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Prehospital Emergency Care Volume 26, 2022 - Issue 6
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Focus on Cardiology

Prehospital Predictors of Atypical STEMI Symptoms

Tyson G. TaylorStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).Correspondence[email protected]
ORCID Iconhttps://orcid.org/0000-0003-0116-0770
ORCID Icon,
Ronald E. StickneyStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
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William J. FrenchStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
,
James G. JollisStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
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Michael C. KontosStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
,
James T. NiemannStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
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Stephen G. SankoStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
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Marc K. EcksteinStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).
&
Nichole BossonStryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB);The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB).ORCID Iconhttps://orcid.org/0000-0001-8356-0772
ORCID Icon show all
Pages 756-763 | Received 23 Jul 2021, Accepted 27 Sep 2021, Published online: 08 Nov 2021
 
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Abstract

Introduction: Rapid prehospital identification of patients with ST-elevation myocardial infarction (STEMI) is a critical step to reduce time to treatment. Broad screening with field 12-lead ECGs can lead to a high rate of false positive STEMI activations due to low prevalence. One strategy to reduce false positive STEMI interpretations is to limit acquisition of 12-lead ECGs to patients who have symptoms strongly suggestive of STEMI, but this may delay care in patients who present atypically and lead to disparities in populations with more atypical presentations. We sought to assess patient factors associated with atypical STEMI presentation.

Methods: We retrospectively analyzed consecutive adult patients for whom Los Angeles Fire Department paramedics obtained a field 12-lead ECG from July 2011 through June 2012. The regional STEMI receiving center registry was used to identify patients with STEMI. Patients were designated as having typical symptoms if paramedics documented provider impressions of chest pain/discomfort, cardiac arrest, or cardiac symptoms, otherwise they were designated as having atypical symptoms. We utilized logistic regression to determine patient factors (age, sex, race) associated with atypical STEMI presentation.

Results: Of the 586 patients who had STEMI, 70% were male, 43% White, 16% Black, 20% Hispanic, 5% Asian and 16% were other or unspecified race. Twenty percent of STEMI patients (n = 117) had atypical symptoms. Women who had STEMI were older than men (74 years [IQR 62–83] vs. 60 years [IQR 53–70], p < 0.001). Univariate predictors of atypical symptoms were older age and female sex (p < 0.0001), while in multivariable analysis older age [odd ratio (OR) 1.05 per year, [95%CI 1.04–1.07, p < 0.0001] and black race (OR vs White 2.18, [95%CI 1.20–3.97], p = 0.011) were associated with atypical presentation.

Conclusion: Limiting prehospital acquisition of 12-lead ECGs to patients with typical STEMI symptoms would result in one in five patients with STEMI having delayed recognition, disproportionally impacting patients of older age, women, and Black patients. Age, not sex, may be a better predictor of atypical STEMI presentation.

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