| Critical to early use of GIK is rapid and accurate identification of patients with threatened or completed AMI in EMS settings. To enhance recognition of potential study patients, based on our prior trials showing improved diagnosis and treatment of ACS and STEMI by the electrocardiograph-based ACI-TIPI and TPI,1.2 electrocardiographs with these predictive instruments will be used by EMS at all study sites. Incorporated into conventional computerized electrocardiographs, the ACI-TIPI (acute cardiac ischemia time-insensitive predictive instrument) prints out on the ECG header a given patient’s 0-100% probability of having acute cardiac ischemia (i.e., ACS), to aid in accurately recognizing those patients who should be treated for ACS (ACI-TIPI Example). Also incorporated into electrocardiographs, the TPI (thrombolytic predictive instrument) is automatically activated when the electrocardiograph detects that the patient may be having a STEMI, and it then prints out on the ECG header the 0-100% predictions of key clinical outcomes for that patient (TPI Example). These aids to immediate recognition and treatment of suitable candidates with ACS/AMI have not been used in prior GIK trials; it is believed that this will be an important advantage for the IMMEDIATE Trial treatment approach.
In the IMMEDIATE Trial, the TPI should be particularly useful for prompting early and accurate treatment of patients with ACS who are having a STEMI, as the electrocardiograph immediately automatically notifies the user that the patient may be having a STEMI. (It also prints out on the ECG header the 0-100% predictions of key clinical outcomes for that patient: 30-day mortality, if or not if given thrombolytic therapy for STEMI; 1-year mortality, if or if not treated with thrombolytic therapy; cardiac arrest if or if not treated; and the probabilities of complications of thrombolysis, intracranial hemorrhage, and major bleeding.) In the TPI Trial, a randomized controlled clinical trial at 28 hospitals in urban, suburban, and rural settings that included 1,197 patients with STEMI, the TPI increased use of thrombolytic therapy, thrombolysis within 1 hour, and overall reperfusion including angioplasty, by 11%-12% for patients with inferior AMI, 18%-22% for women, 30%-34% when consultation with an off-site physician, and 44%-53% at hospitals without on-site ED physicians.2 The fact that the TPI increased use and timeliness of reperfusion in groups of patients who are more commonly missed, such as women and those with less obvious AMIs, and those seen when involved physicians were off-site, suggests that it also should help rapid use of GIK as a treatment for AMI in EMS settings, where recognition is challenging and physicians are not present. Accordingly, along with the ACI-TIPI, TPI printouts will be available on the ECGs for all patients seen in the EMS systems participating in the IMMEDIATE Trial.
1 Selker HP, Beshansky JR, Griffith JL, for the TPI Trial Investigators. Use of the electrocardiograph-based thrombolytic predictive instrument to assist thrombolytic and reperfusion therapy for acute myocardial infarction. Ann Intern Med. 2002;137:87-95.
2 Selker HP, Beshansky JR, Griffith JL, et al. The use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist emergency department triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia: a multicenter controlled clinical trial. Ann Intern Med. 1998;129:845-855.
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