International Journal of Cardiology 199 (2015) 215–220

Contents lists available at ScienceDirect

International Journal of Cardiology

journal homepage: www.elsevier.com/locate/ijcard

Letter to the Editor

Impact of telemedicine support by remote pre-hospital

electrocardiogram on emergency medical service management
of subjects with suspected acute cardiovascular disease
Natale Daniele Brunetti a,b,⁎, Nicola Tarantino a,b, Giulia Dellegrottaglie a,c, Giovanni Abatecola a,d,
Luisa De Gennaro a,e, Angela Ivana Bruno a,f, Francesca Bux a,g, Antonio Gaglione a,b, Matteo Di Biase a,b
a
Cardiology Department, University of Foggia, Foggia, Italy
b
Department of Medical & Surgical Sciences, University of Foggia, Italy
c
Cardio-on-Line Europe s.r.l., Bari, Italy
d
118 Emergency Medical Service, Barletta, Italy
e
Cardiology Department, Ospedale S. Paolo, Bari, Italy
f
118 Emergency Medical Service, Bari, Italy
g
Cardiology Department, Ospedale Di Venere, Bari, Italy

a r t i c l e i n f o Telemedicine support may facilitate the implementation of pre-

hospital triage by electrocardiogram [11–14]. Telemedicine support by
Article history:
Received 25 June 2015 a cardiologist interpreting remote pre-hospital electrocardiogram may
Accepted 27 June 2015 improve the accuracy of electrocardiogram interpretation of automated
Available online 2 July 2015 algorithms and paramedics.
We aimed to report in this study the perceived impact of remote
Keywords:
telemedicine support for pre-hospital electrocardiogram triage in emer-
Tele-cardiology
Pre-hospital electrocardiogram gency medical service (EMS) staff personnel.
Pre-hospital triage A regional EMS service (1-1-8, the Italian corresponding for 9-1-1) is
Acute myocardial infarction currently active in Apulia, Italy, a region with 4-million inhabitants, with
Primary coronary angioplasty
the support of a telemedicine hub located in Bari, the capital city of Apu-
Mortality
Emergency medical service
lia [15]. The region is covered by a single public health care service, a
single public EMS, and a single tele-medicine service provider. A region-
al network for primary angioplasty in STEMI was also started in Apulia
in January 2012 [16].
The telephone number 1-1-8 is the Italian public free service for gen-
eral medical or surgical emergencies, whose aim is an immediate diag-
The use of pre-hospital triage with electrocardiogram is recom- nosis of critical diseases in order to avoid emergency room delay-to-
mended in any case of suspected acute coronary syndrome or acute diagnosis. Final hospitalization is arranged by teams of physicians and
cardiovascular disease [1]. Pre-hospital 12-lead electrocardiogram in 1-1-8 district central, connected by mobile phone: direct admission to
the case of suspected acute myocardial infarction has been advocated a critical care unit is arranged according to the level of care. Patients
and recommended by guidelines [2,3] and scientific statements [4]; are discharged from the ambulance and not transported at all in case
however, its use is still low [5]. of normal findings. According to Italian legislation, 1-1-8 crews usually
Pre-hospital electrocardiogram is particularly useful when primary include a physician skilled in emergency medicine and/or nurses and
angioplasty with direct referral for primary angioplasty by-passing electrocardiogram should be preferably read by a cardiologist.
emergency room (ER) should be performed in subjects with All crews of regional 1-1-8 EMS (N = 154) are therefore equipped
ST-elevation acute myocardial infarction (STEMI). Pre-hospital triage with a CardioVox P12 12-lead electrocardiogram recorder (Aerotel™,
with electrocardiogram [6] and tele-medicine support [7,8] may be Holon, Israel): the devices may record a complete 12-lead ECG which
useful in shortening time to reperfusion, as documented in a series of is read by a cardiologist available 24/7 after (mobile-)telephone trans-
networks for the treatment of STEMI [9,10]. mission to a unique regional telemedicine support “hub”, located in
Bari, capital city of Apulia. 1-1-8 personnel (paramedics and physicians)
may be shown back ECGs on smart-phones connected with tele-
⁎ Corresponding author at: Department of Medical & Surgical Sciences, University of
cardiology hub [17]. Logistic support for telemedicine hub was provided
Foggia, Viale Pinto 1, 71100 Foggia, Italy. by Cardio-online Europe S.r.l., Bari, Italy. A cardiologist available 24/7
E-mail address: natale.brunetti@unifg.it (N.D. Brunetti). within tele-cardiology hub promptly interprets the electrocardiograms

http://dx.doi.org/10.1016/j.ijcard.2015.06.124
0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
216 Letter to the Editor

