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Smith SW, Meyers HP. ST Elevation is a poor surrogate for acute coronary occlusion. Let's Replace STEMI with Occlusion MI (OMI)!! Int J Cardiol 2024; 407:131980. [PMID: 38513733 DOI: 10.1016/j.ijcard.2024.131980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Stephen W Smith
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States; Department of Emergency Medicine, Hennepin Healthcare and The University of Minnesota School of Medicine, United States.
| | - H Pendell Meyers
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States
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Bishop AJ, Nehme Z, Nanayakkara S, Anderson D, Stub D, Meadley BN. Artificial neural networks for ECG interpretation in acute coronary syndrome: A scoping review. Am J Emerg Med 2024; 83:1-8. [PMID: 38936320 DOI: 10.1016/j.ajem.2024.06.026] [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: 04/28/2024] [Revised: 06/13/2024] [Accepted: 06/22/2024] [Indexed: 06/29/2024] Open
Abstract
INTRODUCTION The electrocardiogram (ECG) is a crucial diagnostic tool in the Emergency Department (ED) for assessing patients with Acute Coronary Syndrome (ACS). Despite its widespread use, the ECG has limitations, including low sensitivity of the STEMI criteria to detect Acute Coronary Occlusion (ACO) and poor inter-rater reliability. Emerging ECG features beyond the traditional STEMI criteria show promise in improving early ACO diagnosis, but complexity hinders widespread adoption. The potential integration of Artificial Neural Networks (ANN) holds promise for enhancing diagnostic accuracy and addressing reliability issues in ECG interpretation for ACO symptoms. METHODS Ovid MEDLINE, CINAHL, EMBASE, Cochrane, PubMed and Scopus were searched from inception through to 8th of December 2023. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they reported the use of ANN for ECG interpretation of Acute Coronary Syndrome in the Emergency Department patients. RESULTS The search yielded a total of 244 articles. After removing duplicates and excluding non-relevant articles, 14 remained for analysis. There was significant heterogeneity in the types of ANN models used and the outcomes assessed, making direct comparisons challenging. Nevertheless, ANN appeared to demonstrate higher accuracy than physician interpreters for the evaluated outcomes and this proved independent of both specialty and years of experience. CONCLUSIONS The interpretation of ECGs in patients with suspected ACS using ANN appears to be accurate and potentially superior when compared to human interpreters and computerised algorithms. This appears consistent across various ANN models and outcome variables. Future investigations should emphasise ANN interpretation of ECGs in patients with ACO, where rapid and accurate diagnosis can significantly benefit patients through timely access to reperfusion therapies.
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Affiliation(s)
- Andrew J Bishop
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia.
| | - Ziad Nehme
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Ambulance Victoria, Doncaster, Victoria, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Benjamin N Meadley
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia
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de Alencar Neto JN, Scheffer MK, Correia BP, Franchini KG, Felicioni SP, De Marchi MFN. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Int J Cardiol 2024; 402:131889. [PMID: 38382857 DOI: 10.1016/j.ijcard.2024.131889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/07/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To evaluate the diagnostic sensitivity and specificity of ST-segment elevation on a 12‑lead ECG in detecting ACO across any coronary artery, challenging the current STEMI-NSTEMI paradigm. METHODS Studies from MEDLINE and Scopus (2012-2023) comparing ECG findings with coronary angiograms were systematically reviewed and analyzed following PRISMA-DTA guidelines. QUADAS-2 assessed the risk of bias. STUDY SELECTION Studies included focused on AMI patients and provided data enabling the construction of contingency tables for sensitivity and specificity calculation, excluding those with non-ACS conditions, outdated STEMI criteria, or a specific focus on bundle branch blocks or other complex diagnoses. Data were extracted systematically and pooled test accuracy estimates were computed using MetaDTA software, employing bivariate analyses for within- and between-study variation. The primary outcomes measured were the sensitivity and specificity of ST-segment elevation in detecting ACO. RESULTS Three studies with 23,704 participants were included. The pooled sensitivity of ST-segment elevation for detecting ACO was 43.6% (95% CI: 34.7%-52.9%), indicating that over half of ACO cases may not exhibit ST-segment elevation. The specificity was 96.5% (95% CI: 91.2%-98.7%). Additional analysis using the OMI-NOMI strategy showed improved sensitivity (78.1%, 95% CI: 62.7%-88.3%) while maintaining similar specificity (94.4%, 95% CI: 88.6%-97.3%). CONCLUSION The findings reveal a significant diagnostic gap in the current STEMI-NSTEMI paradigm, with over half of ACO cases potentially lacking ST-segment elevation. The OMI-NOMI strategy could offer an improved diagnostic approach. The high heterogeneity and limited number of studies necessitate cautious interpretation and further research in diverse settings.
