Implications of the Failure to Identify High-Risk Electrocardiogram Findings for the Quality of Care of Patients With Acute Myocardial Infarction

Masoudi, Frederick A.; Magid, David J.; Vinson, David R.; Tricomi, Albert J.; Lyons, Ella E.; Crounse, Laurie; Ho, P. Michael; Peterson, Pamela N.; Rumsfeld, John S.

doi:10.1161/circulationaha.106.623652

Cited by 69 publications

(45 citation statements)

References 28 publications

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“…Patients inadvertently discharged home with MI or not identified at admission with MI have a higher mortality than those identified and treated. 4 Similarly, patients at high risk for adverse outcomes should be treated aggressively. In the case of missed STEMI by 12L, but identified by 80L, aggressive therapy would be rapid reperfusion with primary PCI.…”

Section: Discussionmentioning

confidence: 99%

“…Further, the 12L is severely limited in its detection of inferior, right sided, lateral, and posterior MI and has an especially low sensitivity for MI in patients with bundle branch blocks. [2][3][4][5] This is primarily due to the limited leads and therefore limited resolution of the 12L. Previous studies have shown that 15 leads are more sensitive than 12, and that 18 leads are more sensitive than 15.…”

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confidence: 99%

“…These initial studies of the 80L were all done in veryhigh-risk patients, where the pretest probability of MI was 22% to 62%. 4,[8][9][10][11] The use of the 80L in a more representative, moderate-to high-risk ED population has, to the best of our knowledge, never been reported prior to the Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT MI) study. 13 In addition, the analysis of ST depression as a high-risk ECG finding and the sensitivity of the 80L ECG for detection of ST depression or ST elevation in patients with MI and ACS have never been studied.…”

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confidence: 99%

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Incremental Benefit of 80‐Lead Electrocardiogram Body Surface Mapping Over the 12‐Lead Electrocardiogram in the Detection of Acute Coronary Syndromes in Patients Without ST‐elevation Myocardial Infarction: Results from the Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT MI) Trial

O’Neil

Hoekstra

Pride

et al. 2010

Academic Emergency Medicine

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Incremental Benefit of 80‐Lead Electrocardiogram Body Surface Mapping Over the 12‐Lead Electrocardiogram in the Detection of Acute Coronary Syndromes in Patients Without ST‐elevation Myocardial Infarction: Results from the Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT MI) Trial

O’Neil

Hoekstra

Pride

et al. 2010

Academic Emergency Medicine

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“…3,140 Misdiagnosis of the ECG in the emergency department also contributes to ideal candidates not receiving reperfusion therapy. 141 Goals and training programs must therefore be established and quality control measures instituted to ensure that emergent reperfusion therapy is performed in all STEMI patients without contraindications. Widespread consensus exists that when delivered in a timely fashion at experienced centers, primary PCI compared with fibrinolysis will save lives; enhance myocardial recovery; prevent intracranial bleeding, stroke, reinfarction, and recurrent ischemia; and otherwise enhance cardiovascular outcomes.…”