Fig. 1. Emergency medical service 118 staff personnel age and years of experience with telemedicine pre-hospital electrocardiogram support.

sent by EMS personnel from all over Apulia. In case of STEMI, the
patients are immediately addressed to the nearest cath-lab for the
appropriate treatment.
Fifty consecutive EMS 118 staff personnel randomly selected in the
Bari/Barletta/Andria/Trani districts in Apulia were enrolled in the
study. A questionnaire with 19 items exploring age, gender, personal
qualification (paramedic, physician), years of use of telemedicine pre-
hospital electrocardiogram support, town's population and ER prompt
availability, personal satisfaction with telemedicine electrocardiogram
support, individual indications to pre-hospital telemedicine electrocar-
diogram adopted in everyday clinical practice, and clinical impact on
hospitalization decisions and diagnoses possibly changed after pre-
hospital telemedicine electrocardiogram was administrated to all
participants in the study.
The study was authorized by local Health Authority and agrees with
the declaration of Helsinki.
Continuous variables were reported as mean ± standard deviation
and compared with Student's t-test or ANOVA, dichotomic variables as
percentages and compared with χ2 test. Correlations were tested with
Pearson's test.
A p value b 0.05 was considered as statistically significant.
Questionnaires were returned in 43 subjects of 50 interviewed.
Mean age of subjects enrolled in the study was 44 ± 7 years, 72% of
EMS 118 staff were males; 42% were younger than 40-year old, 35%

Fig. 2. Emergency medical service staff personnel appreciation of telemedicine pre-hospital electrocardiogram support and remote cardiologist consultation (upper panel). Frequency and
indications to telemedicine pre-hospital electrocardiogram by suspected acute cardiovascular disease (lower panel).

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
 Letter to the Editor 217

Fig. 3. Frequency of changed diagnosis after telemedicine pre-hospital electrocardiogram and changed diagnosis according to suspected acute cardiovascular disease.

were 40 to 50-year old, 23% were older than 50-year old (Fig. 1).
Experience with pre-hospital telemedicine electrocardiogram support
was longer than 5 years in 67% of EMS 118 staff members.
Thirty percent were paramedics vs 70% physicians, 37% were EMS
118 staff personnel from towns with a population N15,000 inhabitants,
37% were located in towns without an emergency room promptly
available.
According to interviewed EMS staff members, pre-hospital telemed-
icine electrocardiogram was considered not much useful in just 2.3% of
cases, almost useful in 2.3%, very useful in 2.3% and extremely useful in
93%; cardiologist telemedicine consultation was reported not much
useful in just 2.3% of cases, almost useful in 2.3%, very useful in 2.3%
and extremely useful in 93% (Fig. 2, upper panel).
Pre-hospital telemedicine electrocardiogram was performed often
in a week by 2.3% of interviewed EMS 118 staff personnel, every day
by 88.4% of subjects, more than one in a day by 9.3% (Fig. 2 lower
panel), in 98% of suspected tachycardias, 100% of suspected bradycar-
dias, acute coronary syndromes and syncopes, 91% of uncertain cardio-
vascular diagnosis, in 2% as routine examination (Fig. 2 lower panel).
After pre-hospital telemedicine electrocardiogram diagnosis changed
sometimes in 79% of cases, often in 21% (Fig. 3); diagnosis changed after
pre-hospital telemedicine electrocardiogram in 84% of suspected
tachycardias, 81% of bradycardias, 95% of suspected acute coronary
syndromes, 91% of syncope, 21% of uncertain cardiovascular
diagnoses.
Hospitalization or ER evaluation was avoided in 54% of cases of
suspected acute cardiovascular disease after pre-hospital telemedicine
electrocardiogram, while was decided, although unplanned, after pre-
hospital telemedicine electrocardiogram in 47% of suspected acute
cardiovascular disease (Fig. 4).
Pre-hospital electrocardiogram should have been repeated some-
times by 74.4% of interviewed EMS 118 staff members, almost every
day by 21%; optimal quality for pre-hospital telemedicine electrocardio-
gram was achieved within 1 or 2 attempts by 91% of interviewed EMS
118 staff personnel (Fig. 5).
Overall satisfaction rate about pre-hospital telemedicine electrocar-
diogram support was good in 7% of interviewed EMS 118 staff members,
excellent in 86% (Fig. 6).
No significant correlations were found between age, gender, person-
al qualification and other items included in the interview. Telemedicine
pre-hospital electrocardiogram support was more appreciated by emer-
gency medical service staff personnel located in towns without an

