Background: ST-segment elevation (STE) identifies a subset of ACS patients with acute coronary Occlusion Myocardial Infarction (OMI) who benefit from early reperfusion. We implemented a novel “HEART ALERT” pathway aimed at increasing the identification of ED patients with OMI without STE who would benefit from emergent reperfusion.
Methods: Study Design: Prospective, observational. Setting: Large, academic, suburban ED. Patients and Interventions: In September 2018 we implemented a HEART ALERT protocol which was activated in all ED patients with symptoms and ECGs suggestive of OMI without obvious STEMI. Emergent bedside consultation by a cardiology fellow and immediate review of the ECG by the interventional attending cardiologist was performed in all such patients. Patients were then either upgraded to emergent catheterization, remained as a HEART ALERT, or downgraded. HEART ALERT patients went for urgent catheterization, usually within 24 hours. Main outcomes: Presence of acute coronary OMI on catheterization and door to balloon times. Data Analysis: Descriptive statistics were used to summarize our experience and groups were compared with Chi-square and Mann Whitney U tests.
Results: Between 9/18-12/18 there were 55 HEART ALERTS. Mean (SD) age was 65 years, 37% were females, 84% Caucasian, 7% Hispanic. Of all alerts, 8 (15%) had emergent catheterization, 28 (51%) had urgent catheterization, 19 (34.5%) were not catheterized during the index admission. The number of patients with OMI in emergently and urgently catheterized patients were 3 of 8 (38%) and 3 of 28 (10.7%) respectively (P=0.10). Median (IQR) door-to-balloon times were 88 minutes (62-139) for the 8 emergently catheterized patients and 937 minutes (2214-1774) for the urgently catheterized patients (P=0.04). During the same period there were 40 STEMI activations, 36 (90%) had OMI. Median (IQR) door to balloon time was 23 (16-41) minutes.
Conclusions: A significant minority of patients with Occlusion MI present with non-STE that would have been missed using standard ECG criteria. Institutions should consider implementing a formal protocol allowing rapid assessment and decision-making regarding need for emergent catheterization for patients with active ACS and high risk clinical or ECG features.