38 [95% CI 0.29–0.50], respectively). The certainty of evidence was very low in both systematic reviews.

Conclusions: Our systematic reviews suggest that prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals is beneficial for patients with suspected ACS, although the certainty of evidence is very low. Further investigation is needed to determine the benefit of the prehospital administration of these agents.