Prehospital ECG Research Articles

Thrombolysis versus primary percutaneous coronary intervention in patients with suspected ST-elevation myocardial infarction - a SWEDEHEART observational study

Abstract Background Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in ST-elevation myocardial infarction (STEMI) patients provided time to reperfusion is ≤120 minutes. In patients presenting early with an estimated time to reperfusion >120 minutes, thrombolytic therapy should be considered according to European Society of Cardiology guidelines. However, there is a lack of contemporary data on patients treated with thrombolysis. Aims Our aim was to determine how often thrombolysis was administered in STEMI patients having an estimated time to reperfusion of >120 minutes and to study outcome differences between patients treated with thrombolysis compared to those treated with primary PCI. Methods We calculated transport times to nearest primary PCI centre using three-digit zip codes for each patient enrolled in the SWEDEHEART registry from 2008–2021 in the five geographic areas in Sweden routinely using thrombolysis and included those with >120 min estimated transportation time to reperfusion time. Patients without ST-elevations on prehospital ECG and ongoing chest pain as well as patients with left bundle branch block, pacemaker rhythm and patients with contraindications to thrombolysis were excluded. Patients were grouped by received reperfusion therapy with prehospital thrombolysis or no prehospital thrombolysis and studied with regard to 1- and 3-year mortality using Kaplan-Meier failure estimates and Cox regression adjusted for difference in baseline characteristics. Results A total of 1,840 patients were included of whom 1,381 (75.1%) received thrombolysis. A final diagnosis of STEMI was observed in 92.6% of patients receiving thrombolysis and 80.2% of patients treated with primary PCI. The median transport time estimate to a PCI centre was 153 minutes in both groups. Median time from onset of symptoms to reperfusion therapy was 131 minutes for the thrombolysis group and 255 minutes for the PCI group. Patients who received thrombolysis were on average 2 years younger and had fewer comorbidities such as diabetes, cancer and heart failure. Among patients treated with thrombolysis, a total of 42.7% of patients underwent rescue PCI. There was no significant difference in 365-day mortality (6.7% vs 11.8%, adjusted HR 0.84, 95% CI: 0.59-1.19, p=0.33) or 3-year mortality rates (10.3% vs 16.6%, adjusted HR 0.89, 95% CI: 0.66-1.19, p=0.44) between patients treated with thrombolysis and primary PCI groups. Conclusions In this population-based study of patients where primary PCI cannot be expeditiously used, we observed a commendable adherence rate of 75% to the ESC guidelines for thrombolysis treatment. Moreover, our findings revealed that the administration of thrombolysis was not associated with any discernible benefits or harm.Unadjusted and adjusted Cox-modelKaplan-Meier survival analysis

Predicting ECGs masquerading AS STEMI with machine learning

Abstract Background Advancements in the management of ST elevation myocardial infarction (STEMI) in the last 15 years include early STEMI identification in the prehospital setting leading to expedited cardiac catheterisation laboratory (CCL) activation or fibrinolytic therapy. We have previously reported of patients who met the Glasgow algorithm (GA) ECG criteria for STEMI; 50% did not actually have an acute STEMI according to the 4th universal definition of MI (4UDMI)1. Identifying such patients could avoid unnecessary emergency CCL activations or inappropriate fibrinolytic administration. Methods From June 2010 to October 2021, we identified 2992 patients with ECG transmissions to Liverpool Hospital, Sydney Australia which met GA criteria for STEMI. These were adjudicated according to the 4UDMI for true-positive STEMI. We used univariate and multivariate logistic regression to identify likely patient characteristics that were predictive of true-positive STEMI. We then improved model performance using receiver-operator curve (ROC) with simple random forest machine learning algorithms. Results Among 2994 patients with prehospital ECG transmissions that met GA-criteria, 1553 (51%) were adjudicated as true-positive STEMI, which is comparable to previous findings1. All standard modifiable and non-modifiable risk factors were independently predictive of true-positive STEMI; however, in multivariate logistic regression gender, hypertension and diabetes lost significance. Dyslipidemia and current smoking were positively predictive of true-positive STEMI status (OR = 1.64 and 1.32 respectively), whereas age and previous MI were negatively associated (OR = 0.98 (per year increment) and 0.4). Using these identified predictors in a random forest to predict true-positive STEMI yielded an AUC of 0.65 (Figure 1). Conclusion Specific clarification of dyslipidaemia and current smoking status at first medical contact may be the most salient in predicting a true-positive STEMI during prehospital assessment which may assist in avoiding unnecessary emergency CCL activation or inappropriate fibrinolytic administration.ROC of ST elevation STEMI recognition

