Palladino Nicholas, Shah Aman, McGovern Jeffrey, Burns Kevin, Coughlin Ryan, Joseph Daniel, Cone David C
Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC).
Prehosp Emerg Care. 2022 Jan-Feb;26(1):48-54. doi: 10.1080/10903127.2020.1863533. Epub 2021 Feb 5.
The management of patients with ST-elevation myocardial infarction (STEMI) is time-critical, with a focus on early reperfusion to decrease morbidity and mortality. It is imperative that prehospital clinicians recognize STEMI early and initiate transport to hospitals capable of percutaneous coronary intervention (PCI) with a door-to-balloon time of ≤90 minutes. Three patterns have been identified as STEMI equivalents that also likely warrant prompt attention and potentially PCI: Wellens syndrome, De Winter T waves, and aVR ST elevation. The goal of our study was to assess the incidence of these findings in prehospital patients presenting with chest pain. : We conducted a retrospective chart review from a large urban tertiary care emergency department. We reviewed the prehospital ECG, or ECG upon arrival, of 861 patients who were hospitalized and required cardiac catheterization between 4/10/18 and 5/7/19. Patients who had field catheterization lab activation by EMS for STEMI were excluded. If a prehospital ECG was not available for review, the first ECG obtained in the hospital was used as a proxy. Each ECG was screened for aVR elevation, De Winter T waves, and Wellens syndrome. : Of 278 charts with prehospital ECGs available, 12 met our criteria for STEMI equivalency (4.4%): 6 Wellens syndrome and 6 aVR STEMI. There were no cases of De Winters T waves. Of 573 charts with no prehospital ECG available, 27 had initial hospital ECGs that met our STEMI equivalent criteria (4.7%): 7 Wellens syndrome and 20 aVR STEMI. Again, there were no cases of De Winters T waves. : These preliminary data suggest that there are significant numbers of patients whose prehospital ECG findings do not currently meet criteria for field activation of the cardiac catheterization lab, but who may require prompt catheterization. Further studies are needed to look at outcomes, but these results could support the need for further education of prehospital clinicians regarding recognition of these STEMI equivalents, as well as quality initiatives aimed at decreasing door-to-balloon time for patients with STEMI equivalents.
ST段抬高型心肌梗死（STEMI）患者的管理对时间要求极为严格，重点在于早期再灌注以降低发病率和死亡率。院前临床医生必须尽早识别STEMI，并将患者转运至能够进行经皮冠状动脉介入治疗（PCI）且门球时间≤90分钟的医院。已确定三种模式可作为STEMI等效情况，它们可能也需要及时关注并可能进行PCI：Wellens综合征、De Winter T波和aVR导联ST段抬高。我们研究的目的是评估这些表现出现在胸痛的院前患者中的发生率。我们对一家大型城市三级医疗急诊科进行了回顾性病历审查。我们回顾了2018年4月10日至2019年5月7日期间住院并需要进行心脏导管插入术的861例患者的院前心电图或入院时的心电图。因STEMI由急救医疗服务（EMS）在现场激活导管室的患者被排除。如果无法获得院前心电图进行审查，则将在医院获得的第一份心电图用作替代。对每份心电图进行aVR导联抬高、De Winter T波和Wellens综合征的筛查。在有院前心电图的278份病历中，有12份符合我们的STEMI等效标准（4.4%）：6例Wellens综合征和6例aVR导联STEMI。没有De Winter T波的病例。在没有院前心电图的573份病历中，有27份入院时的心电图符合我们的STEMI等效标准（4.7%）：7例Wellens综合征和20例aVR导联STEMI。同样，没有De Winter T波的病例。这些初步数据表明仍有大量患者的院前心电图表现目前不符合现场激活心脏导管室的标准，但可能需要及时进行导管插入术。需要进一步研究以观察结果，但这些结果可能支持有必要对院前临床医生进行关于识别这些STEMI等效情况的进一步教育，以及开展旨在缩短STEMI等效患者门球时间的质量改进措施。
