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IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.
[object Object],[object Object],[object Object],[object Object],[object Object],A- Background:
[object Object],[object Object],[object Object],[object Object],[object Object],A- Background:
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[object Object],[object Object],[object Object],[object Object],A- Background :
[object Object],[object Object],[object Object],[object Object],A- Background:
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5-  ED role? B- Questions:
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5-  ED role? B- Questions:
B- Questions: B.1- What is the transmitted ECG?
That is the  “transmitted electrocardiogram”  in the pre-arrival activation of the cab lab.
 
B- Questions: B.1- What is the transmited ECG? Emergency Department Science fiction?
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5-  ED role? B- Questions:
[object Object],[object Object],[object Object],B- Questions: B.2- How can transmitted ECG improve D2B strategies?
[object Object],[object Object],[object Object],[object Object],[object Object],B- Questions: B.2- How can transmitted ECG improve D2B strategies?
[object Object],[object Object],[object Object],[object Object],[object Object],B- Questions: B.2- How can transmitted ECG improve D2B strategies?
[object Object],[object Object],[object Object],B- Questions: B.2- How can transmitted ECG improve D2B strategies?
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5-  ED role? B- Questions:
[object Object],[object Object],[object Object],[object Object],B- Questions: B.3- Other impacts to the Cath Lab? ¿¿  ??
Favourable  outcome.   Intermediate outcome. Less favourable outcome.   Intermittent occlusion of the coronary artery   Persistent occlusion of the coronary artery   Dynamic ST-segment changes occur in patients with STEMI before initiation of PCI. Equipment used for transmitted ECG has built-in features for continuous ST-segment monitoring…
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5-  ED role? B- Questions:
[object Object],[object Object],[object Object],B- Questions: B.4- Who should receive the transmitted ECG?
[object Object],[object Object],B- Questions: B.4- Who should receive the transmitted ECG?
B.1-  What is the  transmitted ECG? B.2-  How can transmitted ECG improve D2B strategies? B.3-  Other impacts to the Cath Lab? B.4-  Who should receive the transmitted ECG? B.5- Does it mean that the ED must by ignored? B- Questions:
[object Object],[object Object],[object Object],B- Questions: B.5- ED role?
x x x
[object Object],[object Object],[object Object],[object Object],B- Questions: B.5- ED role?
B- Questions: B.1- What is the transmited ECG? Emergency Department
B- Questions: B.1- What is the transmited ECG? Emergency Department
Conclusions
[object Object],[object Object],C- Conclusions:
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],C- Conclusions:
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],C- Conclusions:
[object Object],[object Object],[object Object],FUTURE GOALS:
Thank you.
1-  Maria Sejersten, MDa et al.  Effect on Treatment Delay of Prehospital Teletransmission of 12-Lead Electrocardiogram to a Cardiologist for Immediate Triage and Direct Referral of Patients With ST-Segment Elevation Acute Myocardial Infarction to Primary Percutaneous Coronary Intervention;  Am J Cardiol 2008;101:941–946. 2-   Christian Juhl Terkelsen, MD, PhDT et al.  Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention;  Journal of Electrocardiology 38 (2005)187– 192. 3-  Elizabeth H. Bradley, Ph.D et al.   Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction;  N Engl J Med 2006;355:2308-20. 4-  Antman EM, Anbe DT, Armstrong PW, et al.  ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction — executive summary: a report of the  American College of Cardiology/American Heart Association Task Force on Practice Guidelines;  Circulation 2004;110:588-636. 5-   Curtis JP, Portnay EL, Wang Y, et al.  The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4 ; J Am Coll Cardiol 2006;47:1544-52. D- References:
