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Alghamdi AS, Alshibani A, Binhotan M, Alharbi M, Algarni SS, Alzahrani MM, Asiri AN, Alsulami FF, Ayoub K, Alabdali A. Shortening Door-to-Balloon Time: The Use of Ambulance versus Private Vehicle for Patients with ST-Segment Elevation Acute Myocardial Infarction. Open Access Emerg Med 2023; 15:457-463. [PMID: 38145227 PMCID: PMC10740716 DOI: 10.2147/oaem.s435446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/09/2023] [Indexed: 12/26/2023] Open
Abstract
Purpose Time is critical when dealing with acute myocardial infarction (AMI) patients in the Emergency Department (ED), as 90 min is crucial for overall health. Using non-EMS transportation for critical patients, such as patients with acute myocardial infarction, to a hospital might delay the rapid identification of the underlying medical disease and initiating definitive treatment. We aim to evaluate the association between the mode of transportation and the D2B time in patients presenting at the ED with AMI. Patients and Methods We conducted a retrospective cohort study with patients who presented at ED with AMI and underwent percutaneous coronary intervention (PCI). The participants were patients with confirmed AMI at the ED of King Abdullah Medical City (KAMC) from January 2019 to December 2019. Results In total, 162 AMI patients were enrolled in the study and divided based on the method of transportation. Less than half (n=65, 40.1%) were transported with an ambulance and 97 (59.9%) patients with a private car. The door-to-balloon (D2B) time for the ambulance group was 93.6±38.31 minutes, and the private car group was 93.8±30.88 minutes. Conclusion There was no statistical significance when comparing the D2B time between the private car group and the ambulance group (P = 0.1870). Finally, ambulance transport significantly shortened the time to first ED physician contact. However, it was not associated with shortened D2B time when compared to private vehicle transport.
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Affiliation(s)
- Abdulrhman Saleh Alghamdi
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alshibani
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshary Binhotan
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshal Alharbi
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Saleh S Algarni
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, 11481, Saudi Arabia
| | - Mohammed Musaed Alzahrani
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmalik Nasser Asiri
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Faisal Faleh Alsulami
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Kamal Ayoub
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdullah Alabdali
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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2
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McLaren JTT, El-Baba M, Sivashanmugathas V, Meyers HP, Smith SW, Chartier LB. Missing occlusions: Quality gaps for ED patients with occlusion MI. Am J Emerg Med 2023; 73:47-54. [PMID: 37611526 DOI: 10.1016/j.ajem.2023.08.022] [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: 05/01/2023] [Revised: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. METHODS This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared. RESULTS Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI." CONCLUSIONS STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Mazen El-Baba
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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4
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Garcia H, Springer B, Vengrenyuk A, Krishnamoorthy P, Pineda D, Wasielewski B, Tan WA, D'Amiento A, Bastone J, Barman N, Bander J, Sweeny J, Dangas G, Gidwani U, Vengrenyuk Y, Ezenkwele U, Warshaw A, Kukar A, Chason K, Redlener M, Bai M, Siller J, Kini AS. Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project. Am Heart J 2022; 253:30-38. [PMID: 35779584 DOI: 10.1016/j.ahj.2022.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer. APPROACH App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care. CONCLUSIONS We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
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Affiliation(s)
- Haydee Garcia
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Andriy Vengrenyuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Parasuram Krishnamoorthy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Derek Pineda
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian Wasielewski
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wilfred As Tan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley D'Amiento
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Julianna Bastone
- Strategic Operations & Integration, Mount Sinai Health System, New York, NY
| | - Nitin Barman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey Bander
- Cardiology, Mount Sinai West, Mount Sinai Health System, New York, NY
| | - Joseph Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umesh Gidwani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuliya Vengrenyuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ugo Ezenkwele
- Emergency Department, Mount Sinai Queens, New York, NY
| | - Abraham Warshaw
- Transfer and Access Services, Mount Sinai Health System, New York, NY
| | - Atul Kukar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin Chason
- Emergency Medicine, Mount Sinai Health System, New York, NY
| | | | - Matthew Bai
- Cardiology, Mount Sinai West, Mount Sinai Health System, New York, NY
| | - Jennifer Siller
- Strategic Operations & Integration, Mount Sinai Health System, New York, NY
| | - Annapoorna S Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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Van Heuverswyn F, De Schepper C, De Buyzere M, Coeman M, De Pooter J, Drieghe B, Kayaert P, Timmers L, Gevaert S, Calle S, Kamoen V, Demolder A, El Haddad M, Gheeraert P. Clinical validation of a 13-lead electrocardiogram derived from a self-applicable 3-lead recording for diagnosis of myocardial supply ischaemia and common non-ischaemic electrocardiogram abnormalities at rest. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:548-558. [PMID: 36710895 PMCID: PMC9779790 DOI: 10.1093/ehjdh/ztac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/22/2022] [Indexed: 11/13/2022]
Abstract
Aims In this study, we compare the diagnostic accuracy of a standard 12-lead electrocardiogram (ECG) with a novel 13-lead ECG derived from a self-applicable 3-lead ECG recorded with the right exploratory left foot (RELF) device. The 13th lead is a novel age and sex orthonormalized computed ST (ASO-ST) lead to increase the sensitivity for detecting ischaemia during acute coronary artery occlusion. Methods and results A database of simultaneously recorded 12-lead ECGs and RELF recordings from 110 patients undergoing coronary angioplasty and 30 healthy subjects was used. Five cardiologists scored the learning data set and five other cardiologists scored the validation data set. In addition, the presence of non-ischaemic ECG abnormalities was compared. The accuracy for detection of myocardial supply ischaemia with the derived 12 leads was comparable with that of the standard 12-lead ECG (P = 0.126). By adding the ASO-ST lead, the accuracy increased to 77.4% [95% confidence interval (CI): 72.4-82.3; P < 0.001], which was attributed to a higher sensitivity of 81.9% (95% CI: 74.8-89.1) for the RELF 13-lead ECG compared with a sensitivity of 76.8% (95% CI: 71.9-81.7; P < 0.001) for the 12-lead ECG. There was no significant difference in the diagnosis of non-ischaemic ECG abnormalities, except for Q-waves that were more frequently detected on the standard ECG compared with the derived ECG (25.9 vs. 13.8%; P < 0.001). Conclusion A self-applicable and easy-to-use 3-lead RELF device can compute a 12-lead ECG plus an ischaemia-specific 13th lead that is, compared with the standard 12-lead ECG, more accurate for the visual diagnosis of myocardial supply ischaemia by cardiologists.
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Affiliation(s)
| | - Céline De Schepper
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Marc De Buyzere
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Jan De Pooter
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Benny Drieghe
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Peter Kayaert
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Liesbeth Timmers
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Simon Calle
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Victor Kamoen
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Anthony Demolder
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Milad El Haddad
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Peter Gheeraert
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
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Shahri B, Vojdanparast M, Keihanian F, Eshraghi A. De Winter presentations and considerations: a case series. J Med Case Rep 2022; 16:368. [PMID: 36217174 PMCID: PMC9552431 DOI: 10.1186/s13256-022-03604-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 09/04/2022] [Indexed: 11/22/2022] Open
Abstract
Background The electrocardiogram has a critical role in the diagnosis and risk assessment of patients presenting with chest pain in the emergency ward. Case presentation We present 11 Iranian patients with diagnosis of de Winter referred to our center. Right coronary artery involvement was seen in four cases, left circumflex artery in three cases, proximal left anterior descending artery in two cases, and middle left anterior descending artery in seven cases. We present the case of a 52-year old Iranian male patient in detail. Conclusion Recognizing the electrocardiogram of de Winter as an ST-elevation myocardial infarction equivalent in cases with suspected acute infarction is very important.