External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS

BackgroundEmergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores...

Pre-hospital heparin is not associated with infarct vessel patency and mortality in ST-segment elevation myocardial infarction patients with out-of-hospital cardiac arrest.

Pre-hospital heparin administration has been reported to improve prognosis in patients with out-of-hospital cardiac arrest (OHCA). This beneficial effect may be limited to the subgroup of ST-segment elevation myocardial infarction (STEMI) patients. To assess the impact of pre-hospital heparin loading on TIMI (Thrombolysis in Myocardial Infarction) flow grade and mortality in STEMI patients with OHCA, we analyzed data from 2,566 consecutive patients from two hospitals participating in the prospective Feedback Intervention and Treatment Times in ST-segment Elevation Myocardial Infarction (FITT-STEMI) trial. In 394 participants with OHCA, 272 (69%) received heparin from the emergency medical service (EMS). Collapse witnessed by EMS (odds ratio (OR) = 3.53, 95%-confidence interval (CI) = 1.54-8.09; p = 0.003) and pre-hospital ECG recording (OR = 3.32, 95% CI = 1.06-10.35; p = 0.039) were identified as parameters significantly associated with pre-hospital heparin use. In univariate analysis, in-hospital mortality was lower in the group receiving heparin in the pre-hospital setting (26.8% vs. 42.6%, p = 0.002). However, in a regression model, pre-hospital heparin use was no longer a significant predictor of mortality (OR = 0.992; p = 0.981). Patency of the infarct artery prior to coronary revascularization, as measured by TIMI flow grade, was not associated with pre-hospital administration of heparin in OHCA patients (OR = 0.840; p = 0.724). In STEMI patients with OHCA, pre-hospital use of heparin is neither associated with improved early patency of the infarct artery nor with a better prognosis. Our results do not support the assumption of a positive effect of heparin administration in the pre-hospital treatment phase in STEMI patients with OHCA. ClinicalTrials.gov: NCT00794001.

Performance of Prehospital ECG and Impact on Prehospital Service Time: Comparison between EMT-II and EMT-P Teams.

Prehospital electrocardiogram (PHECG) shortens door-to-balloon time in patients with ST-elevation myocardial infarction. However, it may increase the prehospital service time, thus offsetting the benefits gained. The performance of PHECG could be influenced by the proficiency of the emergency medical technicians (EMTs). To investigate whether there are differences in the performance of PHECG between EMT-II and EMT-paramedics (EMT-P). This prospectively designed, retrospectively analyzed study of PHECG was conducted in Taipei from February 2019 to April 2021. Comparisons were made between EMT-II and EMT-P teams. The primary outcomes were the acceptance of PHECG suggestions and prehospital service time. The secondary outcomes were gender disparities in the primary outcomes. A total of 2,991 patients were included, of whom 2,617 received PHECG. For the primary outcomes, the acceptance of PHECG was higher in those approached by EMT-P (99.6% vs. 71.5%, p < 0.001). The scene time and scene-to-hospital time showed no significant differences. For gender disparities, the acceptance of PHECG in female patients was significantly lower in those approached by EMT-II (59.3% vs. 99.2%, p < 0.001). The scene time and scene-to-hospital time were generally longer in the female patients, especially in the younger and middle age groups. Compared to EMT-P, both were significantly longer in the female patients approached by EMT-II. The acceptance of PHECG was lower in those approached by EMT-II, especially in females. Although there were generally no significant differences between EMT-II and EMT-P, the scene time and scene-to-hospital time were significantly longer in female patients, especially in those aged < 75 years approached by EMT-II.

