ReviewsThe prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature
Introduction
Several studies have shown that the prehospital 12-lead electrocardiogram (ECG) is accurate in identifying patients with acute myocardial infarction (AMI) and acute cardiac ischemia (ACI) [1], [2], [3]. Obtaining a prehospital ECG is becoming the standard of care [4], [5], and several emergency medical service (EMS) practice guidelines recommend the prehospital ECG [6]. Among many EMS providers, the prehospital ECG is considered an important procedure that improves patient care [7]. In our previous study, cardiologists and emergency physicians were shown to have positive attitudes about the usefulness and benefits of the prehospital ECG [8].
The American Heart Association gives the prehospital ECG a class 1 recommendation [9]. However, most of the data used to support this evidence-based recommendation derive from studies that do not apply to the current system of prehospital emergency care in the United States. For example, much of the data in published studies were generated in EMS systems that administered prehospital fibinolytics, whereas other studies either provided no original data, covered only theoretical time savings, reported on very few patients, or reported on patients who were admitted to services other than EDs. Finally, the only reference that showed a difference in mortality used historical cases as the control group.
The principal clinical benefit of the prehospital ECG is a reduction in the time from the beginning of cardiac symptoms to the initiation of inhospital reperfusion therapy. This study sought to analyze and quantify the existing research to determine if the prehospital ECG has reduced the time to treatment.
This systematic review and embedded meta-analysis were intended to locate all research in all languages that compared cardiac reperfusion times of patients who received a prehospital ECG with patients who did not receive a prehospital ECG. The principal measure of effect was the mean difference in minutes between control (no prehospital ECG) and treatment (prehospital ECG) inhospital reperfusion.
Section snippets
Search strategy
We conducted a search of multiple online databases in all languages and then reviewed the relevant articles that we found. After our preliminary search, we requested any gray literature (unpublished articles) from several authors who had published research related to the prehospital ECG. The databases that we searched were Medline, 1966 to January 2004, the Cumulative Index to Nursing and Allied Health Literature, 1982 to January 2004, the Cochrane Database Systematic Review, ACP Journal Club,
Search results
The original search strategy yielded 2129 publications with 1747 from Medline, 311 from Cumulative Index to Nursing and Allied Health Literature, and 71 from the Cochrane Evidence-Based Medicine Databases. From these, 615 papers were selected for additional investigation based on the relevance of their titles. The abstracts of the 615 papers were read for relevance, and 72 of these appeared to warrant complete retrieval and study. These 72 papers, in addition to several other topical expert
Discussion
We found that the best evidence, when combined, indicates that there is a 24.7-minute reduction in the time to inhospital reperfusion intervention associated with the prehospital ECG. However, with strict inclusion and exclusion criteria based on like-systems and comparable methodologies, there are only 4 published papers with a total of 99 patients. Thus, the evidence of the clinical benefits of the prehospital ECG is relatively weak.
The prehospital ECG likely reduces reperfusion times through
Conclusion
This meta-analysis provides the best-evidence determination of reduced time to reperfusion in AMI and ACI associated with the prehospital ECG. It has a number of implications for clinical care and future research. The time savings of the prehospital ECG in reducing time to reperfusion therapy for patients with ACI/AMI of approximately 25 minutes can now be used to estimate numbers of lives saved, benefits in quality life-years, reduction in morbidity, cost reductions, more efficient allocation
Acknowledgment
Funding was provided by the University of New Mexico Emergency Medical Services Academy.
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