Transtelephonic electrocardiography in the management of patients with acute coronary syndrome

UNCORRECTED PROOF 1T ans elephonic elec oca diog aphy in he managemen o pa ien s 2wi h acu e co ona y synd ome ☆ 3Gyo gyQ1 Papai, MD, a Ildiko Racz, MD, b Daniel Czu iga, MD, PhD, b, ⁎Gyo gy Szabo, MD, c 4Is an Fe enc Edes, MD, PhD, c Is an Edes, MD, DSc b 5 a Hunga ian Na ional Ambulance Se ice 6 b Ins i u e o Ca diology, Uni e si y o Deb ecen, Medical and Heal h Science Cen e , Deb ecen, Hunga y 7 c Hea and Vascula Cen e , Semmelweis Uni e si y, Budapes , Hunga y 8 9Abs ac 10 Backg ound, pu pose: The e icacy o he ans elephonic ECG sys em (TTECG) in he 11 managemen o ST segmen ele a ion myoca dial in a c ion (STEMI) was examined wi h ega d 12 o he ambulance se ice- and pe cu aneous co ona y in e en ion (PCI)- ela ed delay imes, he 13 p ehospi al medical he apy and he in-hospi al mo ali y a e. 14 Me hods: The s udy was conduc ed as a collabo a i e e o be ween he Uni e si y o Deb ecen and 15 he Hunga ian Na ional Ambulance Se ice. Al oge he 397 pa ien s we e ec ui ed in he TTECG 16 g oup, while 378 pa ien s anspo ed o he PCI cen e wi hou TTECG se ed as con ols. 17 Resul s: Mo e accu a e p ehospi al medical he apy was achie ed in he TTECG g oup. The PCI- 18 ela ed delay imes we e signi ican ly sho e , while he in-hospi al mo ali y a e was signi ican ly 19 lowe in he TTECG g oup han among he con ols. 20 Conclusions: The indings illus a e ha TTECG is a aluable ool which may po en ially imp o e 21 he egional managemen o STEMI pa ien s. 22 © 2014 Published by Else ie Inc. 23 24 Keywo ds: T ans elephonic ECG; Acu e co ona y synd ome; STEMI; Eme gency medical se ices 25 26 In oduc ion 27 Recen guidelines [1] s a e ha he imely diagnosis o 28 acu e co ona y synd ome (ACS) is he key o success ul 29 managemen . This is especially ue o pa ien s wi h ST 30 segmen ele a ion myoca dial in a c ion (STEMI). In ca diac 31 eme gency si ua ions, an ea ly diagnosis and he p e en ion 32 o delay a e c i ical as conce ns he ou come. The e y ea ly 33 phase o STEMI is he mos c i ical ime, du ing which he 34 pa ien is liable o su e a ca diac a es and o he 35 complica ions. Mo eo e , he ea lie he ea men ( epe u- 36 sion he apy) is commenced, he g ea e he bene icial e ec 37 (“ ime is muscle”). 38 The p ehospi al p ima y diagnosis o STEMI is usually 39 based on he medical his o y, he physical examina ion and 40 especially he elec oca diog am (ECG) [2], as biochemical 41 ca diac ma ke measu emen s a e no eadily a ailable in 42mos cases. Consequen ly, he co ec in e p e a ion o ECGs 43in ca diac eme gency pa ien s wi h ches pain is o u mos 44impo ance as he co ne s one o he diagnosis. On he o he 45hand, ca diac eme gencies may occu a om specialis 46hospi als ( his is especially ue in Hunga y), and s a a 47many heal hca e se ices, eme gency se ices, ge ia ic 48cen es, o gene al and p i a e p ac ices a e no su icien ly 49expe o no quali ied o in e p e ECGs in de ail. 50One app oach o o e come his p oblem is he use o he 51 ans elephonic ECG (TTECG). This usually in ol es he 52di ec ansmission o a locally eco ded con en ional ECG 53by elephone, which is decoded o a s anda d ECG on a 54compu e in a ca diac cen e [3], whe e e e y hing is 55a ailable o an immedia e p o essional ECG e alua ion and 56in e p e a ion. The use ulness o di e en TTECG and ECG 57moni o ing sys ems has al eady been es ablished in he 58diagnosis and ollow-up o a ious o ms o ischemic hea 59disease [4–7], in he managemen o ou -o -hospi al ches 60pain eme gencies [8,9] and o he de ec ion o a ial 61 ib illa ion and o he a hy hmias in di e en clinical 62si ua ions [10–12]. 