Frequency and Consequences of Recording an Electrocardiogram

>10 Minutes After Arrival in an Emergency Room in

NonST-Segment Elevation Acute Coronary Syndromes
(from the CRUSADE Initiative)
Deborah B. Diercks, MDa,*, W. Frank Peacock, MDb, Brian C. Hiestand, MDc,
Anita Y. Chen, MSe, Charles V. Pollack, Jr., MDg, J. Douglas Kirk, MDa,
Sidney C. Smith, Jr., MDf, W. Brian Gibler, MDd, E. Magnus Ohman, MDf,
Andra L. Blomkalns, MDd, L. Kristin Newby, MD, MHSe, Judith S. Hochman, MDh,
Eric D. Peterson, MD, MPHe, and Matthew T. Roe, MD, MSHe
We sought to determine the frequency of electrocardiographic (ECG) acquisition within
10 minutes of hospital arrival, factors associated with delayed ECG acquisition, and any
relation among delayed ECG acquisition, treatment patterns, and clinical outcomes. We
therefore analyzed data from 63,478 patients (26,615 women, 42%) with high-risk non
ST-segment elevation acute coronary syndromes (designated by positive cardiac markers
and/or ischemic ST-segment changes) who were enrolled in the CRUSADE Quality
Improvement Initiative from February 2001 to March 2004. Patients were categorized
based on time to electrocardiography as delayed (>10 minutes from hospital arrival) or
nondelayed (<10 minutes). Multivariable predictors of delayed ECG acquisition were
determined. Overall, median time to electrocardiography was 15 minutes (25th to 75th
percentile 7 to 32). ECG acquisition was delayed (median 25 minutes, 25th to 75th
percentile 16 to 50) in 41,397 patients (65.2%). In the remaining 34.8%, time to electrocardiography was <10 minutes (median 5 minutes, 25th to 75th percentile 3 to 8).
Women were more likely than men to have delayed ECG acquisition (69% vs 62%), and
female gender was the most significant predictor of delayed ECG acquisition (odds ratio
1.29, 95% confidence interval 1.25 to 1.34). In conclusion, only 33% of high-risk patients
with nonST-segment elevation acute coronary syndrome had an initial electrocardiogram obtained <10 minutes of arrival as recommended. Women were significantly more
likely than men to have delayed ECG acquisition. Emergency departments should focus
on decreasing the time to initial ECG acquisition to improve treatment of acute coronary
syndrome in this group. 2006 Elsevier Inc. All rights reserved. (Am J Cardiol 2006;
97:437 442)

The importance of identifying ST-segment changes in the

patient population with ST-segment elevation myocardial
infarction is well known, but ST-segment deviation also

The aUniversity of California Davis Medical Center, Sacramento, California; the bCleveland Clinic, Cleveland, cThe Ohio State University,
Columbus, and the dUniversity of Cincinnati College of Medicine, Cincinnati, Ohio; the eDuke Clinical Research Institute, Durham, and the fUniversity of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the
g
Pennsylvania Hospital, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania; and the hNew York University School of
Medicine, New York, New York. Manuscript received June 30, 2005;
revised manuscript received and accepted September 8, 2005.
CRUSADE is funded by Millennium Pharmaceuticals, Inc., Boston,
Massachusetts, and Schering Corporation, Kenilworth, New Jersey. Bristol-Myers Squibb (New York, New York)/Sanofi Aventis Pharmaceuticals
(Bridgewater, New Jersey) Partnership provides an unrestricted grant in
support of the program.
* Corresponding author: Tel: 916-734-4052; fax: 916-762-8851.
E-mail address: dbdiercks@ucdavis.edu (D.B. Diercks).
0002-9149/06/$ see front matter 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjcard.2005.09.073

