Paramedics could up their game to meet reperfusion guidelines

By Piriya Mahendra

Researchers say that Canadian guidelines for reperfusion in ST-segment-elevation myocardial infarction (STEMI) can only be met if electrocardiograms (ECGs) are administered by paramedics.

"Through a model of emergency medical services (EMS) prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved," report Robin Ducas (Bergen Cardiac Care Centre, Manitoba, Canada) and co-authors.

The protocol is based on EMS personnel being trained to perform and screen ECGs for patients with suspected STEMI. If positive, the ECGs are transmitted to a physician's handheld device, and if they confirm the STEMI diagnosis, either prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) is initiated.

Ducas and team found that among the 380 transmitted calls received by the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project over a 2-year period, STEMI was confirmed by the on-call physician in 226 cases. Of these, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) received angiography but not revascularization.

As reported in the Canadian Journal of Cardiology, the time from first medical contact to reperfusion in the PPCI group was a median 76 minutes and in the PHL group, time from first medical contact to needle insertion was 32 minutes.

The overall mortality rate for STEMI patients was 8%, with four (8.3%) patients in the PHL group dying, eight (5%) in the PPCI group, and seven (35%) in the medical therapy group.

Further analysis revealed that there were 154 cases in which the physician disagreed with the STEMI diagnosis. These patients were transported to the nearest hospital.

Of these, 44% were later diagnosed with acute coronary syndrome. The mortality rate for these patients overall was 14%. "Transfer of such patients to hospitals with comprehensive cardiac care may be warranted and deserves further evaluation," comment the authors.

In a related commentary, editorialist Robert Welsh writes: "Although this approach is dependent on a motivated group of physicians willing to invest additional time and energy to deliver enhanced STEMI care, it allows pre-hospital confirmation of diagnosis, individual patient risk stratification, immediate decision regarding the optimal mode of reperfusion, and expansion of optimal systems of care to rural patients."

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