63In 2008, a pilo de elopmen al p ojec was ini ia ed in he 64no h-eas e n egion o Hunga y (abou 1.5 million people), A ailable online a www.sciencedi ec .com ScienceDi ec Jou nal o Elec oca diology xx (2014) xxx–xxx www.jecgonline.com ☆ Con lic s o in e es : The au ho s ha e no con lic o in e es o disclose. ⁎Co esponding au ho a : Uni e si y o Deb ecen, Medical and Heal h Science Cen e , Ins i u e o Ca diology, Mó icz Zs. k . 22, H-4032 Deb ecen, Hunga y. E-mail add ess: [email p o ec ed] 0022-0736/$ –see on ma e © 2014 Published by Else ie Inc. h p://dx.doi.o g/10.1016/j.jelec oca d.2014.02.007 YJELC-51830; No o Pages 6 UNCORRECTED PROOF 65 in which he Hunga ian Na ional Ambulance Se ice was 66 uni o mly equipped wi h a TTECG sys em which is 67 ex ensi ely used in all ca diac eme gencies. A 24-hou 68 se ice ne wo k was es ablished be ween he ambulance 69 se ice uni s and he egional ca diac cen e ( he Ins i u e o 70 Ca diology a he Uni e si y o Deb ecen) and he locally 71 egis e ed ECGs a e immedia ely ansmi ed by phone o 72 he cen e. 73 The aim o he p esen s udy is o examine he e icacy o 74 he TTECG sys em, in combina ion wi h consul a ion wi h 75 he ca diologis , in he diagnosis and managemen o pa ien s 76 wi h acu e ches pain, wi h special ocus on STEMI. 77 Conside a ion is gi en o he ambulance se ice con ac 78 and anspo imes, he pe cu aneous co ona y in e en ion 79 (PCI)- ela ed delay imes (doo o shea h inse ion and doo 80 o balloon imes), he p ehospi al medical he apy and he in- 81 hospi al mo ali y a e. 82 Me hods 83 The s udy was conduc ed be ween Janua y 1, 2009 and 84 Decembe 31, 2010 in he no h-eas e n egion o Hunga y as 85 a collabo a i e e o be ween he Ins i u e o Ca diology in 86 Deb ecen and he Hunga ian Na ional Ambulance Se ice. A 87 o al o 48 ambulance uni s p o ided eme gency se ices 88 h oughou he egion o a popula ion o app oxima ely 89 1500000 esiden s. 90 All uni s had been uni o mly equipped wi h bo h 91 con en ional ECG and ba e y-ope a ed 12 lead, po able 92 TTECG sys em (Hea View P12/8 Plus, Ae o el Medical 93 Sys ems). The con en ional ECG machine eco ded 12 leads 94 in 4 consecu i e s eps (3 leads simul aneously) a a s anda d 95 pape speed (25 mm/sec) and ol age se ing (10 mm/mV). 96 The Hea View P12/8 Plus de ice was supplemen ed wi h 3 97 ex e nal, cable-connec ed elec odes, which we e placed on 98 he le and igh a ms and on he le side o he wais . In 99 addi ion, 4 embedded elec odes we e loca ed on he back o 100 he main uni . This a angemen o elec odes allows he 101 eco ding o bo h he limb and p eco dial leads, by placing 102 he main uni in 3 di e en posi ions on he ches . A 103 2.5 second in e al o each lead and a 10 second in e al o 104 he hy hm s ip (lead II) we e eco ded wi h a sampling a e 105 o 375 samples/second (leas signi ican bi ol age esolu- 106 ion o 39 μV), esul ing in a s anda d 12 lead ECG layou 107 wi h e e y lead sepa a ed by 1 mV calib a ion signals. The 108 elec ode posi ions o he con en ional ECG machine and 109 he TTECG sys em we e simila . 110 The ambulance uni s we e s a ed wi h ei he a doc o o a 111 p ima y-ca e pa amedic ained o eme gency ca diac 112 se ice and ad anced ca dio ascula li e suppo . Be o e 113 he s udy, he ambulance s a pa icipa ing in he ial we e 114 ins uc ed how o e alua e pa ien s wi h ches pain (wi h a 115 p esump i e diagnosis o ACS) a he scene and adminis e 116 ace ylsalicylic acid, sodium hepa in, ni oglyce ine and 117 na co ics i necessa y. I was also ou ine p ac ice o he 118 ambulance se ice uni s o eco d a 12-lead ECG wi h a 119 con en ional ECG machine a he scene. The eco ding and 120 ansmission o he TTECG o he PCI cen e we e no 121manda o y, bu we e a he disc e ion o he pa amedics. The 122 a