Fig. 4. Avoided hospitalization or emergency room evaluation after telemedicine pre-hospital electrocardiogram in the case of suspected acute cardiovascular disease (left) or indication to
hospitalization unplanned prior to telemedicine pre-hospital electrocardiogram (right).

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
218 Letter to the Editor

Fig. 5. Technical issues: need of repeat telemedicine pre-hospital electrocardiogram for an optimal interpretation and number of repeat pre-hospital electrocardiograms required to
achieve an optimal quality for remote cardiologist interpretation.

emergency room promptly accessible and requiring longer transfer

(Fig. 7, p b 0.001 and p b 0.01 respectively).
We showed in this study the perceived impact of pre-hospital
telemedicine electrocardiogram support on EMS 118 staff personnel in
the management of suspected diagnosis of acute cardiovascular disease.
To the best of our knowledge, this is one of the first studies reporting on
perceived impact of telemedicine support with remote pre-hospital
electrocardiograms in EMS personnel. Results show that telemedicine
support by a remote 24/7 accessible cardiologist is highly appreciated
by EMS personnel and extensively applied in any case of suspected
acute cardiovascular disease.
Telemedicine support very often changed final clinical decision after
EMS dispatch, both in avoiding unnecessary hospitalization and in
confirming diagnoses of acute cardiovascular disease which could be
missed without remote pre-hospital electrocardiogram.
Pre-hospital electrocardiogram triage and direct referral for primary
angioplasty has been shown in several studies as the optimal treatment
for STEMI [18]. A lower mortality was also found when pre-hospital
Fig. 6. Overall emergency medical service staff personnel appreciation of telemedicine
electrocardiogram triage was used to by-pass any emergency
pre-hospital electrocardiogram support.

Fig. 7. Telemedicine pre-hospital electrocardiogram support was more appreciated by emergency medical service staff personnel located in towns without an emergency room promptly
accessible and requiring longer transfer (p b 0.001 and p b 0.01 respectively).

