Using ECG-To-Activation Time to Assess Emergency Physicians' Diagnostic Time for Acute Coronary Occlusion
Jesse T T McLaren1, Monika Kapoor1, Soojin L Yi1
1Emergency Department, University Health Network, Toronto, Ontario, Canada.
Insights
Emergency physicians lack quality metrics for diagnosing acute coronary occlusion. ECG-to-activation time offers a new metric to improve diagnosis of ST-elevation myocardial infarction (STEMI) and related occlusions.
Area of Science:
- Cardiology
- Emergency Medicine
- Medical Diagnostics
Background:
- No established quality metric exists for assessing emergency physicians' diagnostic time in acute coronary occlusion cases.
- Timely diagnosis of ST-elevation myocardial infarction (STEMI) and related occlusive events is critical for patient outcomes.
Purpose of the Study:
- To quantify diagnostic time related to automated electrocardiogram (ECG) interpretation, classic STEMI criteria, STEMI-equivalents, and subtle occlusions.
- To evaluate ECG-to-activation (ETA) time as a potential quality metric in emergency departments.
Main Methods:
- Multicenter retrospective study of 177 code STEMI patients with confirmed culprit lesions (January 2016 - December 2018).
- Measured door-to-ECG (DTE) and ECG-to-activation (ETA) times.
- Classified first ECGs based on automated interpretation, classic STEMI criteria, STEMI-equivalents, or subtle occlusion rules by blinded emergency physicians.
Main Results:
- Median DTE was 9.0 min; median ETA was 16.0 min.
- Automated interpretation identified STEMI in 55.4% of ECGs (ETA 6.5 min) vs. 44.6% not STEMI (ETA 66 min, p < 0.0001).
- Classic STEMI criteria applied to 63.8% (ETA 8.0 min), STEMI-equivalents to 8.5% (ETA 32.0 min), subtle occlusions to 16.4% (ETA 89.0 min).
Conclusions:
- Classic STEMI criteria on initial ECG missed over one-third of occlusions, though many were identified as STEMI-equivalents or subtle occlusions.
- ECG-to-activation (ETA) time is a viable quality metric for emergency physicians.
- Utilizing ETA can drive improvements in ECG interpretation and quality initiatives for acute coronary occlusions.
Background:
There is no quality metric for emergency physicians' diagnostic time for acute coronary occlusion.
Objective:
We sought to quantify diagnostic time associated with automated interpretation, classic ST-elevation myocardial infarction (STEMI) criteria, STEMI-equivalents, and subtle occlusions, using electrocardiogram (ECG)-to-activation of catheterization laboratory time.
Methods:
This multicenter retrospective study reviewed all code STEMI patients from the emergency department (ED) with confirmed culprit lesions from January 2016 to December 2018. We measured door-to-ECG (DTE) time and ECG-to-activation (ETA) time. We examined the first ED ECGs to determine whether automated interpretation labeled "STEMI," and they met classic STEMI criteria, STEMI-equivalents, or rules for subtle occlusion. ECG analysis was performed by two emergency physicians blinded to clinical scenario, automated interpretation, and angiographic outcome.
Results:
There were 177 code STEMIs with culprit lesions, with a median DTE time of 9.0 min and a median ETA time of 16.0 min. Automated interpretation labeled 55.4% of first ECGs "STEMI" (ETA 6.5 min) and 44.6% not "STEMI" (ETA 66 min, p < 0.0001). Of first ECGs, 63.8% met classic STEMI criteria (ETA 8.0 min), 8.5% had STEMI-equivalents (ETA 32.0 min, p = 0.0026), 16.4% had subtle occlusions (ETA 89.0 min, p = 0.045), and 11.3% had no diagnostic sign of occlusion (ETA 68.0 min, p = 0.20).
Conclusions:
STEMI criteria missed more than one-third of occlusions on first ECG, but most had STEMI-equivalents or rules for subtle occlusion. ETA time can serve as a quality metric for emergency physicians to promote new ECG insights and assess quality improvement initiatives.
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:29Electrocardiogram
Three major waveforms are present in a typical ECG recording: the P wave, the QRS complex, and...
01:24ECG Interpretation of Rhythms
Components of the Electrocardiogram
The primary components of a normal ECG waveform in Normal sinus rhythm(NSR) include the P wave, PR interval, QRS complex, ST segment, T wave, and occasionally a U wave.
ECG waveforms are divided by vertical and horizontal lines at standard intervals.
The horizontal axis measures time and rate, and the vertical axis measures amplitude or voltage....
01:30Acute Coronary Syndrome I: Introduction
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:25Correlation between ECG and Cardiac Cycle
A cardiac action potential originates in the SA node and spreads throughout the atria and the AV node in approximately 0.03 seconds. This results in the P wave in an ECG and triggers atrial contraction. The action potential is then briefly slowed at the AV node, allowing the atria to contract and fill the ventricles with blood before...