hes poin o se ice om he p ima y PCI cen e ( he 123Ins i u e o Ca diology a he Uni e si y o Deb ecen) was 124abou 110 km. 125The uni s we e ins uc ed how o iage pa ien s wi h ches 126pain, independen ly i possible, and o anspo all eligible 127pa ien s wi h a p ehospi al diagnosis o STEMI di ec ly o 128 he PCI cen e, bypassing he eme gency depa men s a he 129coun y hospi als. Pa ien s wi h an onse o ypical symp oms 130b12 hou s and an ST segmen ele a ion o ≥1mmin≥2 131con iguous leads on he p ehospi al 12-lead ECG we e 132conside ed eligible. The p ehospi al diagnosis o STEMI was 133es ablished exclusi ely by he ambulance eam. 134Reco ding and ansmission o he TTECG equi ed abou 1353 minu es and, a e ansmission o he ECG signal (in abou 13650 seconds) ollowing digi al-analogue con e sion (FM 137 one), all o he impo an clinical da a on he pa ien 138(including he ECG indings) and he pa ien ’s anspo we e 139discussed in a b ie consul a ion. The s anda d p o ocol o 140 he consul a ion included egis a ion o he pa ien ’s 141pe sonal da a, ecep ion o he eco ded ECG and a b ie 142pa ien e e al e ealing ele an clinical da a. All TTECG 143da a ansmission was ca ied ou ia he adio elephone 144sys em o he Na ional Ambulance Se ice (Te a). Upon 145a i al a he PCI cen e, all pa ien s we e immedia ely 146in e iewed and examined by a ca diologis and he 147diagnosis o STEMI was con i med. The pa ien s we e 148 hen immedia ely ans e ed o he ca he e iza ion labo a o y 149 o p ima y PCI. All con en ional and necessa y d ug 150 ea men o he pa ien s was allowed and he decisions as o 151 ea men we e made by he medical eam a he PCI cen e. 152The TTECG-assis ed g oup e e ed by he ambulance 153se ice consis ed o 397 pa ien s wi h STEMI (TTECG 154g oup). The con ol g oup comp ised a coho o 378 pa ien s 155wi h STEMI who we e anspo ed by he ambulance se ice 156 o he PCI cen e wi hou TTECG. As conce ns he con ols, 157 he ECGs, he clinical e alua ions and he anspo decision, 158 oge he wi h he medical he apy p o ided, we e ca ied ou 159by he ambulance se ice s a wi hou consul a ion by 160TTECG. In hese cases, he PCI cen e was gi en only a b ie 161no ice abou he pa ien ans e ia he egula elephone. 162All eme gency pa ien s o whom he inal diagnosis was 163o he han STEMI we e excluded om he da abase o he 164p esen s udy. 165The p ima y e icacy ou comes we e he ambulance 166se ice con ac and anspo imes and he PCI- ela ed delay 167 imes (doo o shea h inse ion and doo o balloon imes). 168The ambulance se ice con ac ime was de ined as he ime 169spen a he scene by he ambulance uni ( om he i s 170medical con ac o he depa u e om he scene o he PCI 171cen e). The anspo ime was he du a ion o he jou ney 172 om he scene o he ca diac cen e. The doo o shea h 173inse ion and doo o balloon imes we e de ined as he ime 174be ween he a i al o he ambulance se ice uni a he PCI 175cen e and he inse ion o he shea h o balloon in he 176ca he e iza ion labo a o y. The key seconda y e icacy 177ou come was he in-hospi al mo ali y a e. 178Da a we e collec ed o he s udy wi h he w i en 179app o al o he pa ien s. Da a handling and collec ion we e 2G. Papai e al. / Jou nal o Elec oca diology xx (2014) xxx–xxx UNCORRECTED PROOF 180 app o ed by he ins i u ional e iew boa ds o he Ins i u e o 181 Ca diology a he Uni e si y o Deb ecen and he Hunga ian 182 Na ional Ambulance Se ice. 183 S a is ical analysis was ca ied ou wi h he GB-S a 184 8.0 p og am. Depending on he ype o a iable 185 (quali a i e o quan i a i e pa ame e s), he desc ip i e 186 me hod applied in ol ed he calcula ion o absolu e and 187 ela i e equencies, o he calcula ion o mean and 188 s anda d de ia ion (S.D.). No mally dis ibu ed con inuous 189 a iables we e compa ed by S uden ’s es a an αle el o 190 5%. The pa ame e s ha we e a leas o dinal we e 191 compa ed by means o he Wilcoxon ank-sum es a an 192 αle el o 5%. Fo he cumula i e su i al analysis, he 193 Cox eg ession model (condi ional logis ic eg ession) was 194 used. The isk o dea h cu es we e plo ed by he Kaplan- 195 Meie echnique. 