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Affiliation(s)
- Bahram Shahri
- Interventional Cardiologist, Faculty of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Vojdanparast
- Interventional Cardiologist, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Faeze Keihanian
- Echocardiologist, Faculty of Medicine, Imam Reza and Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Interventional Cardiologist, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
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7
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Kreider DL. The Ischemic Electrocardiogram. Emerg Med Clin North Am 2022; 40:663-678. [DOI: 10.1016/j.emc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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8
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Liu C, Yang F, Hu Y, Zhang J, Li X, Guo Z, Liu Y, Cong H. Combining electrocardiographic criteria for predicting acute total left main coronary artery occlusion. Front Cardiovasc Med 2022; 9:936687. [PMID: 36035902 PMCID: PMC9408578 DOI: 10.3389/fcvm.2022.936687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Prediction of left main artery (LM) occlusion may contribute to the administration of early reperfusion. We sought to identify electrocardiographic (ECG) features associated with acute total LM occlusion and explore the relationship between ECG features and collateral circulation. Methods We retrospectively studied ECGs in 84 consecutive patients with LM occlusion between January 2001 and April 2022. The ECG findings in these patients were compared with those in 468 consecutive patients with LM subtotal occlusion and non-LM occlusion. Results Three main ECG patterns were described according to the characteristics of ST elevation (STE) in LM occlusion: ST-segment elevation myocardial infarction (STEMI), STE in aVR with diffuse ST depression, and STE in both aVR and aVL. These ECG patterns were associated with different collateral filling territories. One-third STEMI in LM occlusion showed STE in the precordial leads including V1, while 2/3 STEMI showed STE in the precordial leads from V2 to V5 without STE in V1. The following ECG characteristics predicted LM occlusion: STE in both aVR and aVL; STE in I, aVL, and V2–V5 without V1; left anterior fascicular block (LAFB); right bundle branch block (RBBB) + LAFB; and prolongation of the QRS interval. The incidences of STE in aVR and STE in aVR and V1 were higher in LM subtotal occlusion than in LM occlusion. The combination of two different STE criteria (STE in aVR and aVL and STE in I, aVL, V2-V5 without V1) predicted LM occlusion with 62% sensitivity and 95% specificity. The combination of the STE criteria and fascicular block criteria (LAFB and LAFB + RBBB) further improved the specificity to 99% but reduced the sensitivity to 39%. Conclusion The combination of STE criteria predicted LM occlusion with high specificity and moderate sensitivity, and the addition of fascicular block criteria further improved the specificity with some loss of sensitivity.
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Affiliation(s)
- Chunwei Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
- Tianjin Medical University, Tianjin, China
| | - Fan Yang
- Department of Diagnostic Ultrasound, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Yuecheng Hu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jingxia Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Ximing Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Zhigang Guo
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Yin Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hongliang Cong
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
- *Correspondence: Hongliang Cong
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Kainat A, Ain NU, Boricha H, Gulzar M, Dueweke EJ. Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion. Cureus 2022; 14:e24724. [PMID: 35673311 PMCID: PMC9165533 DOI: 10.7759/cureus.24724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/28/2022] Open
Abstract
A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) revealed tall, symmetric T-waves with preceding minor concave ST-segment elevations less than 1 mm in the precordial leads (V1-V6) and 0.5 mm ST elevation in the aVR. Due to concerning ECG changes, the patient was treated for a possible non-ST-segment elevation myocardial infarction. A loading dose of aspirin and clopidogrel was given and a heparin drip was initiated. However, the patient's chest pain persisted requiring multiple sublingual nitroglycerin tablets. Later, on further review of the ECGs, the presence of de Winter T-waves was noted and led to activation of the catheterization laboratory, and an urgent left heart catheterization (LHC) was done. LHC revealed a critical 90% occlusion of the left anterior descending artery, and a drug-eluting stent was placed. The patient had a good recovery thereafter. This case emphasizes the rarity of the case and lack of awareness about the atypical de Winter pattern that is considered to be an ST-segment elevation myocardial infarction equivalent. Failure to recognize this can potentially lead to delayed intervention.
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Affiliation(s)
- Aleesha Kainat
- Internal Medicine, University of Pittsburgh Medical Center McKeesport, Pittsburgh, USA
| | - Noor Ul Ain
- Internal Medicine, University of Pittsburgh Medical Center McKeesport, Pittsburgh, USA
| | - Hetal Boricha
- Internal Medicine, University of Pittsburgh Medical Center McKeesport, Pittsburgh, USA
| | - Mahdin Gulzar
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | - Eric J Dueweke
- Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, USA
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Zhang Q, Yang DD, Xu YF, Qiu YG, Zhang ZY. De Winter electrocardiogram pattern due to type A aortic dissection: a case report. BMC Cardiovasc Disord 2022; 22:150. [PMID: 35382768 PMCID: PMC8981714 DOI: 10.1186/s12872-022-02596-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/29/2022] [Indexed: 12/06/2022] Open
Abstract
Background De Winter electrocardiograph (ECG) pattern is an atypical presentation of acute myocardial infarction (AMI) due to severe stenosis of the left anterior descending (LAD). Complications of acute aortic dissection (AD) in the setting of acute myocardial infarction (AMI) with de Winter sign are relatively rare and physicians may easily miss the diagnosis of AD. We report a case of patient with acute chest pain and de Winter ECG pattern due to AD involving the left main coronary artery (LM), LAD and left circumflex artery (LCX). Case presentation A 57-year-old male patient was initially diagnosed with AMI and then the diagnosis of acute AD was supported by transthoracic echocardiograph (TTE). After two stents were implanted respectively into the proximal LM-LAD and LM-LCX, he recovered from cardiogenic shock. Two months later, the patient underwent the surgery of ascending aorta replacement. After the surgery, there was no obvious chest discomfort during follow-up. Conclusions When an ECG shows a “de Winter pattern”, we should also consider the possibility of AD which result in LAD occlusion. TTE is a useful tool in screening for AD. Further research is needed to prove that percutaneous coronary intervention (PCI) may be a useful treatment strategy in the case of AD leading to severe LAD occlusion and unstable hemodynamics when there’s no condition to perform aortic replacement surgery immediately. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02596-8.
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Affiliation(s)
- Qing Zhang
- Department of Neurology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Dong-Dong Yang
- Department of Emergency Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China.
| | - Yi-Fei Xu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Yuan-Gang Qiu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Zhuo-Yi Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
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11
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Liu C, Yang F, Zhang J, Hu Y, Xiao J, Gao M, Wang L, Li X, Guo Z, Cong H, Liu Y. Electrocardiographic patterns predict the presence of collateral circulation and in-hospital mortality in acute total left main occlusion. BMC Cardiovasc Disord 2022; 22:144. [PMID: 35366799 PMCID: PMC8976975 DOI: 10.1186/s12872-022-02585-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/22/2022] [Indexed: 01/05/2023] Open
Abstract
Abstract
Background
Data on the clinical characteristics, electrocardiogram (ECG) findings and outcomes of patients with acute myocardial infarction (AMI) due to total unprotected left main (ULM) artery occlusion is limited.
Methods
Between 2009 and 2021, 44 patients with AMI due to total ULM occlusion underwent primary percutaneous coronary intervention (PCI) at our institution. The ECG, collateral circulation, clinical and procedural characteristics, and in-hospital mortality were retrospectively evaluated.
Results
Twenty five patients presented with shock and 18 patients had in-hospital mortality. Nineteen patients presented with ST-segment elevation myocardial infarction (STEMI), while 25 presented with non-ST-segment elevation myocardial infarction (NSTEMI). ST-segment elevation (STE) in I and STEMI were associated with the absence of collateral circulation, while STE in aVR was associated with its presence. In the NSTEMI group, patients with STE in both aVR and aVL showed more collateral filling of the left anterior descending coronary artery (LAD) territory, while patients with STE in aVR showed more collateral filling of the LAD and the left circumflex artery territory. Compared with total ULM occlusion, patients with partial ULM obstruction presented with more STE in aVR, less STE in aVR and aVL, and less STEMI. Shock, post-PCI TIMI 0–2 flow, non-STE in aVR, STEMI, and STE in I predicted in-hospital mortality. STEMI and the absence of collateral flow were significantly associated with shock.
Conclusions
STE in the precordial leads predicted the absence of collateral circulation while STE in aVR and STE in both aVR and aVL predicted different collateral filling territories in ULM occlusion. STE in I, non-STE in aVR, and STEMI predicted in-hospital mortality in these patients.
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Wu L, Huang G, Yu X, Ye M, Liu L, Ling Y, Liu X, Liu D, Zhou B, Liu Y, Zheng J, Liang S, Pu R, He X, Chen Y, Han L, Qian X. Deep Learning Networks Accurately Detect ST-Segment Elevation Myocardial Infarction and Culprit Vessel. Front Cardiovasc Med 2022; 9:797207. [PMID: 35360023 PMCID: PMC8960131 DOI: 10.3389/fcvm.2022.797207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/01/2022] [Indexed: 12/30/2022] Open
Abstract
Early diagnosis of acute ST-segment elevation myocardial infarction (STEMI) and early determination of the culprit vessel are associated with a better clinical outcome. We developed three deep learning (DL) models for detecting STEMIs and culprit vessels based on 12-lead electrocardiography (ECG) and compared them with conclusions of experienced doctors, including cardiologists, emergency physicians, and internists. After screening the coronary angiography (CAG) results, 883 cases (506 control and 377 STEMI) from internal and external datasets were enrolled for testing DL models. Convolutional neural network-long short-term memory (CNN-LSTM) (AUC: 0.99) performed better than CNN, LSTM, and doctors in detecting STEMI. Deep learning models (AUC: 0.96) performed similarly to experienced cardiologists and emergency physicians in discriminating the left anterior descending (LAD) artery. Regarding distinguishing RCA from LCX, DL models were comparable to doctors (AUC: 0.81). In summary, we developed ECG-based DL diagnosis systems to detect STEMI and predict culprit vessel occlusion, thus enhancing the accuracy and effectiveness of STEMI diagnosis.
