Original Contributions
Door-to-ECG time in patients with chest pain presenting to the ED

Presented at the Society of Academic Emergency Medicine annual meeting, St. Louis MO, May 2002.
https://doi.org/10.1016/j.ajem.2005.05.016Get rights and content

Abstract

Objective

To describe time to electrocardiogram (ECG) acquisition, identify factors associated with timely acquisition, and evaluate the influence of time to ECG on adverse clinical outcomes.

Methods

We measured the door-to-ECG time for emergency department patients enrolled in prospective chest pain registry. Clinical outcomes were defined as occurrence of myocardial infarction or death within 30 days of the visit.

Results

Among patients with acute coronary syndrome (ACS), 34% and 40.9% of patients with non–ST-elevation ACS and ST-elevation myocardial infarction (STEMI), respectively, had an ECG performed within 10 minutes of arrival. A delay in ECG acquisition was only associated with an increase risk of clinical outcomes in patients with STEMI at 30 days (odds ratio, 3.95; 95% confidence interval, 1.06-14.72; P = .04).

Conclusion

Approximately one third of patients with ACS received an ECG within 10 minutes. A prolonged door-to-ECG time was associated with an increased risk of clinical outcomes only in patients with STEMI.

Introduction

Recent guidelines for the management of patients with acute coronary syndrome (ACS) due to suspected unstable angina (UA) or non–ST-elevation myocardial infarction (NSTEMI; collectively, NSTE ACS) recommend that an electrocardiogram (ECG) be obtained within 10 minutes of arrival to the emergency department (ED) in patients with ongoing chest pain and as soon as possible in all others [1]. This recommendation is based in part on previous reports that show a benefit from rapid ECG acquisition in patients with STEMI [2], [3]. Studies in the STEMI population suggest that a prolonged time to ECG acquisition is a significant factor in delayed administration of thrombolytic therapy [3], [4].

There are, however, no studies that support a defined door-to-ECG time in the NSTE ACS population. Although there is little evidence that immediate recognition of the NSTE group presents a clear prognostic advantage, it is logical that early identification of these patients can facilitate appropriate and timely management. Furthermore, there are recommendations that support early aggressive treatment in high-risk patients with NSTE ACS, including early percutaneous coronary intervention (PCI) and advanced antiplatelet therapy [1]. In addition to the limited knowledge about the value of an early ECG in this group, it is also unclear whether this recommendation can be practically implemented in most institutions. The temporal impact of urgent and timely pharmacological or mechanical interventions on adverse clinical outcomes is still being investigated in this patient population. Likewise, the diagnosis of STEMI or UA/NSTEMI is largely based on a combination of ECG parameters and clinical history; therefore, early ECG acquisition is relevant in all patients who present with chest pain consistent with a potential cardiac etiology. Therefore, examining our current ECG acquisition practice, identifying factors that influence ECG adherence, and exploring their relationship to adverse clinical outcome are prudent in all populations who present with chest pain.

This study describes our current performance in obtaining an ECG within a 10-minute period and factors associated with early acquisition. It also evaluates the occurrence of adverse clinical outcomes in patients whose ECGs were obtained beyond the recommended 10-minute interval.

Section snippets

Methods

This is a secondary analysis of prospectively collected data. The subjects in this study were enrolled in the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a registry of undifferentiated patients with chest pain presenting to 8 geographically dispersed EDs in the United States and Canada. All patients older than 24 years in whom an ECG was obtained in the evaluation of potential anginal symptoms were included. Patients with chest pain associated with cocaine use have been

Results

The study sample comprised 7887 patients who made a total of 8885 visits to the ED between June 1, 1999, and October 1, 2001. Patients without chest pain were excluded from analyses (399 patients), leaving 7488 patients with 8425 visits. Overall, 575 patients visited the ED twice; 124 patients visited between 3 and 5 times; 7 patients between 5 and 10 times; and 3 patients visited the ED 10 or more times over the 2-year period. Of the 8425 patient visits, 477 (5.7%) had STEMI; 1267 (15%) met

Discussion

The National Heart Attack Alert Program demonstrated that timely acquisition of an ECG is a critical time point (door, data, decision, drug) in the management of patients with STEMI who are undergoing fibrinolytic therapy [2]. Sagarin et al [3] reported that a delay in ECG acquisition was responsible for 25% of fibrinolytic treatment delays. Until recently, however, this “door-to-data” time point has not been emphasized in the patient with chest pain who does not have STEMI. Recent guidelines,

References (12)

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