196 Resul s 197 Al oge he 1564 ambulance-a ended pa ien s we e 198 sc eened o ches pain du ing he s udy pe iod o whom 199 800 we e diagnosed as ha ing STEMI in he p ehospi al 200 s age. The pa ien low is depic ed in Fig. 1. The inal 201 diagnosis o STEMI was es ablished in 775 pa ien s. In he 202 emaining 25 pa ien s, he ST segmen ele a ion was due o 203 o he easons ( asospasm, myoca di is, e c.). All 25 pa ien s 204 wi hou STEMI we e excluded om he s udy da abase. 205Finally, he e we e 397 pa ien s in he TTECG g oup and 378 206pa ien s in he con ol g oup. 207The baseline cha ac e is ics o he pa ien s in he wo 208g oups a e lis ed in Table 1. The wo g oups we e ela i ely 209well ma ched as ega ds isk ac o s and p e ious medical 210his o y. The e was a end owa ds mo e pa ien s wi h a 211his o y o p e ious conges i e hea ailu e in he con ol 212g oup (p = 0.0885), bu he di e ence was no signi ican . 213All pa ien s in bo h g oups unde wen immedia e ca diac 214ca he e iza ion, and PCI was pe o med in 381 pa ien s 215(96%) in he TTECG g oup and in 351 pa ien s (92.9%) in 216 he con ol g oup. Among he pa ien s in whom PCI was no 217pe o med, 7 pa ien s we e la e e e ed o co ona y bypass 218su ge y and medical he apy was ecommended o he 219 emaining pa ien s. Th omboly ic he apy was no p esc ibed 220 o any pa ien . Mo eo e , no pa ien equi ed eme gency 221bypass su ge y. 222S en s we e deployed in 94.5% o he pa ien s (Table 2) 223and pla ele glycop o ein IIb/IIIa ecep o inhibi o s we e 224used in 25.5% (25% in he TTECG g oup and 26% in he 225con ol g oup). The e was no signi ican di e ence be ween 226 he wo g oups in he s en p ocedu al de ails (Table 2). 227Angiog aphic success was achie ed in 94% o he pa ien s 228(93% in he TTECG g oup and 95% in he con ol g oup) 229who unde wen p ima y PCI. 230De ails o he p ehospi al medical he apy a e p esen ed in 231Table 2. In he TTECG g oup signi ican ly mo e sodium 232hepa in (5000 U) and na co ics we e adminis e ed. On he 233o he hand, ni a es we e used mo e equen ly in he 234con ols. In he cases o he o he medica ions (ace ylsalicylic 235acid and/o clopidog el, a opine and be a-blocke s), he e 236was no signi ican di e ence be ween he wo g oups. 237Da a on he dis ance om he PCI cen e, he ambulance 238se ice con ac and anspo imes and he PCI- ela ed delay 239 imes (doo o shea h inse ion and doo o balloon imes) a e 240 o be seen in Table 3. The dis ance om he PCI cen e was Fig. 1. CONSORT diag am showing he low o pa ien s a each s age o he da a collec ion. Table 1 1:1 Baseline cha ac e is ics o pa ien s. 1:2 1:3TTECG g oup (N = 397) Con ol g oup (N = 378) p alue 1:4Gene al 1:5Age (y) 60.18 ± 12.10 61.75 ± 11.46 0.0642 1:6Men (%) 67.42 67.12 0.8669 1:7An e io myoca dial in a c ion (%) 45.65 50.13 0.1429 1:8P opo ion o pa ien s (%) wi h a p e ious his o y o 1:9Myoca dial in a c ion 9.82 9.52 0.8878 1:10S oke 3.28 4.26 0.4733 1:11Conges i e hea ailu e 7.57 11.14 0.0885 1:12PCI 8.61 7.18 0.4635 1:13Co ona y bypass su ge y 1.51 1.06 0.5795 1:14P opo ion o pa ien s (%) wi h p e ious ca diac isk ac o s 1:15Hype ension 66.16 69.14 0.4214 1:16Diabe es melli us 19.95 24.93 0.0967 1:17Smoking 51.64 45.89 0.1284 1:18Hype choles e olemia 47.72 44.56 0.3779 Values a e means ± S.D. o pe cen ages o subjec s. PCI = pe cu aneous co ona y in e en ion. 1:19 3G. Papai e al. / Jou nal o Elec oca diology xx (2014) xxx–xxx UNCORRECTED PROOF 241 signi ican ly longe o he TTECG g oup han o he 242 con ols (55.2 ± 34.2 s. 39.4 ± 32.2 km). Consequen ly, 243 he anspo ime p o ed o be sligh ly, bu signi ican ly 244 longe in he TTECG g oup. Howe e , when he dis ance/ 245 anspo ime a ios we e calcula ed, he speed o he se ice 246 was somewha be e in he TTECG g oup as compa ed wi h 247 he con ols (1.03 s. 0.96 km/min). 