European Heart Journal Advance Access originally published online on May 4, 2005
European Heart Journal 2005 26(13):1343-1344; doi:10.1093/eurheartj/ehi301
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Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous intervention: reply
Department of cardiology B
Skejby University Hospital
Aarhus
Denmark
E-mail address:christian_juhl_terkelsen{at}hotmail.com
Department of cardiology B
Skejby University Hospital
Aarhus
Denmark
Department of cardiology B
Skejby University Hospital
Aarhus
Denmark
Department of cardiology B
Skejby University Hospital
Aarhus
Denmark
We appreciate that Quinn and colleagues were interested to read our paper.1 In the county of Aarhus, Denmark, primary percutanous coronary intervention (primary PCI) is the preferred reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI)2 Among patients scheduledfor admission to non-interventional hospitals, a substantial reduction in treatment delay is achievable if pre-hospital diagnosis is combined with referral of patients directly to an interventional hospital.1 In this setting, acquisition of pre-hospital ECGs is mandatory. To triage patients on the basis of clinical grounds alone, as mentioned in the letter by Quinn and Whitbread, is not optional because a substantial number of patients would be transferred to the interventional hospital without having STEMI. However, we do agree with Quinn, Whitbread, Miller-Craig, Keeling, and others3–5 that ‘selected qualified paramedics’ may have the skills for establishing the pre-hospital diagnosis of STEMI, provided that the clinical evaluation is supported by acquisition of ECGs. It is worth noting, however, that Miller-Craig et al.3 did not report the accuracy of the diagnosis of STEMI in their study, and paramedic diagnosis was hypothetical only in the study by Whitbread et al.4 In the study by Keeling et al.,5 treatment was actually based on pre-hospital diagnosis established by doctors with the use of telemedicine; however, paramedic diagnosis was also hypothetical. Moreover, doctors identified 90% of patients with STEMI, whereas paramedics identified 71% only (P=0.001). Consequently, if paramedics had been responsible for the initiation of fibrinolytic therapy, a substantial proportion of patients with STEMI would not have received this treatment. In addition, information concerning the positive predictive value of the diagnosis of STEMI when established by paramedics was not available, i.e. how many patients without STEMI would have received fibrinolysis or been transferred to an interventional hospital for primary PCI?
We have demonstrated that pre-hospital diagnosis with the use of telemedicine1 may be an attractive supplement to other pre-hospital diagnostic strategies, and may allow the general population to benefit from a pre-hospital diagnostic approach. We hope that pre-hospital diagnostic programs will be more widely implemented in the future. Regional considerations must decide on the optimal treatment strategy (transfer for primary PCI or pre-hospital fibrinolysis) and which diagnostic strategies to rely on (diagnosis with the use of telemedicine, by paramedics, by ambulance physicians, or by general practitioners).
References
- Terkelsen CJ, Lassen JF, Nørgaard BL, Gerdes JC, Poulsen SH, Bendix K, Ankersen JP, Gotzsche LB-H, Romer FK, Nielsen TT, Andersen HR. Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of prehospital diagnosis and direct referral to primary percutanous coronary intervention. Eur Heart J 2005; 26:770–777.
[Abstract/Free Full Text] - Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, Abildgaard U, Pedersen F, Madsen JK, Grande P, Villadsen AB, Krusell LR, Haghfelt T, Lomholt P, Husted SE, Vigholt E, Kjaergard HK, Mortensen LS, for the DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733–742.
[Abstract/Free Full Text] - Miller-Craig M W, Joy A V, Adamowicz M, Furber R, Thomas B. Reduction in treatment delay by paramedic ECG diagnosis of myocardial infarction with direct CCU admission. Heart 1997;78:456–461.
[Abstract/Free Full Text] - Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J 2002;19:66–67.
[Abstract/Free Full Text] - Keeling P, Hughes D, Price L, Shaw S, Barton A. Safety and feasibility of prehospital thrombolysis carried out by paramedics. BMJ 2003; 327:27–28.
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