Use of Prehospital 12-Lead Electrocardiography and Treatment Times Among ST-Elevation Myocardial Infarction Patients With Atypical Symptoms

Abstract

Objectives: Guidelines advise that a prehospital electrocardiogram (ECG) should be obtained in any patients with chest pain, yet up to 20% of patients with ST-elevation myocardial infarction (STEMI) do not present with chest pain. The objective was to determine the association of atypical presentations in the prehospital setting on the likelihood of receiving a prehospital ECG and subsequent time to reperfusion therapy.Methods: This study used a data set that linked prehospital medical information from a statewide EMS data system with a clinical registry of treatment and outcomes data for patients with STEMI. Among 2,639 STEMI patients from 2008 to 2010, the association between non-chest pain presentations, prehospital ECG use, and reperfusion times among patients undergoing primary percutaneous coronary intervention (PCI) were examined. Inverse probability weights were used to account for observed baseline confounders.Results: Overall, 318 of 2,639 patients (12.1%) presented without chest pain. A prehospital ECG was obtained in 2,021 of 2,321 (87.1%) patients with chest pain compared with only 230 of 318 (72.3%) without chest pain (odds ratio [OR] = 2.24, 95% confidence interval [CI] = 1.69 to 2.98). Among patients without chest pain, those who received a prehospital ECG had significantly shorter first medical contact (FMC) to device times (30.9% < 90 minutes vs. 11.4% > 90 minutes, adjusted OR = 2.81, 95% CI = 1.29 to 6.11, p < 0.01).Conclusions: Over one-quarter of STEMI patients presenting without chest pain did not receive prehospital ECGs and had significantly longer FMC to device times. Future efforts are needed to promote the use of prehospital ECGs to achieve more rapid identification of STEMI patients with atypical presentations in the prehospital setting.ACADEMIC EMERGENCY MEDICINE 2014;21:892-898 © 2014 by the Society for Academic Emergency Medicine C oronary heart disease, including ST-elevation myocardial infarction (STEMI), is the leading cause of morbidity and mortality in the United States.1 Outcomes for STEMI can be improved by early reperfusion therapy, including percutaneous coronary intervention (PCI) or fibrinolytic therapy. 2Greater than 60% of patients with STEMI arrive to the hospital by emergency medical services (EMS), and therefore, a critical component of STEMI care involves prompt diagnosis via a 12-lead electrocardiogram (ECG) at the scene or in the ambulance prior to arrival at the hospital.3 For STEMI patients, the use of a prehospital ECG by EMS has been shown to dramatically shorten time to reperfusion therapy because it allows paramedics to provide advanced notification to receiving emergency departments (EDs) and cardiac

Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest

“…A comparison of our findings with other published studies is difficult because the few studies that have examined EMS treatments by gender have not adequately controlled for important confounders such as EMS capacity (Bush et al, 2013;Cannon et al, 2014;Tataris et al, 2015), age, and race (Benson et al, 1997;Cannon et al, 2014;Rothrock et al, 2000). Controlling for patient demographic characteristics and hospital referral region, Bush et al (2013) reported an ECG rate difference between women and men who presented with CP of À1.7%, identical to that observed in our cohort.…”

Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction – Results of the CASSIOPEIA study

“…We supposed that the criteria needed to be simple and easy to understand to avoid underestimations of STEMI before the implementation of prehospital ECG transmission, with the inclusion of not only typical chest pain but also atypical symptoms, such as syncope or general fatigue [19]. The ECG transmission criteria were created using the chief complaints of consecutive STEMI patients according to past medical records in our hospital between 2006 and 2013.…”

Implementation of an ST-segment elevation myocardial infarction bypass protocol in the Northern United Arab Emirates

“…demonstrated that over one-quarter of STEMI patients presented without chest pain and did not receive a prehospital ECG. [29] Atypical presentations were common in our study, with classic STEMI recognition characteristics (pain, nausea, dyspnea) not present in many cases. Almost 50% of the patients in our study had a pain scale under 5, and many had no pain on assessment.…”