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Published on: May 28, 2019
The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction
Samantha Noll1, Heidi Alvey2, Namita Jayaprakash3
1Departments of Emergency and Internal Medicine, Henry Ford Hospital, Detroit, MI, USA.
Insights
Performing triage electrocardiograms (ECGs) for ST-elevation myocardial infarction (STEMI) is costly and rarely identifies STEMI. This study found no STEMIs and a low yield of non-STEMI diagnoses from triage ECGs, suggesting a review of current guidelines is needed.
Area of Science:
- Cardiology
- Emergency Medicine
Background:
- Current guidelines recommend electrocardiograms (ECGs) within 10 minutes for emergency department (ED) patients with ST-elevation myocardial infarction (STEMI) symptoms.
- This has led to increased frequency of triage ECGs, prompting an evaluation of their utility.
Purpose of the Study:
- To quantify triage ECGs performed at an institution.
- To assess adherence to hospital guidelines for triage ECGs.
- To evaluate the rate of STEMI detection via triage ECGs.
Main Methods:
- A retrospective chart review of ED patients who underwent triage ECG over an 8-day period.
- Excluded cases of bradycardia or tachycardia.
- Collected data included demographics, complaints, cardiac risk factors, troponin levels, and final diagnoses.
Main Results:
- 538 triage ECGs were performed; no STEMIs were identified, but 16 non-STEMI (NSTEMI) diagnoses were made.
- 11.7% of patients did not meet internal criteria for a triage ECG.
- The estimated cost to detect one STEMI via triage ECG was $54,295.
Conclusions:
- Triage ECGs for suspected STEMI have a very low yield, with no STEMIs detected in this study.
- A significant number of ECGs were performed on patients not meeting institutional criteria.
- The high cost and low diagnostic yield suggest a need to review current guidelines for triage ECGs in the ED.
Introduction:
Current AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10minutes of arrival for patients arriving to the Emergency Department (ED) with symptoms concerning for STEMI. In response, there has been a creep towards performing ECGs more frequently in triage. The objectives of this study were to quantify the number of triage ECGs performed at our institution, assess the proportion of ECGs performed within current hospital guidelines, and evaluate the rate of STEMI detection in triage ECGs.
Methods:
A retrospective chart review of all emergency department patients presenting over a period of 8days who had a triage ECG performed. Cases of bradycardia or tachycardia were excluded. Data collection included patient demographics, presenting complaint, cardiac risk factors, troponin values, and final diagnosis. Summary statistics are reported in a descriptive manner.
Results:
During the study period, 538 patients had a triage ECG for possible STEMI with no STEMI identified and 16 NSTEMI diagnoses (confirmed as positive troponins following ED assessment). Sixty-three (11.7%) patients did not meet internal criteria for a triage ECG. A NSTEMI ED diagnosis was identified in 3% of patients who met internal triage ECG criteria and 1.6% who did not meet criteria (p=0.29). A cost analysis was performed using an average of 50 STEMI cases diagnosed in our ED per given year. Current institutional ECG billing rates for ECGs performed and interpreted is $125 per ECG, providing an estimated triage ECG charge to detect one STEMI at $54,295.
Discussion:
This retrospective study of 538 triage ECG's performed over an 8day period identified no STEMIs and 16 NSTEMIs. A very large number of ECGs were done at triage overall and included patients who do not meet our own hospital criteria. Given the extremely low yield and high associated charges, current guidelines for triage ECG for identifying a possible STEMI should be reviewed.
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