Risk assessment by acute bedside echocardiography prior to acute coronary angiography in patients with ST-elevation myocardial infarction: a feasibility study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation. Background Early risk assessment by hemodynamic measurements in patients with ST-elevation myocardial infarction (STEMI) could be useful for early detection of patients at risk of developing hemodynamic instability after primary percutaneous coronary intervention (pPCI). Anterior STEMI patients have larger infarct size and may be of particular interest. Transthoracic echocardiography (TTE) is a quick, non-invasive, and available tool, however, evidence regarding the use of acute TTE prior to acute coronary angiography (CAG) is limited. Purpose To assess the feasibility of acute bedside hemodynamic assessment in the cath. lab. by TTE in addition to clinical examination, and blood samples in STEMI patients without CS at arrival in the cath. lab. Methods STEMI patients without CS at hospital arrival and treated with pPCI were included in the study during a five week period. Clinical examination (Killip class), blood sampling (lactate, troponin T (TNT), proB-type natriuretic peptide (proBNP), and focused bedside 2D TTE with Doppler were performed prior to the acute CAG. The TTE protocol was focused (approx. 5 minutes) on hemodynamic measurements, infarction related complications, and differential diagnoses e.g. aortic dissection. The TTE was performed during preparation for the acute CAG. Patients were stratified in anterior- vs. non-anterior STEMI based on the culprit artery and prehospital ECG. Feasibility was estimated by all of the following echocardiographic parameters; left ventricular ejection fraction (LVEF), left ventricular outflow tract (LVOT) velocity time integral (VTI), and right ventricular function (tricuspid annular plane systolic excursion (TAPSE)). Results A total of 60 STEMI patients (aged mean 63 years, 18% female) were included, and 47% had an anterior STEMI. No differences in baseline characteristics between the two groups were found including comorbidities, clinical parameters, and time from cath. lab. arrival to first wire over the culprit lesion (median (IQR) 28 (23; 38) vs 32 (24; 40) minutes). Admission biomarkers of blood glucose, lactate, and proBNP plasma concentrations were similar between the two groups. Whereas admission TNT were higher for patients with anterior STEMI (median (IQR) 110 (37; 449) vs. 37 (20; 94) ng/L, p=0.01). The feasibility of TTE-study protocol was 93%. Patients with anterior STEMI had lower LVEF (mean: 36±11 vs. 48±9%, p=0.0003; missing: n=0), and a trend to lower LVOT VTI (19 (6.4) vs. 22 (5.0) cm, p=0.06; missing: n=4). No difference in parameters of diastolic function or TAPSE (missing: n=0) were found. None of the included patients had echocardiographic visible complications related to the infarction. Conclusion Acute TTE is to a high degree feasible and does not delay time to acute revascularization in STEMI patients. Patients with anterior STEMI have significantly higher admission TNT levels, lower LVEF, and a trend to lower LVOT VTI compared with non-anterior STEMI patients.

Cardiological emergency and acute myocardial infarction: physician and physiotherapist perceptions of immediate care, use of prehospital ECGS and patient referrals

Doctors and physiotherapists play a key role in reducing the rate of morbidity and mortality from acute myocardial infarction through well-applied care, as well as through the key point of health education, given that most of the risk factors are modifiable. This article is a literature review, which aims to explore the challenges faced by patients with acute myocardial infarction. This review shows that heart attacks are a serious problem. The study proves that this damage can be reduced or minimized with the training of medical and physiotherapy professionals in recognizing the signs and symptoms in good time, as well as the best treatment.