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
 Letter to the Editor
department delay [19]. Several studies showed a dramatic reduction in
STEMI mortality with a pre-hospital triage strategy [20,21].
Data on pre-hospital electrocardiogram triage for the treatment of
AMI are currently available also from our country [22,23], Italy; lower
rates of cardiovascular mortality in subjects with STEMI triaged with
pre-hospital telemedicine electrocardiograms have been also recently
shown [24]. However, the perceived clinical support of telemedicine as-
sistance has not been extensively evaluated so far.
Clinical usefulness of pre-hospital electrocardiogram assessment has
been already in the management and diagnosis of arrhythmias [25,26],
in primary [27,28] and secondary prevention of cardiovascular disease
[29,30], fast track emergency room triage [31], in climate emergencies
[32] or for the assistance of detainees [33,34].
We show for the first time the very high appreciation by EMS staff
personnel. Ninety-three percent of interviewed subjects found telemed-
icine pre-hospital electrocardiogram support extremely useful and
about the same percentage used pre-hospital electrocardiogram
support every day or more than once in a day.
In spite of this, telemedicine support was not perceived as a routine
tool to be used in every case of EMS dispatch, and was actually used just
in the case of suspected acute cardiovascular disease.
The perceived extremely high usefulness of telemedicine pre-
hospital electrocardiogram support was probably based on the impres-
sively high rates of diagnoses changed thus leading to an initially
unplanned or avoiding an unnecessary although initially planned hospi-
talization or ER evaluation. Probably such extremely higher (perceived,
not necessarily real) rates of diagnoses changed after telemedicine pre-
hospital electrocardiogram testify a great dependence on remote
cardiologist confirmation developed by EMS personnel when remote
cardiologist accessibility is so promptly available.
The great appreciation of telemedicine support in not flawed neither
by very small technical limitations observable in this study. Even though
repeat electrocardiogram is sometimes required, in the vast majority of
cases an optimal pre-hospital electrocardiogram quality is achieved
after just one repetition, without significant practical limitations, or, at
least, with practical limitations widely counterbalanced by diagnostic
impact on clinical management of EMS patients with suspected acute
cardiovascular disease.
No significant difference in terms of appreciation of telemedicine
support is detectable according to EMS staff personnel age and gender.
Expectably, telemedicine support is mostly appreciated by EMS staff
members far from an ER which should cover longer drive distance for
ER transfer.
Further confirmations in larger populations, however, are warranted
to confirm such positive preliminary results.
This is an observational, non-randomized study, enrolling a limited
number of subjects.
In conclusion, telemedicine support by pre-hospital electrocardio-
gram is extremely appreciated and utilized by EMS staff personnel.
Clinical impact in terms of avoided unnecessary hospitalizations or
wrong diagnoses in the case of suspected acute cardiovascular disease
perceived by EMS staff is extremely relevant.
Conflict of interest
The authors report no relationships that could be construed as a
conflict of interest.
References
[1] N.D. Brunetti, S. Scalvini, F. Acquistapace, G. Parati, M. Volterrani, F. Fedele, G.
Molinari, Telemedicine for cardiovascular disease continuum: a position paper
from the Italian Society of Cardiology Working Group on Telecardiology and
Informatics, Int. J. Cardiol. 184C (2015) 452–458.
[2] P.G. Steg, S.K. James, D. Atar, L.P. Badano, C. Blömstrom-Lundqvist, M.A. Borger,
