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Prehospital 12 lead ECG

Question Type:
Intervention
Full Question:
Among adult patients with suspected STEMI outside of a hospital  (P), does does prehospital 12-lead ECG with transmission or notification  (I), compared with compared with no ECG or no transmission/notification  (C), change death, time to treatment (first medical contact to balloon time), time to treatment (first medical contact to needle time), time to treatment (door to balloon time), time to treatment (door to needle time) (O)?
Consensus on Science:
For the critical outcome of 30-day mortality in STEMI patients who receive PCI, we have identified low-quality evidence (downgraded for bias, upgraded for treatment effect) from 9 observational studies(Canto 1997, 498-505; Terkelsen 2005, 770-777; Carstensen 2007, 2313-2319; Brown 2008, 158-161; Martinoni 2011, 526-532; Sorensen 2011, 430-436; Chan 2012, 1239-1246; Ong 2013, 339-347; Quinn 2014, 944-950) enrolling 20 402 patients showing benefit of prehospital 12-lead ECG and hospital notification compared with no ECG or no notification (relative risk [RR], 0.68; 95% confidence interval [CI], 0.51–0.91) (Figure 1). This is a 32% relative reduction in mortality.For the critical outcome of 30-day mortality in STEMI patients who receive fibrinolysis, we have identified low-quality evidence (downgraded for bias, upgraded for treatment effect) from 2 observational studies(Canto 1997, 498-505; Quinn 2014, 944-950) enrolling 59 631 patients showing benefit of prehospital ECG and hospital notification compared with no 12-lead ECG or no notification (RR, 0.76; 95% CI, 0.71–0.82) (Figure 2). This is a 24% relative reduction in mortality.For the important outcomes of first medical contact–to–reperfusion, door-to-balloon, and door-to-needle time in STEMI patients, we have identified very-low-quality evidence (downgraded for serious risk of bias) in 7 observational studies,(Terkelsen 2005, 770-777; van de Loo 2006, 112-116; Caudle 2009, 29-35; Martinoni 2011, 526-532; Nestler 2011, 640-646; Sorensen 2011, 430-436; Chan 2012, 1239-1246) 14 observational studies,(Canto 1997, 498-505; Wall 2000, 104-108; Terkelsen 2005, 770-777; Swor 2006, 374-377; van de Loo 2006, 112-116; Carstensen 2007, 2313-2319; Dhruva 2007, 509-513; Brown 2008, 158-161; Caudle 2009, 29-35; Diercks 2009, 161-166; Nestler 2011, 640-646; Sorensen 2011, 430-436; Chan 2012, 1239-1246; Ong 2013, 339-347) and 3 observational studies,(Karagounis 1990, 786-791; Canto 1997, 498-505; Diercks 2009, 161-166) respectively, of consistent reduction in times to reperfusion with prehospital 12-lead ECG and hospital notification. The time to treatment results could not be pooled because of heterogeneity in estimate of effect size.
Treatment Recommendation:
We recommend prehospital 12-lead ECG acquisition with hospital notification for adult patients with suspected STEMI (strong recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we are placing a higher value on the consistent mortality-benefit and consistent reduction-in-reperfusion times in a large number of patients (greater than 80 000) over the risk of bias inherent in observational studies.
CoSTR Attachments:
336 PHTL 30Dec2014.rm5    
336 PHTL ECG GDT SOF Table.pdf    
Prehospital ECG FPs_n.docx    

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