Tele-ECG network reduces reperfusion deLay and mortality in STEMI patients in rural China: a real-world study

Background In China, STEMI mortality is markedly higher in rural than urban areas, primarily due to prolonged pre-hospital diagnostic and reperfusion delays. A tele-electrocardiography (tele-ECG) network addressed this barrier by equipping primary healthcare facilities with portable ECG devices for real-time transmission to a central platform, enabling remote cardiologist interpretation, pre-hospital triage, and pre-activation of the catheterization laboratory. Purposes To assess the real-world effectiveness of the tele-ECG network in reducing reperfusion delays and in-hospital mortality among patients with STEMI. Methods Using data from the Chinese Cardiovascular Association (CCA) Database between January 2022 and May 2025, this retrospective cohort study included adult patients with a confirmed diagnosis of STEMI. Patients with in-hospital symptom onset were excluded. The tele-ECG cohort included patients with ECG records transmitted via the network from primary hospital, community health center or village clinic, and who presented to the chest pain center within 48 hours after ECG acquisition. Patients not enrolled in the ECG network were included in the standard care cohort. Propensity score matching (1:5 ratio) was performed based on demographics, vital signs, cardiovascular risk factors, comorbidities, and hospital characteristics. The primary endpoint was in-hospital all-cause mortality. Secondary endpoints included onset-to-ECG, door-to-wire, and door-to-needle intervals. Results A total of 15,072 patients (median age 67 years; 86.5% male) were included in the analysis, comprising 2,512 in the tele-ECG cohort and 12,560 in the standard care cohort. All baseline covariates were well-balanced after matching (standardized mean differences <0.1). In-hospital all-cause mortality was lower in the tele-ECG cohort than in the standard care cohort (2.4% vs. 3.5%; HR 0.62; 95% CI 0.47–0.82; P<0.001). Onset-to-ECG time was shorter in the tele-ECG cohort than in the standard care cohort (median 130 vs. 160 min; P <0.001). Door-to-wire time (52 vs. 66 min; P<0.001) and door-to-needle time (23 vs. 28 min; P<0.001) were also reduced in the tele-ECG cohort. Conclusion In this large real-world cohort, the lower in-hospital mortality observed in the patients treated in the tele-ECG network may be attributable to more timely pre-hospital diagnosis and faster in-hospital reperfusion. These findings support the implementation of such networks to enhance STEMI care in resource-limited regions.