Artificial intelligence driven prehospital ECG interpretation for the reduction of false positive emergent cardiac catheterization lab activations: A retrospective cohort study

Artificial intelligence driven prehospital ECG interpretation for the reduction of false positive emergent cardiac catheterization lab activations: A retrospective cohort study

Smartphone App for Prehospital ECG Transmission in ST-Elevation Myocardial Infarction Activation: Protocol for a Mixed Methods Study.

Timely diagnosis and treatment for ST-elevation myocardial infarction (STEMI) requires a coordinated response from multiple providers. Rapid intervention is key to reducing mortality and morbidity. Activation of the cardiac catheterization laboratory may occur through verbal communication and may also involve the secure sharing of electrocardiographic images between frontline health care providers and interventional cardiologists. To improve this response, we developed a quick, easy-to-use, privacy-compliant smartphone app, that is SMART AMI-ACS (Strategic Management of Acute Reperfusion and Therapies in Acute Myocardial Infarction Acute Coronary Syndromes), for real-time verbal communication and sharing of electrocardiographic images among health care providers in Ontario, Canada. The app further provides information about diagnosis, management, and risk calculators for patients presenting with acute coronary syndrome. This study aims to integrate the app into workflow processes to improve communication for STEMI activation, resulting in decreased treatment times, improved patient outcomes, and reduced unnecessary catheterization laboratory activation and transfer. Implementation of the app will be guided by the Reach, Effectiveness, Acceptability, Implementation, and Maintenance (RE-AIM) framework to measure impact. The study will use quantitative registry data already being collected through the SMART AMI project (STEMI registry), the use of the SMART AMI app, and quantitative and qualitative survey data from physicians. Survey questions will be based on the Consolidated Framework for Implementation Research. Descriptive quantitative analysis and thematic qualitative analysis of survey results will be conducted. Continuous variables will be described using either mean and SD or median and IQR values at pre- and postintervention periods by the study sites. Categorical variables, such as false activation, will be described as frequencies (percentages). For each outcome, an interrupted time series regression model will be fitted to evaluate the impact of the app. The primary outcomes of this study include the usability, acceptability, and functionality of the app for physicians. This will be measured using electronic surveys to identify barriers and facilitators to app use. Other key outcomes will measure the implementation of the app by reviewing the timing-of-care intervals, false "avoidable" catheterization laboratory activation rates, and uptake and use of the app by physicians. Prospective evaluation will be conducted between April 1, 2022, and March 31, 2023. However, for the timing- and accuracy-of-care outcomes, registry data will be compared from January 1, 2019, to March 31, 2023. Data analysis is expected to be completed in Fall 2024, with the completion of a paper for publication anticipated by the end of 2024. Smartphone technology is well integrated into clinical practice and widely accessible. The proposed solution being tested is secure and leverages the accessibility of smartphones. Emergency medicine physicians can use this app to quickly, securely, and accurately transmit information ensuring faster and more appropriate decision-making for STEMI activation. ClinicalTrials.gov NCT05290389; https://clinicaltrials.gov/study/NCT05290389. DERR1-10.2196/55506.

Improving myocardial infarction emergency care: a joint intervention study of the Berlin Brandenburg Myocardial Infarction Registry (B2HIR) and emergency medical services (QS-Notfall)

