Background

Prehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30 day of initial presentation to the emergency department (ED).

Methods

We included consecutive patients ≥ 21 years during a five-year period (2013–2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days.

Results

We identified 3646 patients (mean age, 59.7 years ±15.7; 45% female) with ECGs, of which N = 3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR = 1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR = 0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30 days (OR = 1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features.

Conclusions

ST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30 days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

中文翻译：

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ST 压低和 T 波倒置的院前心电图与由救护车运送的疑似急性冠状动脉综合征患者新发心力衰竭有关

背景

院前心电图 (ECG) 可以改善急性冠状动脉综合征（ST 段抬高型心肌梗死 [STEMI]、非 STEMI 和不稳定型心绞痛）的早期检测，并告知院前心导管实验室的激活；因此，减少总缺血时间并改善患者预后。然而，关于院前心电图缺血发现与长期不良临床事件之间的关联，我们知之甚少。考虑到这一点，本研究旨在检查：1）急性心肌缺血（ST 抬高、ST 压低和/或 T 波倒置）的院前心电图频率；以及，2) 这些特定的 ECG 特征是否与初次就诊到急诊科 (ED) 后 30 天内的不良临床事件相关。

方法

我们纳入了 5 年期间（2013-2017 年）≥ 21 岁的连续患者，这些患者被救护车运送到急诊室，出现非创伤性胸痛和/或心绞痛等效症状，并接受了院前 12 导联心电图。两名心脏病专家（LG、EC）对临床数据视而不见，应用当前基于指南的缺血标准解释了 12 导联心电图。在 30 天评估不良临床事件、返回 ED 和再住院。

结果

我们确定了 3646 名患者（平均年龄，59.7 岁 ±15.7 岁；45% 为女性）的心电图，其中N  = 3587 人有关于三种感兴趣的缺血标志物的数据。其中，1762 人（49.1%）有心电图缺血证据。在调整后的逻辑回归模型中，T 波倒置的患者新发心力衰竭的几率较高（OR = 1.59），而 ST 抬高与较低的几率相关（OR = 0.69）。ST 抑郁症患者在 30 天内新发心力衰竭和死亡的几率更高（OR = 1.29、1.49），但在控制其他心电图特征后，这种关联减弱。

结论

ST 压低和/或 T 波倒置是新发心力衰竭的独立预测因素，在最初 ED 就诊的 30 天内。我们在一大群患者中进行的研究表明，单独使用 ECG ST 抬高可能无法捕获可能受益于积极抗缺血治疗以减少心肌损伤导致心力衰竭的缺血患者。