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Avdikos G, Michas G, Smith SW. From Q/Non-Q Myocardial Infarction to STEMI/NSTEMI: Why It's Time to Consider Another Simplified Dichotomy; a Narrative Literature Review. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e78 . [PMID: 36426169 PMCID: PMC9676707 DOI: 10.22037/aaem.v10i1.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute coronary syndromes (ACSs) are classified as ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) based on the presence of guideline-recommended ST-segment elevation (STE) criteria on the electrocardiogram (ECG). STEMI is associated with acute total coronary occlusion (ATO) and transmural myocardial necrosis and is managed with emergent reperfusion therapy, and NSTEMI is supposedly synonymous with subendocardial myocardial infarction without ATO. However, coronary angiograms reveal that a significant proportion of patients with NSTEMI have ATO. Here, we review articles that studied the frequency and cardiovascular outcomes of ATO in NSTEMI patients compared with those without ATO. We discuss ECG patterns of patients with suspected acute myocardial infarction that do not fulfill STEMI criteria but are associated with ATO. Under-recognition of these atypical patterns results in delays to reperfusion therapy. We also advocate revision of the current STEMI/NSTEMI paradigm because consideration of STE, by itself, out of context of other clinical and ECG features, leads to the ECG diagnosis of STEMI when the ECG actually represents a mimic ["Pseudo-STEMI"], and suggest renaming the ACSs classification as the Occlusion Myocardial Infarction (OMI)/Non-Occlusion Myocardial Infarction (NOMI) paradigm.
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Kennedy A, Doggart P, Smith SW, Finlay D, Guldenring D, Bond R, McCausland C, McLaughlin J. Device agnostic AI-based analysis of ambulatory ECG recordings. J Electrocardiol 2022; 74:154-157. [PMID: 36283253 DOI: 10.1016/j.jelectrocard.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Deep Convolutional Neural Networks (DCNNs) have been shown to provide improved performance over traditional heuristic algorithms for the detection of arrhythmias from ambulatory ECG recordings. However, these DCNNs have primarily been trained and tested on device-specific databases with standardized electrode positions and uniform sampling frequencies. This work explores the possibility of training a DCNN for Atrial Fibrillation (AF) detection on a database of single‑lead ECG rhythm strips extracted from resting 12‑lead ECGs. We then test the performance of the DCNN on recordings from ambulatory ECG devices with different recording leads and sampling frequencies. We developed an extensive proprietary resting 12‑lead ECG dataset of 549,211 patients. This dataset was randomly split into a training set of 494,289 patients and a testing set of the remaining 54,922 patients. We trained a 34-layer convolutional DCNN to detect AF and other arrhythmias on this dataset. The DCNN was then validated on two Physionet databases commonly used to benchmark automated ECG algorithms (1) MIT-BIH Arrhythmia Database and (2) MIT-BIH Atrial Fibrillation Database. Validation was performed following the EC57 guidelines, with performance assessed by gross episode and duration sensitivity and positive predictive value (PPV). Finally, validation was also performed on a selection of rhythm strips from an ambulatory ECG patch that a committee of board-certified cardiologists annotated. On MIT-BIH, The DCNN achieved a sensitivity of 100% and 84% PPV in detecting episodes of AF. and 100% sensitivity and 94% PPV in quantifying AF episode duration. On AFDB, The DCNN achieved a sensitivity of 94% and PPV of 98% in detecting episodes of AF, and 98% sensitivity and 100% PPV in quantifying AF episode duration. On the patch database, the DCNN demonstrated performance that was closely comparable to that of a cardiologist. The results indicate that DCNN models can learn features that generalize between resting 12‑lead and ambulatory ECG recordings, allowing DCNNs to be device agnostic for detecting arrhythmias from single‑lead ECG recordings and enabling a range of clinical applications.
