Emergency Department, University Health Network, Toronto, Ontario, Canada.
J Emerg Med. 2021 Jan;60(1):25-34. doi: 10.1016/j.jemermed.2020.09.028. Epub 2020 Oct 13.
There is no quality metric for emergency physicians' diagnostic time for acute coronary occlusion.
We sought to quantify diagnostic time associated with automated interpretation, classic ST-elevation myocardial infarction (STEMI) criteria, STEMI-equivalents, and subtle occlusions, using electrocardiogram (ECG)-to-activation of catheterization laboratory time.
This multicenter retrospective study reviewed all code STEMI patients from the emergency department (ED) with confirmed culprit lesions from January 2016 to December 2018. We measured door-to-ECG (DTE) time and ECG-to-activation (ETA) time. We examined the first ED ECGs to determine whether automated interpretation labeled "STEMI," and they met classic STEMI criteria, STEMI-equivalents, or rules for subtle occlusion. ECG analysis was performed by two emergency physicians blinded to clinical scenario, automated interpretation, and angiographic outcome.
There were 177 code STEMIs with culprit lesions, with a median DTE time of 9.0 min and a median ETA time of 16.0 min. Automated interpretation labeled 55.4% of first ECGs "STEMI" (ETA 6.5 min) and 44.6% not "STEMI" (ETA 66 min, p < 0.0001). Of first ECGs, 63.8% met classic STEMI criteria (ETA 8.0 min), 8.5% had STEMI-equivalents (ETA 32.0 min, p = 0.0026), 16.4% had subtle occlusions (ETA 89.0 min, p = 0.045), and 11.3% had no diagnostic sign of occlusion (ETA 68.0 min, p = 0.20).
STEMI criteria missed more than one-third of occlusions on first ECG, but most had STEMI-equivalents or rules for subtle occlusion. ETA time can serve as a quality metric for emergency physicians to promote new ECG insights and assess quality improvement initiatives.
目前尚无用于评估急性冠状动脉闭塞患者诊断时间的质量指标。
我们旨在使用心电图（ECG）至导管室激活时间来量化与自动解读、经典 ST 段抬高型心肌梗死（STEMI）标准、STEMI 等效标准和轻微闭塞相关的诊断时间。
本多中心回顾性研究回顾了 2016 年 1 月至 2018 年 12 月期间所有从急诊科确诊罪犯病变的代码 STEMI 患者。我们测量了门到 ECG（DTE）时间和 ECG 至激活（ETA）时间。我们检查了第一份急诊科 ECG，以确定自动解读是否标记为“STEMI”，并检查其是否符合经典 STEMI 标准、STEMI 等效标准或轻微闭塞规则。ECG 分析由两位对临床情况、自动解读和血管造影结果均不知情的急诊医生进行。
共有 177 例有罪犯病变的代码 STEMI，DTE 时间中位数为 9.0 分钟，ETA 时间中位数为 16.0 分钟。自动解读将 55.4%的第一份 ECG 标记为“STEMI”（ETA 为 6.5 分钟），而将 44.6%的第一份 ECG 标记为非“STEMI”（ETA 为 66 分钟，p<0.0001）。在第一份 ECG 中，63.8%符合经典 STEMI 标准（ETA 为 8.0 分钟），8.5%为 STEMI 等效标准（ETA 为 32.0 分钟，p=0.0026），16.4%为轻微闭塞（ETA 为 89.0 分钟，p=0.045），11.3%没有闭塞的诊断迹象（ETA 为 68.0 分钟，p=0.20）。
第一份 ECG 中的 STEMI 标准漏诊了三分之一以上的闭塞，但大多数存在 STEMI 等效标准或轻微闭塞规则。ETA 时间可作为评估急诊医师质量的指标，以促进新的 ECG 见解并评估质量改进措施。