Abstract Background Rapid myocardial reperfusion is needed to improve clinical outcome after a ST-elevation myocardial infarction (STEMI). Missed early explicit STEMI diagnoses were shown to unfavourably delay STEMI care. A networked approach between emergency medical systems (EMS) and cardiology hospital departments is useful to establish early valid pre-hospital STEMI diagnoses. Purpose The publicly funded "QS-Notfall" joint health services research study intended to improve STEMI care in Berlin (BE) and Brandenburg (BB) by implementing pre-hospital tele-ECG transmission and online ECG training for EMS personnel. Methods As part of B2HIR, 21 cardiology hospital departments (19 in BE, 2 in BB) together with EMS (BE firefighters and regional BB EMS), supported by the Berlin Medical Chamber, established 2 joint interventions to accelerate STEMI care. All EMS and hospitals implemented GDPR compliant telemedical transmission and structured handling of pre-hospital ECGs from patients with chest pain. In addition, we developed an ECG e-learning for emergency physicians and EMS personnel ("STEMI einfach erkennen") and communication between EMS and hospitals was enforced. Patients with acute myocardial infarction (AMI) and symptom onset ≤24h were enrolled. Symptom onset, first medical contact, time of hospital admission ("door"), time of guidewire passage into the coronary artery (reperfusion), and respective care delays were assessed. First obtained ECGs were blindly validated by 3 expert cardiologists. We compared a reference period to a 12-month intervention period with regard to care delays. In addition, STEMI care was analyzed according to the actual use of telemedical ECG transmission and according to the validity of ECG diagnoses. Results N=7303 cases were enrolled (reference period 3657, intervention period 3646, age 66.9y, 27.1% female, STEMI 49.4%). The usage of ECG transmission varied notably between hospitals (7.5%–74%). Tele EMS ECG usage in STEMI was associated with shorter door to reperfusion time (BB 11min, p&amp;lt;0.04, BE 12min, p&amp;lt;0.001) compared to STEMI care w/o ECG transmission. The difference was more pronounced during hospital off-hours (BB 30min, p=0.003 and BE 14min, p&amp;lt;0.001). An unmistaken EMS STEMI diagnosis related to a shorter door to reperfusion time (BE: by 106min; BB: by 49min) compared to an unsettled STEMI diagnosis (p&amp;lt;0.001). The rate of ECG transmission for STEMI patients in BE was 21.4%, in BB 55.7%. Accordingly, we found no significant difference in STEMI door to reperfusion delays between the reference period and the intervention period in BE (+1min) and a shorter reperfusion delay (by 11min) in BB (p=0.049). Conclusions The universal implementation of a joint intervention to improve STEMI care in a complex system of various EMS and hospital departments is challenging. Telemedical ECG transmission and an unmistaken early STEMI diagnosis are associated with a significantly shorter time delay to myocardial reperfusion.

Abstract 16067: The Impact of a Prehospital Mobile Cloud ECG Transmission System on Myocardial Damage and Mid-Term Mortality in Patients With ST-Elevation Myocardial Infarction

Background: Guidelines recommend that the door-to-balloon time (DTBT) should be reduced to ninety minutes or less in patients with STEMI. As such, it is critical that ambulance teams are adequately trained and equipped to identify STEMI utilizing ECG recorders and telemetry when necessary. Aims: This single-center study aims to evaluate the impact of the prehospital mobile cloud 12-lead ECG transmission system (SCUNA ® , MEHERGEN GROUP) on reducing DTBT, myocardial damage, and mortality in STEMI patients. Methods: In June 2018, SCUNA were integrated into the regional emergency medical service (EMS) departments in Uki and Kamimashiki cities in Kumamoto, Japan. We examined and compared door-to-catheterization laboratory time (DTCT), DTBT, peak CK, CK-MB levels, as well as 1-year mortality rates of STEMI cases in the four years before and after the introduction of the SCUNA. From June 2014 to May 2022, a total of 338 STEMI patients were transferred to our institute by ambulances from the two EMS departments. After excluding 29 patients with onset to reperfusion times exceeding 24 hours and 66 patients who were transferred without the use of SCUNA following its introduction, 243 consecutive STEMI patients who underwent emergency percutaneous coronary intervention (PCI) were included in the study. The patients were divided into two groups, 130 patients prior to SCUNA introduction (Pre-SCUNA), 113 patients after SCUNA introduction (Post-SCUNA). Results: There were no significant differences in age, gender, past medical history or Killip classification between the two groups. DTCT, DTBT, and onset to reperfusion time (OTRT) were significantly reduced in the Post-SCUNA group compared to the Pre-SCUNA group (Pre-SCUNA: 40 min vs. Post-SCUNA: 25 min; p &lt; 0.01, 71 min vs. 53 min; p &lt; 0.01, and 201 min vs. 166 min; p = 0.02, respectively). No significant differences were observed between peak CK and CK-MB levels in the two groups. Kaplan-Meier analysis revealed that SCUNA did not improve 30-day and 1-year outcomes compared with the Pre-SCUNA groups. Conclusion: While the prehospital mobile cloud ECG transmission system effectively reduced DTBT, it did not lead to a notable reduction in myocardial damage or mortality rates.

