Michal Golovner

The “SHAHAL” experience in Israel for improving diagnosis of acute coronary syndromes in the prehospital setting

The diagnosis of acute coronary syndromes is frequently missed, and many high-risk patients fail to be admitted to hospital. The aim of this study was to assess the value of cardiac markers in ruling out acute ischemic events in patients with symptoms of possible cardiac origin and nondiagnostic electrocardiograms. The data collected between May 1999 and April 2000 for this prospective cohort study were retrieved from the records of 777 consecutive prehospital patients (mean age 70 years, 62.9% men) whose symptoms lasted for 6 to 48 hours, who were treated by mobile intensive care teams, and for whom the physician could not reach a clear-cut decision whether they should be taken to hospital or left at home. The cardiac markers, creatine kinase (CK-MB), myoglobin, and troponin I, were measured at the scene using a rapid Stat kit to qualitatively detect their presence in whole blood samples. Results were determined after 15 minutes at the scene. The assay was positive in 30 patients, 11 of whom had a definite cardiac diagnosis (acute myocardial infarction in 4 and unstable angina pectoris in 7). Positive and negative predictive values of the assay for detecting a significant coronary event were 36.7% and 100%, respectively. Of the 747 patients with a negative result, 6 patients had a false result (1 with myocardial infarction and in 5 with unstable angina) (99.2% negative predictive value). Thus, cardiac markers are useful in ruling out high-risk coronary syndromes in the prehospital setting when the clinical presentation and electrocardiogram are inconclusive.

Assessment of a creatine kinase-MB/myoglobin kit in the prehospital setting in patients presenting with acute nontraumatic chest pain : The Shahal experience

OBJECTIVES To evaluate the usefulness of a novel qualitative, rapid, bedside immunoassay device for the detection of elevated creatine kinase MBmass (CK-MB) and myoglobin as a supportive tool for decision-making by the physician who is evaluating patients who present with chest pain. DESIGN Prospective study. SETTING Prehospital (mobile intensive care units). PATIENTS Three hundred twenty-eight consecutive patients, age 71+/-13 yrs (64% males), who were admitted to the hospital via Shahals mobile intensive care units. INTERVENTION During a 6-month period, based on clinical presentations and electrocardiograms, the mobiles physicians classified patients into groups of high or low probability of having an acute myocardial infarction and, thereafter, used a rapid bedside STATus kit (Spectral Diagnostics, Toronto, Ontario, Canada) to determine blood creatine kinase/MB and myoglobin. MEASUREMENTS AND MAIN RESULTS Myocardial infarction was confirmed in 59 (18%) patients. If measured >2 hrs after onset, diagnostic sensitivities, specificities, and positive and negative predictive values for physicians were as follows: 71%, 90%, 46%, and 96%, respectively, compared with 100%, 85%, 44%, and 100%, respectively, if assessed by the kit. CONCLUSIONS If used 2 to 12 hrs from the onset of symptoms, this device is a convenient diagnostic aid to prevent a misdiagnosis of acute myocardial infarction or unnecessary hospitalization to exclude infarction. This tool may be a promising cost-cutting factor in these days of escalating expenses and dwindling resources.

Effectiveness of prehospital synchronous direct-current cardioversion for supraventricular tachyarrhythmias causing unstable hemodynamic states

D irect-current (DC) cardioversion is recommended for patients with hemodynamically unstable conditions who experience supraventricular tachyarrhythmia (SVT) with a rapid ventricular rate.1 Although there are numerous reports on the safe application of this measure in hospitalized patients, little is known about its use and safety in the out-of-hospital environment. Moreover, although DC carioversion is widely and successfully used in the prehospital setting to treat ventricular tachyarrhythmias in combination with and without other resuscitation measures,2 we were unable to find any published reports on its similar use in patients with SVT in this setting. Thus, the aims of this study were to investigate the feasibility of safely applying DC cardioversion and to assess the therapeutic outcomes of these patients presenting in the prehospital phase to the “SHL” mobile intensive care unit. • • • “SHL,” a cardiac telemedical facility established in 1987 and described previously in detail,3–10 currently serves approximately 60,000 subscribers. In brief, it operates through a monitoring center managed by intensive care nurses who dispatch mobile intensive care units staffed by physicians and paramedics to subscribers. Each subscriber’s complete medical file (which also includes a 12-lead electrocardiogram [ECG]) is stored in a central computer and is continuously updated. All members carry a cardiobeeper by which they can transmit a 3-lead (I, II, III) or a 12-lead ECG by telephone. Once the caller is identified by name or identification number, his/her medical file is immediately displayed on a computer screen and the nurse obtains all the pertinent facts from the file as well as from a transtelephonic anamnesis. After interpreting the transmitted electrocardiographic data, and based on written protocols, the center’s nurse may (1) dispatch a mobile intensive care unit (staffed by a physician, a paramedic and a driver-medic) to the patient, (2) consult the physician present at the center or on-call, or (3) provide the patient with appropriate medical or behavioral instructions. The study cohort included all patients who presented with a narrow complex paroxysmal SVT including atrial fibrillation (AF) and/or those who did not respond promptly to vagal maneuvers that were tried first and then tried again after intravenously administered medical treatment with 1 of the following intravenously administered drugs: adenosine, verapamil, digoxin, and/or procainamide. All study patients were hemodynamically compromised but did not require cardiopulmonary resuscitation. A 12-lead ECG was obtained before cardioversion and a rhythm strip was recorded during electroshock. A full 12-lead ECG was repeated after DC cardioversion. Before cardioversion, all patients received 5 to 10 mg of diazepam intravenously, and 100% oxygen was administered by mask and continued to be delivered throughout the procedure. Manual ventilation was administered to patients with hypoxemia and breathing difficulties during sleep. A synchronized monophasic DC shock, delivered during the QRS complex, was used for all cardioversions, with an attempt being made to use minimum effective energy. To accomplish this, the shocks were “titrated” upward by doubling the amount of energy, starting at 50 J. In addition, all equipment necessary for emergency resuscitation was immediately accessible. Data were prospectively collected from July 1987 to May 2002. Apart from epidemiologic data contained in the medical file, data included detailed information on other parameters vis-a-vis cardioversion: the immediate reason for deciding to use DC cardioversion, the number of shocks applied, the amount of electrical energy delivered, the resulting final heart rhythm, and the clinical outcome. Descriptive statistics were used and the results for age, heart rate, blood pressure, and the amount and number of DC shocks are expressed as mean 1 SD. Eighty-four patients aged 76 13 years (range 33 to 94, mean 1 SD) who had 86 episodes of SVT were included in the study. The site of treatment was at home, in a public place, or in a health care facility in 78%, 14%, and 8% of patients, respectively. Their epidemiologic and medical characteristics are listed in Table 1 : no patient had Wolff-Parkinson-White syndrome or severe stenotic valvular or hypertrophic cardiomyopathic disease. The major presenting arrhythmia and symptoms are listed in Table 2. Before DC shocks, medical treatment to convert the arrhythmia to sinus rhythm was attempted unsuccessfully in 46 of 86 patients (53%). These consisted of the intravenous administration of adenosine (n From the Department of Cardiology, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University; and the Department of Cardiology, “SHL” Medical Services, Tel-Aviv, Israel. Dr. Roth’s address is: Department of Cardiology, Tel-Aviv Sourasky Medical Center, 6 Weizman Street, Tel-Aviv, 64239 Israel. E-mail: arieroth@tasmc.health.gov.il. Manuscript received June 27, 2002; revised manuscript received and accepted October 2, 2002.

