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(Circulation. 2006;114:1565-1571.)
© 2006 American Heart Association, Inc.

Health Services and Outcomes Research

Implications of the Failure to Identify High-Risk Electrocardiogram Findings for the Quality of Care of Patients With Acute Myocardial Infarction

Results of the Emergency Department Quality in Myocardial Infarction (EDQMI) Study

Frederick A. Masoudi, MD, MSPH; David J. Magid, MD, MPH; David R. Vinson, MD; Albert J. Tricomi, MD; Ella E. Lyons, MS; Laurie Crounse, MPH; P. Michael Ho, MD, PhD; Pamela N. Peterson, MD, MSPH; John S. Rumsfeld, MD, PhD, for the Emergency Department Quality in Myocardial Infarction (EDQMI) Study Investigators

From the Department of Medicine, Denver Health Medical Center, Denver, Colo (F.A.M., P.N.P.); Department of Medicine, University of Colorado at Denver and Health Sciences Center, Denver (F.A.M., P.M.H., P.N.P., J.S.R.); Colorado Health Outcomes Program, University of Colorado at Denver and Health Sciences Center, Aurora (F.A.M.); Clinical Research Unit, Colorado Permanente Medical Group, Denver (D.J.M., E.E.L., L.C.); Kaiser Permanente Medical Center, Roseville, Calif (D.R.V.); Department of Medicine, University of Rochester School of Medicine, Rochester, NY (A.J.H.); and Denver VA Medical Center, Denver, Colo (P.M.H., J.S.R.).

Correspondence to Frederick A. Masoudi, MD, MSPH, Division of Cardiology, MC 0960, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204. E-mail fred.masoudi{at}uchsc.edu

Received February 27, 2006; revision received June 30, 2006; accepted August 4, 2006.

Background— The impact of misinterpretation of the ECG in patients with acute myocardial infarction (AMI) in the emergency department (ED) setting is not well known. Our goal was to assess the prevalence of the failure to identify high-risk ECG findings in ED patients with AMI and to determine whether this failure is associated with lower-quality care.

Methods and Results— In a retrospective cohort study of consecutive patients presenting to 5 EDs in California and Colorado from July 1, 2000, through June 30, 2002, with confirmed AMI (n=1684), we determined the frequency of the failure by the treating provider to identify significant ST-segment depressions, ST-segment elevations, or T-wave inversions on the presenting ECG. In multivariable models, we assessed the relationship between missed high-risk ECG findings and evidence-based therapy in the ED after adjustment for patient characteristics and site of care. High-risk ECG findings were not documented in 201 patients (12%). The failure to identify high-risk findings was independently associated with a higher odds of not receiving treatment among ideal candidates for aspirin (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.51 to 2.94), ß-blockers (OR, 1.85; 95% CI, 1.14 to 3.03), and reperfusion therapy (OR, 7.69; 95% CI, 3.57 to 16.67). Among patients with missed high-risk ECG findings, in-hospital mortality was 7.9% compared with 4.9% among those without missed findings (P=0.1).

Conclusions— The failure to identify high-risk ECG findings in patients with AMI results in lower-quality care in the ED. Systematic processes to improve ECG interpretation may have important implications for patient treatment and outcomes.

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