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Herman R, Meyers HP, Smith SW, Bertolone DT, Leone A, Bermpeis K, Viscusi MM, Belmonte M, Demolder A, Boza V, Vavrik B, Kresnakova V, Iring A, Martonak M, Bahyl J, Kisova T, Schelfaut D, Vanderheyden M, Perl L, Aslanger EK, Hatala R, Wojakowski W, Bartunek J, Barbato E. International evaluation of an artificial intelligence-powered electrocardiogram model detecting acute coronary occlusion myocardial infarction. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:123-133. [PMID: 38505483 PMCID: PMC10944682 DOI: 10.1093/ehjdh/ztad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/13/2023] [Accepted: 11/02/2023] [Indexed: 03/21/2024]
Abstract
Aims A majority of acute coronary syndromes (ACS) present without typical ST elevation. One-third of non-ST-elevation myocardial infarction (NSTEMI) patients have an acutely occluded culprit coronary artery [occlusion myocardial infarction (OMI)], leading to poor outcomes due to delayed identification and invasive management. In this study, we sought to develop a versatile artificial intelligence (AI) model detecting acute OMI on single-standard 12-lead electrocardiograms (ECGs) and compare its performance with existing state-of-the-art diagnostic criteria. Methods and results An AI model was developed using 18 616 ECGs from 10 543 patients with suspected ACS from an international database with clinically validated outcomes. The model was evaluated in an international cohort and compared with STEMI criteria and ECG experts in detecting OMI. The primary outcome of OMI was an acutely occluded or flow-limiting culprit artery requiring emergent revascularization. In the overall test set of 3254 ECGs from 2222 patients (age 62 ± 14 years, 67% males, 21.6% OMI), the AI model achieved an area under the curve of 0.938 [95% confidence interval (CI): 0.924-0.951] in identifying the primary OMI outcome, with superior performance [accuracy 90.9% (95% CI: 89.7-92.0), sensitivity 80.6% (95% CI: 76.8-84.0), and specificity 93.7 (95% CI: 92.6-94.8)] compared with STEMI criteria [accuracy 83.6% (95% CI: 82.1-85.1), sensitivity 32.5% (95% CI: 28.4-36.6), and specificity 97.7% (95% CI: 97.0-98.3)] and with similar performance compared with ECG experts [accuracy 90.8% (95% CI: 89.5-91.9), sensitivity 73.0% (95% CI: 68.7-77.0), and specificity 95.7% (95% CI: 94.7-96.6)]. Conclusion The present novel ECG AI model demonstrates superior accuracy to detect acute OMI when compared with STEMI criteria. This suggests its potential to improve ACS triage, ensuring appropriate and timely referral for immediate revascularization.
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Affiliation(s)
- Robert Herman
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | | | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Dario T Bertolone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Konstantinos Bermpeis
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Michele M Viscusi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Marta Belmonte
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | | | - Vladimir Boza
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Faculty of Mathematics, Physics and Informatics, Comenius University in Bratislava, Bratislava, Slovakia
| | - Boris Vavrik
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Viera Kresnakova
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Department of Cybernetics and Artificial Intelligence, Technical University of Kosice, Kosice, Slovakia
| | - Andrej Iring
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Michal Martonak
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Jakub Bahyl
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Timea Kisova
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry, London, UK
| | - Dan Schelfaut
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Marc Vanderheyden
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petah Tikvah, Israel
| | - Emre K Aslanger
- Department of Cardiology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Robert Hatala
- Department of Arrhythmia and Pacing, National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Jozef Bartunek
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Lindow T, Mokhtari A, Nyström A, Koul S, Smith SW, Ekelund U. Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction. Int J Cardiol 2024; 395:131569. [PMID: 37931659 DOI: 10.1016/j.ijcard.2023.131569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. METHODS The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. RESULTS In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). CONCLUSIONS Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.