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Al-Zaiti S, Macleod R, Dam PV, Smith SW, Birnbaum Y. Emerging ECG methods for acute coronary syndrome detection: Recommendations & future opportunities. J Electrocardiol 2022; 74:65-72. [PMID: 36027675 DOI: 10.1016/j.jelectrocard.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 12/13/2022]
Abstract
Despite being the mainstay for the initial noninvasive assessment of patients with symptomatic coronary artery disease, the 12‑lead ECG remains a suboptimal diagnostic tool for myocardial ischemia detection with only acceptable sensitivity and specificity scores. Although myocardial ischemia affects the configuration of the QRS complex and the STT waveform, current guidelines primarily focus on ST segment amplitude, which constitutes a missed opportunity and may explain the suboptimal diagnostic performance of the ECG. This possible opportunity and the low cost and ease of use of the ECG provide compelling motivation to enhance the diagnostic accuracy of the ECG to ischemia detection. This paper describes numerous computational ECG methods and approaches that have been shown to dramatically increase ECG sensitivity to ischemia detection. Briefly, these emerging approaches can be conceptually grouped into one of the following four approaches: (1) leveraging novel ECG waveform features and signatures indicative of ischemic injury other than the classical ST-T amplitude measures; (2) applying body surface potentials mapping (BSPM)-based approaches to enhance the spatial coverage of the surface ECG to detecting ischemia; (3) developing an inverse ECG solution to reconstruct anatomical models of activation and recovery pathways to detect and localize injury currents; and (4) exploring artificial intelligence (AI)-based techniques to harvest ECG waveform signatures of ischemia. We present recent advances, shortcomings, and future opportunities for each of these emerging ECG methods. Future research should focus on the prospective clinical testing of these approaches to establish clinical utility and to expedite potential translation into clinical practice.
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Bracey A, Meyers HP, Smith SW. Emergency physicians should interpret every triage ECG, including those with a computer interpretation of "normal". Am J Emerg Med 2022; 55:180-182. [PMID: 35361516 DOI: 10.1016/j.ajem.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022] Open
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Gunsolus IL, Schulz K, Sandoval Y, Smith SW, Lindgren B, Okeson B, Apple FS. Diagnostic performance of a rapid, novel, whole blood, point of care high-sensitivity cardiac troponin I assay for myocardial infarction. Clin Biochem 2022; 105-106:70-74. [PMID: 35447148 DOI: 10.1016/j.clinbiochem.2022.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We evaluated the diagnostic performance of a whole blood, point of care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay for myocardial infarction (MI) compared to central laboratory assays. METHODS Consecutive patients presenting to the emergency department with symptoms of ischemia were studied. Serial hs-cTnI testing was based on clinical indication at presentation. Parallel measurements were made using fresh whole blood on Siemens Atellica VTLi POC assay, EDTA plasma on Abbott ARCHITECT i2000 used in practice, and heparin plasma on Siemens Atellica. MI was determined according to the Fourth Universal Definition of MI using 99th percentiles. Sensitivities and negative predictive values (NPV) were calculated using 99th percentile URLs. RESULTS 1089 Patients, 418 females and 671 males, were enrolled. There were 91 (8.4%) MIs. At baseline (0 h), POC hs-cTnI assay had a sensitivity of 65.7% (95% CI 47.8-80.9) for females and 67.9% (54.0-79.7) for males and NPV of 96.4% (93.9-98.1) for females and 96.7% (94.9-98.0) for males. At 2 h, sensitivity improved to 82.9% (66.4-93.4) for females and 80.4% (67.6-89.8) for males, while NPV improved to 98.2% (96.1-99.3) and 97.9% (96.3-99.0), respectively. For central laboratory assays, comparable diagnostics were observed at 2 h: females - sensitivity 94.3% (80.8-99.3) for ARCHITECT and 79.4% (62.1-91.3) for Atellica, and NPV 99.3% (97.6-99.9) and 98.0% (95.8-99.2), respectively; males - sensitivity 87.5% (75.9-94.8) for ARCHITECT and 80.4% (67.6-89.8) for Atellica, NPVs of 98.7% (97.3-99.5) and 97.9% (96.3-99.0), respectively. CONCLUSIONS The POC, whole blood Atellica VTLi hs-cTnI assay demonstrated comparable diagnostic accuracy for MI to central laboratory assays using 99th percentiles.
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit. Resuscitation 2022; 172:24-31. [PMID: 35041876 DOI: 10.1016/j.resuscitation.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA). METHODS OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA. RESULTS 152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6). CONCLUSIONS Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.
