Abstract
Objective
To implement an all-day artificial intelligence (AI)–based system to facilitate chest
pain triage in the emergency department.
Methods
The AI-based triage system encompasses an AI model combining a convolutional neural
network and long short-term memory to detect ST-elevation myocardial infarction (STEMI)
on electrocardiography (ECG) and a clinical risk score (ASAP) to prioritize patients
for ECG examination. The AI model was developed on 2907 twelve-lead ECGs: 882 STEMI
and 2025 non-STEMI ECGs.
Results
Between November 1, 2019, and October 31, 2020, we enrolled 154 consecutive patients
with STEMI: 68 during the AI-based triage period and 86 during the conventional triage
period. The mean ± SD door-to-balloon (D2B) time was significantly shortened from
64.5±35.3 minutes to 53.2±12.7 minutes (P=.007), with 98.5% vs 87.2% (P=.009) of D2B times being less than 90 minutes in the AI group vs the conventional
group. Among patients with an ASAP score of 3 or higher, the median door-to-ECG time
decreased from 30 minutes (interquartile range [IQR], 7−59 minutes) to 6 minutes (IQR,
4−30 minutes) (P<.001). The overall performances of the AI model in identifying STEMI from 21,035
ECGs assessed by accuracy, precision, recall, area under the receiver operating characteristic
curve, F1 score, and specificity were 0.997, 0.802, 0.977, 0.999, 0.881, and 0.998,
respectively.
Conclusion
Implementation of an all-day AI-based triage system significantly reduced the D2B
time, with a corresponding increase in the percentage of D2B times less than 90 minutes
in the emergency department. This system may help minimize preventable delays in D2B
times for patients with STEMI undergoing primary percutaneous coronary intervention.
Abbreviations and Acronyms:
1D (1-dimensional), AI (artificial intelligence), CAD (coronary artery disease), cath lab (catheterization laboratory), CNN (convolutional neural network), D2B (door-to-balloon), ECG (electrocardiography), ED (emergency department), GRACE (Global Registry of Acute Coronary Events), LSTM (long short-term memory), PPCI (primary percutaneous coronary intervention), STEMI (ST-segment elevation myocardial infarction), TIMI (Thrombolysis in Myocardial Infarction)To read this article in full you will need to make a payment
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References
- Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006.Am Heart J. 2008; 156: 1035-1044
- Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction.Am J Cardiol. 2009; 103: 907-912
- Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future?.JAMA. 2005; 293: 979-986
- 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: e78-e140
- 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2018; 39: 119-177
- Electrocardiographic diagnosis of ST segment elevation myocardial infarction: an evaluation of three automated interpretation algorithms.J Electrocardiol. 2016; 49: 728-732
- Causes of prehospital misinterpretations of ST elevation myocardial infarction.Prehosp Emerg Care. 2017; 21: 283-290
- Usefulness of multi-labelling artificial intelligence in detecting rhythm disorders and acute ST-elevation myocardial infarction on 12-lead electrocardiogram.Eur Heart J Digial Health. 2021; 2: 299-310
- Usefulness of machine learning-based detection and classification of cardiac arrhythmias with 12-lead electrocardiograms.Can J Cardiol. 2021; 37: 94-104
- Third universal definition of myocardial infarction.Circulation. 2012; 126: 2020-2035
- Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes.Am Heart J. 2001; 141: 190-199
- Prediction of coronary heart disease using risk factor categories.Circulation. 1998; 97: 1837-1847
- Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study.BMJ. 2009; 338: b1807
- Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction.J Am Coll Cardiol. 2006; 47: 2180-2186
- Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.Lancet. 2015; 385: 1114-1122
- Re-examining the effect of door-to-balloon delay on STEMI outcomes in the context of unmeasured confounders: a retrospective cohort study.Sci Rep. 2019; 919978
- Prognostic implications of door-to-balloon time and onset-to-door time on mortality in patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention.J Am Heart Assoc. 2019; 8e012188
- Age-dependent impact of new ESC-Guideline recommended door-to-balloon times on mid-term survival in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.Int J Cardiol. 2016; 222: 242-246
- Impact of prolonged door-to-balloon times on the diastolic function in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.Acta Cardiol Sin. 2015; 31: 281-291
- In-hospital ‘CODE STEMI’ improves door-to-balloon time in patients undergoing primary percutaneous coronary intervention.Emerg Med Australas. 2018; 30: 222-227
- Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation myocardial infarction.Ann Emerg Med. 2007; 50: 538-544
- An emergency physician activated protocol, ‘Code STEMI’ reduces door-to-balloon time and length of stay of patients presenting with ST-segment elevation myocardial infarction.Int J Clin Pract. 2009; 63: 398-406
- The effect of direct communication between emergency physicians and interventional cardiologists on door to balloon times in STEMI.J Korean Med Sci. 2008; 23: 706-710
- Cardiac cath lab activation by the emergency physician without prior consultation decreases door-to-balloon time.J Invasive Cardiol. 2005; 17: 154-155
- Impact of 24-hr in-hospital interventional cardiology team on timeliness of reperfusion for ST-segment elevation myocardial infarction.Catheter Cardiovasc Interv. 2010; 75: 1015-1023
- Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI.Heart Lung Circ. 2014; 23: 435-443
- STEMI notification by EMS predicts shorter door-to-balloon time and smaller infarct size.Am J Emerg Med. 2016; 34: 1610-1613
- Reduced door-to-balloon times in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.Int J Clin Pract. 2012; 66: 69-76
- Does the physician in triage strategy improve door-to-balloon time for patients with STEMI?.Emerg Med J. 2020; 37: 540-545
- Early detection of ST-segment elevated myocardial infarction by artificial intelligence with 12-lead electrocardiogram.Int J Cardiol. 2020; 317: 223-230
- Impact of around-the-clock in-house cardiology fellow coverage on door-to-balloon time in an academic medical center.Vasc Health Risk Manag. 2017; 13: 139-142
- Comparison of primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction during and prior to availability of an in-house STEMI system: early experience and intermediate outcomes of the HARRT program for achieving routine D2B times <60 minutes.Catheter Cardiovasc Interv. 2015; 86: 186-196
Article info
Publication history
Published online: November 03, 2022
Footnotes
Grant Support: This study was supported in part by the Taiwan Ministry of Science and Technology (MOST 110-2314-B-039-050, MOST 109-2314-B-039-045, and MOST 108-2314-B-039-055) and China Medical University Hospital (DMR-108-013, DMR-109-012, and DMR-110-012). None of these funding sources had a further role in the study design; the collection, analysis, or interpretation of the data; the writing of the report; or the decision to submit the paper for publication.
Identification
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© 2022 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
