Clinical Research Sustained Performance of a “Physicianless” System of Automated Prehospital STEMI Diagnosis and Catheterization Laboratory Activation Brian J. Potter, MDCM, MSc, a,b Alexis Matteau, MD, MSc, a,b Samer Mansour, MD, a,b,c Charbel Naim, MD, b Mounir Riahi, MD, b Richard Essiambre, MD, c Martine Montigny, MD, c Isabelle Sareault, RN, c and François Gobeil, MD b,c a Centre de Recherche du Centre Hospitalier de l’Universit  e de Montr  eal (CRCHUM), Montr  eal, Qu ebec, Canada b Centre Cardiovasculaire du Centre Hospitalier de l’Universit  e de Montr  eal (CHUM), Montr  eal, Qu ebec, Canada c Hôpital de la Cit  e de la Sant  e, Laval, Qu  ebec, Canada ABSTRACT Background: Treatment times for primary percutaneous coronary intervention frequently exceed the recommended maximum delay. Automated “physicianless” systems of prehospital cardiac catheteri- zation laboratory (CCL) activation show promise, but have been met with resistance over concerns regarding the potential for false positive and inappropriate activations (IAs). Methods: From 2010 to 2015, first responders performed electro- cardiograms (ECGs) in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of “acute myocardial infarction” resulted in immediate CCL activation and direct transfer without transmission or human reinterpretation of the ECG prior to patient arrival. Any activation resulting from a nondiagnostic ECG (no ST-elevation) was deemed an IA, whereas activations resulting from ECG’s compatible with ST-elevation myocardial infarction but R  ESUM  E Contexte : Le d elai d’intervention coronarienne percutan ee (ICP) primaire d epasse souvent le d elai maximal recommand e pour ce type d’intervention. Les systèmes d’activation de laboratoire de cath-  et erisme cardiaque (LCC) pr ehospitalier « sans m edecin » semblent prometteurs, mais font face à la r esistance du milieu m edical qui craint la possibilit e de « faux positifs » et d’activation inappropri ee (AI). M ethodes : Entre 2010 et 2015, les premiers r epondants ont effectu e un  electrocardiogramme (ECG) pr ehospitalier à tous les patients se plaignant de douleurs thoraciques ou de dyspn ee. Un diagnostic automatis ed’« infarctus aigu du myocarde » entraînait imm ediate- ment l’activation du LCC et le transfert direct du patient sans trans- mission de message ou relecture de l’ECG par un humain. Toute activation cons ecutive à un ECG ne permettant pas d’ etablir un diag- nostic (sans sus-d ecalage du segment ST)  etait consid er ee être une AI, Reducing total ischemic time is the primary objective of any ST-elevation myocardial infarction (STEMI) management system 1,2 and shorter delays are associated with improved myocardial salvage, survival, and functional status. 3-5 STEMI diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are poised to become the dominant STEMI referral method, with several studies reporting that this combination of strategies can effectively reduce system delay and increase the proportion of STEMI patients who achieve target FMC to device (FMC2D) times. 2,6-18 However, considerable debate continues with regard to exactly who should be activating the CCL and on what basis. 13,19-21 Whereas emergency medical services (EMS)-initiated CCL activation at FMC is an attractive option, variable diagnostic accuracies of EMS electrocardio- gram (ECG) interpretation 11,22,23 have been cited by some decision-makers as a reason to insist on physician over- sight. 11,19,20 Yet, ensuring physician oversight might present its own challenges, particularly in resource-poor set- tings, 11,24,25 the repercussions of which might not be merely financial, but also potentially in terms of poorer FMC2D performance. One proposed solution is to do away with human pre- hospital ECG interpretation altogether, relying instead on the combined value of the clinical presentation (assessed by the first responder) and an automated machine ECG diagnosis. However, the possibility of an increased burden of false Canadian Journal of Cardiology 33 (2017) 148e154 Received for publication July 29, 2016. Accepted October 9, 2016. Corresponding author: Dr Brian J. Potter, Interventional Cardiology Service, Centre Hospitalier de l’Universit  e de Montr  eal, Hôtel-Dieu de Montr  eal 3840, rue St-Urbain, Pavillon Marie-Morin, bureau 4-307, Mon- tr  eal, Qu ebec H2W 1T8, Canada. Tel.: þ1-514-890-8444; fax: þ1-514- 412-7212. E-mail: brian.potter@umontreal.ca See page 153 for disclosure information. http://dx.doi.org/10.1016/j.cjca.2016.10.013 0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.