Reducing Delay to Treatment of ST-Elevation Myocardial Infarction With Software Electrocardiographic Interpretation and Transmission (SCINET).

BACKGROUND: Prehospital diagnosis of ST-elevation myocardial infarction (STEMI) has resulted in improved outcomes. However, many patients still walk in to the emergency department (ED) with STEMI, experiencing delays and worse outcomes. Software electrocardiogram (ECG) diagnosis of STEMI and electronic transmission to a cardiologist may result in improved door-to-device (D2D) times. METHODS: We retrospectively identified all patients presenting with STEMI from January 2015 to September 2016. Components of delay in D2D, ED variables, and the patients' ECGs were extracted from our regional database. All ECGs performed for suspected myocardial infarction in the region were extracted over the study period. We assessed the accuracy of the software 12SL in diagnosing STEMI, ED contributors to delays in D2D, and the potential reduction in D2D if software diagnosis of STEMI resulted in activation of the cardiac catheterization laboratory. RESULTS: A total of 379 patients presented to an ED in our region and received primary percutaneous coronary intervention over the study period. In the 143,574 ECGs performed over the study period for suspected STEMI, the overall sensitivity and specificity of 12SL were 90.5% and 99.98%, respectively. We estimated a potential 17-minute reduction in D2D in the 90.5% of patients correctly identified as having STEMI, with a false activation rate of 4%. Female patients and older patients experienced an even larger potential benefit, with 24- and 25-minute reductions in D2D, respectively. CONCLUSIONS: Patients who walk in to an ED with STEMI experience significant system-related delays in recognition and treatment. Automated software diagnosis of STEMI is accurate and could result in significant improvements in D2D times.

CONTEXTE: Le diagnostic préhospitalier de l'infarctus du myocarde avec élévation du segment ST (STEMI) contribue à améliorer les résultats pour les patients. Toutefois, de nombreux patients subissant un STEMI se présentent encore d'eux-mêmes au service des urgences, ce qui retarde leur traitement et entraîne des conséquences plus graves. Le diagnostic de STEMI au moyen d'un logiciel de prise d'électrocardiogramme (ECG) qui est ensuite transmis à un cardiologue par voie électronique pourrait réduire le délai entre l'arrivée à l'hôpital et la pose d'un dispositif (délai avant l'intervention). MÉTHODOLOGIE: Nous avons rétrospectivement recensé tous les patients ayant subi un STEMI entre janvier 2015 et septembre 2016. Les facteurs entraînant l'augmentation du délai avant l'intervention, les variables relatives au service des urgences et les ECG des patients ont été extraits d'une base de données régionale. Tous les ECG réalisés dans les cas d'infarctus du myocarde suspectés dans la région pendant la période visée ont été extraits. Nous avons évalué l'exactitude des diagnostics de STEMI obtenus à l'aide du logiciel 12SL, les facteurs contribuant au délai avant l'intervention et la réduction potentielle de ce délai lorsque le diagnostic de STEMI obtenu par logiciel a permis au laboratoire de cathétérisme cardiaque de se préparer avant l'arrivée du patient. RÉSULTATS: Au total, 379 patients se sont présentés au service des urgences d'un hôpital de la région et ont subi une intervention coronarienne percutanée primaire durant la période visée par l'étude. Sur les 143 574 ECG réalisés dans les cas de STEMI suspectés durant la période étudiée, la sensibilité et la spécificité globales du logiciel 12SL s'établissaient respectivement à 90,5 % et à 99,98 %. Nous avons estimé que le délai avant l'intervention avait été potentiellement réduit de 17 minutes chez les patients ayant reçu un diagnostic de STEMI correct (90,5 %), le taux d'activation inutile du laboratoire de cathétérisme s'établissant à 4 %. Les femmes et les patients plus âgés sont ceux qui semblent avoir bénéficié le plus de cette stratégie, la réduction potentielle du délai avant l'intervention s'établissant dans leurs cas à 24 et à 25 minutes, respectivement. CONCLUSIONS: Les patients subissant un STEMI qui se présentent eux-mêmes au service des urgences doivent passer par toutes les étapes du processus d'admission avant que leur état soit reconnu et traité. Les outils de diagnostic automatisé du STEMI donnent des résultats justes, et leur utilisation pourrait réduire considérablement le délai entre l'arrivée à l'hôpital et l'intervention.

Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke.

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS: In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS: We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS: Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.

Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke.

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS: In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS: We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS: Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.

Primary Percutaneous Coronary Intervention As Treatment for ST-Elevation Myocardial Infarction in a Centenarian: Choosing Carefully.

We report on a 105-year-old woman presenting with inferior ST-elevation myocardial infarction (STEMI). She was managed with primary percutaneous intervention (PCI) to the right coronary artery with a single bare-metal stent. There were no acute complications, although she experienced delirium and functional decline requiring prolonged hospital admission. She was discharged home and celebrated her 106th birthday. This report describes the oldest centenarian with STEMI found in the literature and managed with PCI. No data exist on how best to manage centenarians with STEMI. Patient comorbidities, functional status, and values should be considered in managing such patients.

Relationship of Extreme Cold Weather and Implantable Cardioverter Defibrillator Shocks.

Cold weather to 0°C has been implicated as a risk factor for ventricular arrhythmias and implantable cardioverter defibrillator (ICD) shocks. The effect of more extreme cold weather on the risk of ventricular arrhythmias and ICD shocks is unknown. We sought to describe the relationship between extreme cold weather and the risk of ICD shocks. We retrospectively identified patients seen at the Pacemaker and Defibrillator Clinic at St. Boniface Hospital in Winnipeg, Manitoba, Canada between 2010 and 2015 with an ICD shock. We excluded multiple shocks occurring on the same day in a single patient. We collected weather data, and evaluated the relationship between ICD shocks and weather on the same day as the shock using Negative Binomial regression. Three hundred and sixty patients experienced a total of 1,355 shocks. When excluding multiple shocks occurring in a single patient on the same day, there were 756 unique shocks. The daily high (DH) was the strongest predictor of receiving an ICD shock. Compared with the warmest days (DH above 10°C), shocks were 25% more common on the coldest days (DH below -10°C), and 8% more common on cold days (DH between -10°C and 10°C). This linear trend was statistically significant, with a p-value of 0.04. In conclusion, we found an association between extreme cold weather and ICD shocks.