248 Bo h he doo o shea h inse ion and doo o balloon 249 imes we e sligh ly, bu signi ican ly sho e in he TTECG 250 g oup ela i e o he con ols (Table 3). 251 The mean leng h o he hospi al s ay o he pa ien s in he 252 TTECG g oup was 6.99 days e sus 6.94 days o hose in 253 he con ol g oup (p = 0.8146). The in-hospi al mo ali y 254 a e was 4.28% in he TTECG g oup, as compa ed wi h 255 8.44% in he con ol g oup. The Kaplan-Meie cu es 256 indica ed ha he e was a signi ican su i al bene i o 257 cumula i e su i al a 10 days (log ank es , p = 0.0350; 258 Fig. 2) in he TTECG g oup in compa ison wi h he con ols. 259Discussion 260ECG changes in acu e myoca dial in a c ion a e highly 261dynamic. The e y ea ly acquisi ion and ansmission o 262ECG da a in acu e myoca dial in a c ion can he e o e 263p o ide aluable, ime-sensi i e da a ha can help inc ease 264 he accu acy o diagnosis by showing se ial ECG changes 265s a ing a an ea lie poin in ime han would o he wise be 266possible. I clea ly eme ged om his s udy ha an in eg a ed 267mul idisciplina y egional app oach in which pa amedics, 268ei he independen ly o a e TTECG-based consul a ion 269wi h ca diologis s, pe o m iage and anspo pa ien s wi h 270STEMI o a designa ed PCI cen e o p ima y PCI, is 271 easible and as . In e es ingly, he s udy e ealed a 272signi ican ly lowe in-hospi al mo ali y a e o he 273TTECG g oup. This somewha unexpec ed inding was 274p obably due o imp o ed p ehospi al medical he apy, and 275a leas in pa o he as e in-hospi al epe usion (imp o ed 276PCI- ela ed delay imes). 277In acco dance wi h p e ious obse a ions [13], indepen- 278den ly om a consul a ion wi h he ca diologis (TTECG 279g oup), he pa amedics in e p e ed he ECG wi h an 280accep able deg ee o accu acy and anspo ed he pa ien s 281immedia ely o he designa ed cen e o p ima y PCI. 282Howe e , signi ican di e ences be ween he g oups we e 283no ed in he p ehospi al medical he apy ini ia ed by he 284pa amedics. Sodium hepa in and na co ics we e used mo e 285 equen ly a e he TTECG-based consul a ion. I seems ha 286 he consul a ion wi h he specialis a he suppo ed he 287p esump i e diagnosis o STEMI, and he ambulance se ice 288uni acco dingly ini ia ed mo e agg essi e medical he apy. 289In he con ols (wi hou TTECG-based consul a ion), he e 290 ended o be an unde use o sodium hepa in and na co ics, 291and an o e use o ni a es, and i is hypo hesised ha he 292la e migh ha e been a he apeu ic excuse. 293The ASSENT-4 PCI ial [14] highligh ed ha he 294subop imum an i h ombo ic p ehospi al co- he apy (unde - 295use o sodium hepa in and o he an i h ombo ic d ugs) in he 296 acili a ed PCI a m was esponsible o he poo e clinical Table 2 2:1 S en p ocedu al de ails and p ehospi al medical he apy. 2:2 2:3TTECG g oup (N = 397) Con ol g oup (N = 378) p alue 2:4S en p ocedu al de ails 2:5S en /pa ien (mean ± S.D.) 1.31 ± 0.88 1.28 ± 0.57 0.5658 2:6D ug-elu ing s en (%) 4.53 5.03 0.7423 2:7*LAD (%) 50.87 52.56 0.7136 2:8*CX (%) 16.76 16.31 0.8936 2:9*RCA (%) 43.35 41.39 0.7430 2:10 P opo ion o pa ien s (%) ecei ing he ollowing p ehospi al medical he apy 2:11 Ace ylsalicylic acid and/o clopidog el 80.51 75.93 0.1453 2:12 Sodium hepa in 84.30 59.10 b0.0001 2:13 Ni oglyce ine 4.81 13.75 b0.0001 2:14 Na co ics 56.99 13.76 b0.0001 2:15 A opine 6.84 4.23 0.1148 2:16 Be a-blocke 4.23 3.70 0.3571 2:17 P opo ion o pa ien s esusci a ed (%) 8.56 8.27 0.8818 Values a e means ± S.D. o pe cen ages o subjec s. *Pa ien s may ha e had in e en ions on mo e han one essel. LAD indica es le an e io descending; CX, le ci cum lex; RCA, igh co ona y a e y. “Pa ien s esusci a ed”a e he pa ien s in whom de ib illa ion was needed du ing he i s medical con ac and/o anspo . 