IJCS | Volume 32, Nº2, March/April 2019

161 Farah et al. Diagnostic telecardiology in chest pain Int J Cardiovasc Sci. 2019;32(2)158-162 Original Article support to the general practitioner in the differential diagnosis of chest pain at the emergency care, directly influencing proper diagnosis, treatment and referral of the patients. The importance of cardiological remote support for diagnosis and clinical management has been described by other authors 7,8 and Molinari et al., 9 that evaluated 456 patients with chest pain and/or other symptoms suggestive of an acute cardiac event, comparing the initial diagnosis of the general practitioner with the final diagnosis of the cardiologist. In this study, 9 two points stand out in our findings: the first one is the high percentage of diagnostic disagreement 31% (140 patients) 9 compared to 27.39% (1,593 patients) in our study, demonstrating the need of the remote specialist; and the second one is the reduction of unnecessary admissions that was 63% 9 compared to 73.9% (1,593 patients) in this study, thus representing effective savings in terms of unnecessary costly hospitalizations. Similar studies 10-13 related to cost reduction have also proved the effectiveness of telecardiology in primary care. Inour study, themainpointsofdiagnosticdisagreement in patients admitted with chest pain were abnormalities on the electrocardiogram, showing ST-segment elevation not recognized at admission, similar to those described by Brunetti et al., 14 high CPK andMBK values ​​with negative troponin defined as non-ST-elevation acute myocardial infarction and other causes of chest pain with positive troponin related and not related to cardiac disorders but not characterizing acute myocardial ischemia, whichwas also described by Chiu et al. 15 Of all the inconsistent diagnoses, it isworthmentioning the patients arriving at the UPA 24h with ST-segment elevation acute myocardial infarction (STEMI) but who did not have this diagnosis recognized by the general practitioner. In this group, 80%of patients presented time from onset of chest pain to admission (delta t) shorter than 12 hours, but only 34% were evaluated in time by the telecardiology and received reperfusion treatment. This result was compatible with the finding in the TIET study, 16 in which 44% of the STEMI patients who were within the 12-hour window of the onset of symptoms did not receive any thrombolytic therapy without any justification. The recognition of this diagnosis by the general practitioner, as well as the percentage of thrombolysis is still very low, as previously reported by other authors, 15,17,18 with a significant impact on morbidity and mortality rates. 19,20 This demonstrates the urgent need to implement measures that allow the rapid diagnosis of STEMI and, consequently, the therapy in a timely manner. Regarding the safety of the thrombolytics administered (alteplase and tenecteplase), there were no reports of hemorrhagic complications or side effects secondary to medication in the period evaluated. A total of 1,255 admissions at tertiary hospital were avoided. As already described by other authors, 10,11 telecardiology plays an important role in avoiding unnecessary hospital admissions in patients with a supposed cardiac event in the first care by the general practitioner. This study also shows the importance of a continued relationship established by telemedicine between the telecardiologist and the general practitioner on a daily basis to guide the management of patients admitted with suspected acute coronary syndrome until outcome, as recommended by the Brazilian Guidelines on Telecardiology in Acute Coronary Syndrome and other Cardiac Diseases. 21 This new procedure of work can be considered a support in the country’s health system. Limitations The retrospective and observational nature does not allow us to make comparisons and associations to demonstrate the statistical significance of telecardiology. The presence of only one telecardiologist per daymay not meet all the demand of the emergency care units when synchronous teleconsulting is required by the general practitioner at the emergency room. Conclusion Telecardiology has been shown to be an important and effective tool to support the differential diagnosis of chest pain in patients admitted at emergency care units, optimizing bed occupancy in the public health system. The use of telecardiology as a remote support for general practitioners handling patients with chest pain symptoms is feasible, resulting on diagnostic support and identifying patients that really need to be transferred to tertiary referral hospital, thus avoiding unnecessary bed occupancy and expensive tests. Authors’ contributions Research creation and design: Farah S. Data acquisition: Farah S, Andréa BR, Silva RC. Data analysis