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McLaren JTT, Meyers HP, Smith SW, Chartier LB. From STEMI to occlusion MI: paradigm shift and ED quality improvement. CAN J EMERG MED 2021; 24:250-255. [PMID: 34967919 PMCID: PMC9001399 DOI: 10.1007/s43678-021-00255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
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Dodd KW, Zvosec DL, Meyers HP, Smith SW. In Response to The Influence of Serial ECG on the Test Characteristics of the Sgarbossa Criteria in Ventricular Paced Rhythms (published in Annals volume 78, issue 6). Ann Emerg Med 2021; 79:89-90. [PMID: 34949416 DOI: 10.1016/j.annemergmed.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Indexed: 11/24/2022]
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc 2021; 10:e022866. [PMID: 34775811 PMCID: PMC9075358 DOI: 10.1161/jaha.121.022866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.
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Khawaja M, Thakker J, Kherallah R, Ye Y, Smith SW, Birnbaum Y. Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms. Curr Cardiol Rep 2021; 23:187. [PMID: 34791609 DOI: 10.1007/s11886-021-01613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW A number of criteria have been developed to aid with the diagnosis of occlusion myocardial infarction (OMI) in patients with left bundle branch block (LBBB) and ventricular paced rhythms (VPR). The current guidelines do not provide clear preference for any specific ECG criteria in LBBB and paced rhythm patients. RECENT FINDINGS This review delineates the difficulties of electrocardiographic diagnosis of OMI in both LBBB and VPR patients. We describe the original Sgarbossa and the newer criteria and their diagnostic performances. We highlight the expected changes of newer pacing modalities and how they may interfere with the electrocardiographic diagnosis of OMI. We recommend utilizing the Cai et al. algorithm, which combines clinical assessment with the Smith Modified Sgarbossa ECG criteria, for both LBBB and right ventricular pacing patients with suspected OMI. There is limited data concerning ECG changes of OMI in patients with the newer pacing modalities, such as biventricular, His-bundle, or left bundle branch pacing.
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Dodd KW, Zvosec DL, Hart MA, Glass G, Bannister LE, Body RM, Boggust BA, Brady WJ, Chang AM, Cullen L, Gómez-Vicente R, Huis In 't Veld MA, Karim RM, Meyers HP, Miranda DF, Mitchell GJ, Reynard C, Rice C, Salverda BJ, Stellpflug SJ, Tolia VM, Walsh BM, White JL, Smith SW. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Ann Emerg Med 2021; 78:517-529. [PMID: 34172301 DOI: 10.1016/j.annemergmed.2021.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/11/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.
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Gregg RE, Yang T, Smith SW, Babaeizadeh S. ECG reading differences demonstrated on two databases. J Electrocardiol 2021; 69S:75-78. [PMID: 34544590 DOI: 10.1016/j.jelectrocard.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Many studies that rely on manual ECG interpretation as a reference use multiple ECG expert interpreters and a method to resolve differences between interpreters, reflecting the fact that experts sometimes use different criteria. The aim of this study was to show the effect of manual ECG interpretation style on training automated ECG interpretation. METHODS The effect of ECG interpretation style or differing ECG criteria on algorithm training was shown in this study by careful analysis of the changes in algorithm performance when the algorithm was trained on one database and tested on a different database. Morphology related ECG interpretation was summarized in eleven abnormalities such as left bundle branch block (LBBB) and old anterior myocardial infarction (MI). Each of the two databases used in the study had a reference interpretation mapped to those eleven abnormalities. F1 algorithm performance scores across abnormalities were compared for four cases. First, the algorithm was trained and tested on randomly split database A and then trained on the training set of database A and tested on randomly chosen test set of database B. The previous two test cases were repeated for opposite databases, train and test on database B and then train on database B and test on the test set of database A. RESULTS F1 scores across abnormalities were generally higher when training and testing on the same database. F1 scores were high for bundle branch blocks (BBB) no matter the training and testing database combination. Old anterior MI F1 score dropped for one cross-database comparison and not the other suggesting a difference in manual interpretation. CONCLUSION For some abnormalities, human experts appear to have used different criteria for ECG interpretation, as evident by the difference between cross-database and within-database performance. Bundle branch blocks appear to be interpreted in a consistent manner.
