Coronary artery disease
Comparison of Early Mortality of Paramedic-Diagnosed ST-Segment Elevation Myocardial Infarction With Immediate Transport to a Designated Primary Percutaneous Coronary Intervention Center to That of Similar Patients Transported to the Nearest Hospital

https://doi.org/10.1016/j.amjcard.2006.06.019Get rights and content

Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). We assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). We developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI). Outcomes of these patients were compared with those of a retrospective cohort of 225 consecutive patients with STEMI transported by ambulance to the nearest hospital emergency department. We treated 108 consecutive patients with STEMI using ambulance services according to the paramedic-referred primary PCI protocol. Primary PCI was performed in 93.5% versus 8.9% in the control group, and the median door-to-balloon time was 63 versus 125 minutes in the control group (p <0.0001 for 2 comparisons). Thrombolytic therapy was prescribed to 80.4% of the control group, with a median door-to-needle time of 41 minutes. In-hospital mortality was 1.9% in the paramedic-referred primary PCI group versus 8.9% in the control group (p = 0.017) and remained significantly lower after statistical adjustment for baseline risk. In conclusion, paramedic-referred primary PCI is a safe and feasible strategy for treating STEMI that is associated with rapid and effective reperfusion and very low in-hospital mortality.

Section snippets

Methods

The study was conducted in the City of Ottawa (Ontario, Canada) as a collaborative effort among the Ottawa Base-Hospital Program, the Ottawa Paramedic Service, the emergency departments from the 4 Ottawa hospitals, and the University of Ottawa Heart Institute. A peak load of 42 ambulance units provide emergency service throughout the city to a population of approximately 800,000 residents. The farthest point of service was 53 km. Most ambulances (70%) were staffed with ≥1 advanced-care

Results

During the paramedic-referred primary PCI period, paramedics transported 130 consecutive patients directly to the PCI center with a preliminary diagnosis of STEMI. Upon hospital arrival, STEMI on the prehospital ECG was confirmed in 108 patients by the admitting cardiologist. These patients comprise the paramedic-referred primary PCI group. During ambulance transportation, 1 patient developed ventricular fibrillation that was treated with immediate, successful defibrillation. The patient was

Discussion

This study confirms that an integrated multidisciplinary metropolitan approach in which paramedics independently triage and transport patients with STEMI to a designated center for primary PCI based on their interpretation of the prehospital ECG is safe and feasible. The very low in-hospital mortality in the paramedic-referred primary PCI group compared with the control group is likely due to 2 key factors: (1) faster reperfusion due to triage at the scene by the paramedics coupled with (2)

Acknowledgment

We thank all the front-line paramedics and management team at the Ottawa Paramedic Service for dedication and enthusiasm, who were responsible for the success of this initiative. We are also indebted to Pat Doucette, RN, and Sheila Ryan, BSc, for invaluable contribution to the paramedic-referred primary PCI protocol.

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