Using ECG-To-Activation Time to Assess Emergency Physicians' Diagnostic Time for Acute Coronary Occlusion.

Abstract

There is no quality metric for emergency physicians' diagnostic time for acute coronary occlusion. We sought to quantify diagnostic time associated with automated interpretation, classic ST-elevation myocardial infarction (STEMI) criteria, STEMI-equivalents, and subtle occlusions, using electrocardiogram (ECG)-to-activation of catheterization laboratory time. This multicenter retrospective study reviewed all code STEMI patients from the emergency department (ED) with confirmed culprit lesions from January 2016 to December 2018. We measured door-to-ECG (DTE) time and ECG-to-activation (ETA) time. We examined the first ED ECGs to determine whether automated interpretation labeled "STEMI," and they met classic STEMI criteria, STEMI-equivalents, or rules for subtle occlusion. ECG analysis was performed by two emergency physicians blinded to clinical scenario, automated interpretation, and angiographic outcome. There were 177 code STEMIs with culprit lesions, with a median DTE time of 9.0min and a median ETA time of 16.0min. Automated interpretation labeled 55.4% of first ECGs "STEMI" (ETA 6.5min) and 44.6% not "STEMI" (ETA 66min, p<0.0001). Of first ECGs, 63.8% met classic STEMI criteria (ETA 8.0min), 8.5% had STEMI-equivalents (ETA 32.0min, p=0.0026), 16.4% had subtle occlusions (ETA 89.0min, p=0.045), and 11.3% had no diagnostic sign of occlusion (ETA 68.0min, p=0.20). STEMI criteria missed more than one-third of occlusions on first ECG, but most had STEMI-equivalents or rules for subtle occlusion. ETA time can serve as a quality metric for emergency physicians to promote new ECG insights and assess quality improvement initiatives.