The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature

Brainard, Andrew; Raynovich, William; Tandberg, Dan; Bedrick, Edward J.

doi:10.1016/j.ajem.2005.02.004

Cited by 58 publications

(28 citation statements)

References 20 publications

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“…Components include prehospital ECGs and notification of the receiving facility, [45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60] and activation of the cardiac catherization team to shorten reperfusion time 54,59,82,89 -92 and other hospital personnel important for treatment and resource allocation.…”

Section: Systems Of Carementioning

confidence: 99%

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

240

167

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Section: Systems Of Carementioning

confidence: 99%

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

240

167

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“…[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] The direction and magnitude of the time savings are clinically relevant, resulting in an approximately 10-minute decrease in door-to-drug time and 15-to 20-minute decrease in door-to-balloon time. 12,13 However, these time savings may not reflect the full potential of prehospital ECGs to decrease delays in reperfusion therapy.…”

Section: What Are the Benefits Of Using Prehospital Ecgs In Patients mentioning

confidence: 99%

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Ting¹,

Krumholz²,

Bradley³

et al. 2008

Circulation

221

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Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3-to 4-mm ST-segment elevation in leads I, aVL, and V 2 through V 6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3. Current Guidelines for Prehospital ECGs Among Patients With ST-Segment-Elevation Myocardial InfarctionAmerican Heart Association national guidelines, 1-3 as well as other consensus and scientific statements, 4 -11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment-elevation myocardial infarction (STEMI), 12,13 and this rate has not substantially changed since the mid1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not effectively translated into action and coordinated with hospital systems of care to decrease delays in reperfusion therapy. 13 The purpose of this article is to summarize evidence concerning the benefits of using prehospital ECGs, review barriers and challenges to routine use, and recommend approaches to enhance their effectiveness for improving quality of care for patients with acute coronary syndromes.The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

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“…Prehospital 12-lead ECGs with advance hospital notification has been shown to be feasible and associated with a reduction in mean time from hospital arrival to fibrinolysis of 11 minutes (from 25 to 36 min). 15,17,18 The AHA/ACC 2007 revision of their 2004 guidelines for STEMI care re-emphasized the need to increase access to prehospital 12-lead ECGs. 7,38 Other recent studies of prehospital alert (with early activation of the catheterization laboratory), expedited transfer and prehospital bypass demonstrate reductions in time to primary PCI 24,39-49 and improved patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…1,[8][9][10][11][12][13][14] The AHA/ACC guidelines stress the importance of the role of emergency medical services (EMS) in the implementation of prehospital strategies, and encourage the development of a systems approach to reduce reperfusion delays. 7 Prehospital 12-lead electrocardiography (ECG) with advance hospital notification for patients with suspected STEMI has been associated with reduced time to reperfusion in several studies, [15][16][17][18] and is recommended as an effective approach to minimize delays. 7 Other recommended strategies to meet reperfusion target times are expedited transfer of STEMI patients from hospitals without PCI capabilities to hospitals with PCI capabilities, and bypassing a non-PCI hospital for a PCI hospital when EMS personnel suspect STEMI.…”

Section: Introductionmentioning

confidence: 99%

Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

Schull

Vaillancourt²,

Donovan³

et al. 2009

CJEM

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Objective: Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada. Methods: We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis. Results: Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%-77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%-41%) were trained in ECG interpretation. Only 18% (95% CI 10%-25%) of operators had prehospital bypass protocols; 45% (95% CI 35%-55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces. Conclusion:The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.

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The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature

Cited by 58 publications

References 20 publications

Part 10: Acute Coronary Syndromes

Part 10: Acute Coronary Syndromes

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

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