occurs in about 40% of patients with nonST-segment elevation (NSTE) acute coronary syndromes (ACSs).1 Although it is intuitive that early identification of NSTE ACS
in patients can facilitate appropriate and timely management, this principle is based on clinical experience without
robust supporting evidence. There are no studies that have
supported a defined time between admission and electrocardiography in the population with NSTE ACS, and it is not
known whether this recommendation is feasible in most
institutions. We evaluated the timing of electrocardiographic (ECG) acquisition in a large, contemporary population of patients with high-risk NSTE ACS to determine
the frequency of ECG acquisition within the recommended
period (10 minutes) according to guidelines of the American College of Cardiology/American Heart Association;
factors associated with a delay in time to ECG acquisition;
and any relation among delays in ECG acquisition, treatment patterns, and clinical outcomes.2
www.AJConline.org

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Methods
Population: The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with
Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE)
Quality Improvement Initiative includes patients who are
prospectively identified in the emergency department and
those who are retrospectively identified by discharge diagnosis or procedural logs. Patient inclusion criteria include
ischemic symptoms (lasting for 10 minutes) at rest within
24 hours of presentation and high-risk features such as
ST-segment depression, transient ST-segment elevation,
and/or positive cardiac biomarkers (increased troponin I or
T level and/or creatine kinase-MB level higher than the
upper limit of normal for the local laboratory assay used at
each participating institution).
The CRUSADE Quality Improvement Initiative analyzes
patient records to determine compliance with American
College of Cardiology/American Heart Association guidelines for patients with NSTE ACS.3 Details of this quality
improvement initiative have previously been reported.3 Risk
stratification criteria, such as ECG and biomarker results,
are documented for each patient. Contraindications for recommended NSTE ACS therapies (medication allergy, symptomatic bradycardia, and so forth) are sought to determine
eligibility for guideline-recommended therapies. Timing of
therapies is recorded for medications and for downstream
interventions, such as percutaneous coronary intervention
and coronary artery bypass grafting. Final disposition
(transfer, discharge, or death) is noted for each patient.
All data collection occurs retrospectively and does not
include any patient-identifying information; therefore, informed consent is waived. All participating institutions are
required to comply with local regulatory and privacy guidelines before participation in CRUSADE. Participating institutions are instructed to submit consecutive eligible patients, and data collection occurs by retrospective chart
review after local institutional review board approval of the
initiative. Data are abstracted by trained data collectors
according to standardized definitions. Variables include demographic and clinical information (including age, race,
gender, insurance status, co-morbid illnesses, medical history, clinical presentation, and medical therapies with associated major contraindications), use and timing of cardiac
procedures, laboratory results, and in-hospital outcomes.
Decisions regarding the use of medications and invasive
procedures are made by treating physicians.3
We analyzed the data from patients who were enrolled in
the CRUSADE Quality Improvement Initiative from February 2001 to March 2004. Only patients who presented to
the emergency department were eligible for enrollment;
patients who had transferred directly to the inpatient service
from a non-CRUSADE site were not included. Patients
were excluded if the available time data were incomplete.
Time to electrocardiography was defined as the time
from hospital arrival to ECG performance. It was assessed