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Birnbaum Y, Ye Y, Smith SW, Jneid H. Rapid Diagnosis of STEMI Equivalent in Patients With Left Bundle-Branch Block: Is It Feasible? J Am Heart Assoc 2021; 10:e023275. [PMID: 34514811 PMCID: PMC8649538 DOI: 10.1161/jaha.121.023275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Aslanger EK, Meyers HP, Smith SW. Recognizing electrocardiographically subtle occlusion myocardial infarction and differentiating it from mimics: Ten steps to or away from cath lab. TURK KARDIYOLOJI DERNEGI ARSIVI : TURK KARDIYOLOJI DERNEGININ YAYIN ORGANIDIR 2021; 49:488-500. [PMID: 34523597 DOI: 10.5543/tkda.2021.21026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
It is increasingly evident that the ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI paradigm that equates STEMI with acute coronary occlusion (ACO) is deceptive. This unfortunate paradigm, adhered to by the current guidelines, misses at least one-fourth of the ACOs, and unnecessarily over-triages a similar fraction of the patients to the catheterization laboratory. Accordingly, we have been calling for a new paradigm, the occlusion/nonocclusion MI (OMI/NOMI). Although this new OMI/NOMI paradigm is not limited to an electrocardiogram (ECG), the ECG will remain the cornerstone of this new paradigm because of its speed, repeatability, noninvasive nature, wide availability, and high diagnostic power for OMI. This review provides a step-by-step approach to ECG for the diagnosis of OMI.
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Daunic AP, Corbett NL, Smith SW, Algina J, Poling D, Worth M, Boss D, Crews E, Vezzoli J. Efficacy of the social-emotional learning foundations curriculum for kindergarten and first grade students at risk for emotional and behavioral disorders. J Sch Psychol 2021; 86:78-99. [PMID: 34051919 DOI: 10.1016/j.jsp.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 01/07/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Abstract
Researchers have shown that children's social-emotional growth is inextricably connected to academic learning. We developed the Social-Emotional Learning Foundations (SELF) intervention, a Grade K-1 curriculum merging social-emotional learning (SEL) and literacy instruction, to promote language supported self-regulation, specifically for primary grade children at early risk for emotional or behavioral difficulties. We report findings from a pretest-posttest cluster randomized efficacy trial with one fixed between-subjects factor to test the effects of teacher-delivered SEL instruction against those of business as usual (BAU). We recruited 163 kindergarten (K) and 141 first grade teachers from 52 schools across 11 school districts within one southeastern state. Our student sample (n = 1154) consisted of 627 kindergarteners and 527 first graders identified by teachers as at risk for internalizing or externalizing emotional and behavioral problems using the Systematic Screening for Behavioral Disorders; 613 of these students participated in the SELF condition and 541 participated in the BAU condition. We randomly assigned schools to SELF or BAU and used a multilevel model with three levels (i.e., children, classrooms, schools) to analyze data on subscales of six (four teacher-report and two direct) assessments related to self-regulation, social-emotional learning, social-emotional vocabulary, and general behavioral functioning. We found positive main effects of SELF compared to BAU on all but one measure, with effect sizes (calculated using Hedges' g) ranging from 0.20 to 0.65. Findings provide evidence for guiding future SEL intervention research and informing practice to improve student outcomes, particularly for children at risk for behavior problems.
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Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. IJC HEART & VASCULATURE 2021; 33:100767. [PMID: 33912650 PMCID: PMC8065286 DOI: 10.1016/j.ijcha.2021.100767] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.
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Key Words
- ACS, Acute coronary syndrome
- AMI, acute myocardial infarction
- Acute coronary syndromes
- ECG, Electrocardiogram
- ED, Emergency department
- Electrocardiography
- LBBB, Left Bundle Branch Block
- MIRO, Myocardial Infarction Ruled Out
- MSC, Modified Sgarbossa Criteria
- NOMI, Non-occlusion myocardial infarction
- NSTEMI, Non-ST-segment elevation myocardial infarction
- OMI, Occlusion myocardial infarction
- Occlusion myocardial infarction
- ST elevation myocardial infarction
- STD, ST-segment depression
- STE, ST-segment elevation
- STEMI, ST-segment elevation myocardial infarction
- VPR, Ventricular Paced Rhythm
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Sandoval Y, Smith SW, Sexter A, Schulz K, Apple FS. Incidence and Prognostic Impact of Infection in Patients with Type 1 and 2 Myocardial Infarction. Clin Chem 2021; 66:1240-1241. [PMID: 32712646 DOI: 10.1093/clinchem/hvaa138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med 2021; 60:273-284. [DOI: 10.1016/j.jemermed.2020.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023]
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Aslanger EK, Meyers HP, Smith SW. Time for a new paradigm shift in myocardial infarction. Anatol J Cardiol 2021; 25:156-162. [PMID: 33690129 PMCID: PMC8114732 DOI: 10.5152/anatoljcardiol.2021.89304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/08/2021] [Indexed: 11/22/2022] Open
Abstract
The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.
