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Non-physician STEMI ECG interpretation

Question Type:
Full Question:
Among adult patients with suspected STEMI outside of a hospital  (P), does do nonphysicians (eg, nurses and paramedics)  (I), compared with compared with physicians  (C), change identify STEMI on an ECG with acceptable rates of false negatives to allow earlier identification and false positives minimizing unnecessary angiography (O)?
Consensus on Science:
For the important outcomes of FP and FN results, we have identified very-low-quality evidence (downgraded for risk of bias, inconsistency, and publication bias) from 3 studies(Feldman 2005, 443-448; Trivedi 2009, 207-214; Ducas 2012, 432-437) including 1360 ECGs of FP results of STEMI recognition ranging from 0.3% to 30.5% (under the assumption of a disease prevalence of 5% [highest expected FP results]), and FN results did not exceed 4% (under the assumption of 20% prevalence [highest expected FN results]). Sensitivity ranged from 80% to 99.6%, and specificity ranged from 68% to 96.8%. For the important outcome of FP/all positive tests, we have identified very-low-quality studies (downgraded for risk of bias and inconsistency) from 9 observational studies(Feldman 2005, 443-448; Davis 2007, 399-402; Strauss 2007, 265-270; Dorsch 2008, 1054-1058; Trivedi 2009, 207-214; Lee 2010, 153-158; Young 2011, 18-22; Ducas 2012, 432-437) including 900 ECGs of FP/all positive tests for STEMI recognition ranging from 8% to 40%.
Treatment Recommendation:
We suggest that in adult patients with suspected STEMI outside of a hospital, nonphysicians may perform ECG interpretation to recognize STEMI in a system where the FP and FN rates are low (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we adopt a balanced approach in between minimizing treatment delays of patients with STEMI and avoiding excess waste of resources resulting from FP system activations. It is recognized that in many prehospital systems, physicians will not be available on-site, and the evidence indicates that highly trained paramedics and nurses can reliably recognize STEMI. This should occur in an organized system of prehospital care where there is a strong initial education program, ongoing oversight, possible adjunctive computer interpretation, and a quality assurance program.It is impossible to provide pooled estimates from the reviewed data, because different study methods and/or gold standards have been used. Nonphysician STEMI ECG recognition was not equally reliable across the various reporting systems of care. This may be relevant to the quality of the ECG obtained and the ECG findings but also to the level of training and individual expertise of healthcare providers. Therefore, each system of care should make every effort to assure optimal diagnostic accuracy from healthcare providers by maintaining adequate training programs and meticulous care for quality control. Timely feedback from STEMI receiving centers, including performance benchmarks, prehospital and in-hospital ECGs, and catheterization findings, may be essential in this regard. Diagnostic performance should always be considered in conjunction with local STEMI prevalence as very high or low prevalence rates may lead to unacceptable FP and/or FN rates despite sensitivity and specificity rates that may seem satisfactory as stand-alone values. This may give important clues as to whether nonphysician STEMI interpretation fits best in the setting of a particular system of care in comparison with other existing options of on-site ECG interpretation such as transmission of ECG for interpretation by an experienced provider or computer-assisted interpretation.
CoSTR Attachments:
ACS 884 GRADE_CoSTR_n.docx    
Data bias non-physician CK5_n.xlsx    

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