as a dichotomous variable (ECG acquisition time 10 or

10 minutes). Sites were not asked to document or ensure
a correlation between clocks in the ECG machines and those
in the emergency department. ECG interpretation was recorded as the report that was documented in the final medical record at each institution.
Mortality rate was examined only as an in-hospital event,
and no differentiation was made as to its cause. Post-admission myocardial infarction in patients who presented without myocardial infarction was defined as any creatine
kinase-MB or troponin values above the upper limit of
normal for the local laboratory assay or new, significant Q
waves in 2 contiguous leads on an electrocardiogram.
Post-admission myocardial infarction in patients who presented with myocardial infarction before revascularization
was defined as new, significant Q waves in 2 contiguous
leads on an electrocardiogram; an increase in creatine kinase-MB or troponin level above the upper limit of normal
(if the most recent cardiac markers before the event were
normal); or an increase in creatine kinase-MB or troponin
level by 50% above the most recent value (if the most
recent cardiac markers before the event were higher than the
upper limit of normal). Within 24 hours of percutaneous
coronary intervention, reinfarction was defined as an increase in creatine kinase-MB level by 50% above the
level before the procedure (if the most recent cardiac markers before procedure were higher than the upper limit of
normal); an increase in creatine kinase-MB level to a value
3 times the upper limit of normal (if the most recent
cardiac markers before the procedure were normal); or new,
significant Q waves in 2 contiguous leads on an electrocardiogram. Post-admission myocardial infarction within 24
hours of coronary artery bypass grafting was defined as an
increase in creatine kinase-MB level to a value 5 times the
upper limit of normal or new, significant Q waves in 2
contiguous leads on an electrocardiogram.
Patients arrival to the emergency department was stratified by time and defined as peak or off peak. Off peak
was defined as weeknights (5 P.M. to 7 A.M. the next day) and
weekends (Friday after 5 P.M. to Monday at 7 A.M.). All
other times were defined as peak. Hospital location was
described in terms of geographic regions of the Northeast,
South, Midwest, and West Coast of the United States.
Statistical analysis: Patient baseline demographics, clinical characteristics, in-hospital care patterns, and outcomes
were evaluated by delay of ECG status. Medians and 25th
and 75th percentiles were reported for continuous variables
and frequencies were reported for categorical variables. To
test for independence of delay of ECG status and in-hospital
care patterns and outcomes, Wilcoxons rank-sum tests
were used for continuous variables and chi-square tests
were used for categorical variables.
To determine the factors associated with delay of
electrocardiography, a generalized estimating equation
method4 was used. The factors, which were carefully

Coronary Artery Disease/Recording an Electrocardiogram 10 Minutes After Arrival

439

Table 1
Demographics, characteristics, and presentation grouped by presentation to electrocardiographic acquisition
Demographic Variables

Total
(n 63,478)

ECG 10 min
(n 22,081)

ECG 10 min
(n 41,397)

p Value

Age (yrs)
Women
White race
Insurance
HMO/private
Medicare
Military
Medicaid
Self/none
Diabetes mellitus
Hypertension
Previous heart failure
Current/recent smoker
Dyslipidemia*
Renal insufficiency
Previous myocardial infarction
Previous coronary angioplasty
Previous coronary bypass
Signs of heart failure
Systolic blood pressure (mm Hg)
Pulse (beats/min)
Increased cardiac markers
ST depression
Transient ST elevation
Off-hours presentation
Academic hospital
No. of beds
Capabilities
No services
Catheterization only
Percutaneous coronary intervention, no surgery
Coronary bypass

69 (5780)
41.9%
78.5%

68 (5779)
36.8%
82.1%

70 (5780)
44.6%
76.5%

0.001
0.001
0.0001
0.001

43.5%
41.2%
0.29%
7.99%
6.0%
33.4%
70.3%
20.8%
25.4%
50.0%
15.1%
31.8%
21.6%
21.1%
25.0%
146 (125, 167)
84 (71, 100)
88.8%
37.9%
7.2%
61.5%
29.2%
377 (251, 518)

45.6%
39.3%
0.2%
7.4%
6.4%
32.0%
69.1%
18.7%
27.3%
48.3%
13.8%
33.4%
24.5%
22.7%
22.8%
146 (126, 168)
84 (70, 100)
88.7%
39.3%
8.3%
64.1%
24.5%
366 (248, 500)

42.4%
42.3%
0.3%
8.3%
5.7%
34.3%
70.9%
22.0%
24.3%
44.7%
15.9%
31.0%
20.2%
20.2%
26.2%
146 (125, 167)
85 (72, 100)
88.9%
37.2%
6.5%
60.2%
31.7%
398 (265, 526)

4.4%
9.6%
6.3%
79.7%

3.8%
8.8%
6.2%
81.2%

4.8%
10.0%
6.4%
78.9%

0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.001
0.0001
0.085
0.001
0.48
0.0001
0.0001
0.00001
0.0001
0.0001

Values are medians (25th, 75th percentiles) or percentages of patients.

