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STEMI activation based on the pre-hospital ECGs (PHECGs) can be challenging to incorporate accurate EKG interpretation in appropriate clinical scenarios. Previously at Cedars-Sinai Medical Center (CSMC) although the cath lab was already activated, a cardiology fellow would assess the patient in the emergency department (ED) and make a decision to proceed with emergent catheterization. This study aims to determine the accuracy of the fellow based process.
This is a single-centered, retrospective cohort study of 100 consecutive patients who were evaluated in the ED at CSMC after PHECG prompted STEMI activation. Angiographic and cardiac biomarker data were reviewed. The EKGs and clinical history were reviewed by a CCU Attending and ED Physician in a blinded fashion. Patients were considered to have true STEMI if they have ischemic symptoms, ST elevation on EKG and typical rise and fall of troponin. A missed STEMI is defined by patient having true STEMI but did not undergo emergent catheterization.
The average age of the group was 68 years old and 41% are female. Out of the 100 patients, 26 were true STEMI; 21 patient went to catheterization lab emergently; 2 patients did not go due to neurologic (1 unclear, 1 stroke); true STEMI was “missed” in 3/26 (11.5%). 75/100 STEMI activations were canceled by cardiology fellows in the ED. 72 were appropriate cancelations and 3 were true STEMI. The top reasons for false activations include poor quality ECG/artifact (27, 36%), bundle branch block (12, 16%), arrhythmia (9, 12%) and early repolarization (9, 12%). Kappa coefficient on decision to cancel STEMI activation for cardiology and emergency medicine attending was 0.80 (95% CI 0.67-0.93) and 0.71 (95% CI 0.55-0.87) respectively. Kappa coefficient of reasons for cancelation was also calculated for the cardiology attending κ = 0.55 (95% CI 0.47-0.63) and ED attending κ = 0.63 (95% CI 0.52-0.74).
The majority (72%) of the STEMI activations were false activation and appropriately canceled but the system led to 3 missed STEMI (11.5%). We subsequently changed to a standardized algorithm system based on Mission Lifeline Preact Program which has decreased false activation to <15%.
CORONARY: Acute Myocardial Infarction