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Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients

Published online by Cambridge University Press:  11 May 2015

Clare L. Atzema ,
Peter C. Austin ,
Jack V. Tu  and
Michael J. Schull
Clare L. Atzema*
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Division of Emergency Medicine, Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON
Peter C. Austin
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON
Jack V. Tu
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Division of General Internal Medicine, Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON
Michael J. Schull
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Division of Emergency Medicine, Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON
*
Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Room G147, Toronto, ON M4N 3M5; clare.atzema@ices.on.ca

Abstract

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Objective:

The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time.

Methods:

This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time.

Results:

In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%.

Conclusions:

Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.

Keywords

acute myocardial infarctionbenchmark timesdoor-to-electrocardiogramemergency departmentfibrinolysis
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 13 , Issue 2 , March 2011 , pp. 79 - 89
Copyright
Copyright © Canadian Association of Emergency Physicians 2011

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