Retrospective description and analysis of consecutive catheterization laboratory ST-segment elevation myocardial
Timothy A Mixon1, Eunice Suhr, Gerald Caldwell
1Division of Cardiology, Scott & White Healthcare, Temple, TX, USA. tmixon@swmail.sw.org
Insights
False activations of cardiac catheterization labs for ST-segment elevation myocardial infarction (STEMI) are surprisingly high. Improving diagnostic accuracy is crucial for patient care and efficient resource allocation in emergency medicine.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- Rapid activation of cardiac catheterization laboratories (CCL) reduces door-to-balloon times for ST-segment elevation myocardial infarction (STEMI), lowering mortality.
- Prehospital electrocardiography and notification accelerate STEMI treatment.
- The rate and characteristics of false CCL activations are not well-defined.
Purpose of the Study:
- To determine the rate of false CCL activations for suspected STEMI.
- To evaluate the diagnostic accuracy of electrocardiograms (ECGs) and clinical characteristics in identifying STEMI.
- To assess the impact of activation source on accuracy and door-to-balloon times.
Main Methods:
- Retrospective analysis of 345 consecutive CCL activations for suspected STEMI over 18 months.
- Review of ECGs, clinical course, and final diagnoses for all activations.
- Two-tiered classification of STEMI activations based on ECG appropriateness and final clinical diagnosis.
Main Results:
- STEMI was not confirmed in 28% of all CCL activations.
- 87.2% of activations had appropriate ECG criteria, but only 82% of these had a final STEMI diagnosis.
- Clinical characteristics did not improve STEMI identification; activations by emergency department physicians were more accurate, but prehospital activations by emergency medical services were faster.
Conclusions:
- False CCL activations for suspected STEMI occur at a high rate.
- ECG and clinical evaluation have limitations in definitively diagnosing STEMI.
- A two-tiered classification system aids in understanding and improving STEMI activation quality.
Background:
Rapid activation of a cardiac catheterization laboratory (CCL) has reduced door-to-balloon times in ST-segment elevation myocardial infarction (STEMI), leading to lower mortality. This process is accelerated with prehospital electrocardiography and notification. False activations of the CCL occur at an unknown rate and have been poorly described.
Methods And Results:
We analyzed 345 consecutive CCL activations for suspected STEMI over 18 months (March 2009-August 2010). We retrospectively reviewed the ECGs that prompted activation, as well as the clinical course and final diagnoses. Among all CCL activations, STEMI was not confirmed in 28%. On review, 301 (87.2%) had appropriate ECG criteria for activation. However, even among the ECG-appropriate patients, only 247 (82%) had a final diagnosis of STEMI. The inclusion of clinical characteristics did not improve the ability to identify patients with STEMI. Activations were modestly more accurate when made by emergency department physicians than by emergency medical service personnel, but door-to-balloon time was noticeably shorter when emergency medical service personnel requested prehospital activation.
Conclusions:
If all CCL activations are considered, the occurrence of false activations is surprisingly high. Although still the gold standard for diagnosis, these data reveal the inherent limitations of clinical evaluation and the ECG in identifying patients with STEMI. Within our retrospective review, we used a 2-tiered classification for STEMI activations based on ECG appropriateness and final clinical diagnosis to give a complete picture of false activations and assist in quality improvement.
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