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Affiliation(s)
- Thomas Lindow
- Clinical Physiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Clinical Physiology, Department of Research and Development, Region Kronoberg, Växjö Central Hospital, Växjö, Sweden.
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Axel Nyström
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Stephen W Smith
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ulf Ekelund
- Emergency Medicine, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Emergency Medicine, Skåne University Hospital, Lund, Sweden
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McLaren JTT, Smith SW. A Bayesian approach to acute coronary occlusion. J Electrocardiol 2023; 81:300-302. [PMID: 37951822 DOI: 10.1016/j.jelectrocard.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023]
Abstract
In the STEMI paradigm, the disease (acute coronary occlusion) is defined and named after one element (ST elevation, without regard to the remainder of the QRST) of one imperfect test (the ECG). This leads to delayed reperfusion for patients with acute coronary occlusion whose ECGs don't meet STEMI criteria. In this editorial, we elaborate on the article by Jose Nunes de Alencar Neto about applying Bayesian reasoning to ECG interpretation. The Occlusion MI (OMI) paradigm offers evidencebased advances in ECG interpretation, expert-trained artificial intelligence, and a paradigm shift that incorporates a Bayesian approach to acute coronary occlusion.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Country Medical Centre, Minneapolis, MN, USA.
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Smith SW, Meyers HP. Hyperacute T-waves Can Be a Useful Sign of Occlusion Myocardial Infarction if Appropriately Defined. Ann Emerg Med 2023; 82:203-206. [PMID: 36872197 DOI: 10.1016/j.annemergmed.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and University of Minnesota School of Medicine, Minneapolis, MN.
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc 2021; 10:e022866. [PMID: 34775811 PMCID: PMC9075358 DOI: 10.1161/jaha.121.022866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.
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Affiliation(s)
- H Pendell Meyers
- Department of Emergency Medicine Carolinas Medical Center Charlotte NC
| | - Alexander Bracey
- Department of Emergency Medicine Albany Medical Center Albany NY
| | - Daniel Lee
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Andrew Lichtenheld
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Wei J Li
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Daniel D Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Zach Rollins
- William Beaumont School of Medicine Oakland University Rochester MI
| | - Jesse A Kane
- Department of Cardiology Stony Brook University Hospital Stony Brook NY
| | - Kenneth W Dodd
- Department of Emergency Medicine Advocate Christ Medical Center Oak Lawn IL
| | - Kristen E Meyers
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Gautam R Shroff
- Division of Cardiology Department of Medicine Hennepin County Medical Center University of Minnesota Medical School Minneapolis MN
| | - Adam J Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Stephen W Smith
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN.,Department of Emergency Medicine University of Minnesota Medical Center Minneapolis MN
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Dodd KW, Zvosec DL, Hart MA, Glass G, Bannister LE, Body RM, Boggust BA, Brady WJ, Chang AM, Cullen L, Gómez-Vicente R, Huis In 't Veld MA, Karim RM, Meyers HP, Miranda DF, Mitchell GJ, Reynard C, Rice C, Salverda BJ, Stellpflug SJ, Tolia VM, Walsh BM, White JL, Smith SW. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Ann Emerg Med 2021; 78:517-529. [PMID: 34172301 DOI: 10.1016/j.annemergmed.2021.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/11/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.