Section: Conclusion: Interventional Strategies In Stemimentioning

confidence: 99%

Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

Stone

2008

Circulation

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A s reviewed in part I of this report, 1 primary PCI without antecedent fibrinolytic therapy has become widely accepted as the preferred reperfusion modality for patients with ST-segment-elevation myocardial infarction (STEMI) presenting at suitably equipped tertiary facilities. However, primary percutaneous coronary intervention (PCI) is not offered at Ն50% of US hospitals, and many of those that do are unable to offer primary PCI as an around-the-clock service. Primary PCI also is less widely available in many other countries than in the United States. Thus, fibrinolytic therapy continues to be administered to many patients with STEMI. 2,3 Given the relatively low rates of successful reperfusion with fibrinolysis, 4,5 revascularization often is required afterward, the indications for and outcomes of which are critically evaluated here. The impact of individual operator and institutional volumes on PCI outcomes is reviewed. Evidencebased recommendations for selecting among the various reperfusion therapy options are then offered for the patients with STEMI presenting at centers with and without interventional capabilities, with distinctions drawn where the evidence-based recommendations in this article differ substantially from recently updated task force guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA). 5 Finally, recent and ongoing investigations to further improve outcomes after catheter-based reperfusion therapy are summarized. Angioplasty After Fibrinolytic TherapyPCI after fibrinolytic therapy in STEMI may be performed in a variety of settings: (1) rescue PCI after failed fibrinolysis in patients with ongoing symptoms, myocardial injury, or persistent coronary occlusion, typically initiated within 60 to 120 minutes after fibrinolytic administration; (2) immediate PCI (also known as facilitated PCI), performed within several hours after fibrinolytic administration, regardless of whether clinical or ECG evidence of ongoing myocardial injury is present; (3) delayed routine PCI, in which patients who are stable for several days after fibrinolytic administration undergo angiography and PCI, regardless of the presence or absence of ischemia or myocardial viability; and (4) delayed selective angioplasty, in which only patients with spontaneous or inducible ischemia after fibrinolysis undergo catheterization and PCI when appropriate.Similar to primary PCI, each of these interventional strategies describes an approach of angiography followed by triage to angioplasty, coronary artery bypass graft surgery, or medical therapy, a decision based on the coronary anatomy, left ventricular function, and other patient-related factors. However, PCI is performed in Ϸ80% to 90% of angiographically screened patients requiring revascularization. Rescue PCIRescue PCI refers to the strategy of urgent catheterization after fibrinolytic therapy has clinically failed to restore reperfusion of the infarct artery. Patients in whom fibrinolysis fails to restore patency of the infarct-related a...

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“…[9][10][11][12][13] Failure to receive reperfusion therapy has been associated with worse outcomes. 5,7,9,10,14,15 Most prior studies examining delays in presentation and the utilization of reperfusion therapy have been conducted in Western populations and developed countries. Practice patterns and patient characteristics in developing regions of the world may differ significantly from what has been observed in Western registries.…”

Section: Introductionmentioning

confidence: 99%

Missed Opportunities in the Management of ST‐Segment Elevation Myocardial Infarction in the Arab Middle East: Patient and Physician Impediments

Al-Mallah

Alsheikh‐Ali

Almahmeed

et al. 2010

Clinical Cardiology

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Background: Lack of timely reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) has been associated with worse outcomes. The aim of this study is to identify the frequency and predictors of delayed presentation and missed reperfusion in patients with STEMI in the Gulf Register of Acute Coronary Events (Gulf RACE) registry. Delayed Presentation and missed reperfusion is associated with increased in hospital mortality in STEMI patients. Methods: Gulf RACE is a prospective, multinational study of all consecutive patients hospitalized with the final diagnosis of acute coronary syndrome in 65 centers in 6 Arab countries. In this analysis, we included 3197 patients with STEMI. The independent predictors of delayed presentation and missed reperfusion therapy were identified using multivariate logistic regression. Results: In total, 929 patients presented >12 hours after symptom onset. The independent predictors of late presentation are older age, atypical symptoms, no family history of coronary artery disease, and being in Yemen. Of the 2268 STEMI patients presenting early, a total of 205 patients (9.3%) did not receive reperfusion therapy despite no contraindications (shortfall). The independent predictors of not receiving appropriate reperfusion therapy are older age, prior stroke, being in Yemen, and atypical symptoms. Lack of reperfusion therapy due to shortfall or delayed presentation was associated with increased in-hospital mortality. Conclusions: Nearly one-third of patients with STEMI in the Arab Middle East present to the hospital >12 hours after symptom onset, and nearly 1 in 10 eligible patients do not receive any reperfusion therapy. Community and physician awareness programs are needed to increase the utilization of appropriate lifesaving therapies.

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Implications of the Failure to Identify High-Risk Electrocardiogram Findings for the Quality of Care of Patients With Acute Myocardial Infarction

Cited by 69 publications

References 28 publications

Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

Missed Opportunities in the Management of ST‐Segment Elevation Myocardial Infarction in the Arab Middle East: Patient and Physician Impediments

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