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Affiliation(s)
- Lin Wu
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endocrine and Metabolic Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guifang Huang
- Center for Artificial Intelligence, Research Institute of Tsinghua, Pearl River Delta, Guangzhou, China
| | - Xianguan Yu
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minzhong Ye
- Novelty-Checking Center, Guangdong Institute of Scientific and Technical Information, Guangzhou, China
| | - Lu Liu
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yesheng Ling
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangyu Liu
- School of Computer Science and Engineering, Sun Yat-sen University, Guangzhou, China
| | - Dinghui Liu
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Zhou
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianrui Zheng
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Suzhen Liang
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Pu
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xuemin He
- Department of Endocrine and Metabolic Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanming Chen
- Department of Endocrine and Metabolic Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Yanming Chen
| | - Lanqing Han
- Center for Artificial Intelligence, Research Institute of Tsinghua, Pearl River Delta, Guangzhou, China
- Lanqing Han
| | - Xiaoxian Qian
- Department of Cardiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Xiaoxian Qian
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Kumar A, Chetiwal R, Tanwar S, Gupta S, Kumar R. Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.4103/jpcs.jpcs_4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Martínez-Sellés M, Juárez M, Marina-Breysse M, Lillo-Castellano JM, Ariza A. Rational and design of ST-segment elevation not associated with acute cardiac necrosis (LESTONNAC). A prospective registry for validation of a deep learning system assisted by artificial intelligence. J Electrocardiol 2021; 69:140-144. [PMID: 34763217 DOI: 10.1016/j.jelectrocard.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with chest pain and persistent ST segment elevation (STE) may not have acute coronary occlusions or serum troponin curves suggestive of acute necrosis. Our objective is the validation and cost-effectiveness analysis of a diagnostic model assisted by artificial intelligence (AI). METHODS Prospective multicenter registry in two groups of patients with STE: I) coronary arteries without significant lesions and without serum troponin curve suggestive of acute necrosis, II) myocardial infarction with acute coronary occlusion. The inclusion criteria are the following: 1) age ≥ 18 years, 2) chest pain or symptoms suggestive of myocardial ischemia, 3) STE at point J in two contiguous leads ≥0.1 mV, in V2 and V3 ≥ 0,2 mV and 4) signature of informed consent. The exclusion criteria are the following: 1) left bundle branch block, 2) acute cardiac necrosis in the absence of significant epicardial coronary artery stenosis, 3) STE ≤ 0.1 mV with pathologic Q wave, 4) severe anemia (hemoglobin <8.0 g/dl). For each patient without acute cardiac necrosis, the next patient from that center of the same sex and similar age (± 5 years) with myocardial infarction and acute coronary occlusion will be included. A manual centralized electrocardiographic analysis and another by deep learning AI will be performed. CONCLUSIONS The results of the study will provide new information for the stratification of patients with STE. Our hypothesis is that an AI analysis of the surface electrocardiogram allows a better distinction of patients with STE due to acute myocardial ischemia, from those with another etiology.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain.
| | - Miriam Juárez
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Manuel Marina-Breysse
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; IDOVEN Research, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
| | - José María Lillo-Castellano
- IDOVEN Research, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
| | - Albert Ariza
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de Bellvitge -IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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15
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Puleo P, Salen P, Manda Y, Vefali H, Agrawal S, Quddus A, Branch K, Shoemaker M, Stoltzfus J. Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation. Coron Artery Dis 2021; 32:197-204. [PMID: 32541211 PMCID: PMC8032215 DOI: 10.1097/mca.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE. METHODS Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)]. RESULTS 87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely. CONCLUSION Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed.
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Affiliation(s)
- Peter Puleo
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Philip Salen
- Department of Emergency Medicine, St. Luke’s University Hospital, Bethlehem, Pennsylvania
| | - Yugandhar Manda
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, The Heart Institute of East Texas, Lufkin, Texas
| | - Huseng Vefali
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, New York – Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Sahil Agrawal
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, St. Francis Hospital, Tulsa, Oklahoma
| | - Abdullah Quddus
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, Franciscan Health System, Michigan City, Indiana
| | | | - Melinda Shoemaker
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Jill Stoltzfus
- Biostatistics, St. Luke’s University Hospital, Bethlehem, Pennsylvania, USA
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16
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McLaren JTT, Taher AK, Kapoor M, Yi SL, Chartier LB. Sharing and Teaching Electrocardiograms to Minimize Infarction (STEMI): reducing diagnostic time for acute coronary occlusion in the emergency department. Am J Emerg Med 2021; 48:18-32. [PMID: 33838470 DOI: 10.1016/j.ajem.2021.03.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/19/2021] [Accepted: 03/21/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Limits to ST-Elevation Myocardial Infarction (STEMI) criteria may lead to prolonged diagnostic time for acute coronary occlusion. We aimed to reduce ECG-to-Activation (ETA) time through audit and feedback on STEMI-equivalents and subtle occlusions, without increasing Code STEMIs without culprit lesions. METHODS This multi-centre, quality improvement initiative reviewed all Code STEMI patients from the emergency department (ED) over a one-year baseline and one-year intervention period. We measured ETA time, from the first ED ECG to the time a Code STEMI was activated. Our intervention strategy involved a grand rounds presentation and an internal website presenting weekly local challenging cases, along with literature on STEMI-equivalents and subtle occlusions. Our outcome measure was ETA time for culprit lesions, our process measure was website views/visits, and our balancing measure was the percentage of Code STEMIs without culprit lesions. RESULTS There were 51 culprit lesions in the baseline period, and 64 in the intervention period. Median ETA declined from 28.0 min (95% confidence interval [CI] 15.0-45.0) to 8.0 min (95%CI 6.0-15.0). The website garnered 70.4 views/week and 27.7 visitors/week in a group of 80 physicians. There was no change in percentage of Code STEMIs without culprit lesions: 28.2% (95%CI 17.8-38.6) to 20.0% (95%CI 11.2-28.8%). Conclusions Our novel weekly web-based feedback to all emergency physicians was associated with a reduction in ETA time by 20 min, without increasing Code STEMIs without culprit lesions. Local ECG audit and feedback, guided by ETA as a quality metric for acute coronary occlusion, could be replicated in other settings to improve care.
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Affiliation(s)
- Jesse T T McLaren
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Ahmed K Taher
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monika Kapoor
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Soojin L Yi
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Fessele K, Fandler M, Gotthardt P. [High-risk ECGs in acute chest pain : Signs of acute ischemia beyond STEMI]. Med Klin Intensivmed Notfmed 2021; 117:510-516. [PMID: 33704510 DOI: 10.1007/s00063-021-00802-7] [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: 09/01/2020] [Revised: 12/26/2020] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obtaining an electrocardiogram (ECG) is the gold standard for initial diagnostics of atraumatic chest pain. To provide optimal patient care, the treating physician has to be proficient in recognizing early signs of myocardial ischemia. Information from the clinical assessment and typical ECG signs have to be recognized promptly in order to diagnose myocardial ischemia early. METHODS A selective literature search in international databases (PubMed, Cochrane Library, Google Scholar) was conducted; current, topic-specific websites and literature were also included and evaluated. RESULTS Several subtle ECG abnormalities exist besides the typical ST-elevation myocardial infarction (STEMI) and well-known STEMI equivalents and may point to possible myocardial ischemia. DISCUSSION To fully evaluate the ECG in patients with atraumatic chest pain, typical signs of ischemia like STEMI as well as subtle ECG signs should be recognized to allow early cardiac intervention.
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Affiliation(s)
- Klaus Fessele
- Klinik für Kardiologie, Zentrale Notaufnahme Klinikum Süd, Klinikum Nürnberg, Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Nürnberg, Deutschland
| | - Martin Fandler
- Zentrale Notaufnahme, Sozialstiftung Bamberg/Klinikum Bamberg, Bamberg, Deutschland
| | - Philipp Gotthardt
- Zentrale Notaufnahme, Klinikum Fürth, Jakob-Henle-Str. 1, 90766, Fürth, Deutschland.
