1
|
Rodríguez-Leor O, Cid-Álvarez AB, Pérez de Prado A, Rosselló X, Ojeda S, Serrador A, López-Palop R, Martín-Moreiras J, Rumoroso JR, Cequier Á, Ibáñez B, Cruz-González I, Romaguera R, Raposeiras S, Moreno R. Analysis of the management of ST-segment elevation myocardial infarction in Spain. Results from the ACI-SEC Infarction Code Registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:669-680. [PMID: 35067471 DOI: 10.1016/j.rec.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/25/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES ST-segment elevation myocardial infarction (STEMI) networks should guarantee STEMI care with good clinical results and within the recommended time parameters. There is no contemporary information on the performance of these networks in Spain. The objective of this study was to analyze the clinical characteristics of patients, times to reperfusion, characteristics of the intervention performed, and 30-day mortality. METHODS Prospective, observational, multicenter registry of consecutive patients treated in 17 STEMI networks in Spain (83 centers with the Infarction Code), between April 1 and June 30, 2019. RESULTS A total of 5401 patients were attended (mean age, 64±13 years; 76.9% male), of which 4366 (80.8%) had confirmed STEMI. Of these, 87.5% were treated with primary angioplasty, 4.4% with fibrinolysis, and 8.1% did not receive reperfusion. In patients treated with primary angioplasty, the time between symptom onset and reperfusion was 193 [135-315] minutes and the time between first medical contact and reperfusion was 107 [80-146] minutes. Overall 30-day mortality due to STEMI was 7.9%, while mortality in patients treated with primary angioplasty was 6.8%. CONCLUSIONS Most patients with STEMI were treated with primary angioplasty. In more than half of the patients, the time from first medical contact to reperfusion was <120 minutes. Mortality at 30 days was relatively low.
Collapse
Affiliation(s)
- Oriol Rodríguez-Leor
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Ana Belén Cid-Álvarez
- Servicio de Cardiología, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | | | - Xavier Rosselló
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Servicio de Cardiología, Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Soledad Ojeda
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Ana Serrador
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain
| | - Ramón López-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Javier Martín-Moreiras
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - José Ramón Rumoroso
- Servicio de Cardiología, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain
| | - Ángel Cequier
- Servicio de Cardiología, Hospital de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Borja Ibáñez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Servicio de Cardiología, IIS-Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Ignacio Cruz-González
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Rafael Romaguera
- Servicio de Cardiología, Hospital de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergio Raposeiras
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Instituto de Investigación Sanitaria Galicia Sur, Vigo, Pontevedra, Spain
| | - Raúl Moreno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital de La Paz, Madrid, Spain
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Shoaib M, Huish W, Woollard EL, Aguila J, Coxall D, Alexander M, Hicks D, McQuillan B. Impact of Pre-Hospital Activation of STEMI on False Positive Activation Rate and Door to Balloon Time. Heart Lung Circ 2021; 31:447-455. [PMID: 34920950 DOI: 10.1016/j.hlc.2021.11.007] [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: 07/09/2021] [Revised: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pre-hospital identification of ST-segment elevation myocardial infarction (STEMI) by paramedical staff reduces reperfusion time. However, the impact of this approach on the rate of unnecessary activation of coronary catheterisation lab (CCL) remains unclear. METHODS The study reviewed consecutive STEMI patients over 3 years (July 2015 to June 2018) from all primary percutaneous coronary intervention (PPCI) centres and inter-hospital transfers (IHT) from non-PPCI capable centres in Western Australia. Out-of-hospital cardiac arrests (OOHCA) and STEMI calls for in-patients receiving treatment for other medical reasons were excluded. RESULTS During the 3 years study period, 1,736 STEMI cases were recorded. Pre-hospital (PH) activation occurred in 799 (46%) cases. Median door to balloon time (D2BT) was 68 minutes (IQR 63 mins). D2BT for PH activation (40 min [IQR 25 min]) was significantly lower than both the PPCI centre emergency department (ED) activation (86 min [IQR 55 min]) and IHT activation groups (108 min [IQR 55 min]), p-value <0.00001. In PH activation group 98% patients received primary PCI in less than 90 minutes compared to 54% and 26% patients in the ED and the IHT activation groups, respectively. False positive STEMI activation rate was lower in the PH activation group (2.75%) compared to ED activation (5.4%) and IHT group (6%), p-value 0.0115. The false positive rate did not vary significantly between working hours and out-of-hour calls (5% vs 4%, p-value=0.304). Pericarditis, coronary artery disease other than STEMI, atypical chest pain, and stress induced cardiomyopathy were the common diagnoses in false positive activations. CONCLUSION Pre-hospital activation of STEMI leads to reduced door to balloon times without a significant increase in inappropriate procedures, though false positive activation rates are unclear. The majority of STEMI patients transferred from non-PPCI centres failed to receive reperfusion therapy within 90 minutes of initial hospital presentation. Further studies are required to assess the benefits of thrombolysis in selected patients in inter-hospital transfer group.
