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Computerized interpretation of the prehospital electrocardiogram: predictive value for ST segment elevation myocardial infarction and impact on on-scene time

Published online by Cambridge University Press:  04 March 2015

François de Champlain ,
Lucy J. Boothroyd ,
Alain Vadeboncoeur ,
Thao Huynh ,
Viviane Nguyen ,
Mark J. Eisenberg ,
Lawrence Joseph ,
Jean-François Boivin  and
Eli Segal
François de Champlain*
Affiliation:
Department of Emergency Medicine, McGill University Health Centre, Montreal General Hospital Department of Family Medicine, McGill University Corporation d’Urgences-santé
Lucy J. Boothroyd
Affiliation:
Institut national d’excellence en santé et en services sociaux (INESSS) Department of Epidemiology, Biostatistics and Occupational Health, McGill University
Alain Vadeboncoeur
Affiliation:
Department of Emergency Medicine, Montreal Heart Institute
Thao Huynh
Affiliation:
Department of Cardiology, McGill University Health Centre
Viviane Nguyen
Affiliation:
Department of Cardiology, McGill University Health Centre
Mark J. Eisenberg
Affiliation:
Department of Epidemiology, Biostatistics and Occupational Health, McGill University Division of Cardiology, Jewish General Hospital Centre for Clinical Epidemiology and Community Studies, Lady Davis Research Institute for Medical Research, Jewish General Hospital
Lawrence Joseph
Affiliation:
Department of Epidemiology, Biostatistics and Occupational Health, McGill University Department of Clinical Epidemiology, McGill University Health Centre
Jean-François Boivin
Affiliation:
Department of Epidemiology, Biostatistics and Occupational Health, McGill University Centre for Clinical Epidemiology and Community Studies, Lady Davis Research Institute for Medical Research, Jewish General Hospital
Eli Segal
Affiliation:
Department of Family Medicine, McGill University Corporation d’Urgences-santé Department of Emergency Medicine, Jewish General Hospital, Montreal, QC
*
Department of Emergency Medicine, Montreal General Hospital, 1650 Cedar Avenue, Room B2.117, MontrealQC H3G 1A4; [email protected]

Abstract

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Introduction:

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.

Keywords

electrocardiogramon-scene timepredictive valueprehospitalST segment elevation myocardial infarction
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 16 , Issue 2 , March 2014 , pp. 94 - 105
Copyright
Copyright © Canadian Association of Emergency Physicians 2014