* History of hypercholesterolemia or elevated triglyceride levels by patient self-report.

Serum creatinine level 2.0 mg/dl, creatinine clearance 30 ml/min, or need for renal dialysis.

Weeknights (5 P.M. to 7 A.M. the next day) and weekends (Friday after 5 P.M. through 7 A.M. Monday morning).
ECG electrocardiography; HMO health maintenance organization.

selected by the investigators, consisted of baseline patient factors (including age, gender, race, insurance status, family history of coronary artery disease, hypertension, diabetes, smoking status, hypercholesterolemia,
previous myocardial infarction, previous percutaneous
coronary intervention, previous coronary artery bypass
grafting, previous congestive heart failure, previous
stroke, positive cardiac biomarker levels, evidence of acute
decompensated congestive heart failure, heart rate, and systolic
blood pressure) and provider and hospital characteristics (physician specialty, total number of hospital beds, facilities
available, region, and whether the hospital was considered
academic or nonacademic).
Acute treatment composite scores were created using a
summation of guideline-recommended pharmacologic treatments for the first 24 hours after presentation.2 To assess a
potential hospital effect, participating institutions were examined in quartiles based on the percentage of patients with
a time 10 minutes to electrocardiography. Acute medica-

tion composite adherence scores were compared across

quartiles of hospitals as determined by the percentage of
patients with a time 10 minutes to electrocardiography.
These composite scores were calculated by determining the
percentage of care opportunities that class IA or IB acute
(24 hours) guideline recommendations (aspirin, blockers, unfractionated or low-molecular-weight heparin, and
glycoprotein IIb/IIIa inhibitors) were administered to ideal
patients without listed contraindications for each medication class.
A p value 0.05 was considered statistically significant
for all tests. All statistical analyses were performed with
SAS 8.2 (SAS Institute, Cary, North Carolina).

Results
Patient characteristics: During the study, 98,571 patients were enrolled in CRUSADE. Of these, 83,581 patients presented to the emergency department, and 18,716

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Table 2
Factors associated with electrocardiographic acquisition after 10 minutes
Variable
Female gender
Off-hours presentation*
Previous percutaneous
coronary intervention
Nonwhite
Insurance
Self/none (HMO self-pay)
Medicare (HMO self-pay)
Medicaid (HMO self-pay)
Current/recent smoker
Academic (vs nonacademic)
Diabetes mellitus
Previous myocardial infarction
Dyslipidemia
Region
Midwest (vs South)
West (vs South)
Northeast (vs South)
Previous heart failure
Previous coronary bypass
Signs of heart failure
Family history of coronary
artery disease

Adjusted OR
(95% CI)

Chi-square

1.29 (1.251.34)
0.86 (0.830.9)
0.86 (0.820.90)

253.0
50.0
48.2

1.16 (1.101.22)

33.8
29.8

0.88 (0.820.94)
1.06 (1.021.1)
1.07 (1.001.14)
0.91 (0.870.94)
1.39 (1.201.60)
1.07 (1.031.10)
0.94 (0.900.97)
0.94 (0.900.98)
0.79 (0.690.92)
0.87 (0.721.04)
0.94 (0.811.08)
1.08 (1.031.13)
0.94 (0.900.98)
1.07 (1.021.12)
0.95 (0.910.99)

23.3
20.3
14.4
11.0
10.75
9.88

9.07
8.51
7.24
6.93

* Weeknights (5 P.M. to 7 A.M. the next day) and weekends (Friday after
5 P.M. through 7 A.M. Monday morning).