Collapse
Affiliation(s)
- Muhammad Shoaib
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Wade Huish
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | | | - Jay Aguila
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Dean Coxall
- Clinical Services, St John WA, Perth, WA, Australia
| | - Mikhail Alexander
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - David Hicks
- Department of Engineering, UWA, Perth, WA, Australia
| | - Brendan McQuillan
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| |
Collapse
|
4
|
Rodríguez-Leor O, Cid-Álvarez AB, Pérez de Prado A, Rosselló X, Ojeda S, Serrador A, López-Palop R, Martín-Moreiras J, Rumoroso JR, Cequier Á, Ibáñez B, Cruz-González I, Romaguera R, Raposeiras S, Moreno R. Análisis de la atención al infarto con elevación del segmento ST en España. Resultados del Registro de Código Infarto de la ACI-SEC. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2021.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
5
|
Fakhri Y, Andersson H, Gregg RE, Babaeizadeh S, Kastrup J, Holmvang L, Clemmensen P. Diagnostic performance of a new ECG algorithm for reducing false positive cases in patients suspected acute coronary syndrome. J Electrocardiol 2021; 69:60-64. [PMID: 34571467 DOI: 10.1016/j.jelectrocard.2021.07.005] [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: 01/25/2021] [Revised: 07/03/2021] [Accepted: 07/04/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Early and correct diagnosis of ST-segment elevation myocardial infarction (STEMI) is crucial for providing timely reperfusion therapy. Patients with ischemic symptoms presenting with ST-segment elevation on the electrocardiogram (ECG) are preferably transported directly to a catheterization laboratory (Cath-lab) for primary percutaneous coronary intervention (PPCI). However, the ECG often contains confounding factors making the STEMI diagnosis challenging leading to false positive Cath-lab activation. The objective of this study was to test the performance of a standard automated algorithm against an additional high specificity setting developed for reducing the false positive STEMI calls. METHODS We included consecutive patients with an available digital prehospital ECG triaged directly to Cath-lab for acute coronary angiography between 2009 and 2012. An adjudicated discharge diagnosis of STEMI or no myocardial infarction (no-MI) was assigned for each patient. The new automatic algorithm contains a feature to reduce false positive STEMI interpretation. The STEMI performance with the standard setting (STD) and the high specificity setting (HiSpec) was tested against the adjudicated discharge diagnosis in a retrospective manner. RESULTS In total, 2256 patients with an available digital prehospital ECG (mean age 63 ± 13 years, male gender 71%) were included in the analysis. The discharge diagnosis of STEMI was assigned in 1885 (84%) patients. The STD identified 165 true negative and 1457 true positive (206 false positive and 428 false negative) cases (77.3%, 44.5%, 87.6% and 17.3% for sensitivity, specificity, PPV and NPV, respectively). The HiSpec identified 191 true negative and 1316 true positive (180 false positive and 569 false negative) cases (69.8%, 51.5%, 88.0% and 25.1% for sensitivity, specificity, PPV and NPV, respectively). From STD to HiSpec, false positive cases were reduced by 26 (12,6%), but false negative results were increased by 33%. CONCLUSIONS Implementing an automated ECG algorithm with a high specificity setting was able to reduce the number of false positive STEMI cases. However, the predictive values for both positive and negative STEMI identification were moderate in this highly selected STEMI population. Finally, due the reduced sensitivity/increased false negatives, a negative AMI statement should not be solely based on the automated ECG statement.
Collapse
Affiliation(s)
- Yama Fakhri
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark; Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark; Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.
| | - Hedvig Andersson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Richard E Gregg
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
| | - Saeed Babaeizadeh
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
| | - Jens Kastrup
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Di Marco A, Rodriguez M, Cinca J, Bayes‐Genis A, Ortiz‐Perez JT, Ariza‐Solé A, Sanchez‐Salado JC, Sionis A, Rodriguez J, Toledano B, Codina P, Solé‐González E, Masotti M, Gómez‐Hospital JA, Cequier Á, Anguera I. New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block. J Am Heart Assoc 2020; 9:e015573. [PMID: 32627643 PMCID: PMC7660719 DOI: 10.1161/jaha.119.015573] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the presence of left bundle branch block. Methods and Results A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre-2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%-95%), negative predictive value (96%-97%), efficiency (91%-94%) and area under the receiver operating characteristic curve (0.92-0.93), significantly higher than previous electrocardiographic rules (P<0.01); the specificity was good in both groups (89%-94%) as well as the control group (90%). Conclusions In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.