Safety of Nitrate Withdrawal in Angina- Free and Hemodynamically Stable Patients With Coronary Artery Disease*

STUDY OBJECTIVES To assess the consequences of nitrate withdrawal in angina-free and hemodynamically stable coronary patients. DESIGN Prospective, open, intervention study. SETTING Cardiology outpatient clinic of a university-affiliated municipal hospital. PATIENTS Angina-free patients who were hemodynamically stable for at least 3 months before study onset were enrolled. They were all regularly receiving nitrates for symptom control. Those with significant reasons to avoid stopping nitrates, such as heart failure (ejection fraction <35%) or high BP (> 160 mm Hg systolic and/or > 100 mm Hg diastolic), and noncompliant patients were excluded. INTERVENTIONS After providing informed consent and undergoing an exercise test (whenever possible), the participants were randomized to abruptly discontinue (study group) or continue (control group) nitrate treatment. Follow-up continued for at least 3 months after study entry. MEASUREMENTS AND RESULTS Eighty patients were randomized to the study group and 40 patients to the control group (mean age [+/- 1 SD], 65.5 +/- 11 years and 66.1 +/- 10.9 years, respectively; p = not significant). The first month, eight study patients (10%) had a recurrence of anginal symptoms, compared with one control subject (2.5%) [p = not significant]. All eight patients responded promptly and favorably to the resumption of nitrate administration. CONCLUSIONS Nitrate administration can be safely discontinued in angina-free and hemodynamically stable coronary patients who receive this medication on a regular basis. If relapse of anginal symptoms occurs, it will be within 1 month following nitrate withdrawal, and will resolve satisfactorily with reinstatement of treatment.

New Real‐Time Loop Recorder Diagnosis of Symptomatic Arrhythmia Via Telemedicine

One disadvantage of current loop recorders is the long interval between recording an electrocardiogram (ECG), establishing a diagnosis, and taking appropriate medical measures. The Cardio R loop recorder transmits cardiac recordings by cellular communication at the push of a button. Users can concomitantly relay symptoms, thereby providing a symptom/cardio‐rhythm correlation.

Expediting Time from Symptoms to Medical Contact Utilizing a Telemedicine Call Center

BACKGROUND No definitive solution has been forthcoming for the often dangerously long interval between symptom onset and seeking medical care in the prehospital setting. We examined the implementation of telemedicine technology and characterization of its utilizers for its efficacy in reducing this possibly life-threatening time lag. MATERIALS AND METHODS A retrospective observational study was performed on the working database of an operational telemedicine facility that included all subscribers. Time-to-contact measurements throughout 2012 were retrieved from its medical files, and data on age, gender, medical history, and main complaint were analyzed. RESULTS Throughout 2012, 22,274 of a total of 46,556 calls (47.8%) were made ≤60 min from symptom onset. It is important that 26.9% of all calls (12,522/46,556) were made in <15 min. Significantly more males (10,794/22,229 [49%]) contacted in ≤60 min compared with females (11,480/24,327 [47%], p<0.03). Subjects <60 years of age (2,889/5,717 [51%]) called earlier than those >60 years (19,386/40,839 [47%], p<0.001). Patients with prior resuscitation and/or myocardial infarction contacted significantly more rapidly than those with other cardiac diseases. Over one-half of patients with cardiac complaints contacted the call center ≤60 min from symptom onset, as did those who suffered physical trauma, but not patients with gastrointestinal symptoms or pain elsewhere. CONCLUSIONS A telemedicine system with rapid accessibility to a professional call center and prompt triage thereafter could be an additional promising strategy for shortening the interval between symptom onset and call for medical assistance. Implementation of a widespread telemedicine infrastructure may bridge the unmet gap between occurrence of symptoms to initiation of medical treatment.