Do not pass go, do not collect $200.00 and do not stop in the ER. Go straight to the CCU or cath lab. That’s the message of an observational study published in the October issue of Heart. Patients with ST segment elevation MI who were shipped directly to the CCU or cath lab were admitted earlier (by 48 min) and had a lower mortality than those who were admitted via the ER.
Mortality for ER patients was 8.6% for ER patients and 4.9% for those directly transported to the cath lab or CCU. By my math that means that the benefits of direct transport are RRR 43%, ARR 3.7%, NNT 27. In terms of relative risk, mortality rose by 0.9% per minute of delay, translating into 54% per hour.
This is one more piece of evidence that ER delays are lethal (see this recent post citing evidence that, across the board wait time is associated with 20% mortality per hour for all patients admitted) and that by some folks’ definition there are lots of emergency department homicides out there.
So how do you know if you’re having a STEMI (as opposed to NSTEMI or non cardiac chest pain)? Well, you don’t, initially. But the paramedics can tell from their pre-hospital ECG.
That raises another point. If you experience chest pain DO NOT come to the ER in a private car. Call an ambulance. Transport by private car was the first mistake in the Illinois heart attack death recently ruled a homicide.
2 comments:
Assuming of course that the hospital you went to have a cardiologist already in house waiting in the cath lab who can provide emergent rescue angioplasty and coronary stenting with full cardiothoracic surgery back up. Otherwise, the ER is still your best bet.
At our hospital EMS faxes the EKG's into the ER, if it's a STEMI the on call cardiologist is notified. Our door to needle time is around 20-30 minutes. It takes that long for the entire cath team to be assembled, especially in the middle of the night, unless they're already in the cath lab. In that 20-30 minutes, the ED manages cardiogenic shock, arrhythmias, pulmonary edema, and whatever to get the routine things out of the way, IV access, CXR, meds, heparin, NTG, labs, etc...Sending patients directly from the ambulance to the cath lab and having them lie there to wait 20-30 minutes for the cath team to arrive is dangerous.
Good gawd, ever since the story about that inapproriately triaged patient who died in the waiting room of an MI came out, our ED has been inundated, INUNDATED, with folks coming in by ambulance for chest pains. Even the 20-something y/o crowd.
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