Swipe om te navigeren naar een ander artikel
In pre-hospital settings handled by paramedics, identification of patients with myocardial infarction (MI) remains challenging when automated electrocardiogram (ECG) interpretation is inconclusive. We aimed to identify those patients and to get them on the right track to primary percutaneous coronary intervention (PCI).
In the Rotterdam-Rijnmond region, automated ECG devices on all ambulances were supplemented with a modem, enabling transmission of ECGs for online expert interpretation. The diagnostic protocol for acute chest pain was modified and monitored for 1 year.
Patients with an ECG that met the criteria for ST-elevation myocardial infarction (STEMI) were immediately transported to a PCI hospital. ECGs that did not meet the STEMI criteria, but showed total ST deviation ≥800 µv were transmitted for online interpretation by the ECG expert. Online supervision was offered as a service if ECGs showed conduction disorders, or had an otherwise ‘suspicious’ pattern according to the ambulance paramedics.
We enrolled 1,076 patients with acute ischaemic chest pain who did not meet the automated STEMI criteria. Their mean age was 63 years; 64% were men. After online consultation, 735 (68%) patients were directly transported to a PCI hospital for further treatment. PCI within 90 min was performed in 115 patients.
During a 1-year evaluation of the modified pre-hospital triage protocol for patients with acute ischaemic chest pain, over 100 acute MI patients with an initially inconclusive ECG received primary PCI within 90 min. Because of these results, we decided to continue the operation of the modified protocol.
Terkelsen CJ, Sorensen JT, Maeng M, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010;304:763–71. CrossRef
Rathore SS, Curtis JP, Chen J, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ. 2009;338:b1807. CrossRef
Carstensen S, Nelson GC, Hansen PS, et al. Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome. Eur Heart J. 2007;28:2313–9. CrossRef
Fokkema ML, Wieringa WG, van der Horst IC, et al. Quantitative analysis of the impact of total ischemic time on myocardial perfusion and clinical outcome in patients with ST-elevation myocardial infarction. Am J Cardiol. 2011;108:1536–41. CrossRef
Jobs A, Mehta SR, Montalescot G, et al. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet. 2017;390:737–46. CrossRef
Milosevic A, Vasiljevic-Pokrajcic Z, Milasinovic D, et al. Immediate versus delayed invasive intervention for non-STEMI patients: the RIDDLE-NSTEMI study. JACC Cardiovasc Interv. 2016;9:541–9. CrossRef
Boersma E, Maas AC, Hartman JA, Ilmer B, et al. [Twelve year triage and thrombolysis treatment prior to hospitalization for myocardial infarction patients in the Rotterdam area of the Netherlands: outstanding short-term and long-term results] 12 jaar triage en trombolytische behandeling voor ziekenhuisopname bij hartinfarctpatienten in de regio Rotterdam: uitstekende korte- en langetermijnresultaten. Ned Tijdschr Geneeskd. 2001;145:2029–35. PubMed
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–177.
Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:267–315. CrossRef
Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569–619. CrossRef
Miedema MD, Newell MC, Duval S, et al. Causes of delay and associated mortality in patients transferred with ST-segment-elevation myocardial infarction. Circulation. 2011;124:1636–44. CrossRef
Wang TY, Nallamothu BK, Krumholz HM, et al. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011;305:2540–7. CrossRef
National Cardiovascular Data Registry, Chakrabarti A, Krumholz HM, Wang Y, et al. Time-to-reperfusion in patients undergoing interhospital transfer for primary percutaneous coronary intervention in the U.S: an analysis of 2005 and 2006 data from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2008;51:2442–3. CrossRef
Quinn T, Johnsen S, Gale CP, et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project. Heart. 2014;100:944–50. CrossRef
Cheskes S, Turner L, Foggett R, et al. Paramedic contact to balloon in less than 90 minutes: a successful strategy for st-segment elevation myocardial infarction bypass to primary percutaneous coronary intervention in a canadian emergency medical system. Prehosp Emerg Care. 2011;15:490–8. CrossRef
Daudelin DH, Sayah AJ, Kwong M, et al. Improving use of prehospital 12-lead ECG for early identification and treatment of acute coronary syndrome and ST-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;3:316–23. CrossRef
O’Donnell D, Mancera M, Savory E, et al. The availability of prior ECGs improves paramedic accuracy in recognizing ST-segment elevation myocardial infarction. J Electrocardiol. 2015;48:93–8. CrossRef
Lee CH, Van Gelder CM, Cone DC. Early cardiac catheterization laboratory activation by paramedics for patients with ST-segment elevation myocardial infarction on prehospital 12-lead electrocardiograms. Prehosp Emerg Care. 2010;14:153–8. CrossRef
Potter BJ, Matteau A, Mansour S, et al. Sustained performance of a “physicianless” system of automated prehospital STEMI diagnosis and catheterization laboratory activation. Can J Cardiol. 2017;33:148–54. CrossRef
Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308–20. CrossRef
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. CrossRef
Mawri S, Michaels A, Gibbs J, et al. The comparison of physician to computer interpreted electrocardiograms on ST-elevation myocardial infarction door-to-balloon times. Crit Pathw Cardiol. 2016;15:22–5. CrossRef
Bosson N, Sanko S, Stickney RE, et al. Causes of prehospital misinterpretations of ST elevation myocardial infarction. Prehosp Emerg Care. 2017;21:283–90. CrossRef
Dieker HJ, Liem SS, El Aidi H, et al. Pre-hospital triage for primary angioplasty: direct referral to the intervention center versus interhospital transport. JACC Cardiovasc Interv. 2010;3:705–11. CrossRef
Larson DM, Menssen KM, Sharkey SW, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298:2754–60. CrossRef
Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835–42. CrossRef
Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163:2345–53. CrossRef
Kip MMA, Koffijberg H, Moesker MJ, et al. The cost-utility of point-of-care troponin testing to diagnose acute coronary syndrome in primary care. BMC Cardiovasc Disord. 2017;17:213. CrossRef
Van Hise CB, Greenslade JH, Parsonage W, et al. External validation of heart-type fatty acid binding protein, high-sensitivity cardiac troponin, and electrocardiography as rule-out for acute myocardial infarction. Clin Biochem. 2018;52:161. https://doi.org/10.1016/j.clinbiochem.2017.10.001. CrossRefPubMed
- e-Transmission of ECGs for expert consultation results in improved triage and treatment of patients with acute ischaemic chest pain by ambulance paramedics
S. S. Anroedh
K. M. Akkerhuis
B. van der Hulst
G. J. Deddens
- Bohn Stafleu van Loghum