Reducing Time to Optimal Treatment, Not Just Time to Hospital Arrival

In this issue of the Journal, Yufu et al demonstrate that, even in urban areas, in-hospital delays are significantly greater outside of a hospital’s business hours compared with during business hours.¹ However, conducting a prehospital 12-lead ECG significantly shortens in-hospital delays, even in urban areas. In urban areas of Japan, there is a high concentration of hospitals providing emergency medical care within a small radius, resulting in very short transport times, but the utility of prehospital 12-lead ECGs has not been established, making this study significant in providing important results.

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In general, prehospital 12-lead ECGs have 3 important advantages (Table 1).^2,3 The first one is field triage, which ensures the transfer of ST-elevation acute myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI)-capable hospitals rather than PCI-incapable hospitals. The second advantage is early notification of the catheterization team and early activation of the cardiac catheterization laboratory. The third advantage is the improvement of acute coronary syndrome (ACS) diagnosis by detecting ECG changes in the early stages after onset. However, the benefits of prehospital 12-lead ECGs, such as hospital selection and early notification, vary significantly depending on the local circumstances, including emergency medical service (EMS) and emergency hospitals within the region. In rural areas with long transport distances to hospitals, emergency medical staff may consider the risk of prolonged transport times for patients complaining of chest pain and transfer of such patients to nearby PCI-incapable emergency hospitals, and even patients judged to have a low risk of ACS might be selected for transport to nearby hospitals. Therefore, in rural areas, the utility of performing prehospital 12-lead ECGs for prehospital diagnosis and hospital selection is considered to be high. Additionally, in rural areas where transport times are longer, the benefits of early notification and early activation of the cardiac catheterization team are also believed to be significant. In urban areas patients often have easier access to emergency medical facilities, and transport distances are relatively shorter. Does this mean there is less need for prehospital 12-lead ECGs in urban areas? A previous small-scale study in Japan suggested that the utilization of prehospital 12-lead ECGs and prehospital diagnosis may lead to a reduction in ‘door-to-balloon time’ in urban settings.⁴ The findings of the present study offer a definitive response to this inquiry. The authors have demonstrated that even in urban areas, the time from first medical contact to reperfusion and the time from first medical contact to the catheterization laboratory was significantly shorter in STEMI patients who underwent prehospital 12-lead ECGs than in those who did not, especially for patients who developed symptoms outside of the hospital’s business hours.¹ In urban areas, although there are numerous emergency hospitals, the availability of healthcare facilities capable of maintaining the same level of care and staffing during nighttime as in daytime is considerably restricted.⁵ This limitation has potentially influenced the results of the current study by extending the ‘door-to-balloon time’ at many hospitals during nighttime. The utility of prehospital 12-lead ECGs even in urban areas is now confirmed, especially for patients who develop symptoms outside of hospital business hours. Next, how do prehospital 12-lead ECGs affect patient care during regular hospital business hours in urban areas? As the authors state, the implementation rate of prehospital 12-lead ECGs remains relatively low nationwide in Japan. We previously conducted a survey among emergency medical staff in Yokohama city,² and the results indicated that factors such as advanced age and symptom onset during hospital business hours were associated with a decreased likelihood of emergency medical staff performing prehospital 12-lead ECGs. In urban areas, where there are numerous primary care physicians and small to medium-sized emergency hospitals nearby, the destination for patient transport can be relatively easily determined during hospital business hours. This situation explains why prehospital 12-lead ECGs are not frequently administered in such cases. However, what is crucial is not just swiftly transporting patients complaining of chest pain to hospital but rather initiating timely and optimal treatment. This understanding should be shared among all healthcare professionals involved in cardiovascular emergencies, guiding them from initial response to early treatment. If a STEMI patient is initially transported to a hospital where primary PCI cannot be performed and is later diagnosed with STEMI, leading to a transfer to a PCI-capable hospital, there can be a delay of >1 h in receiving optimal treatment compared with direct transport to a PCI-capable hospital.² In this manner, even in urban areas where there are multiple hospital options and during hospital business hours, prehospital 12-lead ECGs for prehospital diagnosis and triage become essential. The potential benefits of prehospital 12-lead ECGs are summarized in Table 2, categorized by urban or rural areas and inside or outside of hospital business hours.

