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.
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