References

REFERENCES

1. O’Connor, RE, Brady, W, Brooks, SC, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S787–817, doi:10.1161/CIRCULATIONAHA.110.971028.Google ScholarPubMed
2. Tubaro, M, Danchin, N, Goldstein, P, et al. Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology. Acute Card Care 2011;13:56–67, doi:10.3109/17482941.2011.581292.Google Scholar
3. Youngquist, ST, Kaji, AH, Lipsky, AM, et al. A bayesian sensitivity analysis of out-of-hospital 12-lead electrocardiograms: implications for regionalization of cardiac care. Acad Emerg Med 2007;14:1165–71, doi:10.1111/j.1553-2712.2007.tb02338.x.Google Scholar
4. Clark, EN, Sejersten, M, Clemmensen, P, et al. Automated electrocardiogram interpretation programs versus cardiologists’ triage decision making based on teletransmitted data in patients with suspected acute coronary syndrome. Am J Cardiol 2010;106:1696–702, doi:10.1016/j.amjcard.2010.07.047.Google Scholar
5. Morrison, LJ, Brooks, S, Sawadsky, B, et al. Prehospital 12- lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med 2006;13:84–9, doi:10.1111/j.1553-2712.2006.tb00989.x.Google Scholar
6. Brown, JP, Mahmud, E, Dunford, JV, et al. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in STsegment elevation acute myocardial infarction. Am J Cardiol 2008;101:158–61, doi:10.1016/j.amjcard.2007.07.082.CrossRefGoogle ScholarPubMed
7. Caudle, JM, Piggott, Z, Dostaler, S, et al. Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction. CJEM 2009;11:29–35.Google Scholar
8. Hutchison, AW, Malaiapan, Y, Jarvie, I, et al. Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times: ambulance Victoria andMonashHEART AcuteMyocardial Infarction (MonAMI) 12-lead ECG project. Circ Cardiovasc Interv 2009;2:528–34, doi:10.1161/CIRCINTERVENTIONS.109.892372.Google Scholar
9. Sejersten, M, Sillesen, M, Hansen, PR, et al. Effect on treatment delay of prehospital teletransmission of 12-lead electrocardiogram to a cardiologist for immediate triage and direct referral of patients with ST-segment elevation acute myocardial infarction to primary percutaneous coronary intervention. Am J Cardiol 2008;101:941–6, doi:10.1016/j.amjcard.2007.11.038.CrossRefGoogle ScholarPubMed
10. Drew, BJ, Sommargren, CE, Schindler, DM, et al. A simple strategy improves prehospital electrocardiogram utilization and hospital treatment for patients with acute coronary syndrome (from the ST SMART Study). Am J Cardiol 2011;107:347–52, doi:10.1016/j.amjcard.2010.09.027.Google Scholar
11. Clemmensen, P, Sejersten, M, Sillesen, M, et al. Diversion of ST-elevation myocardial infarction patients for primary angioplasty based on wireless prehospital 12-lead electrocardiographic transmission directly to the cardiologist’s handheld computer: a progress report. J Electrocardiol 2005;38(4 Suppl):194–8.Google Scholar
12. Turnipseed, SD, Amsterdam, EA, Laurin, EG, et al. Frequency of non-ST-segment elevation injury patterns on prehospital electrocardiograms. Prehosp Emerg Care 2010;14: 1–5, doi:10.3109/10903120903144924.Google Scholar
13. Provo, TA, Frascone, RJ. 12-Lead electrocardiograms during basic life support care. Prehosp Emerg Care 2004;8:212–6.Google Scholar
14. Dendukuri, N, Joseph, L. Bayesian approaches to modeling the conditional dependence between multiple diagnostic tests. Biometrics 2001;57:158–67, doi:10.1111/j.0006-341X.2001.00158.x.Google Scholar
15. Dendukuri, N, Hadgu, A,Wang, L. Modeling conditional dependence between diagnostic tests: a multiple latent variable model. Stat Med 2009;28:441–61, doi:10.1002/sim.3470.Google Scholar
16. GE Medical Systems. 12SLTM physician’s guide. Milwaukee (WI): GE Medical Systems Information Technologies; 2000.Google Scholar
17. Antman, EM, Anbe, DT, Armstrong, PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:E1–211, doi:10.1016/j.jacc.2004.07.014.Google Scholar
18. Larson, DM, Menssen, KM, Sharkey, SW, et al. “Falsepositive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA 2007;298:2754–60, doi:10.1001/jama.298.23.2754.Google Scholar
19. Barge-Caballero, E, Vázquez-Rodríguez, JM, Estévez-Loureiro, R, et al. Prevalence, etiology and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction. Rev Esp Cardiol 2010;63:518–27, doi:10.1016/S0300-8932(10)70113-5.Google Scholar
20. Willson, AB, Mountain, D, Jeffers, JM, et al. Door-to-balloon times are reduced in ST-elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer. Med J Aust 2010;193:207–12.Google Scholar
21. Youngquist, ST, Shah, AP, Niemann, JT, et al. A comparison of door-to-balloon times and false-positive activations between emergency department and out-of-hospital activation of the coronary catheterization team. Acad Emerg Med 2008;15:784–7, doi:10.1111/j.1553-2712.2008.00186.x.Google Scholar
22. Davis, DP, Graydon, C, Stein, R, et al. The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram. Prehosp Emerg Care 2007;11:399–402, doi:10.1080/10903120701536784.Google Scholar