6-  Elizabeth H. Bradley, PhD et al.  Summary of Evidence Regarding Hospital Strategies to Reduce Door-to-Balloon Times for Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention;  Crit Pathways in Cardiol 2007;6:91–97. 7-  Michael F. Dorsch, PhD et al.  Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention;  Am Heart J 2008;155:1054-8. 8 -  Sekulic, M et al.  Feasibility of early emergency room notification to improve door-to-balloon times for patients with acute ST elevation myocardial infarction.  Catheter Cardiovasc Interv. 2005 Nov;66(3):316-9. 9-  Adams, GL et al.  Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from de TIME-NE);  Am J Cardiol. 2006 Nov 1;98(9); 1160-4. 10-   Tekelsen, CJ et al.  Reduction of treatment delay in patients with ST elevation myocardial infarction: impact of prehospital diagnosis and direct referral to primary percutanous intervention;  European Heart Journal (2005) 26, 770-777. D- References (cont.):
11-   Dhruva, VN, Abdelhadi, SI, Anis, A, et al.  ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial.  J Am Coll Cardiol 2007; 50:509. 12-  Moscucci, M, Eagle, KA.  Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation.  N Engl J Med 2006; 355:2364. 13-  Paul T. Campbell, MD.  Prehospital triage of acute myocardial infarction: wireless transmission of electrocardiograms to the on-call cardiologist via a handheld computer;  Journal of Electrocardiology 38 (2005) 300–309. 14-  Henry H. Ting, Harlan M. Krumholz, Elizabeth H. Bradley et al.  Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome: A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology;  Circulation 2008;118;1066-1079. 15-  Scholz KH, Hilgers R, Ahlersmann D, Duwald H, Nitsche R, von Knobelsdorff G, Volger B, Möller K, Keating FK.  Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction.  Am J Cardiol. 2008;101:46 –52. D- References (cont.):
16-  Wall T, Albright J, Livingston B, et al:  “Prehospital ECG transmission speeds  Reperfusion for patients with acute myocardial infarction.”  North Carolina Medical Journal. 61(2):104–108, 2000. 17-  Leibrandt PN, Bell SJ, Savona MR, et al:  “Validation of cardiologists’ decisions to initiate reperfusion therapy for acute myocardial infarction with electrocardiograms viewed on liquid crystal displays of cellular telephones.”  American Heart Journal. 140(5):747–752, 2000. 18-  De Luca G, Suryapranata H, Ottervanger JP, et al:  Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: Every minute of delay counts.  Circulation. 109(10):1223–1225, 2004. 19-  Sejersten M, Young D, Clemmenson P, et al:  “Comparison of the ability of paramedics with that of cardiologists in diagnosing ST-segment elevation acute myocardial infarction in patients with acute chest pain.”  American Journal of Cardiology. 90:995–998, 2002. 20-   Jason P. Brown, et al:  Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction;  Am J Cardiol 2008;101:158 –161. D- References (cont.):
IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.

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Impact of transmitted ECG, pre-arrival activation of cath lab

  • 1. IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  • 8. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  • 9. B- Questions: B.1- What is the transmitted ECG?
  • 10. That is the “transmitted electrocardiogram” in the pre-arrival activation of the cab lab.
  • 11.  
  • 12. B- Questions: B.1- What is the transmited ECG? Emergency Department Science fiction?
  • 13. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  • 19.
  • 20. Favourable outcome. Intermediate outcome. Less favourable outcome. Intermittent occlusion of the coronary artery Persistent occlusion of the coronary artery Dynamic ST-segment changes occur in patients with STEMI before initiation of PCI. Equipment used for transmitted ECG has built-in features for continuous ST-segment monitoring…
  • 21. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  • 22.
  • 23.
  • 24. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- Does it mean that the ED must by ignored? B- Questions:
  • 25.
  • 26. x x x
  • 27.
  • 28. B- Questions: B.1- What is the transmited ECG? Emergency Department
  • 29. B- Questions: B.1- What is the transmited ECG? Emergency Department
  • 31.
  • 32.
  • 33.
  • 34.
