VIII. Telemedicine in electrocardiology, from acute diagnosis in ischemia and arrhythmias to seamless pacemaker/ICD control and programming
Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention

https://doi.org/10.1016/j.jelectrocard.2005.06.034Get rights and content

Abstract

In patients with ST-elevation myocardial infarction, fast initiation of reperfusion therapy is mandatory. It is well established that prehospital diagnosis results in earlier initiation of fibrinolysis, but there is limited evidence concerning the value of prehospital evaluation in patients treated with primary percutaneous coronary intervention (PCI). The present paper proposes various prehospital strategies that may be of relevance in treating the latter patients: (1) a substantial reduction in treatment delay may be achieved by prehospital diagnosis, especially if combined with rerouting of patients directly to interventional hospital; (2) use of telemedicine may allow a widespread implementation of a prehospital diagnostic program; (3) a rerouting strategy may result in prolonged transportation. In this setting, continuous real-time 1-lead ECG transmission from ambulance to hospital may allow physicians to support ambulance personnel in the treatment of arrhythmias during transportation; and (4) equipment used for prehospital ECG acquisition and transmission has built-in features for continuous ST-segment monitoring. It is hypothesized that continuous ST-segment monitoring performed in the prehospital phase and during primary PCI may provide important prognostic information, with the potential of triaging future pharmacological and interventional treatment at time of PCI.

Introduction

In patients with acute ST-elevation myocardial infarction (STEMI), timely treatment with fibrinolysis or primary percutaneous coronary intervention (PCI) is mandatory to ensure a favorable patient outcome. Primary PCI is considered as the preferred treatment strategy in patients admitted directly to interventional hospitals [1]. In patients admitted to noninterventional hospitals, immediate transfer to an interventional hospital for primary PCI is recommended (transfer patients) if time from first medical contact to balloon inflation is kept less than 90 minutes [1], [2], [3], [4], [5], [6], [7]. In previous studies, transfer patients have waited for 30 to 73 minutes at the local hospitals before transfer to the interventional hospital [3], [4], [6]. This local hospital delay may be reduced by prehospital diagnosis or even eliminated if a combined strategy of rerouting patients directly to an interventional hospital is implemented. Limited evidence is available concerning the benefit, safety, and feasibility of a rerouting strategy in patients with STEMI scheduled for primary PCI. The present paper focuses on different aspects of an advanced prehospital evaluation program that may be of benefit for the patients in the future.

Section snippets

Prehospital diagnosis and rerouting of patients with STEMI

In STEMI patients admitted directly to an interventional hospital, door-to-balloon time of 90 minutes is often observed in randomized controlled trials [3]. In some countries, door-to-balloon times are even 120 to 180 minutes [8], [9]. A single study by Wall et al [10] demonstrated that a 30-minute reduction in door-to-balloon time is achievable if prehospital diagnosis is established with the use of telemedicine and the catheterization personnel is alerted before patient arrival. To achieve

Prehospital diagnosis with the use of telemedicine

In areas where ambulances are not staffed with physicians or highly skilled paramedics, use of telemedicine seems attractive to allow the general population to benefit from a prehospital diagnostic approach [12], [15], [16]. The use of standard headsets allows online physician-patient interview [12], [16]. Thereby, ambulance personnel are not functioning as an interposed link, but as a listener who can complement the information achieved from the patient. The direct patient-physician

Continuous real-time 1-lead ECG transmission from ambulance to hospital

Continuous real-time 1-lead ECG transmission from ambulance to hospital was initially introduced in the late 1960s and early 1970s to allow hospital-based physicians to support ambulance personnel in defibrillating patients with ventricular fibrillation [19], [20], [21], [22]. Today, ambulance personnel are fully capable of defibrillating patients without the assistance from physicians. However, if a strategy of rerouting STEMI patients directly to interventional hospitals is implemented,

Continuous 12-lead ST-segment monitoring in the prehospital phase and during PCI

In treating STEMI patients with primary PCI, one third of patients may have impaired tissue perfusion and poor outcome despite reestablishment of a normal coronary epicardial blood flow [23], [24], [25], [26], [27], [28]. Future pharmacological and mechanical treatment strategies may improve outcome in such patients [29], [30], [31]. However, the latter treatments may have to be initiated before or during coronary intervention. In this setting, it would be of value if methods were available for

Conclusions

In the era of primary PCI, various prehospital evaluation strategies may prove of importance in treating patients with STEMI. A substantial reduction in treatment delay may be achieved by prehospital diagnosis, both among patients scheduled for admission directly to interventional hospital and to an even larger extent in patients scheduled for admission to noninterventional hospital if combined with rerouting of these patients to interventional hospital. Use of telemedicine may allow a more

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