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Prasad RM, Al-abcha A, Elshafie A, Radwan YA, Baloch ZQ, Abela GS. The rare presentation of the de Winter's pattern: Case report and literature review. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 3:100013. [PMID: 38558929 PMCID: PMC10978127 DOI: 10.1016/j.ahjo.2021.100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 04/04/2024]
Abstract
Although not classified as a ST elevated myocardial infarction (STEMI), the patterns known as equivalents also require prompt recognition and treatment. A 50-year-old male with no pertinent history presented to the emergency department for chest pain that radiated to his left shoulder. An electrocardiogram (EKG) revealed findings consistent with the de Winter's pattern, which were greater than 1 mm upsloping ST depressions at the J point in leads V3-V6 (maximally in leads V3-V5), tall, peaked T waves in leads II, III, and V3-V5, ST elevations in lead aVR, and 1 mm ST elevation in V1 and V2. The physical exam, troponins, and other laboratory investigations were unrevealing. Urgent, diagnostic coronary angiography revealed complete occlusion of the proximal left anterior descending (LAD) artery, which was successfully treated with percutaneous coronary intervention (PCI) and two drug-eluting stents. After the stent placement, arterial blood flow was re-established and the ECG normalized. The patient was started on guideline based treatment and discharged home once medically stable. The de Winter's pattern on electrocardiogram indicates a significant coronary artery disease. This pattern requires urgent intervention, typically percutaneous stent placement.
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Affiliation(s)
- Rohan Madhu Prasad
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
| | - Abdullah Al-abcha
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
| | - Ahmed Elshafie
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
| | - Yasser Amr Radwan
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
| | - Zulfiqar Qutrio Baloch
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
| | - George S. Abela
- Michigan State University - Sparrow Hospital, 1200 E Michigan Ave, Ste 510, Lansing, MI. 48912, United States of America
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Affiliation(s)
- Yi-Wei Cao
- Department of Electrocardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
| | - Hao-Yu Wu
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
| | - Lei Liang
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
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20
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McLaren JT, Kapoor M, Yi SL, Chartier LB. Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion. J Emerg Med 2021; 60:25-34. [DOI: 10.1016/j.jemermed.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/24/2020] [Accepted: 09/12/2020] [Indexed: 12/27/2022]
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21
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Di Toro M, Weissbacher S, Wakeling J, Stub D. The de Winter electrocardiogram pattern in a 52-year-old-male: a case report. Eur Heart J Case Rep 2020; 4:1-4. [PMID: 33447727 PMCID: PMC7793239 DOI: 10.1093/ehjcr/ytaa321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/24/2020] [Accepted: 08/19/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The 12-lead electrocardiogram (ECG) remains the primary test for diagnosis of acute myocardial infarction (MI) secondary to acute coronary occlusion or near occlusion, with insufficient collateral circulation. Decisions regarding urgent reperfusion are based on whether or not there's new ST-segment elevation. The de Winter ECG pattern is a distinct ECG pattern without any ST-segment elevation, it may be missed by anyone unfamiliar with it. CASE SUMMARY We present a case whose chief complaint was severe central chest pain, the patient was diagnosed with acute MI secondary to a culprit lesion in the left anterior descending artery, despite the ECG not meeting standard STEMI criteria. After the ECG's significance was recognized by paramedics, the patient received immediate percutaneous coronary intervention with stenting and was discharged home after a brief hospital admission. DISCUSSION In some cases, acute MI presents with ECG features that do not meet the standard criteria for STEMI diagnosis. The de Winter ECG pattern is one such example. This pattern should be immediately recognizable to those responsible for the activation of the catheterization laboratory, physicians, and paramedics included.
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Affiliation(s)
- Matthew Di Toro
- Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia
| | | | - Jarrod Wakeling
- Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia
| | - Dion Stub
- Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Cardiology, Western Health, 176 Furlong Road, St Albans, VIC 3021, Australia
- Department of Medicine, Monash University, 264 Ferntree Gully Road, Notting Hill, VIC 3168, Australia
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22
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Boivin-Proulx LA, Matteau A, Pacheco C, Bastiany A, Mansour S, Kokis A, Quan É, Gobeil F, Potter BJ. Effect of Real-Time Physician Oversight of Prehospital STEMI Diagnosis on ECG-Inappropriate and False Positive Catheterization Laboratory Activation. CJC Open 2020; 3:419-426. [PMID: 34027344 PMCID: PMC8129458 DOI: 10.1016/j.cjco.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022] Open
Abstract
Background ST-elevation myocardial infarction diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are associated with reduced total ischemic time and therefore have become the dominant ST-elevation myocardial infarction referral method in primary percutaneous coronary intervention systems. We sought to determine whether physician oversight was associated with improved diagnostic performance in a prehospital CCL activation system and what effect the additional interpretation has on treatment delay. Methods Between 2012 and 2015, all patients in 2 greater Montreal catchment areas with a chief symptom of chest paint or dyspnea had an in-the-field electrocardiogram (ECG). A machine diagnosis of "acute myocardial infarction" resulted either in automatic CCL (automated cohort without oversight) or transmission of the ECG to the receiving centre emergency physician for reinterpretation before CCL activation. System performance was assessed in terms of the proportion of false positive and inappropriate activations (IA), as well as the proportion of patients with FMC-to-device times ≤ 90 minutes. Results Four hundred twenty-eight (428) activations were analyzed (311 automated; 117 with physician oversight). Physician oversight tended to decrease IAs (7% vs 3%; P = 0.062), but was also associated with a smaller proportion of patients achieving target FMC-to-device (76% vs 60%; P < 0.001). There was no significant effect on the proportion of false positive activation. Conclusions Real-time physician oversight might be associated with fewer IAs, but also appears to have a deleterious effect on FMC-to-device performance. Identifying predictors of IA could improve overall performance by selecting ECGs that merit physician oversight and streamlining others. Larger clinical studies are warranted.
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Affiliation(s)
- Laurie-Anne Boivin-Proulx
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Alexis Matteau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | - Samer Mansour
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - André Kokis
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Éric Quan
- Hôpital Charles-Lemoyne, Greenfield Park, Québec, Canada
| | - François Gobeil
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Brian J Potter
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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Di Toro M, Stub D. Acute Myocardial Infarction Identified by Paramedics Using the Smith-Modified Sgarbossa Criteria: A Case Report. PREHOSP EMERG CARE 2020; 25:851-853. [PMID: 33151103 DOI: 10.1080/10903127.2020.1846825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Identifying acute MI in the setting of left bundle branch block (LBBB) is challenging because ST-segment elevation is often found at baseline. When faced with LBBB and ischemic symptoms, identifying which patients require urgent reperfusion therapy is critical. Sgarbossa et al. derived three criteria that can be used to help identify these patients, Smith et al. refined these criteria creating the Smith-modified Sgarbossa criteria. We present a case of LBBB meeting the Smith-modified Sgarbossa criteria, recognized by paramedics and used to activate the catheterization laboratory after normal business hours. The patient was found with 95% stenosis of the left anterior descending artery and received stenting.
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Nakayama M, Uchiyama T, Tanaka N, Ohkawauchi T, Miwa S, Hijikata N, Kobori Y, Matsuo H, Iwasaki K. Diagnostic Performance and Pressure Stability of a Novel Myocardial Ischemic Diagnostic Index - The Intracoronary-Electrocardiogram-Triggered Distal Pressure/Aortic Pressure Ratio. Circ Rep 2020; 2:665-673. [PMID: 33693193 PMCID: PMC7937502 DOI: 10.1253/circrep.cr-20-0099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 01/10/2023] Open
Abstract
Background: We hypothesized that the intracoronary-electrocardiogram (IC-ECG)-based pressure index would be more stable and precise than the instantaneous flow reserve (iFR). We investigated the usefulness of the IC-ECG-based pressure index for diagnosing myocardial ischemia. Methods and Results: Thirty-seven consecutive patients with coronary stenosis requiring physiological assessment were enrolled in the study. iFR was measured at rest and under hyperemia in 51 and 40 lesions, respectively. The IC-ECG-triggered distal pressure (Pd)/aortic pressure (Pa) ratio (ICE-T) was defined as the mean Pd/Pa ratio in the period corresponding to the isoelectric line. The ICE-T was significantly lower than the iFR both at rest and during hyperemia (P<0.00001 for both). Fluctuations in the ICE-T pressure parameters (Pd/Pa, Pa, and Pd) were significantly smaller than those of iFR both at rest and during hyperemia. The diagnostic accuracy of predicting a fractional flow reserve (FFR) ≤0.80 of the ICE-T at rest was significantly higher than that of iFR (P=0.008). Receiver operating characteristic curve analyses showed that the ICE-T predicts FFR ≤0.80 more accurately than the iFR (area under curve 0.897 vs. 0.810 for ICE-T and iFR, respectively). Conclusions: We identified the period in the IC-ECG in which resting Pd/Pa was low and constant. The IC-ECG-based algorithm may improve the accuracy of diagnosing myocardial ischemia, without increasing invasiveness, compared with pressure-dependent indices.
