Skip to main content Accessibility help

A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction

  • Mat Goebel (a1), Florin Vaida (a2), Christopher Kahn (a3) (a4) and J. Joelle Donofrio (a3) (a4) (a5)



ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.


An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.


Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.


There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).


Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.


Corresponding author

Correspondence: Mat Goebel, MD, MAS, NR-P Baystate Medical Center Dept of Emergency Medicine 759 Chestnut St. Springfield, Massachusetts 01199 USA E-mail:


Hide All
1. Sanchis-Gomar, F, Perez-Quilis, C, Leischik, R, Lucia, A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med. 2016;4(13):256.
2. Utah Department of Public Health. Complete Health Indicator Report ‐ Heart Attack: Hospitalizations. Public Health Indicator Based Information System. Accessed May 8, 2018.
3. Bossaert, L, O’Connor, RE, Arntz, H-R, et al. Part 9: acute coronary syndromes. Resuscitation. 2010;81(1):e175e212.
4. Brown, JP, Mahmud, E, Dunford, J V, Ben-Yehuda, O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol. 2008;101(2):158161.
5. Rao, A, Kardouh, Y, Darda, S, et al. Impact of the prehospital ECG on door-to-balloon time in ST elevation myocardial infarction. Catheter Cardiovasc Interv. 2010;75(2):174178.
6. Hutchison, AW, Malaiapan, Y, Jarvie, I, et al. Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times. Circ Cardiovasc Interv. 2009;2(6).
7. Davis, M, Lewell, M, McLeod, S, Dukelow, A. A prospective evaluation of the utility of the prehospital 12-lead electrocardiogram to change patient management in the emergency department. Prehosp Emerg Care. 2014;18(1):914.
8. Cheskes, S, Turner, L, Foggett, R, et al. Paramedic contact to balloon in less than 90 minutes: a successful strategy for ST-segment elevation myocardial infarction bypass to primary percutaneous coronary intervention in a Canadian emergency medical system. Prehosp Emerg Care. 2011;15(4):490498.
9. Clark, E, Sejersten, M, Clemmensen, P, Macfarlane, PW. Effectiveness of electrocardiogram interpretation programs in the ambulance setting. Comput Cardiol 2009. 2009:117120.
10. American Heart Association. Recommendations for Criteria for STEMI Systems of Care. Accessed December 21, 2016.
11. Feldman, JA, Brinsfield, K, Bernard, S, White, D, Maciejko, T. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Am J Emerg Med. 2005;23(4):443448.
12. Al-Akchar, M, Aguirre, FV, Mahmaljy, H, et al. Abstract 18253: reliance on electrocardiogram computer algorithm interpretation to activate ST elevation myocardial infarction processes of care and initiate reperfusion therapy: impact on false activation. Circulation. 2017;136(Suppl 1).
13. Garvey, JL, Zegre-Hemsey, J, Gregg, R, Studnek, JR. Electrocardiographic diagnosis of ST segment elevation myocardial infarction: an evaluation of three automated interpretation algorithms. J Electrocardiol. 2016;49(5):728732.
14. Sanko, S, Eckstein, M, Bosson, N, et al. Accuracy of out-of-hospital automated ST segment elevation myocardial infarction detection by LIFEPAK 12 and 15 devices: the Los Angeles experience. Ann Emerg Med. 2015;66(4):S6S7.
15. de Champlain, F, Boothroyd, LJ, Vadeboncoeur, A, et al. Computerized interpretation of the prehospital electrocardiogram: predictive value for ST segment elevation myocardial infarction and impact on on-scene time. Can J Emerg Med. 2014;16(2):94105.
16. Wilson, RE, Kado, HS, Percy, RF, et al. An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services. Am J Emerg Med. 2013;31(7):10981102.
