1
|
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.
Collapse
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
| |
Collapse
|
2
|
McLaren JTT, Meyers HP, Smith SW, Chartier LB. Emergency department Code STEMI patients with initial electrocardiogram labeled "normal" by computer interpretation: A 7-year retrospective review. Acad Emerg Med 2024; 31:296-300. [PMID: 37620163 DOI: 10.1111/acem.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, North Carolina, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Wu YH, Li AH, Chen TC, Liu JK, Tsai KC, Ho MP. Compared with physician overread, computer is less accurate but helpful in interpretation of electrocardiography for ST-segment elevation myocardial infarction. J Electrocardiol 2023; 81:60-65. [PMID: 37572584 DOI: 10.1016/j.jelectrocard.2023.07.013] [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: 06/21/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION Previous studies have demonstrated varying sensitivity and specificity of computer-interpreted electrocardiography (CIE) in identifying ST-segment elevation myocardial infarction (STEMI). This study aims to evaluate the accuracy of contemporary computer software in recognizing electrocardiography (ECG) signs characteristic of STEMI compared to emergency physician overread in clinical practice. MATERIAL AND METHODS In this retrospective observational single-center study, we reviewed the records of patients in the emergency department (ED) who underwent ECGs and troponin tests. Both the Philips DXL 16-Lead ECG. Algorithm and on-duty emergency physicians interpreted each standard 12‑lead ECG. The sensitivity and specificity of computer interpretation and physician overread ECGs for the definite diagnosis of STEMI were calculated and compared. RESULTS Among the 9340 patients included in the final analysis, 133 were definitively diagnosed with STEMI. When "computer-reported infarct or injury" was used as the indicator, the sensitivity was 87.2% (95% CI 80.3% to 92.4%) and the specificity was 86.2% (95% CI 85.5% to 86.9%). When "physician-overread STEMI" was used as the indicator, the sensitivity was 88.0% (95% CI 81.2% to 93.0%) and the specificity was 99.9% (95% CI 99.8% to 99.9%). The area under the receiver operating characteristic curve for physician-overread STEMI and computer-reported infarct or injury were 0.939 (95% CI 0.907 to 0.972) and 0.867 (95% CI 0.834 to 0.900), respectively. CONCLUSIONS This study reveals that while the sensitivity of the computer in recognizing ECG signs of STEMI is similar to that of physicians, physician overread of ECGs is more specific and, therefore, more accurate than CIE.
Collapse
Affiliation(s)
- Yuan-Hui Wu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan.
| | - Ai-Hsien Li
- Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tsan-Chi Chen
- Department of Medical Research, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Jen-Kuei Liu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuang-Chau Tsai
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| |
Collapse
|
4
|
Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, Paulmichl R, Giudiceandrea A, Bonora A, Pfeifer N, Turcato G. Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study. Int Emerg Nurs 2023; 68:101273. [PMID: 36924577 DOI: 10.1016/j.ienj.2023.101273] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. METHODS All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event. RESULTS Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). CONCLUSIONS ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.
Collapse
Affiliation(s)
- Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano-Bozen, Italy; Institute of Nursing Science, Department of Public Health, University of Basel, Switzerland
| | - Serena Sibilio
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Elia Toccolini
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Rupert Paulmichl
- Department of Cardiology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | | | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| |
Collapse
|
5
|
Bracey A, Meyers HP, Smith SW. Emergency physicians should interpret every triage ECG, including those with a computer interpretation of "normal". Am J Emerg Med 2022; 55:180-182. [PMID: 35361516 DOI: 10.1016/j.ajem.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, USA.
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, 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
| |
Collapse
|
6
|
Holmes JF, Winters LJ, Bing ML. In response to "Emergency physicians should interpret every triage ECG, including those with a computer interpretation of normal". Am J Emerg Med 2022; 55:183-184. [PMID: 35339335 DOI: 10.1016/j.ajem.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- James F Holmes
- UC Davis School of Medicine, Department of Emergency Medicine, USA.
| | - Leigha J Winters
- UC Davis School of Medicine, Department of Emergency Medicine, USA
| | - Mary L Bing
- UC Davis School of Medicine, Department of Emergency Medicine, USA
| |
Collapse
|
7
|
Tabner A, Jones M, Fakis A, Johnson G. Can an ECG performed during emergency department triage and interpreted as normal by computer analysis safely wait for clinician review until the time of patient assessment? A pilot study. J Electrocardiol 2021; 68:145-149. [PMID: 34450449 DOI: 10.1016/j.jelectrocard.2021.08.006] [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: 04/15/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Electrocardiograms (ECGs) are frequently performed during patient triage in Emergency Departments (EDs). Emergency Physicians (EPs) are interrupted during other tasks to review ECGs. Critics believe this practice could lead to distraction with consequent medical error and decision fatigue. ECGs can be interpreted by computer software at the time of capture; some evidence exists to suggest that an ECG performed during ED triage with an immediate computer interpretation (ICI) of 'normal' will seldom contain information necessitating a change to triage management. MATERIAL AND METHODS All ED triage ECGs performed in the Royal Derby Hospital between 13th July 2017 and 12th July 2018 in patients without chest pain and with an ICI of 'normal' were identified through a database search. Forty were randomly selected and reviewed by two EPs (blinded to patient details, ICI and outcome) who were asked to identify those that required a change to triage management. RESULTS The study processes were feasible. At least one of the two EP reviewers felt that a change to triage management was required in 48% of cases (e.g. "review patient", "obtain blood gas", "review old ECGs"); they agreed on the need for change of management in 13% of cases. An ICI of normal had a NPV of 53% (95% CI 37-67%) for the need for a change to triage management based upon ECG findings. Inter-observer agreement was poor (kappa = 0.17). CONCLUSIONS Based on these results, ED triage ECGs should still be presented to EPs for immediate review regardless of the ICI. Inter-observer agreement between EPs was poor. Further research is required to link triage ECG interpretation, need for intervention and patient outcome.
