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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

The Pre-Hospital Electrocardiogram and Time to Reperfusion in Patients With Acute Myocardial Infarction, 2000–2002

Findings From the National Registry of Myocardial Infarction-4

Jeptha P. Curtis, MD^_*, Edward L. Portnay, MD^_*, Yongfei Wang, MS^_*, Robert L. McNamara, MD, MHS^_*, Jeph Herrin, PhD^_*, Elizabeth H. Bradley, PhD, David J. Magid, MD^,, Martha E. Blaney, PharmD^||, John G. Canto, MD, MSPH, FACC^¶ and Harlan M. Krumholz, MD, SM, FACC^_*,,#,_**,_*

^_* Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
Clinical Research Unit, Kaiser Permanente, Denver, Colorado
Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, Colorado
^|| Genentech Inc., South San Francisco, California
^¶ Watson Clinic, Lakeland, Florida and Division of Cardiovascular Diseases, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
^# Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
^_** Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut

Manuscript received August 8, 2005; revised manuscript received October 5, 2005, accepted October 10, 2005.

^_* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Yale University School of Medicine, 333 Cedar Street, PO Box 208088, New Haven, Connecticut 06520-8088. (Email: harlan.krumholz{at}yale.edu).

OBJECTIVES: The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times.

BACKGROUND: Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness.

METHODS: Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics.

RESULTS: A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p < 0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p < 0.0001).

CONCLUSIONS: The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

Abbreviations and Acronyms   AMI = acute myocardial infarction   ECG = electrocardiogram   EMS = Emergency Medical Services   LBBB = left bundle-branch block   NRMI = National Registry of Myocardial Infarction   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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