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The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction

Published:February 03, 2018DOI:https://doi.org/10.1016/j.ajem.2018.01.083

      Abstract

      Introduction

      Current AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10 minutes 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 8 days 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 8 day 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.

      Keywords

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      References

        • Mozaffarian D.
        • Benjamin E.J.
        • Go A.S.
        • Arnett D.K.
        • et al.
        Heart disease and stroke statistics—2015 update.
        Circulation. 2015; 131: 29-322
        • McNamara R.L.
        • Wang Y.
        • Herrin J.
        • Curtis J.P.
        • et al.
        Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction.
        J Am Coll Cardiol. 2006; 47: 2180-2186
        • Rathore S.S.
        • Curtis J.P.
        • Chen J.
        • Wang Y.
        • et al.
        Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study.
        BMJ. 2009; 338: 1807
        • De Luca G.
        • Suryapranata H.
        • Ottervanger J.P.
        • Antman E.M.
        Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts.
        Circulation. 2004; 109: 1223-1225
        • Steg P.G.
        • James S.K.
        • Atar D.
        • Badano L.P.
        • et al.
        ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
        Eur Heart J. 2012; 33: v2569-2619
        • Centers for Medicare and Medicaid Services
        National Quality Measures Clearinghouse. Acute myocardial infarction (AMI)/chest pain: median time from ED arrival to ECG (performed in the ED prior to transfer) for patients with AMI or chest pain.
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • Casey Jr., D.E.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
        J Am Coll Cardiol. 2013; 61: 78-140
        • Jacobs A.K.
        • Antman E.M.
        • Ellrodt G.
        • Faxon D.P.
        • et al.
        Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention.
        Circulation. 2006; 113: 2152-2163
        • Glickman S.W.
        • Shofer F.S.
        • Wu M.C.
        • Scholer M.G.
        • et al.
        Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction.
        Am Heart J. 2012; 163: 372-382
        • Graff L.R.
        Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints.
        Ann Emerg Med. 2000; 36: 554-560
        • Wiler J.L.
        Optimizing emergency department front-end operations.
        Ann Emerg Med. 2010; 5: 142-160
        • Krumholz H.M.
        • Herrin J.
        • Miller L.E.
        • et al.
        Improvements in door-to-balloon time in the United States, 2005 to 2010.
        Circulation. 2011; 124: 1038-1045
        • Jacobs A.K.
        • Antman E.M.
        • Ellrodt G.
        • et al.
        Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention.
        Circulation. 2006; 113: 2152-2163
        • Borden W.B.
        • Fennessy M.M.
        • O'Connor A.M.
        • Mulliken R.A.
        • et al.
        Quality improvement in the door-to-balloon times for stemi without chest pain.
        Catheter Cardiovasc Interv. 2012; 79: 851-858
        • Phelan M.P.
        Improving emergency department door-to-electrocardiogram time in ST segment elevation myocardial infarction.
        Crit Pathw Cardiol. 2009; 8: 119-121
        • Agarwal S.
        • Menon V.
        An algorithmic approach to ST-elevation myocardial infarction triage: effective but not foolproof.
        Am Heart J. 2012; 163: 313-314
        • Jayes Jr., R.L.
        Physician electrocardiogram reading in the emergency department-accuracy and effect on triage decisions.
        J Gen Intern Med. 1992; 7: 387-392
        • Brady W.J.
        • Perron A.
        • Ullman E.
        Errors in emergency physician interpretation of ST-segment elevation in emergency department chest pain patients.
        Acad Emerg Med. 2000; 7: 1256-1260
        • Takakuwa K.M.
        • Burek G.A.
        • Estepa A.T.
        • Shofer F.S.
        A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction.
        Acad Emerg Med. 2009; 16: 921-927
        • Takakuwa K.M.
        A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction.
        Acad Emerg Med. 2009; 16: 921-927
        • Bhuiya F.A.
        • Pitts S.R.
        • McCaig L.F.
        Emergency department visits for chest pain and abdominal pain: United States, 1999–2008.
        NCHS Data Brief. 2010; 43
        • Daudelin D.H.
        Medical error prevention in ED triage for ACS: use of cardiac care decision support and quality improvement feedback.
        Cardiol Clin. 2005; 23: 601-614
        • McCabe J.M.
        • Armstrong E.J.
        • Ku I.
        • Kulkarni A.
        • et al.
        Physician accuracy in interpreting potential ST-segment elevation myocardial infarction electrocardiograms.
        JAHA. 2013; 2e000268
        • Larson D.M.
        • Menssen K.M.
        • Sharkey S.W.
        • Duval S.
        • et al.
        “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction.
        JAMA. 2007; 298: 754-2760
        • Fox K.A.
        Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006.
        JAMA. 2007; 297: 1892-1900
        • Yeh Robert
        Population trends in the incidence and outcomes of acute myocardial infarction.
        N Engl J Med. 2010; 362: 2155-2165