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Affiliation(s)
- Masafumi Nakayama
- Cardiovascular Center, Todachuo General Hospital Toda Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University Tokyo Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center Hachioji Japan
| | | | - Shunsuke Miwa
- Cardiovascular Center, Todachuo General Hospital Toda Japan
| | | | - Yuichi Kobori
- Cardiovascular Center, Todachuo General Hospital Toda Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center Gifu Japan
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University Tokyo Japan
- Department of Modern Mechanical Engineering, Waseda University Tokyo Japan
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Early detection of ST-segment elevated myocardial infarction by artificial intelligence with 12-lead electrocardiogram. Int J Cardiol 2020; 317:223-230. [PMID: 32376417 DOI: 10.1016/j.ijcard.2020.04.089] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/30/2020] [Indexed: 11/23/2022]
Abstract
Patient delay is a worldwide unsolved problem in ST-segment elevated myocardial infarction (STEMI). An accurate warning system based on electrocardiogram (ECG) may be a solution for this problem, and artificial intelligence (AI) may offer a path to improve its accuracy and efficiency. In the present study, an AI-based STEMI autodiagnosis algorithm was developed using a dataset of 667 STEMI ECGs and 7571 control ECGs. The algorithm for detecting STEMI proposed in the present study achieved an area under the receiver operating curve (AUC) of 0.9954 (95% CI, 0.9885 to 1) with sensitivity (recall), specificity, accuracy, precision and F1 scores of 96.75%, 99.20%, 99.01%, 90.86% and 0.9372 respectively, in the external evaluation. In a comparative test with cardiologists, the algorithm had an AUC of 0.9740 (95% CI, 0.9419 to 1), and its sensitivity (recall), specificity, accuracy, precision, and F1 score were 90%, 98% and 94%, 97.82% and 0.9375 respectively, while the medical doctors had sensitivity (recall), specificity, accuracy, precision and F1 score of 71.73%, 89.33%, 80.53%, 87.05% and 0.8817 respectively. This study developed an AI-based, cardiologist-level algorithm for identifying STEMI.
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26
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Rokos IC. Artificial intelligence for STEMI detection: The "Shanghai Algorithm" provides a step forward. Int J Cardiol 2020; 317:231-232. [PMID: 32659291 DOI: 10.1016/j.ijcard.2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ivan C Rokos
- Geffen School of Medicine at UCLA, Olive View-UCLA Hospital, Methodist Hospital of Arcadia, Los Angeles, CA, United States of America.
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Yuanyuan X, Zhongguo F, Bao XU, Shenghu HE. [de Winter syndrome, an easily ignored but life-threatening disease: a case report]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:919-921. [PMID: 32895157 DOI: 10.12122/j.issn.1673-4254.2020.07.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
de Winter syndrome is a special equivalent of anterior ST-segment elevation myocardial infarction (STEMI) characterized by the absence of overt ST-elevation with upsloping ST-segment depression followed by tall symmetrical T-waves in the precordial leads, often associated with total occlusion of the proximal left anterior descending coronary artery. Herein we present a case of de Winter syndrome in a 63-year-old man, whose initial ECG showed no ST-segment elevation, but subsequent coronary angiography confirmed total occlusion of the proximal LAD coronary artery. The patient was successfully treated via mechanical reperfusion therapy and stenting through percutaneous coronary intervention (PCI). de Winter syndrome is associated with a high mortality often due to insufficient awareness of this condition by clinicians. Immediate reperfusion therapy by PCI is the life-saving treatment for the patients diagnosed with this syndrome, and prompt recognition of the ECG pattern is critical to ensure the timely administration of the therapy.
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Affiliation(s)
- Xiao Yuanyuan
- Department of Cardiology, Subei People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - Fan Zhongguo
- Department of Cardiology, Subei People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - X U Bao
- Dalian Medical University, Dalian 116044, China
| | - H E Shenghu
- Department of Cardiology, Subei People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
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Lu B, Fu D, Zhou X, Gui M, Yao L, Li J. A middle-aged male patient with de Winter syndrome: a case report. BMC Cardiovasc Disord 2020; 20:342. [PMID: 32682405 PMCID: PMC7368740 DOI: 10.1186/s12872-020-01619-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
Abstract
Background De Winter syndrome accounts for approximately 2% of all patients with acute anterior myocardial infarction admitted to the emergency department, and is characterized by severe stenosis of the left anterior descending coronary artery (LAD). The ECG changes are not recognized by ECG software, and poor understanding of the syndrome among physicians may lead to misdiagnosis, delayed reperfusion, and mortality. Case presentation A 51-year-old male patient presented with a newly developed ECG pattern suggestive of de Winter Syndrome. Coronary angiography revealed anterior myocardial infarction. Based on the ECG and clinical manifestations, the patient was diagnosed with de Winter syndrome and underwent timely percutaneous coronary intervention to revascularize the left anterior descending artery (LAD). The patient showed good outcomes and no complications at 4 months after the operation. Conclusions This case highlights the importance of being aware of the possibility of de Winter syndrome in patients with symptoms of myocardial infarction but atypical ECG in order to conduct early revascularization and treatments.
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Affiliation(s)
- Bo Lu
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Deyu Fu
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China.
| | - Xunjie Zhou
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Mingtai Gui
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Lei Yao
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Jianhua Li
- Department of Cardiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No. 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
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Guo H, Zhang W, Ni C, Cai Z, Chen S, Huang X. Heat map visualization for electrocardiogram data analysis. BMC Cardiovasc Disord 2020; 20:277. [PMID: 32513239 PMCID: PMC7281952 DOI: 10.1186/s12872-020-01560-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 05/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most electrocardiogram (ECG) studies still take advantage of traditional statistical functions, and the results are mostly presented in tables, histograms, and curves. Few papers display ECG data by visual means. The aim of this study was to analyze and show data for electrocardiographic left ventricular hypertrophy (LVH) with ST-segment elevation (STE) by a heat map in order to explore the feasibility and clinical value of heat mapping for ECG data visualization. METHODS We sequentially collected the electrocardiograms of inpatients in the First Affiliated Hospital of Shantou University Medical College from July 2015 to December 2015 in order to screen cases of LVH with STE. HemI 1.0 software was used to draw heat maps to display the STE of each lead of each collected ECG. Cluster analysis was carried out based on the heat map and the results were drawn as tree maps (pedigree maps) in the heat map. RESULTS In total, 60 cases of electrocardiographic LVH with STE were screened and analyzed. STE leads were mainly in the V1, V2 and V3 leads. The ST-segment shifts of each lead of each collected ECG could be conveniently visualized in the heat map. According to cluster analysis in the heat map, STE leads were clustered into two categories, comprising of the right precordial leads (V1, V2, V3) and others (V4, V5, V6, I, II, III, aVF, aVL, aVR). Moreover, the STE amplitude in 40% (24 out of 60) of cases reached the threshold specified in the STEMI guideline. These cases also could be fully displayed and visualized in the heat map. Cluster analysis in the heat map showed that the III, aVF and aVR leads could be clustered together, the V1, V2, V3 and V4 leads could be clustered together, and the V5, V6, I and aVL leads could be clustered together. CONCLUSION Heat maps and cluster analysis can be used to fully display every lead of each electrocardiogram and provide relatively comprehensive information.
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Affiliation(s)
- Haisen Guo
- Department of Cardiology, Shantou Central Hospital, Shantou, 515000, Guangdong, China
| | - Weidai Zhang
- Department of Cardiology, Shantou Central Hospital, Shantou, 515000, Guangdong, China
| | - Chumin Ni
- Department of Cardiology, Shantou Central Hospital, Shantou, 515000, Guangdong, China
| | - Zhixiong Cai
- Department of Cardiology, Shantou Central Hospital, Shantou, 515000, Guangdong, China
| | - Songming Chen
- Department of Cardiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Shantou, 515000, Guangdong, China
| | - Xiansheng Huang
- Department of Cardiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Shantou, 515000, Guangdong, China.
