Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61)

BACKGROUND: Early recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy. METHODS: Three anonymously linked New Zealand national datasets (July 2016–November 2018) were used to assess the utilisation of ambulance transport in STEMI cases, the concordance between ambulance initial clinical impressions and hospital STEMI diagnoses, and the association between initial paramedic clinical impressions and 30-day mortality. The St John Ambulance electronic record captures community call-outs and paramedic initial clinical impressions. The national cardiac (ANZACS-QI) registry and national administrative datasets capture all New Zealand public hospital admission diagnoses and mortality data. RESULTS: Of 5465 patients with STEMI, 73% were transported to hospital by ambulance. For these patients, the initial paramedic impression was STEMI in 50.7%, another acute coronary syndrome (ACS) diagnosis in 19.9% and non-ACS diagnosis in 29.7%. Only 37% of the 5465 patients with STEMI were both transported by ambulance and clinically suspected of STEMI by paramedics. Compared with patients with paramedic-‘suspected STEMI’, 30-day mortality was over threefold higher for patients thought to have a non-ACS condition (10.9% and 34.9%, respectively), but after adjustment for available covariates, this was substantially ameliorated (HR 1.48, 95% CI 1.22 to 1.80). CONCLUSIONS: In this national data linkage study, only 4 out of every 10 patients with STEMI were both transported by ambulance and had STEMI suspected by paramedics. Although patients with STEMI not suspected of an ACS diagnosis by paramedics had the highest mortality rate, this is largely explained by the different risk profile of these patients.