C. Di Mario, G. Ducrocq, F. Fernandez-Aviles, A.H. Gershlick, P. Giannuzzi, S.
Halvorsen, K. Huber, P. Juni, A. Kastrati, J. Knuuti, M.J. Lenzen, K.W. Mahaffey,
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
219
M. Valgimigli, A. van 't Hof, P. Widimsky, D. Zahger, ESC Guidelines for the man-
agement of acute myocardial infarction in patients presenting with ST-segment
elevation, Eur. Heart J. 33 (2012) 2569–2619.
[3] E.M. Antman, M. Hand, P.W. Armstrong, E.R. Bates, L.A. Green, L.K. Halasyamani,
et al., 2007 focused update of the ACC/AHA 2004 guidelines for the management
of patients with ST-elevation myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines:
developed in collaboration with the Canadian Cardiovascular Society, endorsed by
the American Academy of Family Physicians: 2007 writing group to review new
evidence and update the acc/aha 2004 guidelines for the management of patients
with ST-elevation myocardial infarction, writing on behalf of the 2004 writing
committee, Circulation 117 (2008) 296–329.
[4] J.L. Garvey, B.A. MacLeod, G. Sopko, M.M. Hand, on behalf of the National Heart
Attack Alert Program (NHAAP) Coordinating Committee, Pre-hospital 12-lead
electrocardiography programs. a call for implementation by emergency medical
services systems providing advanced life support — National Heart Attack Alert
Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood
Institute (NHLBI); National Institutes of Health, J. Am. Coll. Cardiol. 47 (2006) 485–491.
[5] D.B. Diercks, M.C. Kontos, A.Y. Chen, C.V. Pollack, S.D. Wiviott, J.S. Rumsfeld, D.J.
Magid, W.B. Gibler, C.P. Cannon, E.D. Peterson, M.T. Roe, Utilization and impact of
prehospital electrocardiograms for patients with acute ST-segment elevation myo-
cardial infarction: data from the NCDR (National Cardiovascular Data Registry)
ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry,
J. Am. Coll. Cardiol. 53 (2009) 161–166.
[6] J.P. Curtis, E.L. Portnay, Y. Wang, R.L. McNamara, J. Herrin, E.H. Bradley, D.J. Magid, M.E.
Blaney, J.G. Canto, H.M. Krumholz, National Registry of Myocardial Infarction-4., The
pre-hospital electrocardiogram and time to reperfusion in patients with acute myo-
cardial infarction, 2000–2002: findings from the National Registry of Myocardial
Infarction-4, J. Am. Coll. Cardiol. 47 (2006) 1544–1552.
[7] N.D. Brunetti, L. De Gennaro, G. Amodio, G. Dellegrottaglie, P.L. Pellegrino, M. Di
Biase, G. Antonelli, Telecardiology improves quality of diagnosis and reduces delay
to treatment in elderly patients with acute myocardial infarction and atypical
presentation, Eur. J. Cardiovasc. Prev. Rehabil. 17 (2010) 615–620.
[8] N.D. Brunetti, G. Amodio, L. De Gennaro, G. Dellegrottaglie, P.L. Pellegrino, M. Di
Biase, G. Antonelli, Telecardiology applied to a region-wide public emergency
health-care service, J. Thromb. Thrombolysis 28 (2009) 23–30.
[9] M.R. Le May, D.Y. So, R. Dionne, C.A. Glover, M.P. Froeschl, G.A. Wells, R.F. Davies, H.L.
Sherrard, J. Maloney, J.F. Marquis, E.R. O'Brien, J. Trickett, P. Poirier, S.C. Ryan, A. Ha,
P.G. Joseph, M. Labinaz, A citywide protocol for primary PCI in ST-segment elevation
myocardial infarction, N. Engl. J. Med. 358 (2008) 231–240.
[10] J.G. Jollis, M.L. Roettig, A.O. Aluko, K.J. Anstrom, R.J. Applegate, J.D. Babb, P.B. Berger, D.J.
Bohle, S.M. Fletcher, J.L. Garvey, W.R. Hathaway, J.W. Hoekstra, R.V. Kelly, W.T. Maddox
Jr., J.R. Shiber, F.S. Valeri, B.A. Watling, B.H. Wilson, C.B. Granger, Reperfusion of Acute
Myocardial Infarction in North Carolina Emergency Departments (RACE) Investigators,
Implementation of a statewide system for coronary reperfusion for ST-segment eleva-
tion myocardial infarction, JAMA 298 (2007) 2371–2380.
[11] J.P. Brown, E. Mahmud, J.V. Dunford, O. Ben-Yehuda, 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. 101 (2008) 158–161.
[12] M. Sejersten, M. Sillesen, P.R. Hansen, S.L. Nielsen, H. Nielsen, S. Trautner, D.
