Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous intervention

Tom Quinn

School of Health and Social Sciences Coventry University
Richard Crossman Building Priory Street
Coventry CV1 5FB
UK
Tel: +44 247679 5871
Fax: +44 2476795941
E-mail address: t.quinn{at}coventry.ac.uk

Mark Whitbread

London Ambulance Service NHS Trust
Waterloo Road
London SE1 8SD
UK

We were interested to read the paper by Terkelsen et al.1 describing pre-hospital identification, by physicians, of patients suitable for primary angioplasty. We would suggest, however, that physician involvement in the decision to transfer a patient for primary PCI might be unnecessary if appropriate training and protocols for ambulance personnel are in place. In the UK, where ambulances are not generally physician-manned, several strategies have been evaluated to assess whether paramedics can accurately identify patients with acute coronary syndromes and refer directly to an appropriate hospital facility. For example, paramedics were able, on clinical grounds alone, to identify high-risk patients for admission to CCU.2 When a 12-lead ECG was available alongside a facility to discuss patients with CCU nurses prior to admission, paramedics were able to expedite CCU admission with a high degree of accuracy.3 In London, paramedics' recognition of ST segment elevation was as good as that of emergency physicians, without the need to resort to telemetry.4 Moreover, a study of paramedics' identification of patients eligible for thrombolytic therapy demonstrated high accuracy.5

We would suggest that in emergency medical systems without physician-manned ambulances, suitably trained paramedics could accurately identify patients with ST elevation MI and refer directly to an interventional facility, reducing delays to reperfusion.

References

  1. Terkelsen CJ, Lassen JF, Norgaard BL, Gerdes JC, Poulsen SH, Bendix K, Ankersen JP, Gotzsche LB, Romer FK, Nielsen TT, Andersen HR. Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous intervention. Eur Heart J 2005;26:770–777.[Abstract/Free Full Text]
  2. Quinn T, Allen TF, Thompson DR, Pawelec J, Boyle RM. Identification of patients suitable for direct admission to a coronary care unit by ambulance paramedics. Pre-hospital Immediate Care 1999;3:126–130.
  3. Millar-Craig MW, Joy AV, 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]
  4. Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. J Emerg Med 2002;19:66–67.[CrossRef]
  5. 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.[Free Full Text]




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