TCT-251 A Systematic Review and Meta-Analysis of the Effect of Pre-hospital ECG Transmission for ST-Segment Elevation Myocardial Infarction Patients on Door-to-Device Time and Mortality

TCT-251 A Systematic Review and Meta-Analysis of the Effect of Pre-hospital ECG Transmission for ST-Segment Elevation Myocardial Infarction Patients on Door-to-Device Time and Mortality

Post hoc labeling an acute ECG as ischemic or non-ischemic based on clinical data: A necessary challenge

The ECG is crucial in the prehospital (and early inhospital) phase of patients with symptoms suggestive of myocardial ischemia. Therefore, new algorithms for ECG-based myocardial ischemia detection are continuously being researched. Development and validation of these algorithms require a database of acute ECGs (from the prehospital or emergency department setting) including a representative mix of cases (ischemia present) and controls (no ischemia present). Therefore, for every patient in this mix, the “truth” regarding the actual presence or absence of myocardial ischemia during the recording of the acute ECG has to be determined to compare the newly developed algorithm against. This post hoc adjudication process of determining whether an acute (either prehospitally acquired or acquired in the emergency department) ECG was made under ischemic conditions should use all available clinical data (the clinical diagnosis, cardiac imaging data, and laboratory values) of the subsequent patient's admission.Even with all data at hand, post hoc labeling a patient and their acute ECG as a myocardial ischemia case or control cannot be forced into a binary division between definite cases and definite controls. More specifically, to be used for the development of a new algorithm, the patients' ECG has to be scored for the presence or absence of myocardial ischemia at the exact moment of its recording, which renders the classification even more difficult. For instance, even though it may be plausible that myocardial ischemia was present at a given moment during the patient's admission, this is not necessarily proof that the prehospital (or early inhospital) ECG was also made in ischemic conditions: ischemia can be a fluctuating process (as is, e.g., the case in unstable angina pectoris). Therefore, post hoc classification of an acute ECG in terms of the absence or presence of ischemia requires a multipoint scale ranging between definite ischemic to definite non-ischemic, for instance using a 5-point scale (presumed non-ischemic, probably non-ischemic, uncertain, probably ischemic, presumed ischemic).To summarize, the post hoc adjudication process of ECGs of ambulance (and emergency department) patients cannot result in a binary division into definite cases and controls (i.e., patients with or without myocardial ischemia during the recording of the acute ECG), as myocardial ischemia is often dynamic rather than constant. ECGs could be labeled on a multi-point scale, in which the label represents the probability of the actual presence (or absence) of myocardial ischemia at the exact moment of the recording of that ECG. Further development of algorithms for myocardial ischemia detection should consider this concept.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry.

Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

What is the truth? Possibilities and impossibilities of post-hoc labeling a prehospital ECG

Recent studies suggest that up to a quarter of physicians in training suffer from burnout and psychological disorders. Scientist-physicians, cardiologists, cardiology residents, and first-year medical residents seem to be more prone to developing varying degrees of emotional distress. Concerned about the new generations of clinicians and researchers, the authors aim to provide guidelines for reconciling professional success with a fulfilling and satisfying personal life. The figure of Antonio Bayés de Luna (cardiology and electrocardiology guru) is used as the ideal example to learn how to combine one's personal life, family, and friendships with science and their professional career. This can be done in a healthy and balanced way, prioritizing the former while continuing to have an intense dedication to the latter.

