MedWire News: The American Heart Association (AHA) has issued a statement highlighting the need to implement prehospital 12-lead electrocardiogram (ECG) assessments to improve acute coronary syndrome management.
Despite being recommended by the AHA's own guidelines and by other consensus and scientific statements, prehospital ECGs are used in fewer than 10% of patients with ST-elevation myocardial infarction (STEMI), the statement's authors say.
Yet identifying STEMI promptly is critical in achieving optimal reperfusion, lead author Henry Ting (Mayo Clinic, Rochester, Minnesota, USA) emphasized.
"The clock starts ticking from the moment a person develops symptoms of a heart attack," Ting said.
Evaluating reperfusion system performance by door-to-balloon or door-to-drug times cannot tell the whole story. According to Ting, "the pertinent measure of system performance is from the time of first medical contact with paramedics or other emergency medical personnel to reperfusion therapy."
In the statement, Ting and colleagues review evidence supporting use of prehospital ECGs and current barriers to implementing their routine use.
They explain that current effective prehospital ECG programs currently involve activating the cardiac catheterization laboratory while the patient is still being transported to hospital and then taking them directly to the cath lab without emergency room evaluation.
The ECG can be wired to the hospital for interpretation by a physician or interpreted directly by trained paramedics or using computer algorithms, depending on resources or local geography.
One study in Germany, involving the ECG being faxed to the hospital cardiac intensive care unit for a physician to interpret, showed that the mean door-to-balloon time was brought down to under 30 minutes, with the entire process from first medical contact to balloon taking just 74 minutes.
The statement identifies patients' reluctance to call the emergency medical services (EMS) as a major obstacle to realizing the potential benefits of greater prehospital ECG use. More than half of STEMI patients take themselves to hospital rather than using EMS, according to studies.
Other logistical barriers include the need to: improve collaboration among EMS, emergency departments, and cardiology; increase EMS capacity; and improve regional hospital network coordination to provide ideal patient care rather than optimize market share.
Direct financial barriers include the need to prove cost-effectiveness and obtain reimbursement for the technology to gain support from payors, providers, and healthcare systems.
The statement highlights that 90% of EMS systems serving the largest 200 US cities already have 12-lead ECG equipment in their ambulance systems.
Ting commented: "It is a lost opportunity to improve the quality of care for STEMI patients if the information from a prehospital ECG is not used to change downstream processes of care."
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