23. Lee, C, 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, doi:10.3109/10903120903537213.Google Scholar
24. Young, DR, Murinson, M, Wilson, C, et al. Paramedics as decision makers on the activation of the catheterization laboratory in the presence of acute ST-elevation myocardial infarction. J Electrocardiol 2010;44:18–22, doi:10.1016/j.jelectrocard.2010.06.010.Google Scholar
25. Le May, MR, Dionne, R, Maloney, J, et al. Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. Can J Emerg Med 2006;8:401–7.Google Scholar
26. Cheskes, S, Turner, L, Foggett, R, et al. Paramedic contact to balloon in less than 90 minutes: a successful strategy for STsegment elevation myocardial infarction bypass to primary percutaneous coronary intervention in a Canadian emergency medical system. Prehosp Emerg Care 2011;15:490–8, doi:10.3109/10903127.2011.598613.Google Scholar
27. Adams, G, Abusaid, G, Lee, B, et al. From theory to practice: implementation of pre-hospital electrocardiogram transmission in ST-elevation myocardial infarction - a multicenter experience. J Invasive Cardiol 2010;22:520–5.Google Scholar
28. Kudenchuk, PJ, Ho, MT, Weaver, WD, et al. Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy. MITI Project Investigators. J Am Coll Cardiol 1991;17:1486–91, doi:10.1016/0735-1097(91)90636-N.Google Scholar
29. Eckstein, M, Cooper, E, Nguyen, T, et al. Impact of paramedic transport with prehospital 12-lead electrocardiography on door-to-balloon times for patients with STsegment elevation myocardial infarction. Prehosp Emerg Care 2009;13:203–6, doi:10.1080/10903120802472020.CrossRefGoogle Scholar
30. Diercks, DB, Kontos, MC, Chen, AY, et al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol 2009;53:161–6, doi:10.1016/j.jacc.2008.09.030.Google Scholar
31. Rao, A, Kardouh, Y, Darda, S, et al. Impact of the prehospital ECG on door-to-balloon time in ST elevation myocardial infarction. Catheter Cardiovas Interv 2010;75:174–8, doi:10.1002/ccd.22257.Google Scholar
32. Baran, KW, Kamrowski, KA, Westwater, JJ, et al. Very rapid treatment of ST-segment-elevation myocardial infarction:utilizing prehospital electrocardiograms to bypass the emergency department. Circ Cardiovasc Qual Outcomes 2010;3:431–7, doi:10.1161/CIRCOUTCOMES.110.942631.CrossRefGoogle ScholarPubMed
33. Ortolani, P, Marzocchi, A, Marrozzini, C, et al. Pre-hospital ECG in patients undergoing primary percutaneous interventions within an integrated system of care: reperfusion times and long-term survival benefits. EuroIntervention 2011;7:449–57, doi:10.4244/EIJV7I4A74.Google Scholar
34. Zanini, R, Aroldi, M, Bonatti, S, et al. Impact of prehospital diagnosis in the management of ST elevation myocardial infarction in the era of primary percutaneous coronary intervention: reduction of treatment delay and mortality. J Cardiovasc Med (Hagerstown) 2008;9:570–5, doi:10.2459/JCM.0b013e3282f2c9bd.Google Scholar
35. Sivagangabalan, G, Ong, AT, Narayan, A, et al. Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction. Am J Cardiol 2009;103:907–12, doi:10.1016/j.amjcard.2008.12.007.Google Scholar
36. Swan, PY, Nighswonger, B, Boswell, GL, et al. Factors associated with false positive emergency medical services triage for percutaneous coronary intervention. West J Emerg Med 2009;10:208–12.Google Scholar
37. Schull, MJ, Vermeulen, MJ, Stukel, TA. The risk of missed diagnosis of acute myocardial infarction associated with emergency department volume. Ann Emerg Med 2006;48:647–55, doi:10.1016/j.annemergmed.2006.03.025.CrossRefGoogle ScholarPubMed
38. Pope, JH, Aufderheide, TP, Rothazer, R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163–70, doi:10.1056/NEJM200004203421603.Google Scholar
39. Kudenchuk, PJ, Maynard, C, Cobb, LA, et al. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: theMyocardial Infarction Triage and Intervention (MITI) Project. J Am Coll Cardiol 1998;32:17–27, doi:10.1016/S0735-1097(98)00175-2.Google Scholar
40. Feldman, JA, Brinsfield, K, Bernard, S, et al. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Am J Emerg Med 2005;23:443–8, doi:10.1016/j.ajem.2004.10.011.Google Scholar
41. Sejersten, M, Young, D, Clemmensen, P, et al. Comparison of the ability of paramedics with that of cardiologists in diagnosing ST-segment elevation acute myocardial infarction in patients with acute chest pain. Am J Cardiol 2002;90:995–8, doi:10.1016/S0002-9149(02)02685-1.Google Scholar
42. Joseph, L, Gyokos, T, Coupal, L. Bayesian estimation of disease prevalence and the parameters of diagnostic tests in the absence of a gold standard. Am J Epidemiol 1995;141:263–72.Google Scholar
43. Verbeek, PR, Ryan, D, Turner, L, et al. Serial prehospital 12- lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care 2012;16:109–14, doi:10.3109/10903127.2011.614045.Google Scholar