Table 1.

Advantages of Prehospital 12-Lead ECGs in Cardiovascular Emergency

Shortening the time to optimal treatment (revascularization)

• Transferring STEMI patients to PCI-capable hospitals rather than PCI-incapable hospitals

• Early activation of the cardiac catheterization laboratory and prompt notification of the catheterization team

• Reducing total system delays

• Reducing door-to-balloon time

Improving diagnosis by detecting ECG changes in the early stage after onset

ECG, electrocardiogram; PCI, percutaneous coronary intervention; STEMI, ST-elevation acute myocardial infarction.

Table 2.

Presumed Benefits of Prehospital 12-Lead ECGs, Categorized by Urban or Rural Area and Inside or Outside of Hospital Business Hours

	Hospital business hours	Outside of the hospital business hours
Urban area	Field triage and hospital selection (◎)	Field triage and hospital selection (○)
	Decreasing in-hospital delay (△)	Decreasing in-hospital delay (◎)
Rural area	Field triage and hospital selection (◎)	Field triage and hospital selection (◎)
	Decreasing in-hospital delay (○)	Decreasing in-hospital delay (◎)

(◎) represents usefulness, (○) indicates the potential for usefulness, and (△) signifies uncertainty. ECG, electrocardiogram.

In the future, as the elderly population continues to grow, there is an expected significant increase in cardiovascular diseases, especially heart failure. Furthermore, the revised Medical Care Act, which includes “workstyle reforms” for physicians, was enacted in 2021 in Japan. This amendment includes a policy to limit excess working hours for physicians from the fiscal year 2024. Given the projected increase in cardiovascular disease patients and the alterations in disease epidemiology within cardiovascular diseases, maintaining and improving healthcare quality while enhancing the working environment for healthcare professionals are both essential. Instead of expecting every individual hospital to comprehensively manage all phases of cardiovascular diseases, an alternative strategy involves hospitals differentiating and specializing their services, concentrating on their respective areas of expertise. Particularly concerning acute cardiovascular emergency care, it is expected that more hospitals will be unable to maintain a 24-h staff of cardiovascular specialists. Therefore, it is necessary to promptly establish collaborative networks, taking into account the regional conditions on a broader scale rather than at the hospital level. Specifically, this involves the promotion of prehospital on-site triage by the EMS with prehospital 12-lead ECGs and the differentiation and specialization of regional hospital functions. As a consequence, prehospital 12-lead ECGs, already deemed a vital instrument, are poised to become increasingly indispensable in the foreseeable future within in the field of medical care. In light of the increasing body of compelling evidence and the significant transformations occurring in the healthcare environment, the widespread adoption of prehospital 12-lead ECGs across all regions in Japan is strongly advocated.

Disclosures

K.T. is a member of Circulation Journal’s Editorial Team.

References

• 1.   Yufu K, Shimomura T, Kawano K, Sato H, Yonezu K, Saito S, et al. Usefulness of prehospital 12-lead electrocardiography system in ST-segment elevation myocardial infarction patients in Oita: Comparison between urban and rural areas, weekday daytime and weekday nighttime/holidays. Circ J 2023, doi:10.1253/circj.CJ-23-0365.
• 2.   Matsuzawa Y, Kosuge M, Fukui K, Suzuki H, Kimura K. Present and future status of cardiovascular emergency care system in urban areas of Japan: Importance of prehospital 12-lead electrocardiogram. Circ J 2022; 86: 591–599.
• 3.   Kikuchi M, Tahara Y, Yamaguchi J, Nakashima T, Nomura O, Tanaka A, et al. Executive summary: Acute coronary syndrome in the Japan Resuscitation Council guidelines for resuscitation 2020. Circ J 2023; 87: 866–878.
• 4.   Takeuchi I, Fujita H, Yanagisawa T, Sato N, Mizutani T, Hattori J, et al. Impact of doctor car with mobile cloud ECG in reducing door-to- balloon time of Japanese ST-elevation myocardial infarction patients. Int Heart J 2015; 56: 170–173.
• 5.   Nakayama N, Kimura K, Endo T, Fukui K, Himeno H, Iwasawa Y, et al. Current status of emergency care for ST-elevation myocardial infarction in an urban setting in Japan. Circ J 2009; 73: 484–489.