2:18 Table 3 3:1 P ima y e icacy ou come and mo ali y da a o he s udy popula ion. 3:2 3:3TTECG g oup (N = 397) Con ol g oup (N = 378) p alue 3:4Dis ance om PCI cen e (km) 55.2 ± 34.2 39.4 ± 32.2 b0.0001 3:5Con ac ime (min) 29.31 ± 10.67 24.13 ± 13.23 b0.0001 3:6T anspo ime (min) 53.75 ± 32.97 40.78 ± 21.30 b0.0001 3:7Time om symp om onse o i s medical con ac (min) 224.41 ± 395.59 259.95 ± 323.51 0.2581 3:8Doo o shea h inse ion ime (min) 43.37 ± 18.57 46.95 ± 17.75 0.0124 3:9Doo o balloon ime (min) 60.31 ± 19.50 63.73 ± 21.13 0.0426 3:10 Hospi alisa ion (days) 6.99 ± 3.45 6.94 ± 3.48 0.8146 3:11 In-hospi al mo ali y a e (%) 4.28 8.44 0.0350 Values a e means ± S.D. o pe cen ages o subjec s. 3:12 Fig. 2. Kaplan-Meie cu es depic ing in-hospi al su i al a 10 days in he wo g oups. The numbe a isk indica es he numbe o in-hospi al pa ien s a a gi en ime poin in he TTECG and con ol g oups, espec i ely. 4G. Papai e al. / Jou nal o Elec oca diology xx (2014) xxx–xxx UNCORRECTED PROOF 297 ou come in hese pa ien s. The ASSENT-4 PCI ial d ew 298 a en ion o he impo ance o adequa e an i h ombo ic 299 p ehospi al he apy. Consequen ly, i appea s likely ha he 300 subop imum an i h ombo ic ea men was esponsible a 301 leas in pa o he inc eased mo ali y a e no ed in he 302 p esen s udy among he con ol pa ien s. In e es ingly, a 303 signi ican ly highe p opo ion o he con ol g oup ecei ed 304 ni a es han ha in he TTECG g oup (13.75% s. 4.81%). 305 Howe e , p e ious la ge clinical ials (GISSI-3 and ISIS-4) 306 clea ly showed ha ni a es did no a ec he mo ali y 307 a e [15,16]. 308 Hypo he ically, an inc eased numbe o en icula 309 ib illa ion episodes equi ing ca diopulmona y esusci a ion 310 (CPR) in he con ol g oup would ha e p o ided a plausible 311 explana ion o he highe mo ali y a e among hese 312 pa ien s, and could also ha e been he eason o he 313 pa amedic eam deciding agains TTECG consul a ion, while 314 ans e ing he pa ien s immedia ely o he PCI cen e o 315 in asi e in es iga ion. Howe e , ou e alua ion o he 316 occu ence o en icula ib illa ion did no e eal a 317 signi ican ly highe le el in he con ol g oup han in he 318 TTECG g oup (Table 2). Ano he explana ion o he mo e 319 cau ious use o sodium hepa in migh ha e been he highe 320 numbe o unconscious pa ien s and/o he need o assis ed 321 espi a ion in he con ol g oup (suba achnoid haemo hage 322 can mani es as sudden loss o consciousness, e en in he 323 p esence o an ST segmen ele a ion [17]). Howe e , he 324 da abase did no indica e any signi ican di e ences be ween 325 he wo g oups om hese aspec s. 326 Fas e in-hospi al epe usion was no ed in he TTECG 327 g oup han in he con ols (Table 3). The imp o ed PCI- 328 ela ed delay imes we e likely o be due o as e decision- 329 making, ans e and p epa a ion o he pa ien o p ima y 330 PCI in he ca he e iza ion labo a o y. In e es ingly, TTECG 331 was used mo e equen ly by he pa amedics i he scene o 332 he pa ien s was mo e dis an om he PCI cen e. Upon 333 inqui y, he ambulance se ice pe sonnel explained his as 334 “ he longe he dis ance om he PCI cen e, he mo e 335 impo an i is o make a p ope diagnosis”. 