Collapse
Affiliation(s)
- Andrew Tabner
- REMEDY (Research Emergency Medicine Derby), Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
| | - Michael Jones
- Research and Development Department, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - Apostolos Fakis
- Research and Development Department, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - Graham Johnson
- REMEDY (Research Emergency Medicine Derby), Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
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]
|
10
|
De Bie J, Diemberger I, Mason JW. Comparison of PR, QRS, and QT interval measurements by seven ECG interpretation programs. J Electrocardiol 2020; 63:75-82. [PMID: 33142185 DOI: 10.1016/j.jelectrocard.2020.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/21/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Electrocardiograph-generated measurements of PR, QRS, and QT intervals are generally thought to be more precise than manual measurements on paper records. However, the performance of different programs has not been well compared. METHODS Routinely obtained digital electrocardiograms (ECGs), including over 500 pediatric ECGs, were used to create over 2000 10 s analog ECGs that were replayed through seven commercially available electrocardiographs. The measurements for PR interval, QRS duration, and QT interval made by each program were extracted and compared against each other (using the median of the programs after correction for program bias) and the population mean values. RESULTS Small but significant systematic biases were seen between programs. The smallest and largest variation from the population mean differed by 4.7 ms for PR intervals, 5.8 ms for QRS duration, and 12.4 ms for QT intervals. In pairwise comparison programs showed similar accuracy for most ECGs, with the average absolute errors at the 75th percentile for PR intervals being 4-6 ms from the median, QRS duration 4-8 ms, and QT interval 6-10 ms. However, substantial differences were present in the numbers and extent of large, clinically significant errors (e.g at the 98th percentile), for which programs differed by a factor of two for absolute errors, as well as differences in the mix of overestimations and underestimations. CONCLUSIONS When reading digital ECGs, users should be aware that small systematic differences exist between programs and that there may be large clinically important errors in difficult cases.
Collapse
Affiliation(s)
- J De Bie
- Mortara Instrument Europe s.r.l., Bologna, Italy.
| | - I Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - J W Mason
- Mason Cardiac Safety Consulting, Reno, Nevada, USA
| |
Collapse
|
11
|
12-Lead Electrocardiograms Acquired and Transmitted by Emergency Medical Technicians are of Diagnostic Quality and Positively Impact Patient Care. Prehosp Disaster Med 2020; 36:47-50. [PMID: 33118893 DOI: 10.1017/s1049023x20001259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Existing peer-reviewed literature describing emergency medical technician (EMT) acquisition and transmission of 12-lead electrocardiograms (12L-ECGs), in the absence of a paramedic, is largely limited to feasibility studies. STUDY OBJECTIVE The objective of this retrospective observational study was to describe the impact of EMT-acquired 12L-ECGs in Suffolk County, New York (USA), both in terms of the diagnostic quality of the transmitted 12L-ECGs and the number of prehospital percutaneous coronary intervention (PCI)-center notifications made as a result of transmitted 12L-ECGs demonstrating a ST-elevation myocardial infarction (STEMI). METHODS A pre-existing database was queried for Emergency Medical Services (EMS) calls on which an EMT acquired a 12L-ECG from program initiation (January 2017) through December 31, 2019. Scanned copies of the 12L-ECGs were requested in order to be reviewed by a blinded emergency physician. RESULTS Of the 665 calls, 99 had no 12L-ECG available within the database. For 543 (96%) of the available 12L-ECGs, the quality was sufficient to diagnose the presence or absence of a STEMI. Eighteen notifications were made to PCI-centers about a concern for STEMI. The median time spent on scene and transporting to the hospital were 18 and 11 minutes, respectively. The median time from PCI-center notification to EMS arrival at the emergency department (ED) was seven minutes (IQR 5-14). CONCLUSION In the event a cardiac monitor is available, after a limited educational intervention, EMTs are capable of acquiring a diagnostically useful 12L-ECG and transmitting it to a remote medical control physician for interpretation. This allows for prehospital PCI-center activation for a concern of a 12L-ECG with a STEMI, in the event that a paramedic is not available to care for the patient.
Collapse
|