Canadian Journal of Cardiology

Cardiac Outcomes Through Digital Evaluation (CODE) STEMI Project: Prehospital Digitally-Assisted Reperfusion Strategies

Published:April 12, 2012DOI:



      Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times.


      In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physician's hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room.


      From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%.


      Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.



      Des lignes directrices sur la reperfusion dans l'infarctus du myocarde (IM) avec sus-décalage du segment ST ont été récemment adoptées par la Société canadienne de cardiologie (SCC). Nous avons élaboré un modèle mixte d'activation du traitement thrombolytique préhospitalier (TPH) ou de l'intervention coronarienne percutanée primaire (ICPP) pour atteindre les délais recommandés par les lignes directrices.


      Dans notre centre urbain de 658 700 personnes, les services médicaux d'urgence (SMU) étaient formés pour exécuter et évaluer les électrocardiogrammes (ECG) lors de suspicion d'IM avec sus-décalage du segment ST. Les ECG suspects étaient transmis au terminal mobile d'un médecin. Si le médecin confirmait le diagnostic, ils coordonnaient le TPH ou l'ICPP. Dans les cas où les médecins trouvaient un ECG préhospitalier négatif pour l'IM avec sus-décalage du segment ST (PHENST), les patients étaient transportés à la salle des urgences la plus proche.


      Du 21 juillet 2008 au 21 juillet 2010, le projet STEMI (ST-elevation myocardial infarction : IM avec sus-décalage du segment ST) de la Cardiac Outcomes Through Digital Evaluation (CODE) a reçu 380 appels. Il y eu 226 cas d'IM avec sus-décalage du segment ST confirmés par le médecin sur appel, 158 (70 %) ont subi une ICPP, 48 (21 %) ont subi un TPH et 20 (9 %) ont passé une angiographie, mais n'ont pas eu de revascularisation. Pour l'ICPP, le temps médian du premier contact médical à la reperfusion a été de 76 minutes (intervalle interquartile [IIQ], 64-93). Pour le TPH, le temps médian du premier contact médical à l'injection a été de 32 minutes (IIQ, 29-39). Le taux de mortalité global des patients ayant un IM avec sus-décalage du segment ST a été de 8 % (TPH = 4 [8,3 %], ICPP = 8 [5 %], traitement médical = 7 [35 %]). Des 154 patients qui ont eu une PHENST, 44 % ont reçu plus tard un diagnostic de syndrome coronarien aigu. Le taux de mortalité des patients ayant eu une PHENST a été de 14 %.


      Par un modèle d'interprétation d'ECG préhospitalières par les SMU, la transmission numérique, la communication directe avec un médecin et un service rapide bien coordonné, nous avons démontré que les délais de référence pour la reperfusion lors d'IM avec sus-décalage du segment ST peuvent être atteints.
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