Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61)
Becky Yi-Wen Liao1,2, Mildred Ai Wei Lee3, Bridget Dicker4,5
1Department of Cardiology, Middlemore Hospital, Auckland, New Zealand beckywliao@gmail.com.
Insights
Early recognition of ST-segment elevation myocardial infarction (STEMI) is crucial. Paramedic suspicion of STEMI during ambulance transport was low, impacting patient outcomes.
Area of Science:
- Cardiology
- Emergency Medicine
- Public Health
Background:
- Timely recognition of ST-segment elevation myocardial infarction (STEMI) is essential for prompt cardiac monitoring and reperfusion therapy.
- Accurate initial clinical assessment by paramedics is critical for effective STEMI management.
Purpose of the Study:
- To evaluate ambulance transport utilization in STEMI cases in New Zealand.
- To assess the agreement between paramedics' initial clinical impressions and hospital STEMI diagnoses.
- To determine the association between paramedics' initial impressions and 30-day mortality in STEMI patients.
Main Methods:
- Utilized linked national datasets from New Zealand (July 2016-November 2018).
- Included St John Ambulance electronic records, national cardiac registry (ANZACS-QI), and hospital administrative data.
- Analyzed ambulance transport rates, concordance of clinical impressions, and 30-day mortality.
Main Results:
- 73% of STEMI patients used ambulance transport; paramedics suspected STEMI in 50.7% of these cases.
- Only 37% of STEMI patients were both transported by ambulance and suspected of STEMI by paramedics.
- Patients with non-ACS impressions had higher mortality, but this was largely explained by covariate-adjusted risk profiles.
Conclusions:
- A significant gap exists in paramedic STEMI suspicion among patients transported by ambulance.
- While initial clinical impression impacts mortality, patient risk profiles are a key confounding factor.
- Improving paramedic recognition of STEMI is vital for better patient outcomes.
Background:
Early recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy.
Methods:
Three anonymously linked New Zealand national datasets (July 2016-November 2018) were used to assess the utilisation of ambulance transport in STEMI cases, the concordance between ambulance initial clinical impressions and hospital STEMI diagnoses, and the association between initial paramedic clinical impressions and 30-day mortality. The St John Ambulance electronic record captures community call-outs and paramedic initial clinical impressions. The national cardiac (ANZACS-QI) registry and national administrative datasets capture all New Zealand public hospital admission diagnoses and mortality data.
Results:
Of 5465 patients with STEMI, 73% were transported to hospital by ambulance. For these patients, the initial paramedic impression was STEMI in 50.7%, another acute coronary syndrome (ACS) diagnosis in 19.9% and non-ACS diagnosis in 29.7%. Only 37% of the 5465 patients with STEMI were both transported by ambulance and clinically suspected of STEMI by paramedics. Compared with patients with paramedic-'suspected STEMI', 30-day mortality was over threefold higher for patients thought to have a non-ACS condition (10.9% and 34.9%, respectively), but after adjustment for available covariates, this was substantially ameliorated (HR 1.48, 95% CI 1.22 to 1.80).
Conclusions:
In this national data linkage study, only 4 out of every 10 patients with STEMI were both transported by ambulance and had STEMI suspected by paramedics. Although patients with STEMI not suspected of an ACS diagnosis by paramedics had the highest mortality rate, this is largely explained by the different risk profile of these patients.
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