  • 36. 1- Maria Sejersten, MDa et al. Effect on Treatment Delay of Prehospital Teletransmission of 12-Lead Electrocardiogram to a Cardiologist for Immediate Triage and Direct Referral of Patients With ST-Segment Elevation Acute Myocardial Infarction to Primary Percutaneous Coronary Intervention; Am J Cardiol 2008;101:941–946. 2- Christian Juhl Terkelsen, MD, PhDT et al. Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention; Journal of Electrocardiology 38 (2005)187– 192. 3- Elizabeth H. Bradley, Ph.D et al. Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction; N Engl J Med 2006;355:2308-20. 4- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction — executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Circulation 2004;110:588-636. 5- Curtis JP, Portnay EL, Wang Y, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4 ; J Am Coll Cardiol 2006;47:1544-52. D- References:
  • 37. 6- Elizabeth H. Bradley, PhD et al. Summary of Evidence Regarding Hospital Strategies to Reduce Door-to-Balloon Times for Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention; Crit Pathways in Cardiol 2007;6:91–97. 7- Michael F. Dorsch, PhD et al. Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention; Am Heart J 2008;155:1054-8. 8 - Sekulic, M et al. Feasibility of early emergency room notification to improve door-to-balloon times for patients with acute ST elevation myocardial infarction. Catheter Cardiovasc Interv. 2005 Nov;66(3):316-9. 9- Adams, GL et al. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from de TIME-NE); Am J Cardiol. 2006 Nov 1;98(9); 1160-4. 10- Tekelsen, CJ et al. Reduction of treatment delay in patients with ST elevation myocardial infarction: impact of prehospital diagnosis and direct referral to primary percutanous intervention; European Heart Journal (2005) 26, 770-777. D- References (cont.):
  • 38. 11- Dhruva, VN, Abdelhadi, SI, Anis, A, et al. ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial. J Am Coll Cardiol 2007; 50:509. 12- Moscucci, M, Eagle, KA. Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation. N Engl J Med 2006; 355:2364. 13- Paul T. Campbell, MD. Prehospital triage of acute myocardial infarction: wireless transmission of electrocardiograms to the on-call cardiologist via a handheld computer; Journal of Electrocardiology 38 (2005) 300–309. 14- Henry H. Ting, Harlan M. Krumholz, Elizabeth H. Bradley et al. Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome: A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology; Circulation 2008;118;1066-1079. 15- Scholz KH, Hilgers R, Ahlersmann D, Duwald H, Nitsche R, von Knobelsdorff G, Volger B, Möller K, Keating FK. Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction. Am J Cardiol. 2008;101:46 –52. D- References (cont.):
  • 39. 16- Wall T, Albright J, Livingston B, et al: “Prehospital ECG transmission speeds Reperfusion for patients with acute myocardial infarction.” North Carolina Medical Journal. 61(2):104–108, 2000. 17- Leibrandt PN, Bell SJ, Savona MR, et al: “Validation of cardiologists’ decisions to initiate reperfusion therapy for acute myocardial infarction with electrocardiograms viewed on liquid crystal displays of cellular telephones.” American Heart Journal. 140(5):747–752, 2000. 18- De Luca G, Suryapranata H, Ottervanger JP, et al: Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: Every minute of delay counts. Circulation. 109(10):1223–1225, 2004. 19- Sejersten M, Young D, Clemmenson P, et al: “Comparison of the ability of paramedics with that of cardiologists in diagnosing ST-segment elevation acute myocardial infarction in patients with acute chest pain.” American Journal of Cardiology. 90:995–998, 2002. 20- Jason P. Brown, et al: Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction; Am J Cardiol 2008;101:158 –161. D- References (cont.):
  • 40. IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.

Editor's Notes

  1. Good afternoon. My name is Francisco Malagón and I come from the Emergency Department of the “Hospital Universitario Puerta de Hierro Majadahonda”, in Madrid. I would like to thank the Organization Committee of the Congress and the 3 emergency societies for inviting me to speak about this very interesting subject: The impact of the transmitted electrocardiogram, especially in the pre-arrival activation of the Cath Lab.