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Affiliation(s)
- Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | | | - Michael A Hart
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN; Minneapolis Heart Institute, Minneapolis, MN
| | - George Glass
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA
| | - Laura E Bannister
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard M Body
- Department of Emergency Medicine, Central Manchester University Hospital, Manchester, United Kingdom
| | - Brett A Boggust
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - William J Brady
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA
| | - Anna M Chang
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Rafael Gómez-Vicente
- Department of Cardiology, Central Defense Hospital, Alcala University, Madrid, Spain
| | | | - Rehan M Karim
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - H Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - David F Miranda
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN; Minneapolis Heart Institute, Minneapolis, MN
| | - Gary J Mitchell
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Charles Reynard
- Department of Emergency Medicine, Central Manchester University Hospital, Manchester, United Kingdom
| | - Clifford Rice
- Department of Emergency Medicine, NorthShore University HealthSystem, Evanston, IL
| | | | | | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Brooks M Walsh
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, CT
| | - Jennifer L White
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
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10
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Barnicle RN, Correia AR, Meyers HP. Anterior ST Elevation: Early Repolarization or Occlusion Myocardial Infarction? Ann Emerg Med 2021; 77:593-596. [PMID: 34030773 DOI: 10.1016/j.annemergmed.2020.09.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ryan N Barnicle
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Amanda R Correia
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
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Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. IJC HEART & VASCULATURE 2021; 33:100767. [PMID: 33912650 PMCID: PMC8065286 DOI: 10.1016/j.ijcha.2021.100767] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.
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Key Words
- ACS, Acute coronary syndrome
- AMI, acute myocardial infarction
- Acute coronary syndromes
- ECG, Electrocardiogram
- ED, Emergency department
- Electrocardiography
- LBBB, Left Bundle Branch Block
- MIRO, Myocardial Infarction Ruled Out
- MSC, Modified Sgarbossa Criteria
- NOMI, Non-occlusion myocardial infarction
- NSTEMI, Non-ST-segment elevation myocardial infarction
- OMI, Occlusion myocardial infarction
- Occlusion myocardial infarction
- ST elevation myocardial infarction
- STD, ST-segment depression
- STE, ST-segment elevation
- STEMI, ST-segment elevation myocardial infarction
- VPR, Ventricular Paced Rhythm
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Affiliation(s)
- H. Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Albany Medical Center, Albany NY, USA
| | - Daniel Lee
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrew Lichtenheld
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Wei J. Li
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Daniel D. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Zach Rollins
- William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | - Jesse A. Kane
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Kenneth W. Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kristen E. Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Gautam R. Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stephen W. Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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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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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med 2021; 60:273-284. [DOI: 10.1016/j.jemermed.2020.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023]
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Bracey A, Meyers HP, Smith SW. Post-arrest wide complex rhythm: What is the cause of death? Am J Emerg Med 2021; 45:683.e5-683.e7. [PMID: 33353817 DOI: 10.1016/j.ajem.2020.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old man presented to the ED following witnessed cardiac arrest. After return of spontaneous circulation, an ECG was performed which demonstrated a wide complex rhythm with "shark fin" morphology. With careful examination it is possible to identify the J point and determine that the electrocardiogram (ECG) findings actually represent massive ST-elevation indicative of occlusion myocardial infarction (OMI). Initial troponin was undetectable. The patient underwent emergent cardiac catheterization and had a 100% proximal LAD occlusion that was successfully stented. The patient was discharged home neurologically intact several days later. This case highlights the importance of careful ECG interpretation and the limitations of troponin assays in the evaluation of acute coronary syndrome. Most importantly, we demonstrate how to evaluate for ST elevation in the context of a widened QRS complex.
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Affiliation(s)
- Alexander Bracey
- Albany Medical Center, Department of Emergency Medicine, Albany, NY, USA.
| | - H Pendell Meyers
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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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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Lindow T, Smith SW. The Search for Strategies to Better Identify Patients With Acute Coronary Occlusion But No ST Elevation Should Not Be Abandoned. Am J Cardiol 2020; 126:108-109. [PMID: 32359716 DOI: 10.1016/j.amjcard.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Region Kronoberg, Sweden Clinical Physiology, Clinical Sciences, Lund University, Sweden.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
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