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Aslanger EK, Meyers HP, Bracey A, Smith SW. The STEMI/NonSTEMI Dichotomy needs to be replaced by Occlusion MI vs. Non-Occlusion MI. Int J Cardiol 2021; 330:15. [PMID: 33577907 DOI: 10.1016/j.ijcard.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
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Wereski R, Chapman AR, Lee KK, Smith SW, Lowe DJ, Gray A, Mills NL. High-Sensitivity Cardiac Troponin Concentrations at Presentation in Patients With ST-Segment Elevation Myocardial Infarction. JAMA Cardiol 2021; 5:1302-1304. [PMID: 32785613 PMCID: PMC7675101 DOI: 10.1001/jamacardio.2020.2867] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kavsak PA, Hammarsten O, Worster A, Smith SW, Apple FS. Cardiac Troponin Testing in Patients with COVID-19: A Strategy for Testing and Reporting Results. Clin Chem 2021; 67:107-113. [PMID: 33045044 PMCID: PMC7665403 DOI: 10.1093/clinchem/hvaa225] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged late in 2019 causing COVID-19 (coronavirus disease-2019) may adversely affect the cardiovascular system. Publications from Asia, Europe, and North America have identified cardiac troponin as an important prognostic indicator for patients hospitalized with COVID-19. We recognized from publications within the first 6 months of the pandemic that there has been much uncertainty on the reporting, interpretation, and pathophysiology of an increased cardiac troponin concentration in this setting. CONTENT The purpose of this mini-review is: a) to review the pathophysiology of SARS-CoV-2 and the cardiovascular system, b) to overview the strengths and weaknesses of selected studies evaluating cardiac troponin in patients with COVID-19, and c) to recommend testing strategies in the acute period, in the convalescence period and in long-term care for patients who have become ill with COVID-19. SUMMARY This review provides important educational information and identifies gaps in understanding the role of cardiac troponin and COVID-19. Future, properly designed studies will hopefully provide the much-needed evidence on the path forward in testing cardiac troponin in patients with COVID-19.
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Bracey A, Meyers HP, Smith SW. Post-arrest wide complex rhythm: What is the cause of death? Am J Emerg Med 2021; 45:683.e5-683.e7. [PMID: 33353817 DOI: 10.1016/j.ajem.2020.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old man presented to the ED following witnessed cardiac arrest. After return of spontaneous circulation, an ECG was performed which demonstrated a wide complex rhythm with "shark fin" morphology. With careful examination it is possible to identify the J point and determine that the electrocardiogram (ECG) findings actually represent massive ST-elevation indicative of occlusion myocardial infarction (OMI). Initial troponin was undetectable. The patient underwent emergent cardiac catheterization and had a 100% proximal LAD occlusion that was successfully stented. The patient was discharged home neurologically intact several days later. This case highlights the importance of careful ECG interpretation and the limitations of troponin assays in the evaluation of acute coronary syndrome. Most importantly, we demonstrate how to evaluate for ST elevation in the context of a widened QRS complex.
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Smith SW, Strobel AM, Saenger AK, Apple FS. Laboratory findings in a child with SARS-CoV-2 (COVID-19) multisystem inflammatory syndrome. Clin Chem Lab Med 2021; 59:e259-e261. [PMID: 33554562 DOI: 10.1515/cclm-2020-1699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
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Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. Respone to: "Limitations of Retrospective Chart Reviews to Determine Rare Events, and the Unknown Relative Risk of Droperidol". West J Emerg Med 2020; 22:396-397. [PMID: 33856329 PMCID: PMC7972375 DOI: 10.5811/westjem.2020.9.49870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
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