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30
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Alahmad Y, Sardar S, Swehli H. De Winter T-wave Electrocardiogram Pattern Due to Thromboembolic Event: A Rare Phenomenon. Heart Views 2020; 21:40-44. [PMID: 32082500 PMCID: PMC7006330 DOI: 10.4103/heartviews.heartviews_90_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022] Open
Abstract
De winter pattern on the ECG is associated with occlusion of proximal left anterior descending artery. It is an atypical presentation of acute myocardial infarction due to LAD occlusion. We report a case due to thromboembolic occlusion of LAD after chemical cardioversion. It is imperative for cardiologists and physicians to instantly identify the De Winter pattern on ECG to appropriately triage these patients without delay.
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Affiliation(s)
- Yaser Alahmad
- Department of Adult Cardiology, Heart Hospital, Doha, Qatar
| | - Sundus Sardar
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Swehli
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
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31
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Occluded or Not? JACC Case Rep 2019; 1:663-665. [PMID: 34316901 PMCID: PMC8288577 DOI: 10.1016/j.jaccas.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/19/2019] [Accepted: 09/13/2019] [Indexed: 11/20/2022]
Abstract
This report describes the case of a 48-year-old man whose electrocardiogram after cardiopulmonary resuscitation showed up-sloping ST-segment depression at the J point in precordial leads combined with tall symmetrical T waves. This electrocardiographic pattern corresponded to de Winter syndrome and is related to proximal left anterior descending coronary artery occlusion. (Level of Difficulty: Beginner.)
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32
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Asatryan B, Vaisnora L, Manavifar N. Electrocardiographic Diagnosis of Life-Threatening STEMI Equivalents: When Every Minute Counts. JACC Case Rep 2019; 1:666-668. [PMID: 34316902 PMCID: PMC8288700 DOI: 10.1016/j.jaccas.2019.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lukas Vaisnora
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Negar Manavifar
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
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33
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Hillinger P, Strebel I, Abächerli R, Twerenbold R, Wildi K, Bernhard D, Nestelberger T, Boeddinghaus J, Badertscher P, Wussler D, Koechlin L, Zimmermann T, Puelacher C, Rubini Gimenez M, du Fay de Lavallaz J, Walter J, Geigy N, Keller DI, Reichlin T, Mueller C. Prospective validation of current quantitative electrocardiographic criteria for ST-elevation myocardial infarction. Int J Cardiol 2019; 292:1-12. [DOI: 10.1016/j.ijcard.2019.04.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/06/2019] [Accepted: 04/11/2019] [Indexed: 01/18/2023]
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Lange DC, Conte S, Pappas-Block E, Hildebrandt D, Nakamura M, Makkar R, Kar S, Torbati S, Geiderman J, McNeil N, Cercek B, Tabak SW, Rokos I, Henry TD. Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 11:e004464. [PMID: 30354373 DOI: 10.1161/circoutcomes.117.004464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCLX) remain a challenging problem. We examined the reasons for CCLX, clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCLX. METHODS AND RESULTS We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCLX was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009). CONCLUSIONS In this study, prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCLX patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCLX and influence clinical outcomes.
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Affiliation(s)
- David C Lange
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (D.C.L.)
| | - Stanley Conte
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Effie Pappas-Block
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - David Hildebrandt
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Mamoo Nakamura
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Raj Makkar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Saibal Kar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Sam Torbati
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joel Geiderman
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Nathan McNeil
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bojan Cercek
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Steven W Tabak
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA Olive View Medical Center, Los Angeles, CA (I.R.)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
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Nestelberger T, Cullen L, Lindahl B, Reichlin T, Greenslade JH, Giannitsis E, Christ M, Morawiec B, Miro O, Martín-Sánchez FJ, Wussler DN, Koechlin L, Twerenbold R, Parsonage W, Boeddinghaus J, Rubini Gimenez M, Puelacher C, Wildi K, Buerge T, Badertscher P, DuFaydeLavallaz J, Strebel I, Croton L, Bendig G, Osswald S, Pickering JW, Than M, Mueller C. Diagnosis of acute myocardial infarction in the presence of left bundle branch block. Heart 2019; 105:1559-1567. [PMID: 31142594 DOI: 10.1136/heartjnl-2018-314673] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Louise Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Bertil Lindahl
- Department of Cardiology, University Hospital Uppsala, Uppsala, Sweden
| | - Tobias Reichlin
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Jaimi H Greenslade
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Beata Morawiec
- Department of Cardiology, University Hospital, Zabrze, Poland
| | - Oscar Miro
- Department of Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Desiree Nadine Wussler
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Tobias Buerge
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jeanne DuFaydeLavallaz
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Lukas Croton
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Garnet Bendig
- Roche Forschungs-, Entwicklungs- und Produktionszentrum, Penzberg, Germany
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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Hu KC, Yu YC, Hsu CW, Chu KCW, Huang WC. De Winter Syndrome: An Underrecognized Electrocardiography Finding in Myocardial Infarction. J Emerg Med 2019; 57:97-99. [PMID: 31060843 DOI: 10.1016/j.jemermed.2019.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/22/2019] [Accepted: 03/04/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Kai-Chun Hu
- Department of Emergency, School of Medicine, College of Medicine, and the Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chung Yu
- Department of Emergency, School of Medicine, College of Medicine, and the Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chin-Wang Hsu
- Department of Emergency, School of Medicine, College of Medicine, and the Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Karen Chia Wen Chu
- Department of Emergency, School of Medicine, College of Medicine, and the Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Emergency, School of Medicine, College of Medicine, and the Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Homorodean C, Iancu AC, Dregoesc IM, Spînu M, Ober MC, Tãtaru D, Leucuţa D, Olinic M, Olinic DM. Renal Failure Impact on the Outcomes of ST-Segment Elevation Myocardial Infarction Patients Due to a Left Main Coronary Culprit Lesion Treated Using a Primary Percutaneous Coronary Intervention. J Clin Med 2019; 8:E565. [PMID: 31027307 PMCID: PMC6518004 DOI: 10.3390/jcm8040565] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (PPCI) on a left main culprit lesion have very high mortality rates. The interaction of chronic kidney disease (CKD) with such a catastrophic acute event on the background of their highly complex atherosclerotic lesions is not well established. Therefore, we sought to evaluate in these patients the influence of the estimated glomerular filtration rate (eGFR) on short- and long-term mortality. METHODS We retrospectively analyzed renal function in 81 patients with STEMI and PPCI on a left main culprit lesion from two tertiary centers. RESULTS Patients were divided in two groups according to an eGFR cut-off of 60 mL/min/1.73 m2: 40 patients with CKD and 41 without CKD. Patients with renal failure were older, had more diabetes, and had experienced more frequent myocardial infarction MIs. CKD patients had a higher baseline-SYNTAX score (p = 0.015), higher residual-SYNTAX score (p < 0.001), and lower SYNTAX revascularization index-SRI (p = 0.003). Mortality at 30-day, 1-year, and 3-year follow-ups were not significantly different between the two groups. However, when analyzed as a continuous variable, eGFR emerged as a predictor of 1-year mortality, both in univariate analysis (OR = 0.97, 95% CI: 0.95-0.99, p = 0.005) and in multivariate analysis, after adjusting for cardiogenic shock and Thrombolysis in Myocardial Infarction TIMI 0/1 flow (OR = 0.975, 95% CI: 0.95-0.99, p = 0.021). CONCLUSIONS In STEMI with PPCI on a left main culprit lesion, renal failure was associated with more complex coronary lesions and less complete revascularization, and turned out to be an independent predictor of mortality at 1-year follow-up.
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Affiliation(s)
- Cãlin Homorodean
- 1st Dept. of Internal Medicine, "Iuliu Hatieganu " University of Medicine and Pharmacy, 4000060 Cluj-Napoca, Romania.
- Emergency County Hospital, 400000 Cluj-Napoca, Romania.
| | - Adrian Corneliu Iancu
- Department of Cardiology, "Niculae Stãncioiu" Heart Institute, "Iuliu Hatieganu " University of Medicine and Pharmacy, 400001 Cluj-Napoca, Romania.
| | - Ioana Mihaela Dregoesc
- Department of Cardiology, "Niculae Stãncioiu" Heart Institute, "Iuliu Hatieganu " University of Medicine and Pharmacy, 400001 Cluj-Napoca, Romania.
| | - Mihai Spînu
- 1st Dept. of Internal Medicine, "Iuliu Hatieganu " University of Medicine and Pharmacy, 4000060 Cluj-Napoca, Romania.
| | | | - Dan Tãtaru
- 1st Dept. of Internal Medicine, "Iuliu Hatieganu " University of Medicine and Pharmacy, 4000060 Cluj-Napoca, Romania.
| | - Daniel Leucuţa
- Dept. of Medical Informatics and Biostatistics, "Iuliu Hatieganu " University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania.
| | - Maria Olinic
- 1st Dept. of Internal Medicine, "Iuliu Hatieganu " University of Medicine and Pharmacy, 4000060 Cluj-Napoca, Romania.
