Some “missed” STEMI malpractice lawsuits obscure the fact that nothing was missed at all, at least not at the time of the ED visit.

“We rely on the ECG in combination with symptoms to make the diagnosis of STEMI in the emergency department. The ECG is dynamic,” explains Bryn Mumma, MD, an EP at UC Davis Medical Center and assistant professor in the department of emergency medicine at UC Davis School of Medicine.

A STEMI pattern may develop minutes, hours, or days after a patient’s initial presentation. When this occurs, the case appears to be a “missed STEMI,” even though the STEMI pattern was not present on the initial ECG.

The ED chart can mislead expert reviewers on this point, with perceptions colored by the patient’s eventual diagnosis. Repeat ECGs give a more complete picture. Mumma says ECGs should be repeated “when the clinical presentation is concerning for STEMI or when the initial ECG is abnormal but not diagnostic of STEMI.”

“Missed STEMI” is not necessarily a legal accusation. It also comes up in internal quality improvement efforts. “These patients often do not meet the metric of 90-minute door-to-balloon time, but it’s because they didn’t have a STEMI at the ‘door,’” Mumma explains. Anyone with crushing chest pain is very likely to undergo a quick ECG, while someone with epigastric pain could wait for hours. “The patient’s presentation is a factor that contributes to delayed recognition of STEMI,” Mumma notes.

Similarly, an older patient with a history of cardiovascular disease is more likely to undergo a timely ECG than a younger patient without risk factors. “We’ve all heard that ‘time is muscle’ in STEMI, and minutes matter,” Mumma says.

To rapidly identify and treat STEMI, Mumma says prehospital providers should perform 12-lead ECGs, transport patients directly to a STEMI receiving center when feasible, and provide early notification. This allows activation of the cardiac catheterization lab team prior to the patient’s arrival at the hospital, shortening the overall time to treatment.

Further, referral hospitals and receiving centers should create clear, streamlined processes for the rapid transfer of STEMI patients from the referral hospital to the cardiac catheterization lab in the STEMI receiving center.1

“Repeating the ECG and showing that it is unchanged may also be helpful because patients with STEMI usually have evolving ECG changes,” Mumma says.

REFERENCE

  1. Mumma BE, Williamson C, Khare RK, et al. Minimizing transfer time to an ST segment elevation myocardial infarction-receiving center: A modified Delphi consensus. Crit Pathw Cardiol 2014;13:20-24.