Hampton, G.S. Wagner, P. Clemmensen, Effect on treatment delay of prehospital
teletransmission of 12-lead electrocardiogram to a cardiologist for immediate triage
and direct referral of patients with ST-segment elevation acute myocardial infarc-
tion to primary percutaneous coronary intervention, Am. J. Cardiol. 101 (2008)
941–946.
[13] C.J. Terkelsen, J.F. Lassen, B.L. Nørgaard, J.C. Gerdes, S.H. Poulsen, K. Bendix, J.P.
Ankersen, L.B. Gøtzsche, F.K. Rømer, T.T. Nielsen, H.R. Andersen, Reduction of
treatment delay in patients with ST-elevation myocardial infarction: impact of
pre-hospital diagnosis and direct referral to primary percutaneous coronary
intervention, Eur. Heart J. 26 (2005) 770–777.
[14] J.T. Sørensen, C.J. Terkelsen, B.L. Nørgaard, S. Trautner, T.M. Hansen, H.E. Bøtker, J.F.
Lassen, H.R. Andersen, Urban and rural implementation of pre-hospital diagnosis
and direct referral for primary percutaneous coronary intervention in patients
with acute ST-elevation myocardial infarction, Eur. Heart J. 32 (2011) 430–436.
[15] N.D. Brunetti, L. De Gennaro, G. Dellegrottaglie, D. Amoruso, G. Antonelli, M. Di Biase,
A regional prehospital electrocardiogram network with a single telecardiology
“hub” for public emergency medical service: technical requirements, logistics,
manpower, and preliminary results, Telemed. J. E Health 17 (2011) 727–733.
[16] N.D. Brunetti, G. Di Pietro, A. Aquilino, A.I. Bruno, G. Dellegrottaglie, G. Di Giuseppe,
C. Lopriore, L. De Gennaro, S. Lanzone, P. Caldarola, G. Antonelli, M. Di Biase, Pre-
hospital electrocardiogram triage with tele-cardiology support is associated with
shorter time-to-balloon and higher rates of timely reperfusion even in rural areas:
data from the Bari-Barletta/Andria/Trani public emergency medical service 118 reg-
istry on primary angioplasty in ST-elevation myocardial infarction, Eur. Heart J.
Acute Cardiovasc. Care 3 (2014) 204–213.
[17] N.D. Brunetti, L. De Gennaro, G. Dellegrottaglie, G. Di Giuseppe, G. Antonelli, M. Di
Biase, All for one, one for all: remote telemedicine hub pre-hospital triage for the
public Emergency Medical Service 118 in a regional network for primary PCI in
Apulia, Italy, Eur. Res. Telemed. 3 (2014) 9–15.
[18] S. Carstensen, G.C.I. Nelson, P.S. Hansen, L. Macken, S. Irons, M. Flynn, et al., Field tri-
age to primary angioplasty combined with emergency department bypass reduces
treatment delays and is associated with improved outcome, Eur. Heart J. 28
(2007) 2313–2319.
[19] G. Sivagangabalan, A.T.L. Ong, A. Narayan, N. Sadick, P.S. Hansen, G.C.I. Nelson, G.C.
Nelson, M. Flynn, D.L. Ross, S.C. Boyages, P. Kovoor, Effect of prehospital triage on
220 Letter to the Editor
revascularization times, left ventricular function, and survival in patients with
ST-elevation myocardial infarction, Am. J. Cardiol. 103 (2009) 907–912.
[20] A.W. Chan, J. Kornder, H. Elliott, R.I. Brown, J.F. Dorval, J. Charania, R. Zhang, L. Ding,
A. Lalani, R.A. Kuritzky, G.J. Simkus, Improved survival associated with pre-hospital
triage strategy in a large regional ST-segment elevation myocardial infarction
program, JACC Cardiovasc. Interv. 5 (2012) 1239–1246.
[21] R. Estévez-Loureiro, R. Calviño-Santos, A. López-Sainz, J.M. Vázquez-Rodríguez, M.R.
Soler-Martín, O. Prada-Delgado, E. Barge-Caballero, J. Salgado-Fernández, G.
Aldama-López, P. Piñón-Esteban, X. Flores-Ríos, M. Barreiro-Díaz, J. Varela-Portas,
M. Freire-Tellado, M. García-Guimaraes, N. Vázquez-González, A. Castro-Beiras,
Long-term prognostic benefit of field triage and direct transfer of patients with
ST-segment elevation myocardial infarction treated by primary percutaneous
coronary intervention, Am. J. Cardiol. 111 (2013) 1721–1726.
[22] A. Martinoni, S. De Servi, E. Boschetti, R. Zanini, T. Palmerini, A. Politi, G. Musumeci,
G. Belli, M. De Paolis, F. Ettori, E. Piccaluga, D. Sangiorgi, A. Repetto, M. D'Urbano, B.