Diagnosis of coronary artery disease or a myocardial infarction in

first-degree relatives at 55 years of age.
CI confidence interval; OR odds ratio; other abbreviation as in
Table 1.

patients were excluded because they were transferred from

another institution to the enrolling CRUSADE site. Of the
64,865 emergency department patients, 1,387 (2.1%) were
excluded due to incomplete ECG data, resulting in a final
patient population of 63,468 patients. Demographic and
clinical variables are presented in Table 1. In this cohort,
22,081 (34.8%) underwent electrocardiography within 10
minutes (median 5 minutes, 25th to 75th percentile 3 to 8)
and 41,397 (65.2%) did not (median 25 minutes, 25th to
75th percentile 16 to 50).
Factors associated with a delay in time to ECG acquisition: In multivariable modeling, the factor most
strongly associated with delayed ECG acquisition (performed 10 minutes after hospital presentation) was female
gender (Table 2). Other factors that were strongly associated
with ECG delays included off-hour presentation, previous
percutaneous coronary intervention, nonwhite race, Medicaid or Medicare insurance status, current smoking, and
treatment at a teaching hospital.
Treatment and clinical outcome differences: Patients
who underwent electrocardiography within 10 minutes of
presentation more often received acute (within 24 hours)
therapy, including aspirin, blockers, heparin, and glycoprotein IIb/IIIa inhibitors as recommended in the American

College of Cardiology/American Heart Association guidelines (Table 3). After adjusting for confounders, patients
without delay in ECG acquisition were more likely to receive heparin, glycoprotein IIb/IIIa inhibitors, and clopidogrel within 24 hours of arrival.
Although there was an increased incidence of unadjusted
in-hospital death in patients with a delayed electrocardiogram (5.4% vs 4.7%, p 0.001), there was no statistically
significant difference in the adjusted risk of death and other
adverse clinical outcomes (Table 4).
Hospital acute treatment patterns and ECG acquisition:
Among hospitals in the lowest quartile of delayed ECG
acquisition, the median acute medication adherence score
was 75.8% (25th to 75th percentile 67.3 to 81.6), whereas
among hospitals in the highest quartile of delayed ECG
acquisition, the median acute medication adherence score
was 71.1% (25th to 75th percentile 63.1 to 79.6).

Discussion
In a large, contemporary population of patients with NSTE
ACS, we have demonstrated that only 33% of patients with
ischemic symptoms at presentation undergo electrocardiography within 10 minutes of hospital presentation as recommended in evidence-based guidelines. We also found that
the factor most strongly associated with ECG delays is
female gender.
The initial standard for time to ECG acquisition was set
by the National Heart Attack Alert Program, when timely
acquisition of an electrocardiogram was demonstrated to be
a critical time point in the management of patients who have
ST-segment elevation myocardial infarction and undergo
fibrinolytic therapy.5 A time-to-ECG goal should arguably
be in place for all patients with chest pain to identify the
presence of ST-segment elevation, which drives treatment
algorithms. Further, at the time of triage of patients with
chest pain, identification of those subsequently found to
have ST-segment elevation myocardial infarction or NSTE
ACS is obviously unknown. However, the temporal effect of
urgent and timely pharmacologic or mechanical interventions
on adverse clinical outcomes continues to be investigated in
patients with NSTE ACS, and we found no link between early
ECG acquisition and adjusted risk of adverse events (in-hospital mortality and recurrent myocardial infarction).
Of significant concern is the increased likelihood of
delay in time to ECG acquisition in women. Although
gender-related disparities in the treatment of NSTE ACS
have been reported previously, we found that, among patient characteristics, female gender was the strongest independent predictor of a delay in ECG acquisition, which far
exceeded the association with other factors.6 This phenomenon has been reported previously in the ST-segment elevation myocardial infarction population.7 Data from the
National Registry of Myocardial Infarction-1 indicate that

Coronary Artery Disease/Recording an Electrocardiogram 10 Minutes After Arrival

441

Table 3
Acute (within 24 hours) medications and invasive procedures*
Variable

Aspirin
Blocker
Heparin, any
Glycoprotein IIb/IIIa inhibitor
Clopidogrel
Cardiac catheterization 24 hours
Cardiac catheterization 48 hours
Percutaneous coronary intervention
Coronary artery bypass grafting

Total
(n 63,478)

Electrocardiogram
10 mins
(n 22,081)