Collapse
Affiliation(s)
- Andrea Di Marco
- Heart Disease InstituteBellvitge University HospitalBarcelonaSpain
| | - Marcos Rodriguez
- Heart Disease InstituteBellvitge University HospitalBarcelonaSpain
| | - Juan Cinca
- Cardiology DepartmentHospital de la Santa Creu I Sant PauIIB‐SantpauCIBERCVUniversitat Autonoma de BarcelonaSpain
| | - Antoni Bayes‐Genis
- Cardiology DepartmentGermans Trias i Pujol University HospitalCIBERCVBadalonaSpain
| | | | | | | | - Alessandro Sionis
- Cardiology DepartmentHospital de la Santa Creu I Sant PauIIB‐SantpauCIBERCVUniversitat Autonoma de BarcelonaSpain
| | - Jany Rodriguez
- Cardiology DepartmentHospital ClinicCIBERCVBarcelonaSpain
| | - Beatriz Toledano
- Cardiology DepartmentGermans Trias i Pujol University HospitalCIBERCVBadalonaSpain
| | - Pau Codina
- Cardiology DepartmentGermans Trias i Pujol University HospitalCIBERCVBadalonaSpain
| | - Eduard Solé‐González
- Cardiology DepartmentHospital de la Santa Creu I Sant PauIIB‐SantpauCIBERCVUniversitat Autonoma de BarcelonaSpain
| | - Monica Masotti
- Cardiology DepartmentHospital ClinicCIBERCVBarcelonaSpain
| | | | - Ángel Cequier
- Heart Disease InstituteBellvitge University HospitalBarcelonaSpain
| | - Ignasi Anguera
- Heart Disease InstituteBellvitge University HospitalBarcelonaSpain
| |
Collapse
|
9
|
Burlacu A, Tinica G, Artene B, Simion P, Savuc D, Covic A. Peculiarities and Consequences of Different Angiographic Patterns of STEMI Patients Receiving Coronary Angiography Only: Data from a Large Primary PCI Registry. Emerg Med Int 2020; 2020:9839281. [PMID: 32765909 PMCID: PMC7387982 DOI: 10.1155/2020/9839281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/14/2020] [Accepted: 07/07/2020] [Indexed: 02/05/2023] Open
Abstract
Background. Inappropriate cardiac catheterization lab activation together with false-positive angiographies and no-culprit found coronary interventions are now reported as costly to the medical system, influencing STEMI process efficiency. We aimed to analyze data from a high-volume interventional centre (>1000 primary PCIs/year) exploring etiologies and reporting characteristics from all "blank" coronary angiographies in STEMI. METHODS In this retrospective observational single-centre cohort study, we reported two-year data from a primary PCI registry (2035 patients). "Angio-only" cases were assigned to one of these categories: (a) Takotsubo syndrome; (b) coronary embolisation; (c) myocardial infarction with nonobstructive coronary arteries; (d) myocarditis; (e) CABG-referred; (f) normal coronary arteries (mostly diagnostic errors); and (g)others (refusals and death prior angioplasty). Univariate analysis assessed correlations between each category and cardiovascular risk factors. RESULTS 412 STEMI patients received coronary angiography "only," accounting for 20.2% of cath lab activations. Barely 77 patients had diagnostic errors (3.8% from all patients) implying false-activations. 40% of "angio-only" patients (n = 165) were referred to surgery due to severe atherosclerosis or mechanical complications. Patients with diagnostic errors and normal arteries displayed strong correlations with all cardiovascular risk factors. Probably, numerous risk factors "convinced" emergency department staff to call for an angio. CONCLUSIONS STEMI network professionals often confront with coronary angiography "only" situations. We propose a classification according to etiologies. Next, STEMI guidelines should include audit recommendations and specific thresholds regarding "angio-only" patients, with specific focus on MINOCA, CABG referrals, and diagnostic errors. These measures will have a double impact: a better management of the patient, and a clearer perception about the usefulness of the investments.