Okluzija u dominantnom levom koronarnom sistemu - EKG dilema u radu lekara hitne pomoći

Introduction/Objective Acute chest pain is the main clinical manifestation of acute coronary syndrome. A posterior myocardial infarction (MI) most commonly occurs as a complication or extension of an inferior MI because of the overlapping coronary vascularization. We are presenting a case in which the patient exhibited mild anginal symptoms and an ECG pattern which did not correlate with a devastating infarction. Case report: The Emergency Medical Team (EMT) was dispatched at 5 am to help a 62-year-old patient, who had been woken from his sleep by a feeling of tightness in his chest and weakness in both arms. Upon examination, the patient was hypertensive (160/90 mmHg) and moderately bradycardic (58-62/min), with normal oxygen saturation on room air (SaO2 98%). His prehospital ECG findings were as follows: sinus rhythm, horizontal ST depression in V1-V3 1 to 2mm, ST elevation ≤1mm in lead V6, subtle ST depression in D1 and aVL &lt;1mm, ST elevation in D3 and aVF &lt;1mm. After attaching additional posterior leads, the modified ECG recording showed an ST elevation of 1 to 2 mm in V7-V9. Continuous laboratory monitoring of cardiac enzyme markers showed elevated and increasing values: Troponin T -2377, 3756 ng/l; CK -1572, 1564 U/l. Coronary angiography: The LCA system was dominant. The RCA was nondominant with a 70-80% stenosis, and a complete Occlusion Myocardial Infarction (OMI) distally. Using the most accurate LCxc/RCA occlusion algorithms, the ECG finding suggested an occlusion in the right dominant coronary system, which does not correlate with the coronary angiography report. Conclusion: Excellent knowledge of recording, analysis, and interpretation of ECG tracings, facilitates adequate pre-hospital care and precise planning for further processing of patients with chest pain. It is recommended to record posterior and right unipolar leads in all patients with inferior and suspicion of posterior myocardial infarctions and to include the ST-elevation myocardial infarction equivalent into the STEMI network. Given the physiological differences in left ventricular vascularization and the possible predominance of the left coronary system over the right, future studies must focus on establishing more precise algorithms for assessing RCA/LCx occlusion.

Prehospital 12-Lead Electrocardiography System in Oita Assisted Transport of "True" Acute Coronary Syndrome Patients to Optimal Institutes.

Mobile cloud electrocardiography (C-ECG) can reduce the door-to-balloon time of acute coronary syndrome (ACS) patients, so we hypothesized it would also assist in transporting ACS-suspected patients to the optimal institutes.Methods and Results: Initially, 10 fire departments in Oita had 10 ambulances equipped with C-ECG. Ambulance crews recorded a 12-lead ECG from the patient at the first point of contact and transmitted them to 18 hospitals (13 institutions (PCII) with 24-h availability for percutaneous coronary intervention (PCI) and 5 regional core hospitals (RCH) without 24-h PCI) for analysis by a cardiologist. During 41 months, 476 ECGs suspected to be ACS were transmitted and analyzed. Of these, 24 ECGs transmitted to PCII were judged as not requiring PCI, and the patients were directly transported to a RCH (PCII-RCH); 35 ECGs sent to a RCH were judged as requiring PCI, and the patients were directly transported to a PCII (RCH-PCII). The prevalence of cardiovascular disease was significantly higher in the RCH-PCII group than in the PCII-RCH group (P<0.01). There was no significant difference in the door-to-balloon time between the RCH-PCII and the group in which the C-ECG was sent to a PCII and the patients were transported directly to PCII (PCII-PCII) (49±14 vs. 59±20 min, P=0.14). Prehospital 12-lead ECG can assist in transporting ACS-suspect patients to the optimal treatment facility.

Should doctors replace machines in prehospital electrocardiogram interpretation?

Should doctors replace machines in prehospital electrocardiogram interpretation?

Feasibility of prehospital identification of non-ST-elevation myocardial infarction by ECG, troponin and echocardiography

BackgroundPrehospital identification and selection of treatment strategy in patients with suspected non-ST-elevation myocardial infarction (NSTEMI) is challenging. The aim of this study was to evaluate the feasibility and diagnostic accuracy...