Electrocardiogram
10 mins
(n 41,397)

p Value

Adjusted OR
(95% CI)

91.8%
79.2%
81.9%
33.7%
40.5%
31.3%
49.5%
40.2%
12.2%

92.5%
80.2%
84.6%
39.0%
44.4%
36.6%
55.4%
44.7%
12.9%

91.4%
78.6%
80.4%
30.8%
38.4%
28.3%
46.2%
37.6%
11.8%

0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0002

0.95 (0.881.01)
0.96 (0.921.00)
0.87 (0.830.91)
0.80 (0.770.84)
0.88 (0.850.91)
0.78 (0.750.82)
0.81 (0.770.85)
0.85 (0.810.89)
0.98 (0.931.04)

* Medication use is reported only for patients without listed contraindications.

Electrocardiogram obtained after 10 minutes versus that obtained within 10 minutes (reference).

Subset on hospitals with surgical capabilities.

Abbreviations as in Table 2.

Table 4
Clinical outcomes
Variable
Death
Postadmission myocardial infarction
Death or myocardial infarction

Total
(n 63,478)

ECG 10 min
(n 22,081)

ECG 10 min
(n 41,397)

p Value

Adjusted Risk
(95% CI)

5.2%
2.9%
7.5%

4.7%
2.9%
7.1%

5.4%
2.9%
7.7%

0.0001
0.92
0.004

1.01 (0.941.09)
1.01 (0.901.12)
1.01 (0.941.08)

Abbreviations as in Tables 1 and 2.

women have a longer time to initial electrocardiography

than do men.8 Possible explanations for this delay in ECG
acquisition may include an increased frequency of atypical
presentations of ACS in women, women more frequently
present after chest pain resolution, and the logistical need
for a location that allows for patient privacy when obtaining
an electrocardiogram in women.9 11
The results of our study suggest that emergency departments usually do not achieve the recommended door-toECG benchmark of 10 minutes. Only 34.8% of patients in
the CRUSADE Quality Improvement Initiative underwent
electrocardiography within 10 minutes of arrival. In those
hospitals with an adherence score in the top quartile, this
percentage reached only 55%. This identifies an important
area for quality improvement in the emergency department.
The low percentage of hospitals that are able to follow this
guideline raises the concern that achieving this time benchmark may not be feasible. Reasons for the overall delay may
be overcrowding, a large number of patients with a complaint of chest pain, lack of triage protocols, and a decreased
sense of urgency in patients whose pain may have resolved
during the initial evaluation. Potential solutions may include
a designated site within the emergency department with
adequate privacy for ECG acquisition, institution-based
protocols for ECG acquisition, and review of time to electrocardiography in all patients who present with chest pain
as a quality improvement project to increase awareness of
current local practices.
Although the present results highlight factors that are

associated with a delay in ECG acquisition, we noted several limitations. First, we did not adjust for variation in
institutional policies or protocols. Second, we did not collect data on mode of transportation to the emergency department (emergency medical services vs private vehicle),
which has been reported to influence the period between
presentation to electrocardiography. Third, we did not account for other co-existing medical complaints that may
have affected ECG acquisition time and adverse clinical
outcome. Fourth, due to the retrospective nature of quality
improvement initiatives, we could not determine which patients had active pain at the time of presentation, recurrent
pain during evaluation in the emergency department, or an
atypical presentation that may have led to delayed ECG
acquisition. Fifth, we used a dichotomous cut-off time to
electrocardiography. Although this is consistent with
guidelines of the American College of Cardiology/American Heart Association, it assumes that there is no difference between a delay of 11 minutes and a delay of 120
minutes.
Although we were unable to link conclusively a delay in
ECG acquisition with adverse events in this patient population, obtaining a timely electrocardiogram is a critical step
in the evaluation of the undifferentiated population with
chest pain. Future studies need to assess the effect of overcrowding between presentation and ECG acquisition and to
determine whether internal guidelines can decrease the time
to ECG acquisition in patients who present with the complaint of chest pain.

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