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False-Positive STEMI Diagnoses May Be Common at Primary PCI Centers

Issue: July/August 2012

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More than one-third of patients who were referred for primary PCI at two primary PCI centers in California did not have STEMI, according to registry data published by the Archives of Internal Medicine.

In the analysis, 411 consecutive STEMI diagnoses were evaluated from the Activate-SF Registry, which included patients admitted to EDs of two centers with primary PCI capacity between October 2008 and April 2011. The researchers defined a false-positive STEMI activation as lack of a culprit lesion by angiography or by assessment of clinical, electrocardiographic and biomarker data in the absence of angiography.

Overall, 36% of the STEMI activations were classified as false-positive activations, of which structural heart disease and/or HF were the most common diagnoses (19%) followed by nonspecific chest pain (17%) and demand ischemia with severe concomitant illness (14%). Independent predictors of an increased odds for false-positive STEMI activations included echocardiographic left ventricular hypertrophy (adjusted OR=3.15; P=.001) and, to a lesser extent, prior illicit drug abuse (adjusted OR=2.67; P=.02) and a history of CAD (adjusted OR=1.93; P=.04). However, patients had a decreased likelihood of a false-positive activation if they presented with angina (adjusted OR=0.91; P<.001) or had increasing BMI (adjusted OR=0.91; P=.004).

For more information:

McCabe JM. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.945.

 

Anthony A. Bavry

This study provides a timely contribution to the literature. Minimizing door-to-balloon time is an important national quality metric; however, it is inevitable that for a primary PCI center to have average door-to-balloon times (<90 minutes) there will be an increase in the rate of false-positive diagnoses. Although some increase in this rate is expected, the reported frequency of 36% in this paper appears too high. This illustrates that establishing an accurate diagnosis of a STEMI is a difficult process. There are certainly safety concerns from a high rate of false-positive STEMIs. Some alternative diagnoses that were documented in this paper include decompensated HF, severe concomitant illness (intracranial process or gastrointestinal bleeding), primary rhythm disturbance, metabolic derangement and abdominal condition. Although catheterization would delay management for some of these disorders, the use of potent antiplatelets/anticoagulants could be life-threatening for patients with an unrecognized bleeding disorder.

– Anthony A. Bavry, MD

Cardiology Today Intervention Editorial Board member

Disclosure: Dr. Bavry reports no relevant financial disclosures.