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Invited Commentary
June 11, 2012

Activating Primary Percutaneous Coronary Intervention for STEMI That Is Not: The Collateral Damage of Improving Door-to-Balloon Time: Comment on “Prevalence and Factors Associated With False-Positive ST-Segment Elevation Myocardial Infarction Diagnoses at Primary Percutaneous Coronary Intervention–Capable Centers”

Author Affiliations

Author Affiliations: Department of Medicine/Cardiology, University of Minnesota, Minneapolis.

Arch Intern Med. 2012;172(11):871. doi:10.1001/archinternmed.2012.1117

Coronary arterial thrombosis secondary to plaque rupture (most common), erosion, or calcified nodule often results in acute ischemic symptoms and electrocardiographic (ECG) changes, specifically ST-segment elevation. Timely clinical identification of ST-segment elevation myocardial infarction (STEMI) is based on acute symptoms and ECG changes. Prompt and effective revascularization of the infarct-related artery can save myocardium and reduce morbidity and mortality.1 The Door-to-Balloon (D2B) Alliance recognizes the importance of door-to-balloon time (DBT) as a core measure of quality for primary percutaneous coronary intervention (PCI) and emphasizes methods to decrease DBT.2 Multiple strategies to reduce DBT include a dedicated on-call (24 hours per day/7 days per week) cardiac catheterization laboratory (CCL) team activated by a single page, acquisition of an ECG at the scene with “computer” interpretation with or without electronic transmission to an emergency department (ED), autonomous activation of the CCL by ED staff or emergency medical service, and organized review of experience with direct feedback to all involved in STEMI recognition and treatment.3 These strategies decrease DBT, but a potential downside to this increasingly fast process is more inappropriate CCL use. This occurs for multiple reasons including “misinterpretation” of clinical findings, primarily of the ECG, alternative diagnosis discovered after activation, activation protocol violation, and morbid conditions with ECG changes mimicking myocardial infarction for which a coronary angiogram would be contraindicated. Inappropriate CCL activation increases cost and exposes patients to unnecessary risk. Frequent, inappropriate CCL activation may result in interdisciplinary distrust, disinterest, and tension. A variety of terms have been proposed to report CCL activation that did not result in CCL use. These have been variably defined as “inappropriate activation,” “overactivation,” “unnecessary activation,” and “false-positive activation”; hence, reports of their occurrence vary widely.