336 In summa y, ou indings indica e ha 1) he eco ding 337 and ansmission o TTECG and he TTECG-based 338 consul a ion be ween he pa amedics and he ca diologis s 339 du ing he i s medical con ac wi h STEMI pa ien s a e 340 easible and as , 2) con i ma ion o he diagnosis o STEMI 341 by he specialis imp o ed he medical he apy ini ia ed by 342 he pa amedics, and 3) TTECG signi ican ly sho ened he 343 PCI- ela ed delay imes and may imp o e he in-hospi al 344 mo ali y a e. 345 Limi a ions o he s udy 346 One limi a ion o ou s udy is he ac ha he da abase 347 was no andomised and a selec ion bias could ha e 348 in luenced he esul s. We gua ded agains his possibili y 349 in di e en ways. Fi s ly, he decision o ob ain TTECG was 350 based on he disc e ion o he pa amedics. Some eams 351 ob ained and ans e ed TTECG om all pa ien s and o he 352 eams made i only i hey had p oblems wi h he clinical 353diagnosis and/o wi h he in e p e a ion o he ECG. 354Secondly, he wo g oups (TTECG and con ol) we e 355 ela i ely well ma ched, including isk ac o s, p e ious 356medical his o y, CPR, assis ed espi a ion and ca diogenic 357shock. Thi dly, all pa ien s wi h a hospi al diagnosis o 358STEMI unde wen ca diac ca he e iza ion independen ly 359 om he s udy a m. This measu e aimed agains any e ec 360modi ie bias o he TTECG consul a ion. Finally, a 361 ela i ely long inclusion ime (2 yea s) was in ol ed in he 362s udy and all pa ien s wi h a hospi al diagnosis o STEMI we e 363included in he da abase. O e all, he lack o andomisa ion 364and he limi ed numbe o pa ien s ende i di icul o make 365compa isons and o d aw i m conclusions om his s udy; 366none heless, some bene i s o he egional managemen o 367STEMI pa ien s by TTECG ha e been demons a ed. 368Acknowledgmen s 369We would like o exp ess ou g a i ude and app ecia ion 370 o Kla a A. To h and Ildiko B. Laszlo o hei in aluable 371help in he da a collec ion. 372 Q2Re e ences 373[1] S eg PG, James SK, A a D, e al. ESC Guidelines o he managemen 374o acu e myoca dial in a c ion in pa ien s p esen ing wi h ST-segmen 375ele a ion. Eu Hea J 2012;33(20):2569–619. 376[2] Can o JG, Roge s WJ, Bowlby LJ, F ench WJ, Pea ce DJ, Wea e 377WD. The p ehospi al elec oca diog am in acu e myoca dial in a c ion: 378is i s ull po en ial being ealized? Na ional Regis y o Myoca dial 379In a c ion 2 In es iga o s. J Am Coll Ca diol 1997;29(3):498–505. 380[3] Kekes E, Edes I. The eal alue o he ans elephonic ECG sys em in 381 he clinical ca diological p ac ice. O He i 2007;148(31):1443–9. 382[4] Zaliunas R, Bene is R, Vanagas G, Slapikas R, Vaino as A. Implemen- 383 a ion o in e na ional ans elephonic ECG pla o m o pa ien s wi h 384ischemic hea disease. Medicina (Kaunas) 2009;45(2):104–10. 385[5] Clemmensen P, Seje s en M, Sillesen M, Hamp on D, Wagne GS, 386Loumann-Nielsen S. Di e sion o ST-ele a ion myoca dial in a c ion 387pa ien s o p ima y angioplas y based on wi eless p ehospi al 12-lead 388elec oca diog aphic ansmission di ec ly o he ca diologis 's handheld 389compu e : a p og ess epo . J Elec oca diol 2005;38(4 Suppl):194–8. 390[6] Seje s en M, Pahlm O, Pe e sson J, e al. Compa ison o EASI-de i ed 39112-lead elec oca diog ams e sus pa amedic-acqui ed 12-lead elec- 392 oca diog ams using Mason-Lika limb lead con igu a ion in pa ien s 393wi h ches pain. J Elec oca diol 2006;39(1):13–21. 394[7] Akke huis KM, Maas AC, Kloo wijk PA, e al. Recu en ischemia 395du ing con inuous 12-lead ECG-ischemia moni o ing in pa ien s wi h 396acu e co ona y synd omes ea ed wi h ep i iba ide: ela ion wi h dea h 397and myoca dial in a c ion. PURSUIT ECG-Ischemia Moni o ing 398Subs udy In es iga o s. Pla ele glycop o ein IIb/IIIa in Uns able 399angina: Recep o Supp ession Using In eg ilin The apy. J Elec o- 400ca diol 2000;33(2):127–36. 