Collapse
Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, "Grigore T. Popa" University of Medicine, Iasi, Romania
| | - Grigore Tinica
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, "Grigore T. Popa" University of Medicine, Iasi, Romania
| | - Bogdan Artene
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Paul Simion
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Diana Savuc
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
- "Grigore T. Popa" University of Medicine, Iasi, Romania
- The Academy of Romanian Scientists (AOSR), Bucharest, Romania
| |
Collapse
|
10
|
Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, Manoukian SV, Suter RE, Travis DT, Garvey JL. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program. J Am Heart Assoc 2020; 9:e011963. [PMID: 31957530 PMCID: PMC7033830 DOI: 10.1161/jaha.119.011963] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michael C Kontos
- Pauley Heart Center Virginia Commonwealth University Richmond VA
| | | | | | - David C Lange
- The Permanente Medical Group Kaiser Permanente Santa Clara Santa Clara CA
| | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute Torrance CA.,David Geffen School of Medicine at UCLA Los Angeles CA
| | - Timothy D Henry
- The Lindner Center for Research and Education at The Christ Hospital Cincinnati OH
| | - James J McCarthy
- Department of Emergency Medicine McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alice K Jacobs
- Section of Cardiology Department of Medicine Boston University Medical Center Boston MA
| | | | | | - Robert E Suter
- Department of Emergency Medicine UT Southwestern and Augusta University Dallas Texas.,Department of Military and Emergency Medicine Uniformed Services University Dallas TX
| | | | - J Lee Garvey
- Department of Emergency MedicineCarolinas Medical Center Charlotte NC
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Chartrain AG, Kellner CP, Mocco J. Pre-hospital detection of acute ischemic stroke secondary to emergent large vessel occlusion: lessons learned from electrocardiogram and acute myocardial infarction. J Neurointerv Surg 2018; 10:549-553. [PMID: 29298860 DOI: 10.1136/neurintsurg-2017-013428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 11/03/2022]
Abstract
Currently, there is no device capable of detecting acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO) in the pre-hospital setting. The inability to reliably identify patients that would benefit from primary treatment with endovascular thrombectomy remains an important limitation to optimizing emergency medical services (EMS) triage models and time-to-treatment. Several clinical grading scales that rely solely on clinical examination have been proposed and have demonstrated only moderate predictive ability for ELVO. Consequently, a technology capable of detecting ELVO in the pre-hospital setting would be of great benefit. An analogous scenario existed decades ago, in which pre-hospital detection of acute myocardial infarction (AMI) was unreliable until the emergence of the 12-lead ECG and its adoption by EMS providers. This review details the implementation of pre-hospital ECG (PHECG) for the detection of AMI and explores how early experience with PHECG may be applied to ELVO detection devices, once they become available.
Collapse
Affiliation(s)
| | | | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Potter BJ, Matteau A, Mansour S, Naim C, Riahi M, Essiambre R, Montigny M, Sareault I, Gobeil F. Sustained Performance of a "Physicianless" System of Automated Prehospital STEMI Diagnosis and Catheterization Laboratory Activation. Can J Cardiol 2016; 33:148-154. [PMID: 28024553 DOI: 10.1016/j.cjca.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/01/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treatment times for primary percutaneous coronary intervention frequently exceed the recommended maximum delay. Automated "physicianless" systems of prehospital cardiac catheterization laboratory (CCL) activation show promise, but have been met with resistance over concerns regarding the potential for false positive and inappropriate activations (IAs). METHODS From 2010 to 2015, first responders performed electrocardiograms (ECGs) in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of "acute myocardial infarction" resulted in immediate CCL activation and direct transfer without transmission or human reinterpretation of the ECG prior to patient arrival. Any activation resulting from a nondiagnostic ECG (no ST-elevation) was deemed an IA, whereas activations resulting from ECG's compatible with ST-elevation myocardial infarction but without angiographic evidence of a coronary event were deemed false positive. In 2012, the referral algorithm was modified to exclude supraventricular tachycardia and left bundle branch block. RESULTS There were 155 activations in the early cohort (2010-2012; prior to algorithm modification) and 313 in the late cohort (2012-2015). Algorithm modification resulted in a 42% relative decrease in the rate of IAs (12% vs 7%; P < 0.01) without a significant effect on treatment delay. CONCLUSIONS A combination of prehospital automated ST-elevation myocardial infarction diagnosis and "physicianless" CCL activation is safe and effective in improving treatment delay and these results are sustainable over time. The performance of the referral algorithm in terms of IA and false positive is at least on par with systems that ensure real-time human oversight.
Collapse
Affiliation(s)
- 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.
| | - 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; Hôpital de la Cité de la Santé, Laval, Québec, Canada
| | - Charbel Naim
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mounir Riahi
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | | | - François Gobeil
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Hôpital de la Cité de la Santé, Laval, Québec, Canada
| |
Collapse
|