Castiglioni, F. Fabbiocchi, M. Onofri, N. De Cesare, G. Sangiorgi, C. Lettieri, F. Poletti, S.
Pirelli, S. Klugmann, Lombardima Study Group, Importance and limits of pre-
hospital electrocardiogram in patients with ST elevation myocardial infarction un-
dergoing percutaneous coronary angioplasty, Eur. J. Cardiovasc. Prev. Rehabil. 18
(2011) 526–532.
[23] R. Zanini, M. Aroldi, S. Bonatti, F. Buffoli, A. Izzo, C. Lettieri, M. Romano, L. Tomasi,
M.R. Ferrari, Impact of prehospital diagnosis in the management of ST elevation
myocardial infarction in the era of primary percutaneous coronary intervention:
reduction of treatment delay and mortality, J. Cardiovasc. Med. 9 (2008) 570–575.
[24] N.D. Brunetti, L. Bisceglia, G. Dellegrottaglie, A.I. Bruno, G. Di Pietro, L. De Gennaro,
M. Di Biase, Lower mortality with pre-hospital electrocardiogram triage by telemed-
icine support in high risk acute myocardial infarction treated with primary angio-
plasty: preliminary data from the Bari-BAT public Emergency Medical Service 118
registry, Int. J. Cardiol. 185 (2015) 224–228.
[25] N.D. Brunetti, L. De Gennaro, G. Dellegrottaglie, G. Antonelli, D. Amoruso, M. Di Biase,
Prevalence of cardiac arrhythmias in pre-hospital tele-cardiology electrocardio-
grams of emergency medical service patients referred for syncope, J. Electrocardiol.
45 (2012) 727–732.
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 13, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
[26] N.D. Brunetti, L. De Gennaro, P.L. Pellegrino, G. Dellegrottaglie, G. Antonelli, M. Di
Biase, Atrial fibrillation with symptoms other than palpitations: incremental diag-
nostic sensitivity with at-home tele-cardiology assessment for emergency medical
service, Eur. J. Prev. Cardiol. 19 (2012) 306–313.
[27] N.D. Brunetti, G. Dellegrottaglie, G. Di Giuseppe, C. Lopriore, G. Gardini, S. Patruno, T.
Loiacono, L. De gennaro, M. Di Biase, YOUng Football Italian amateur players,
Remote electrocardiogram screening with telemedicine (YOU FIRST) study:
preliminary results, Int. J. Cardiol. 176 (2014) 1257–1258.
[28] N.D. Brunetti, A.R. Conoscitore, G. Dellegrottaglie, G. Di Giuseppe, L. De Gennaro, G.
Antonelli, A. Bruna, M. Di Biase, Exercise training and obesity in Italian children
directly assessed by primary school teachers with tele-cardiology support: a pilot
experience, Int. J. Cardiol. 168 (2013) 1699–1702.
[29] N.D. Brunetti, G. Dellegrottaglie, G. Di Giuseppe, M. Di Biase, Remote tele-medicine
cardiologist support for care manager nursing of chronic cardiovascular disease:
preliminary report, Int. J. Cardiol. 176 (2014) 552–556.
[30] N.D. Brunetti, L. De Gennaro, G. Dellegrottaglie, E. Straziota, V. Novielli, G. Antonelli, M.
Di Biase, Rationale and design for a cardiovascular screening and prevention study
with tele-cardiology in Mediterranean Italy: The CAPITAL study (CArdiovascular
Prevention wIth Telecardiology in ApuLia), Int. J. Cardiol. 149 (2011) 130–133.
[31] N.D. Brunetti, L. De Gennaro, G. Dellegrottaglie, V. Procacci, M. Di Biase, Fast and
furious: telecardiology for acute myocardial infarction triage in emergency room,
Eur. Res. Telemed. 2 (2013) 75–78.
[32] N.D. Brunetti, D. Amoruso, L. De Gennaro, G. Dellegrottaglie, G. Di Giuseppe, G.
Antonelli, M. Di Biase, Hot Spot: Impact of July 2011 heat-wave in southern Italy
(Apulia) on cardiovascular disease assessed by Emergency Medical Service and
tele-medicine support, Telemed. J. E Health 20 (2014) 272–281.
[33] N.D. Brunetti, G. Dellegrottaglie, G. Di Giuseppe, L. De Gennaro, M. Di Biase, Prison
break: remote tele-cardiology support for cardiology emergency in Italian
penitentiaries, Int. J. Cardiol. 168 (2013) 3138–3140.
[34] N.D. Brunetti, G. Dellegrottaglie, L. De Gennaro, M. Di Biase, Telemedicine pre-
hospital electrocardiogram for acute cardiovascular disease management in
detainees: an update, Eur. Res. Telemed. 4 (2015) 25–32.