- Emergency County Hospital, 400000 Cluj-Napoca, Romania.
| | - Dan Mircea Olinic
- 1st Dept. of Internal Medicine, "Iuliu Hatieganu " University of Medicine and Pharmacy, 4000060 Cluj-Napoca, Romania.
- Emergency County Hospital, 400000 Cluj-Napoca, Romania.
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Degheim G, Berry A, Zughaib M. False activation of the cardiac catheterization laboratory: The price to pay for shorter treatment delay. JRSM Cardiovasc Dis 2019; 8:2048004019836365. [PMID: 31007905 PMCID: PMC6456844 DOI: 10.1177/2048004019836365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction In patients with acute ST elevation myocardial ischemia (STEMI), national
efforts have focused on reducing door-to-balloon (D2B) times for primary
percutaneous coronary intervention (PCI). This emphasis on time-to-treatment
may increase the rate of inappropriate cardiac catheterization laboratory
(CCL) activations and unnecessary healthcare utilization. To achieve lower
D2B times, community hospitals and EMS systems have enabled emergency
medical technicians (EMTs) and emergency department (ED) physicians to
activate the CCLs without immediately consulting a cardiologist. Objective The purpose of this study is to determine the rate and main causes of
inappropriate activation of the CCL which will aid in finding solutions to
reduce this occurrence. Method This is a retrospective study, based on an electronic medical system review
of all inappropriate CCL activation who presented to Providence Hospital and
Medical Centers (PHMC) in Michigan, from January 2015 to July 2016. Results The CCL was activated 375 times for suspected STEMI. The false STEMI
activation was identified in 47 patients which represents 12.5% of total CCL
activation. The vast majority of this false activation was due to
non-diagnostic electrocardiogram (ECG) that did not meet the STEMI
criteria. Conclusion The subjective interpretation of the ECG by EMTs and ED physicians tend to
show a wide variability, which may lead to higher-than-anticipated false
activation rates of up to 36% in one study. Some studies had reported that
up to 72% of inappropriate activations were caused by ECG
misinterpretations. These false activations have ramifications that lead to
both clinical and financial costs.
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Affiliation(s)
- George Degheim
- Department of Cardiology, Providence Hospital and Medical Centers/Michigan State University, Southfield, MI, USA
| | - Abeer Berry
- Department of Cardiology, Providence Hospital and Medical Centers/Michigan State University, Southfield, MI, USA
| | - Marcel Zughaib
- Department of Cardiology, Providence Hospital and Medical Centers/Michigan State University, Southfield, MI, USA
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Canakci ME, Turgay Yildirim Ö, Acar N, Mert KU. Evaluation of acute anterior myocardial infarction cases with de-Winter T waves by coronary angiography images. Turk J Emerg Med 2019; 19:83-86. [PMID: 31065609 PMCID: PMC6495063 DOI: 10.1016/j.tjem.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/28/2018] [Accepted: 10/13/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute myocardial infarction (AMI) is the leading cause of mortality worldwide and with immediate invasive strategy, the extent of myocardial injury can be reduced. In recent studies, de-Winter T waves were defined as a sign of proximal left anterior descending artery (LAD) occlusion. In this electrocardiography (ECG) pattern, no ST elevation is seen, but an upsloping ST segment depression (>1mm) beginning from J-point, and symmetrical, long and significant T waves are seen in precordial leads. CASE REPORTS We present three patients who were admitted to emergency department with symptoms of chest pain. Their ECGs revealed de-Winter T waves, therefore, coronary angiography was performed. Total LAD occlusion was observed in all patients, and stents were implanted to the culprit lesion. CONCLUSION We aim to emphasize the importance of de-Winter T waves since physicians should recognize this ECG pattern immediately in emergency situations to provide appropriate treatment to STEMI patients.
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Affiliation(s)
| | | | - Nurdan Acar
- Department of Emergency Medicine, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Kadir Ugur Mert
- Department of Cardiology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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New Predictors of Early and Late Outcomes after Primary Percutaneous Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Unprotected Left Main Coronary Artery Culprit Lesion. J Interv Cardiol 2019; 2019:8238972. [PMID: 31772547 PMCID: PMC6739789 DOI: 10.1155/2019/8238972] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 03/04/2019] [Indexed: 12/04/2022] Open
Abstract
Objectives The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA). Background Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients. Methods 30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA. Results Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049). Conclusions In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.
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Improving Electrocardiography Diagnostic Accuracy in Emergency Medical Services Personnel. CJC Open 2019; 1:28-34. [PMID: 32159079 PMCID: PMC7063641 DOI: 10.1016/j.cjco.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/29/2018] [Indexed: 01/06/2023] Open
Abstract
Background Accuracy of electrocardiogram (ECG) interpretation is important for identification of ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) personnel who recognize STEMI in the field and activate the coronary catheterization laboratory. According to previous research, there is improvement in diagnosis of STEMIs for healthcare providers who read an average of > 20 ECGs per week. This study evaluated the effectiveness of online ECG modules on improving diagnostic accuracy. Methods EMS personnel received 25 ECGs per week to interpret via an online program. Diagnostic accuracy was assessed for improvement via completion of an ECG evaluation package before and after the intervention. Job satisfaction data were collected to determine the impact of the educational initiative. Results A total of 64 participants completed the study. Overall, there was an improvement in ECG diagnostic accuracy from 50.8% to 61.2% (95% confidence interval [CI], 7.7-13.2; P < 0.0001). Specifically, there was significant improvement in the diagnosis of STEMI (8.5%; 95% CI, 4.9-12.3; P < 0.003) and supraventricular tachycardia (39.0%; 95% CI, 17.2-60.8; P < 0.008), with a trend toward improvement in all other diagnoses. These effects were sustained to 3 months (9.6%; 95% CI, 6.4-12.7; P < 0.0001). Improvement was seen regardless of employment experience and training. There was no significant impact on job satisfaction. Conclusions ECG exposure remains an important factor in improving the accuracy of ECG diagnosis in EMS personnel. Online education modules provide an easily accessible way of improving ECG interpretation with the opportunity for positive downstream effects on patient outcomes and resource use.
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Heckle MR, Efeovbokhan N, Thomas F, Blumer M, Chumpia M, Ibebuogu U, Reed GL, Khouzam RN. Accurate Prediction of False ST-Segment Elevation Myocardial Infarction: Ready for Prime Time? Curr Probl Cardiol 2018; 43:400-412. [DOI: 10.1016/j.cpcardiol.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Should de Winter T-Wave Electrocardiography Pattern Be Treated as ST-Segment Elevation Myocardial Infarction Equivalent with Consequent Reperfusion? A Dilemmatic Experience in Rural Area of Indonesia. Case Rep Cardiol 2018; 2018:6868204. [PMID: 29850267 PMCID: PMC5914128 DOI: 10.1155/2018/6868204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/01/2018] [Accepted: 03/13/2018] [Indexed: 12/17/2022] Open
Abstract
Background Although de Winter T-wave electrocardiography pattern is rare, it signifies proximal left anterior descending artery occlusion and is often unrecognized by physicians. The aim of this case report was to highlight the dilemma in the management of a patient with de Winter T-wave pattern in the hospital without interventional cardiology facility. Case Presentation A 65-year-old male presented with typical chest pain since 2 hours before admission, and ECG showed sinus rhythm of 57 bpm and >1 mm upsloping ST depression with symmetric tall T in lead V2-3 characteristic of de Winter T-wave ECG pattern. He was given dual antiplatelet therapy, nitrate, statin, and anticoagulant. He refused referral to interventional cardiology available hospital. 3 hours after admission, the electrocardiography transformed into Q-waves consistent with final stages of acute STEMI and ST-segment elevation that barely meets the threshold in the guideline, and thrombolytic was administered and successful. There is a suggestion that de Winter T-wave electrocardiography should be treated as ST-segment myocardial infarction equivalent and should undergo coronary angiography; however, not every hospital has the luxury of interventional cardiology facility. The other modality for reperfusion is thrombolysis; however, without a clear guideline and scarcity of study, we prefer to resort to conservative treatment. “Fortunately,” transformation into ST-segment elevation helps us to determine the course of action which is reperfusion using thrombolytic. Conclusions de Winter T-wave ECG pattern is not mentioned in any guidelines regarding acute coronary syndromes, and there are no clear recommendations. Physicians in rural area without interventional cardiology facility face a dilemma with the lack of evidence-based guideline. Fibrinolytic may be appropriate in those without contraindications with strong chest pain consistent with acute coronary occlusion, less than 3 hours of symptoms, and convincing de Winter T-wave ECG pattern for a rural non-PCI hospital far away from PCI capable hospital.
