title: Editor's Choice-Is the pre-hospital ECG after out-of-hospital cardiac arrest accurate for the diagnosis of ST-elevation myocardial infarction?
abstract: BACKGROUND
  Current guidelines recommend that comatose out-of-hospital cardiac arrest patients with ST-segment elevations (STEs) following return of spontaneous circulation (ROSC) should be referred for an acute coronary angiography. We sought to investigate the diagnostic value of the pre-hospital ROSC-ECG in predicting ST-elevation myocardial infarction (STEMI).
  
  
  METHODS
  ROSC-ECGs of 145 comatose survivors of out-of-hospital cardiac arrest, randomly assigned in the Target Temperature Management trial, were classified according to the current STEMI ECG criteria (third universal definition of myocardial infarction).
  
  
  RESULTS
  STEs were present in the pre-hospital ROSC-ECG of 78 (54%) patients. A final diagnosis revealed that 69 (48%) patients had STEMI, 31 (21%) patients had non-STEMI and 45 (31%) patients had no myocardial infarction. STE in ROSC-ECGs had a sensitivity of 74% (95% confidence interval (CI) 62-84), specificity of 65% (95% CI 53-75) and a positive and negative predictive value of 65% (95% CI 54-76) and 73% (95% CI 61-83) in predicting STEMI. Time to ROSC was significantly longer (24 minutes vs. 19 minutes, P=0.02) in STE compared with no STE patients. Percutaneous coronary intervention was successful in 68% versus 36% (P<0.001) of STE compared to no STE patients. No significant difference was found in 180-day mortality rates between STE and no STE patients (36% vs. 30%, Plogrank=0.37).
  
  
  CONCLUSIONS
  The pre-hospital ROSC-ECG is a suboptimal diagnostic tool to predict STEMI and therefore not a sensitive tool for triage to cardiac centres. This supports the incentive of referring all comatose survivors of out-of-hospital cardiac arrest of suspected cardiac origin to a tertiary heart centre with the availability of acute coronary angiography, even in the absence of STEs.
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Idrees
authors.initials: I
authors.lastname: Salam
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Hassager
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark jakob@jht.com.
authors.forename: Jakob Hartvig
authors.initials: JH
authors.lastname: Thomsen
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Sandra
authors.initials: S
authors.lastname: Langkjær
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Helle
authors.initials: H
authors.lastname: Søholm
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: John
authors.initials: J
authors.lastname: Bro-Jeppesen
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Lia
authors.initials: L
authors.lastname: Bang
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Lene
authors.initials: L
authors.lastname: Holmvang
authors.affiliation: Department of Cardiology, Skåne University Hospital, Sweden.
authors.forename: David
authors.initials: D
authors.lastname: Erlinge
authors.affiliation: Department of Cardiothoracic Anaesthesia 4142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Wanscher
authors.affiliation: Emergency Medical Services, University of Copenhagen, Denmark.
authors.forename: Freddy K
authors.initials: FK
authors.lastname: Lippert
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Køber
authors.affiliation: Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark.
authors.forename: Jesper
authors.initials: J
authors.lastname: Kjaergaard
mesh_terms: D000368:Aged; D003128:Coma / Q000209:etiology / Q000628:therapy*; D017023:Coronary Angiography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000401:mortality; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011897:Random Allocation; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D012680:Sensitivity and Specificity
keywords: ECG; Out-of-hospital cardiac arrest (OHCA); ST-segment elevation; STEMI; acute coronary angiography; triage