Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation

Abstract

Aim

To assess whether telemedicine technology applied to public emergency healthcare system improves overall quality of home diagnosis in case of acute myocardial infarction among elderly patients, often characterized by higher rates of atypical presentation.

Methods

About 27 841 patients from Apulia (Italy) who called public emergency healthcare number ‘118’ underwent home ECG evaluation. Data were transmitted with a mobile telephone support to a telecardiology ‘hub’ active continuously (24/7). Data from elderly patients (>70 years) were compared with younger ones.

Results

Thirty-nine percent of patients complained of chest (or epigastric) pain; ST elevation acute myocardial infarction (STEMI) was diagnosed in 1.9% of patients enrolled; 50.2% of patients with STEMI were above 70 years of age. Among STEMI patients older than 70 years, atypical presentation was detected in 32% [95% confidence interval (CI): 26.8–38.1] of patients (vs. 11% 95% CI: 7.8–15.5, P<0.001). Rate of atypical STEMI presentation, immediately diagnosed, thanks to telecardiology, rose up from 9.2% (95% CI: 5–17%) in the class of age 60–69 years to 25.6% (95% CI: 20–35%) in the class of age 70–79 years, to 35.2% (95% CI: 26–45%) in the class 80–89, and to 46.1% (95% CI: 26–67%) in the class greater than 89 years of age (P<0.01 in all cases). Number needed to treat (to avoid a single missed STEMI diagnosis) was 9.4 (95% CI: 6.4–12.9) for patients younger than 70 years versus 3.1 (95% CI: 2.6–3.7) among those older than 70 years (P<0.001).

Keywords

elderly ST elevation acute myocardial infarction telecardiology

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References

1. Fisch

The clinical electrocardiogram: sensitivity and specificity. In: Fisch

, editor. ACC current journal review. New York, NY: Elsevier Science Inc.; 1997. pp. 71–75.

2. Lee

Rouan

Weisberg

Brand

Cook

Acampora

Goldman

Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 h of hospitalization. Ann Intern Med 1987; 106:181–186.

3. ÇulicA

EterovicA

MiricA

SilicA

Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144:1012–1017.

4. Grossman

Brown

Chang

Chung

Cranmer

Dan

. Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes. Am J Emerg Med 2003; 21:425–428.

5. Berton

Cordiano

Palmieri

Guarnieri

Stefani

Palatini

Clinical features associated with pre-hospital time delay in acute myocardial infarction. Ital Heart J 2001; 2:766–771.

6. Molinari

Valbusa

Terrizzano

Bazzano

Torelli

Girardi

Barsotti

Nine years' experience of telecardiology in primary care. J Telemed Telecare 2004; 10:249–253.

7. Antman

Bassand

Klein

Ohman

Lopez

Sendon JL

Rydén

. Myocardial infarction redefined. A consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J 2000; 21:1502–1513.

8. Brunetti

Dellegrottaglie

De Gennaro

Amodio

Di Biase

Antonelli

Acute myocardial infarction home diagnosis in a region wide telecardiology network for public emergency health care service: an experience from Italy. Eur Heart J 2006; 27 (Suppl):140 [abstract].

9. Brunetti

De Gennaro

Amodio

Dellegrottaglie

Pellegrino

Di Biase

Antonelli

Telecardiology applied to a region-wide public emergency health care service. J Thromb Thrombolysis 2009; 28:23–30.

10.

10. Spencer

Goldberg

Becker

Gore

JM.

For the participants in the national registry of myocardial infarction. Seasonal distribution of acute myocardial infarction in the second national registry of myocardial infarction. J Am Coll Cardiol 1998; 31:1226–1233.

11.

11. Madjid

Miller

Zarubaev

Marinich

Kiselev

Lobzin

. Influenza epidemics and acute respiratory disease activity are associated with a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects. Eur Heart J 2007; 28:1205–1210.

12.

12. Boulay

Berthier

Sisteron

Gendreike

Gibelin

Seasonal variation in chronic heart failure hospitalizations and mortality in France. Circulation 1999; 100:280–286.

13.

13. Gupta

Tabas

Kohn

MA.

Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med 2002; 40:180–186.

14.

14. Stewart

McIntyre

Capewell

McMurray

JJV.

Heart failure in a cold climate seasonal variation in heart failure-related morbidity and mortality. J Am Coll Cardiol 2002; 39:760–766.

15.

15. Madias

Chintalapaly

Choudry

Chalavarya

Kegan

Correlates and in-hospital outcome of painless presentation of acute myocardial infarction: a prospective study of a consecutive series of patients admitted to the coronary care unit. J Invest Med 1995; 43:567–574.

16.

16. Nielsen

Larsen

Foldspang

Faergeman

Living alone and atypical clinical presentation are associated with higher mortality in patients with all components of the acute coronary syndrome. Eur J Cardiovasc Prev Rehabil 2007; 14:152–154.

17.

17. Canto

Shlipak

Rogers

Malmgren

Frederick

Lambrew

. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000; 283:3223–3229.

18.

18. Dorsch

Lawrance

Sapsford

Durham

Oldham

Greenwood

EMMACE Study Group. Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart 2001; 86:494–498.

19.

19. Magid

Masoudi

Vinson

van der Vlugt

Padgett

Tricomi

. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Em Med 2005; 46:14–21.

20.

20. Rathore

Mehta

Wang

Radford

Krumholz

HM.

Effects of age on the quality of care provided to older patients with acute myocardial infarction. Am J Med 2003; 114:307–315.

21.

21. De Luca

Suryapranata

Ottervanger

Antman

EM.

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction. Circulation 2004; 109:1223–1225.

22.

22. Berger

Ellis

Holmes

Jr Granger

Criger

Betriu

. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial for the GUSTO-II investigators. Circulation 1999; 100:14–20.

23.

23. Steg

Bonnefoy

Chabaud

Lapostolle

Dubien

Cristofini

.; For the Comparison of Angioplasty and Prehospital Thrombolysis in acute Myocardial infarction (CAPTIM) Investigators. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty. Data from the CAPTIM randomized clinical trial. Circulation 2003; 108: 2851–2856.

24.

24. Nallamothu

Bates

Herrin

Wang

Bradley

Krumholz

; for the NRMI Investigators. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation 2005; 11: 761–767.

25.

25. Terkelsen

Lassen

Norgaard

Gerdes

Poulsen

Bendix

. Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous coronary intervention. Eur Heart J 2005; 26:770–777.

26.

26. Schuler

Maier

Behrens

Thimme

Present treatment of acute myocardial infarction in patients over 75 years–data from the Berlin Myocardial Infarction Registry (BHIR). Clin Res Cardiol 2006; 95:360–367.

27.

27. Ortaolani

Marzocchi

Marrozzini

Palmerini

Saia

Serantoni

. Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction. Eur Heart J 2006; 27:1550–1557.

28.

28. Curtis

Portnay

Wang

McNamara

Herrin

Bradley

. National Registry of Myocardial Infarction-4. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol 2006; 47:1544–1552.

29.

29. Bradley

Herrin

Wang

Barton

Webster

Mattera

. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006; 355:2308–2320.