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Failure to Identify High-Risk ECG Findings in AMI Patients

A retrospective study shows that providers missed suggestive findings.

Identifying acute myocardial ischemia in the emergency department is essential for providing prompt and appropriate medical therapy. These authors evaluated the frequency with which ED providers at five hospitals missed electrocardiogram evidence of acute myocardial infarction and the possible effects of missed findings on quality of care.

The authors retrospectively reviewed the medical records of 1684 consecutive patients who presented to the EDs of five Kaiser Permanente–affiliated hospitals and received a discharge diagnosis of AMI. Patients with both ST–segment-elevation MI and non-STEMI were included. The authors were unable to characterize the identities, training, or experience of the clinicians who had interpreted the electrocardiograms in the ED. Care was defined as being substandard if aspirin, ß-blockers, or reperfusion therapy was not administered to an eligible patient with AMI.

Overall, 201 patients (12%) had high-risk ECG abnormalities that were missed (ST-segment elevation in 18%, ST-segment depression in 68%, and T-wave inversion in 32%). In multivariate analysis, failure to identify high-risk ECG findings was significantly associated with increased odds of a patient’s not receiving aspirin (odds ratio, 2.13), ß-blockers (OR, 1.85), and reperfusion therapy (OR, 7.69).

Comment: The authors did not know who read the initial ECGs, whether multiple ECGs were done, or whether prior ECGs were available to ED providers. Similarly, the authors did not specify the level of training or experience of ED personnel or whether or when the apparent misses were picked up by the admitting services. They recommend that competency in ECG interpretation be stressed in emergency medicine residency training, as is already required. Their conclusion that failure to identify high-risk ECG findings led to lower quality of care cannot be drawn from this retrospective analysis as cause and effect cannot be ascertained.

Whether these findings can be generalized or simply reflect a weakness in the study hospitals’ systems of care is unknown; why these issues were not properly addressed during peer review is a mystery. ECG interpretation is important, to be sure, but this study leaves us with more questions than answers.

— Aaron E. Bair, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine November 9, 2006

Citation(s):

Masoudi FA et al. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: Results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study. Circulation 2006 Oct 10; 114:1565-71.

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