Original ContributionsDoor-to-ECG time in patients with chest pain presenting to the ED
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)
- et al.
ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)
J Am Coll Cardiol
(2000) - et al.
Delay in thrombolysis administration: causes of extended door-to-drug times and the asymptote effect
J Emerg Med
(1998) - et al.
Effect of a patient's sex on the timing of thrombolytic therapy
Ann Emerg Med
(1996) - et al.
CQI: improving the time to thrombolytic therapy for patients with acute myocardial infarction in the emergency department
J Emerg Med
(1996) - et al.
Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints
Ann Emerg Med
(2000) Rapid identification and treatment of patients with acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment Working Group
Ann Emerg Med
(1994)
Cited by (66)
Beyond chest pain: Incremental value of other variables to identify patients for an early ECG
2023, American Journal of Emergency MedicineA prospective analysis of time to screen protocol ECGs in adult Emergency Department triage patients
2021, American Journal of Emergency MedicineCitation Excerpt :Thus, interruptions and task switching, which are inevitable in Emergency Medicine, may increase clinical errors in interpreting difficult ECG readings potentially impacting patient care and safety. In addition, delay in door to ECG time has been shown to be associated with worse clinical outcome and morbidity for patients with acute STEMI [12]. Our current study demonstrates that nearly half of ECGs screened during the study period were either normal or otherwise normal.
Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion
2021, Journal of Emergency MedicineImprovement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting
2018, Journal of Emergency NursingCitation Excerpt :This was similar to the findings of Atzema and colleagues,8 who noted that 50.3% of patients experiencing MI were given lower triage acuity, and the result of undertriage delayed acquiring ECGs by 4.4 minutes. Diercks et al9 performed a prospective study on clinical outcomes associated with ECGs over 10 minutes and found that there was an association between the ECG delay and adverse clinical outcomes. Bradley et al10 noted that triage RNs not recognizing symptoms suggestive of MI caused delays in acquiring ECGs within 10 minutes.
An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit
2018, American Journal of Emergency MedicineContemporary Determinants of Delayed Benchmark Timelines in Acute Myocardial Infarction in Men and Women
2017, American Journal of Cardiology