17. Kado, HS, Wilson, RE, Strom, JA, Box, LC. Retrospective validation of pre-hospital electrocardiogram with ZOLL e-series monitoring system for field identification of ST elevation myocardial infarction patients. Circ Cardiovasc Qual Outcomes. 2012;5(3).
18. Bhalla, MC, Mencl, F, Gist, MA, Wilber, S, Zalewski, J. Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2012;17(2):121015065524007.
19. Bosson, N, Sanko, S, Stickney, RE, et al. Causes of prehospital misinterpretations of ST elevation myocardial infarction. Prehosp Emerg Care. 2017;21(3):283290.
20. Swan, PY, Nighswonger, B, Boswell, GL, Stratton, SJ. Factors associated with false-positive emergency medical services triage for percutaneous coronary intervention. West J Emerg Med. 2009;10(4):208212.
21. Simel, DL, Matchar, DB, Feussner, JR. Diagnostic tests are not always black or white: or, all that glitters is not [a] gold [standard]. J Clin Epidemiol. 1991;44(9):967970; discussion 970-971.
22. Sackett, DL. Clinical reality, binary models, babies and bath water. J Clin Epidemiol. 1991;44(2):217219.
23. Jamart, J. Chance-corrected sensitivity and specificity for three-zone diagnostic tests. J Clin Epidemiol. 1992;45(9):10351039.
24. Feinstein, AR. The clinical reality of three-zone. J Clin Epidemiol. 1990;43(1):109113.
25. Coste, J, Pouchot, J. A grey zone for quantitative diagnostic and screening tests. Int J Epidemiol. 2003;32(2):304313.
26. Cannesson, M. The “grey zone” or how to avoid the binary constraint of decision-making. Can J Anesth Can d’anesthésie. 2015;62(11):11391142.
27. Cannesson, M, Le Manach, Y, Hofer, CK, et al. Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a “gray zone” approach. Anesthesiology. 2011;115(2):231241.
28. Pilbery, R, Teare, MD, Goodacre, S, Morris, F. The recognition of STEMI by paramedics and the effect of computer interpretation (RESPECT): a randomized crossover feasibility study. Emerg Med J. 2016;33(7):471476.
29. Coffey, C, Serra, J, Goebel, M, Espinoza, S, Castillo, E, Dunford, J. Prehospital acute ST-elevation myocardial infarction identification in San Diego: a retrospective analysis of the effect of a new software algorithm. J Emerg Med. 2018;55(1):7177.
30. Verbeek, PR, Ryan, D, Turner, L, Craig, AM. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2012;16(1):109114.
31. Tanguay, A, Lebon, J, Lau, L, Hébert, D, Bégin, F. Detection of STEMI using prehospital serial 12-lead electrocardiograms. Prehosp Emerg Care. 2018;22(4):419426.
32. Westbrook, JI, Raban, MZ, Walter, SR, Douglas, H. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. BMJ Qual Saf. January 2018;27(8):655663.
33. Berg, LM, Källberg, A-S, Göransson, KE, Östergren, J, Florin, J, Ehrenberg, A. Interruptions in emergency department work: an observational and interview study. BMJ Qual Saf. 2013;22(8):656663.
34. Blocker, RC, Heaton, HA, Forsyth, KL, et al. Physician, interrupted: workflow interruptions and patient care in the emergency department. J Emerg Med. 2017;53(6):798804.
35. Chisholm, CD, Dornfeld, AM, Nelson, DR, Cordell, WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38(2):146151.
36. Menees, DS, Peterson, ED, Wang, Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013;369(10):901909.
37. Chen, FC, Lin, YR, Kung, CT, Cheng, CI, Li, CJ. The association between door-to-balloon time of less than 60 minutes and prognosis of patients developing ST segment elevation myocardial infarction and undergoing primary percutaneous coronary intervention. Biomed Res Int. 2017;2017:1910934.
38. Fanari, Z, Abraham, N, Kolm, P, et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc. 2015;90(12):16141622.


A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction

  • Mat Goebel (a1), Florin Vaida (a2), Christopher Kahn (a3) (a4) and J. Joelle Donofrio (a3) (a4) (a5)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed