We were concerned to read the paper by Figgan et al (1) demonstrating
the ambulance clinicians lack of compliance with prehospital guidance
during assessment of chest pain presentations. Chauhan et al (2) also
appropriately highlight the need for accurate assessment of posterior
myocardial infarction (PMI) and that this particular presentation of Acute
Coronary Syndrome (ACS) appears to have received little attention in past
JRCALC guidance. Of interest was the statement regarding isolated PMI
accounting for up to 7% of all STEMI. A recent paper (3) focussing on the
challenges around the pre-hospital treatment and diagnosis of Left Bundle
Branch Block (LBBB) suggested LBBB was also an uncommon presentation of
acute coronary syndrome. Others have documented the prevalence of LBBB
ranging between 2.4% to 6.1%.(4&5) However, despite being so infrequently
encountered, LBBB has been included in Scottish Ambulance Service (SAS)
thrombolysis guidelines since 2005/06.(3) Additional education and
training was provided during its introduction. Challenges, however, have
been faced in treating this less than common presentation. SAS audit data
during 2008/09 demonstrate that of the 61 (2.5%) patients diagnosed with
LBBB and ACS just 0.6% (n=1) received prehospital thrombolysis.3
Anecdotal evidence suggested that the low incidence of thrombolysis may
have been due to the inability of ambulance clinicians to determine
whether the presenting ECG changes were new or old. As a result they
erred on the side of caution and did not initiate thrombolysis.
We completely agree with the recommendation by Chauhan et al (2) to
expand education and training for ambulance clinicians on the less common
presentations of ACS such as PMI and for its future inclusion in JRCALC
guidelines. As suggested, isolated PMI is relatively straightforward to
diagnose with Ambulance clinicians requiring some additional education
around lead positioning and ECG interpretation. However in addition to
this, ambulance services need to ensure reliable telemetry systems are in
place and that there are robust decision support systems established with
expert clinicians in Coronary Care Units. Without this multi/inter-
professional approach to emergency care it is unlikely that education or
the inclusion of PMI in JRCALC guidance will, on their own, facilitate a
change in practice and improvement in care.
Ref
1. Figgis K, Slevin O, Cunningham JB. Identification of paramedics
compliance with clinical practice guidelines for the management of chest
pain. Emerg Med J 2010;27:151-5.
2. Chauhan A, Khan JN, Khan JM, Varma C. Prehospital assessment and
management of chest pain needs improving. Emerg Med J doi:10.1136/emermed-
2011-200625
3. Fitzpatrick D, McLean S. Reperfusion of the old or new: left
bundle branch block? Journal of Paramedic Practice, Vol. 2, Iss. 2, 26 Feb
2010, pp 50 - 55
4. Kontos MC, McQueen RH, Jesse RL et al. Can myocardial infarction
be rapidly identified in emergency department patients who have left
bundle branch block? Ann Emerg Med 2001. 37(5): 431-8
5 Edhouse JA, Sakr M, Angus J et al. Suspected myocardial infarction
and left bundle branch block: electrocardiographic indicators of acute
ischaemia. J Accid Emerg Med 1999.16(5): 331-5
Conflict of Interest:
None declared
We were concerned to read the paper by Figgan et al (1) demonstrating the ambulance clinicians lack of compliance with prehospital guidance during assessment of chest pain presentations. Chauhan et al (2) also appropriately highlight the need for accurate assessment of posterior myocardial infarction (PMI) and that this particular presentation of Acute Coronary Syndrome (ACS) appears to have received little attention in past JRCALC guidance. Of interest was the statement regarding isolated PMI accounting for up to 7% of all STEMI. A recent paper (3) focussing on the challenges around the pre-hospital treatment and diagnosis of Left Bundle Branch Block (LBBB) suggested LBBB was also an uncommon presentation of acute coronary syndrome. Others have documented the prevalence of LBBB ranging between 2.4% to 6.1%.(4&5) However, despite being so infrequently encountered, LBBB has been included in Scottish Ambulance Service (SAS) thrombolysis guidelines since 2005/06.(3) Additional education and training was provided during its introduction. Challenges, however, have been faced in treating this less than common presentation. SAS audit data during 2008/09 demonstrate that of the 61 (2.5%) patients diagnosed with LBBB and ACS just 0.6% (n=1) received prehospital thrombolysis.3 Anecdotal evidence suggested that the low incidence of thrombolysis may have been due to the inability of ambulance clinicians to determine whether the presenting ECG changes were new or old. As a result they erred on the side of caution and did not initiate thrombolysis.
We completely agree with the recommendation by Chauhan et al (2) to expand education and training for ambulance clinicians on the less common presentations of ACS such as PMI and for its future inclusion in JRCALC guidelines. As suggested, isolated PMI is relatively straightforward to diagnose with Ambulance clinicians requiring some additional education around lead positioning and ECG interpretation. However in addition to this, ambulance services need to ensure reliable telemetry systems are in place and that there are robust decision support systems established with expert clinicians in Coronary Care Units. Without this multi/inter- professional approach to emergency care it is unlikely that education or the inclusion of PMI in JRCALC guidance will, on their own, facilitate a change in practice and improvement in care.
Ref
1. Figgis K, Slevin O, Cunningham JB. Identification of paramedics compliance with clinical practice guidelines for the management of chest pain. Emerg Med J 2010;27:151-5.
2. Chauhan A, Khan JN, Khan JM, Varma C. Prehospital assessment and management of chest pain needs improving. Emerg Med J doi:10.1136/emermed- 2011-200625
3. Fitzpatrick D, McLean S. Reperfusion of the old or new: left bundle branch block? Journal of Paramedic Practice, Vol. 2, Iss. 2, 26 Feb 2010, pp 50 - 55
4. Kontos MC, McQueen RH, Jesse RL et al. Can myocardial infarction be rapidly identified in emergency department patients who have left bundle branch block? Ann Emerg Med 2001. 37(5): 431-8
5 Edhouse JA, Sakr M, Angus J et al. Suspected myocardial infarction and left bundle branch block: electrocardiographic indicators of acute ischaemia. J Accid Emerg Med 1999.16(5): 331-5
Conflict of Interest:
None declared