  2. In patients with ST-elevation myocardial infarction, there is no question that “time is muscle”. Indeed, time to reperfusion is critical for outcome in patients with STEMI. In fact, every 30 minutes of delay to treatment results in an 8% increase in one-year mortality. Since Percutaneous Coronary intervention (PCI) has become the preferred approach for treating STEMI… … the term Door-to-balloon time, defined as the time between arrival at the hospital and PCI, is increasingly used.
  3. The American College of Cardiology and the American Heart Association Guidelines recommend that Door-to-Balloon time should be 90 minutes or less. However, only few hospitals meet this objective. Therefore, prehospital emergency medical service (EMS), emergency departments and cardiologists are seeking ways to reduce door-to-balloon time. So was created the D2B campaign “Door-to-balloon: an alliance for quality”, with the specific aim of increasing the percentage of patients with STEMI achieving PCI in 90 minutes. In this context, some groups tried to identify hospital strategies that were significantly associated with a faster door-to-balloon time.
  4. In multivariate analysis, the identified strategies were: To always perform a prehospital 12-lead ECG.
  5. It is clear that the common start point for the latter strategies is the prehospital 12-lead ECG. That is why have been put into operation all around the world a lot of strategies to improve door-to-balloon times called: “prehospital 12-lead ECG programs” which are Class I recommendation. Despite all these efforts, nowadays less than 40% of patients who receive PCI are treated within the 90-minute window. What can we do?
  6. The following is extracted from some very important papers:
  7. I would like to propose a few questions: … .not related to time?
  8. Let’s go with the first question: What is the transmitted ECG?
  9. Patient with chest pain phones the EMS… … who arrives and performs a 12-lead ECG. If STEMI is suspected, EMS transmits the electrocardiogram wirelessly from the ambulance to the hospital where the emergency department physicians and/or the cardiologist activate the cath lab if necessary.
  10. Let see it more in detail:
  11. The ambulance defibrillator acquires the ECG and transmits it with a Bluetooth protocol to a nearby cellular phone which functions as a router and transmits the data to a central receiving station in the hospital ED. The ECG is displayed on a standard PC screen, stored, printed, and can be transmitted to the on-call cardiologist who is carrying a handheld device which alerts him of an incoming ECG. The cardiologist must then decide whether to pre-activate the cath lab or to refer the patient to the Emergency Department at his arrival to the hospital.
  12. When the ambulance arrives to the hospital, either the Cath Lab or the Emergency Department are ready to receive to patient. Is that science fiction? Did you know that more than one third of all ambulances in Europe and the United States carry this equipment?
  13. In what concerns… Tekelsen found a… Sejersten demonstrated that…
  14. The same author in a different paper showed that…
  15. But, are there other impacts of the transmitted ECG the patient being transferred to the Cath Lab?
  16. In the cath lab, high risk patients may need pharmacological or mechanical treatments additional to PCI. Continuous ST-segment monitoring is an easy method to early identify those high risk patients. How?
  17. In patients achieving spontaneous ST-segment resolution before coronary intervention we expect a favourable outcome. In patients with a great dynamic in ST-segment before PCI because an intermittent occlusion of the coronary artery, an intermediate outcome may be expected. Nevertheless, limited dynamic in ST-segment elevation is due to a persistent occlusion of the coronary artery and is associated with a less favourable outcome.
  18. 3 important papers give us the answer:
  19. Does it mean that the Emergency Department must be ignored? Of course, not. What is the Emergency Department role?
  20. Good afternoon. My name is Francisco Malagón and I come from the Emergency Department of the “Hospital Universitario Puerta de Hierro Majadahonda”, in Madrid. I would like to thank the Organization Committee of the Congress and the 3 emergency societies for inviting me to speak about this very interesting subject: The impact of the transmitted electrocardiogram, especially in the pre-arrival activation of the Cath Lab.