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CLINICAL RESEARCH: MYOCARDIAL INFARCTION

Utilization and Impact of Pre-Hospital Electrocardiograms for Patients With Acute ST-Segment Elevation Myocardial Infarction

Data From the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry

Deborah B. Diercks, MD, MSc^_*,_*, Michael C. Kontos, MD, Anita Y. Chen, MS, Charles V. Pollack, Jr, MD, MS, Stephen D. Wiviott, MD^||, John S. Rumsfeld, MD, PhD^¶, David J. Magid, MD, MPH^¶, W. Brian Gibler, MD^#, Christopher P. Cannon, MD^_**, Eric D. Peterson, MD, MPH, Matthew T. Roe, MD, MHS on behalf of the NCDR ACTION Registry Participants

^_* University of California Davis Medical Center, Sacramento, California
Virginia Commonwealth University Health System, Richmond, Virginia
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
Pennsylvania Hospital, Philadelphia, Pennsylvania
^|| Brigham and Women's Hospital, Boston, Massachusetts
^¶ University of Colorado Medical Center, Denver, Colorado
^# University of Cincinnati Hospital, Cincinnati, Ohio
^_** TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts

Manuscript received July 11, 2008; revised manuscript received September 10, 2008, accepted September 15, 2008.

^_* Reprint requests and correspondence: Dr. Deborah B. Diercks, Department of Emergency Medicine, University of California, Davis Medical Center, 2315 Stockton Boulevard, PSSB 2100, Sacramento, California 95661 (Email: dbdiercks{at}ucdavis.edu).

Objectives: This study sought to determine the association of pre-hospital electrocardiograms (ECGs) and the timing of reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI).

Background: Pre-hospital ECGs have been recommended in the management of patients with chest pain transported by emergency medical services (EMS).

Methods: We evaluated patients with STEMI from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry who were transported by EMS from January 1, 2007, through December 31, 2007. Patients were stratified by the use of pre-hospital ECGs, and timing of reperfusion therapy was compared between the 2 groups.

Results: A total of 7,098 of 12,097 patients (58.7%) utilized EMS, and 1,941 of these 7,098 EMS transport patients (27.4%) received a pre-hospital ECG. Among the EMS transport population, primary percutaneous coronary intervention was performed in 92.1% of patients with a pre-hospital ECG versus 86.3% with an in-hospital ECG, whereas fibrinolytic therapy was used in 4.6% versus 4.2% of patients. Median door-to-needle times for patients receiving fibrinolytic therapy (19 min vs. 29 min, p = 0.003) and median door-to-balloon times for patients undergoing primary percutaneous coronary intervention (61 min vs. 75 min, p < 0.0001) were significantly shorter for patients with a pre-hospital ECG. A suggestive trend for a lower risk of in-hospital mortality was observed with pre-hospital ECG use (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01).

Conclusions: Only one-quarter of these patients transported by EMS receive a pre-hospital ECG. The use of a pre-hospital ECG was associated with a greater use of reperfusion therapy, faster reperfusion times, and a suggested trend for a lower risk of mortality.

Key Words: myocardial infarction • pre-hospital electrocardiogram • reperfusion

Abbreviations and Acronyms   CHF = congestive heart failure   DTB = door-to-balloon time   DTN = door-to-needle time   ECG = electrocardiogram   EMS = emergency medical services   IQR = interquartile range   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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