401[8] Ba on-Esqui ias G, San ana-Cabeza JJ, Ha o R, e al. T ans elephonic 402elec oca diog aphy o managing ou -o -hospi al ches pain eme gen- 403cies. J Elec oca diol 2011;44(6):755–60. 404[9] Pang HW, Campbell D, Hopman WM, e al. E ec i eness and 405 easibili y o a ans elephonic moni o ing p og am: implica ions o a 406 ime o c isis. In J Ca diol 2010;145(3):529–30. 407[10] Liu J, Fang PH, Hou Y, e al. The alue o ans elephonic 408elec oca diog am moni o ing sys em du ing he "Blanking Pe iod" 409a e abla ion o a ial ib illa ion. J Elec oca diol 2010;43(6):667–72. 410[11] Vassilikos VP, Vogas V, Giannakoulas G, e al. The use o 411 ans elephonic loop eco de s o he assessmen o symp oms and 412a hy hmia ecu ence a e adio equency ca he e abla ion. Telemed 413J E Heal h 2010;16(7):792–8. 5G. Papai e al. / Jou nal o Elec oca diology xx (2014) xxx–xxx UNCORRECTED PROOF 414 [12] Gailla d N, Del ou S, Vilo ije ic B, e al. De ec ion o pa oxysmal 415 a ial ib illa ion wi h ans elephonic EKG in TIA o s oke pa ien s. 416 Neu ology 2010;74(21):1666–70. 417 [13] Le May MR, Da ies RF, Dionne R, e al. Compa ison o ea ly mo ali y 418 o pa amedic-diagnosed ST-segmen ele a ion myoca dial in a c ion 419 wi h immedia e anspo o a designa ed p ima y pe cu aneous co ona y 420 in e en ion cen e o ha o simila pa ien s anspo ed o he nea es 421 hospi al. Am J Ca diol 2006;98(10):1329–33. 422 [14] P ima y e sus enec eplase- acili a ed pe cu aneous co ona y in e en- 423 ion in pa ien s wi h ST-segmen ele a ion acu e myoca dial in a c ion 424 (ASSENT-4 PCI): andomised ial. Lance 2006;367(9510):569–78. 425[15] ISIS-4: a andomised ac o ial ial assessing ea ly o al cap op il, 426o al mononi a e, and in a enous magnesium sulpha e in 58,050 427pa ien s wi h suspec ed acu e myoca dial in a c ion. ISIS-4 (Fou h 428In e na ional S udy o In a c Su i al) Collabo a i e G oup. Lance 4291995;345(8951):669–85. 430[16] GISSI-3: e ec s o lisinop il and ansde mal glyce yl ini a e singly 431and oge he on 6-week mo ali y and en icula unc ion a e acu e 432myoca dial in a c ion. G uppo I aliano pe lo S udio della Sop a i- 433 enza nell'in a o Mioca dico. Lance 1994;343(8906):1115–22. 434[17] Cha e jee S. ECG Changes in Suba achnoid Haemo hage: A 435Synopsis. Ne h Hea J 2011;19(1):31–4. 436 437 6G. Papai e al. / Jou nal o Elec oca diology xx (2014) xxx–xxx AUTHOR QUERY FORM Jou nal: YJELC Please e-mail o ax you esponses and any co ec ions o: Else ie E-mail: co ec ions.esi@else ie .spi ech.com Fax: +1 619 699 6721 A icle Numbe : 51830 Dea Au ho , Please check you p oo ca e ully and ma k all co ec ions a he app op ia e place in he p oo (e.g., by using on-sc een anno a ion in he PDF ile) o compile hem in a sepa a e lis . No e: i you op o anno a e he ile wi h so wa e o he han Adobe Reade hen please also highligh he app op ia e place in he PDF ile. To ensu e as publica ion o you pape please e u n you co ec ions wi hin 48 hou s. Fo co ec ion o e ision o any a wo k, please consul h p://www.else ie .com/a wo kins uc ions. Any que ies o ema ks ha ha e a isen du ing he p ocessing o you manusc ip a e lis ed below and highligh ed by lags in he p oo . Click on he ‘Q’link o go o he loca ion in he p oo . Loca ion in a icle Que y / Rema k: click on he Q link o go Please inse you eply o co ec ion a he co esponding line in he p oo Q1 Please con i m ha gi en names and su names ha e been iden i ied co ec ly. Q2 As pe jou nal s yle, i he e a e mo e han six au ho s, he i s six au ho names a e lis ed ollowed by “e al.”; please p o ide he names o he i s six au ho s ollowed by “e al.” o Re s. [1,6-13]. Please check his box i you ha e no co ec ions o make o he PDF ile. □ Thank you o you assis ance. Ou e e ence: YJELC 51830 P-au ho que y- 11 Page 1 o 1