A Simple Strategy Improves Prehospital Electrocardiogram Utilization and Hospital Treatment for Patients with Acute Coronary Syndrome (from the ST SMART Study)

Abstract

Although the American Heart Association recommends a prehospital electrocardiogram (ECG) be recorded for all patients who access the emergency medical system with symptoms of acute coronary syndrome (ACS), widespread use of prehospital ECG has not been achieved in the United States. A 5-year prospective randomized clinical trial was conducted in a predominately rural county in northern California to test a simple strategy for acquiring and transmitting prehospital ECGs that involved minimal paramedic training and decision making. A 12-lead ECG was synthesized from 5 electrodes and continuous ST-segment monitoring was performed with ST-event ECGs automatically transmitted to the destination hospital emergency department. Patients randomized to the experimental group had their ECGs printed out in the emergency department with an audible voice alarm, whereas control patients had an ECG after hospital arrival, as was the standard of care in the county. The result was that nearly 3/4 (74%) of 4,219 patients with symptoms of ACS over the 4-year study enrollment period had a prehospital ECG. Mean time from 911 call to first ECG was 20 minutes in those with a prehospital ECG versus 79 minutes in those without a prehospital ECG (p <0.0001). Mean paramedic scene time in patients with a prehospital ECG was just 2 minutes longer than in those without a prehospital ECG (95% confidence interval 1.2 to 3.6, p <0.001). Patients with non–ST-elevation myocardial infarction or unstable angina pectoris had a faster time to first intravenous drug and there was a suggested trend for a faster door-to-balloon time and lower risk of mortality in patients with ST-elevation myocardial infarction. In conclusion, increased paramedic use of prehospital ECGs and decreased hospital treatment times for ACS are feasible with a simple approach tailored to characteristics of a local geographic region.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…140 By im plementation of a 12lead ECG from 5 electrodes and continuous STsegment monitoring transmitted via tele phone to the local EDs in northern California, patients (n=4219) with symptoms of ACS had a faster time to first intravenous drug; among patients with STEMI, there was a trend toward faster doortoballoon time and lower mortality risk. 141 In another prospective study of 678 patients with chest pain with suspected ACS, 26 patients had their therapy changed as a consequence of new injury or ischemia identified early through con tinuous STsegment monitoring. 142 It is reasonable to implement continuous ischemia monitoring with 12 leads to augment troponins in units with staff who are equipped with the appropriate education, protocol, and resources such as the ED and coronary care unit to improve early risk stratification for select patients with intermediate to high risk of ACS.…”

Normal prehospital electrocardiography is linked to long-term survival in patients presenting to the emergency department with symptoms of acute coronary syndrome

“…Data for this retrospective analysis were obtained from the ST SMART (Synthesized Twelve-lead ST Monitoring and Real-time Tele-electrocardiography) Trial, a prospective randomized clinical trial in Santa Cruz County, California from 2003-2009 [12]. The primary aims of the ST SMART Trial were to compare patients with and without PH ECG ST-segment monitoring in paramedic scene time, hospital time to treatment, and survival over the period of the study.…”

“…Community assent was obtained by a front-page report in the county's newspaper ( Santa Cruz Sentinel, 2003) and by information posted on hospitals’ and EMS agencies’ websites [12]. Once study participants were comfortable and hemodynamically stable at the hospital, research nurses obtained written consent.…”

“…new onset shortness of breath not due to asthma or syncope not due to drug overdose or intoxication). Exclusion criteria were participants who were unwilling or unable to consent [12]. …”

Contributions to Novel Methods in Electrophysiology Aided by Electronic Devices and Circuits

“…At the opposite extreme are placed the grave cases that don't benefit in time about these kinds of centers. The mobile ECG platform provide in 1-2 minutes the main electrocardiograph shape, at home, and can alert the person if a dangerous situation is recorded, as emergency in cardiovascular diseases, (Drew, 2011).…”