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Raheja P, Sekhar A, Lewis D, Samson R, Sardana V, Coram R. Wellens' syndrome over the past three decades. J Cardiovasc Med (Hagerstown) 2018; 18:803-804. [PMID: 23466752 DOI: 10.2459/jcm.0b013e32835ffbf8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Prafull Raheja
- aDivision of Cardiology, University of Louisville, Kentucky bDivision of Cardiology, University of Washington, Washington cDivision of Cardiology, University of Florida, Florida, USA
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45
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Muhrbeck J, Persson J, Hofman-Bang C. Catheterization laboratory activations and time intervals for patients with pre-hospital ECGs. SCAND CARDIOVASC J 2018; 52:74-79. [DOI: 10.1080/14017431.2018.1430899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Josephine Muhrbeck
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Jonas Persson
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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46
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Miranda DF, Lobo AS, Walsh B, Sandoval Y, Smith SW. New Insights Into the Use of the 12-Lead Electrocardiogram for Diagnosing Acute Myocardial Infarction in the Emergency Department. Can J Cardiol 2017; 34:132-145. [PMID: 29407007 DOI: 10.1016/j.cjca.2017.11.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 01/05/2023] Open
Abstract
The 12-lead electrocardiogram (ECG) remains the most immediately accessible and widely used initial diagnostic tool for guiding management in patients with suspected myocardial infarction (MI). Although the development of high-sensitivity cardiac troponin assays has improved the rule-in and rule-out and risk stratification of acute MI without ST elevation, the immediate management of the subset of acute MI with acute coronary occlusion depends on integrating clinical presentation and ECG findings. Careful interpretation of the ECG might yield subtle features suggestive of ischemia that might facilitate more rapid triage of patients with subtle acute coronary occlusion or, conversely, in identification of ST-elevation MI mimics (pseudo ST-elevation MI patterns). Our goal in this review article is to consider recent advances in the use of the ECG to diagnose coronary occlusion MIs, including the application of rules that allow MI to be diagnosed on the basis of atypical ECG manifestations. Such rules include the modified Sgarbossa criteria allowing identification of acute MI in left bundle branch block or ventricular pacing, the 3- and 4-variable formula to differentiate normal ST elevation (formerly called early repolarization) from subtle ECG signs of left anterior descending coronary artery occlusion, the differentiation of ST elevation of left ventricular aneurysm from that of acute anterior MI, and the use of lead aVL in the recognition of inferior MI. Improved use of the ECG is essential to improving the diagnosis and appropriate early management of acute coronary occlusion MIs, which will lead to improved outcomes for patients who present with acute coronary syndrome.
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Affiliation(s)
- David F Miranda
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Angie S Lobo
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Brooks Walsh
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Yader Sandoval
- Mayo Clinic, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA.
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47
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Goktas MU, Sogut O, Yigit M, Kaplan O. A Novel Electrocardiographic Sign of an ST-Segment Elevation Myocardial Infarction-Equivalent: De Winter Syndrome. Cardiol Res 2017; 8:165-168. [PMID: 28868102 PMCID: PMC5574289 DOI: 10.14740/cr576w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 08/03/2017] [Indexed: 12/17/2022] Open
Abstract
Patients with de Winter syndrome, also termed anterior ST-segment elevation myocardial infarction (STEMI)-equivalent, represent 2% of all patients with acute anterior myocardial infarctions admitted to emergency departments (EDs). STEMI-equivalents do not present with classical electrocardiogram (ECG) changes but exhibit a critical stenosis of the left anterior descending (LAD) coronary artery. This is under-recognized by clinicians and is therefore associated with high morbidity and mortality. Here, we report a rare case of a novel, typical, STEMI-equivalent ECG pattern without obvious ST-segment elevation in a 34-year-old female who presented to our ED with substantial chest pain and a large, acute, transmural anterior myocardial infarction caused by acute occlusion of the LAD coronary artery. However, she presented as a non-STEMI case. A definite diagnosis of de Winter syndrome was made on the basis of clinical and ECG findings.
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Affiliation(s)
- Mustafa Ugur Goktas
- Department of Emergency Medicine, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozgur Sogut
- Department of Emergency Medicine, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Yigit
- Department of Emergency Medicine, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Onur Kaplan
- Department of Emergency Medicine, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Lange DC, Rokos IC, Garvey JL, Larson DM, Henry TD. False Activations for ST-Segment Elevation Myocardial Infarction. Interv Cardiol Clin 2017; 5:451-469. [PMID: 28581995 DOI: 10.1016/j.iccl.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
First-medical-contact-to-device (FMC2D) times have improved over the past decade, as have clinical outcomes for patients presenting with ST-elevation myocardial infarction (STEMI). However, with improvements in FMC2D times, false activation of the cardiac catheterization laboratory (CCL) has become a challenging problem. The authors define false activation as any patient who does not warrant emergent coronary angiography for STEMI. In addition to clinical outcome measures for these patients, STEMI systems should collect data regarding the total number of CCL activations, the total number of emergency coronary angiograms, and the number revascularization procedures performed.
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Affiliation(s)
- David C Lange
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Ivan C Rokos
- Department of Emergency Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Lee Garvey
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - David M Larson
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
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49
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Patel N, Baker SM, Paterick TE, Tajik AJ. The de Winter Variation: Anterior ST-Elevation Myocardial Infarction. Am J Med 2017; 130:288-289. [PMID: 27913100 DOI: 10.1016/j.amjmed.2016.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Nachiket Patel
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville.
| | | | - Timothy E Paterick
- Methodist Cardiovascular Consultants, Methodist Health System, Dallas, Tex
| | - A Jamil Tajik
- Cardiac Specialty Centers, Aurora Health Care, Milwaukee, Wisc
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50
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Tanguay A, Brassard E, Lebon J, Bégin F, Hébert D, Paradis JM. Effectiveness of a Prehospital Wireless 12-Lead Electrocardiogram and Cardiac Catheterization Laboratory Activation for ST-Elevation Myocardial Infarction. Am J Cardiol 2017; 119:553-559. [PMID: 27939226 DOI: 10.1016/j.amjcard.2016.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/29/2022]
Abstract
The aim of the study was to determine the prevalence of false-positive and inappropriate cardiac catheterization laboratory (CCL) activation in patients suspected with ST-elevation myocardial infarction (STEMI) diverted to a percutaneous coronary intervention (PCI) facility after paramedics wireless 12-lead electrocardiogram transmission to an emergency physician at an online medical control center. This retrospective study collected data from medical records of patients with suspected STEMI from 2006 to 2014. It included demographics, coronaropathic risk factors, cardiac biomarkers, time from the first medical contact to treatment, and final diagnosis. Primary outcome was the rate of false-positive and inappropriate CCL activation. As secondary outcomes, we compared patient characteristics between cases of appropriate and inappropriate CCL activation, and we assessed the presence of cardiac biomarkers, time from first medical contact to start of PCI, and final diagnosis. Overall, 673 patients with suspected STEMI were included in the analysis. A total of 640 patients (95%) had coronarography, of which 10% (62 of 640) did not have a culprit coronary artery (false positive). Angiography was canceled for 5% (33 of 673) of patients. The total false-positive and inappropriate CCL activation rate was 14% (95 of 673). Average time from the first medical contact to the start of PCI was 47 ± 18.1 minutes. Unwanted CCL activations were more likely to involve men aged >65 years and patients with a history of coronary artery disease. In conclusion, our system of transmitted prehospital electrocardiography and STEMI interpretation by emergency physicians at an online medical control center showed a total false-positive and inappropriate CCL activation rate of 14% over the 8-year study period.
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Affiliation(s)
- Alain Tanguay
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada
| | - Eric Brassard
- Faculté de Médecine Université Laval, Québec, Québec, Canada
| | - Johann Lebon
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada.
| | - François Bégin
- Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada; Faculté de Médecine Université Laval, Québec, Québec, Canada
| | - Denise Hébert
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada
| | - Jean-Michel Paradis
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
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