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Domingo-Gardeta T, Montero-Cabezas JM, Jurado-Román A, Sabaté M, Aboal J, Baranchuk A, Carrillo X, García-Zamora S, Dores H, van der Valk V, Scherptong RWC, Andrés-Cordón JF, Vidal P, Moreno-Martínez D, Toribio-Fernández R, Lillo-Castellano JM, Cruz R, De Guio F, Marina-Breysse M, Martínez-Sellés M. Rationale and design of the artificial intelligence scalable solution for acute myocardial infarction (ASSIST) study. J Electrocardiol 2024; 86:153768. [PMID: 39126971 DOI: 10.1016/j.jelectrocard.2024.153768] [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: 05/31/2024] [Revised: 07/23/2024] [Accepted: 07/28/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Acute coronary syndrome (ACS), specifically ST-segment elevation myocardial infarction is a major cause of morbidity and mortality throughout Europe. Diagnosis in the acute setting is mainly based on clinical symptoms and physician's interpretation of an electrocardiogram (ECG), which may be subject to errors. ST-segment elevation is the leading criteria to activate urgent reperfusion therapy, but a clear ST-elevation pattern might not be present in patients with coronary occlusion and ST-segment elevation might be seen in patients with normal coronary arteries. METHODS The ASSIST project is a retrospective observational study aiming to improve the ECG-assisted assessment of ACS patients in the acute setting by incorporating an artificial intelligence platform, Willem™ to analyze 12‑lead ECGs. Our aim is to improve diagnostic accuracy and reduce treatment delays. ECG and clinical data collected during this study will enable the optimization and validation of Willem™. A retrospective multicenter study will collect ECG, clinical, and coronary angiography data from 10,309 patients. The primary outcome is the performance of this tool in the correct identification of acute myocardial infarction with coronary artery occlusion. Model performance will be evaluated internally with patients recruited in this retrospective study while external validation will be performed in a second stage. CONCLUSION ASSIST will provide key data to optimize Willem™ platform to detect myocardial infarction based on ECG-assessment alone. Our hypothesis is that such a diagnostic approach may reduce time delays, enhance diagnostic accuracy, and improve clinical outcomes.
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Affiliation(s)
- Tomás Domingo-Gardeta
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | | | - Alfonso Jurado-Román
- Cardiology Department, La Paz University Hospital, Fundación de Investigación Hospital La Paz, IdiPaz Madrid, Spain
| | - Manel Sabaté
- Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jaime Aboal
- Servicio de Cardiología, Hospital Universitario Josep Trueta, Girona, Spain
| | - Adrián Baranchuk
- Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | | | | | - Hélder Dores
- Luz Hospital Lisbon, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal; CHRC, NOVA Medical School, Lisbon, Portugal
| | - Viktor van der Valk
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Pablo Vidal
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Daniel Moreno-Martínez
- Hospital Germans Trias i Pujol, Badalona, Spain; Research group on innovation, health economics and digital transformation, Germans Trias i Pujol Research Institute
| | | | - José María Lillo-Castellano
- Idoven Research, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
| | | | | | - Manuel Marina-Breysse
- Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Idoven Research, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain; Facultad de Ciencias de la Salud, Universidad Europea, Villaviciosa de Odón, 28670 Madrid, Spain.
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2
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McLaren JTT, El-Baba M, Sivashanmugathas V, Meyers HP, Smith SW, Chartier LB. Missing occlusions: Quality gaps for ED patients with occlusion MI. Am J Emerg Med 2023; 73:47-54. [PMID: 37611526 DOI: 10.1016/j.ajem.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. METHODS This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared. RESULTS Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI." CONCLUSIONS STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Mazen El-Baba
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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3
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Faour A, Pahn R, Cherrett C, Gibbs O, Lintern K, Mussap CJ, Rajaratnam R, Leung DY, Taylor DA, Faddy SC, Lo S, Juergens CP, French JK. Late Outcomes of Patients With Prehospital ST-Segment Elevation and Appropriate Cardiac Catheterization Laboratory Nonactivation. J Am Heart Assoc 2022; 11:e025602. [PMID: 35766276 PMCID: PMC9333384 DOI: 10.1161/jaha.121.025602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - Reece Pahn
- The University of New South Wales Sydney New South Wales
| | - Callum Cherrett
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Karen Lintern
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - David A Taylor
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | | | - Sidney Lo
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - John K French
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales.,Ingham Institute Sydney New South Wales
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4
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Lim K, Moon H, Park JS, Cho YR, Park K, Park TH, Kim MH, Kim YD. The Busan Regional CardioCerebroVascular Center Project��s Experience Over a Decade in the Treatment of ST-segment Elevation Myocardial Infarction. J Prev Med Public Health 2022; 55:351-359. [PMID: 35940190 PMCID: PMC9371786 DOI: 10.3961/jpmph.22.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/29/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives The Regional CardioCerebroVascular Center (RCCVC) project was initiated to improve clinical outcomes for patients with acute myocardial infarction or stroke in non-capital areas of Korea. The purpose of this study was to evaluate the outcomes and issues identified by the Busan RCCVC project in the treatment of ST-segment elevation myocardial infarction (STEMI). Methods Among the patients who were registered in the Korean Registry of Acute Myocardial Infarction for the RCCVC project between 2007 and 2019, those who underwent percutaneous coronary intervention (PCI) for STEMI at the Busan RCCVC were selected, and their medical data were compared with a historical cohort. Results In total, 1161 patients were selected for the analysis. Ten years after the implementation of the Busan RCCVC project, the median door-to-balloon time was reduced from 86 (interquartile range [IQR], 64–116) to 54 (IQR, 44–61) minutes, and the median symptom-to-balloon time was reduced from 256 (IQR, 180–407) to 189 (IQR, 118–305) minutes (p<0.001). Inversely, the false-positive PCI team activation rate increased from 0.6% to 21.4% (p<0.001). However, the 1-year cardiovascular death and major adverse cardiac event rates did not change. Even after 10 years, approximately 75% of the patients had a symptom-to-balloon time over 120 minutes, and approximately 50% of the patients underwent inter-hospital transfer for primary PCI. Conclusions A decade after the implementation of the Busan RCCVC project, although time parameters for early reperfusion therapy for STEMI improved, at the cost of an increased false-positive PCI team activation rate, survival outcomes were unchanged.
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Affiliation(s)
- Kyunghee Lim
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Hyeyeon Moon
- Department of Endocrinology, Dong-A University Hospital, Busan,
Korea
| | - Jong Sung Park
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Young-Rak Cho
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Kyungil Park
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Tae-Ho Park
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Moo-Hyun Kim
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
| | - Young-Dae Kim
- Department of Cardiology, Busan Regional CardioCerebroVascular Center, Dong-A University Hospital, Busan,
Korea
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5
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Puleo P, Salen P, Manda Y, Vefali H, Agrawal S, Quddus A, Branch K, Shoemaker M, Stoltzfus J. Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation. Coron Artery Dis 2021; 32:197-204. [PMID: 32541211 PMCID: PMC8032215 DOI: 10.1097/mca.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE. METHODS Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)]. RESULTS 87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely. CONCLUSION Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed.
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Affiliation(s)
- Peter Puleo
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Philip Salen
- Department of Emergency Medicine, St. Luke’s University Hospital, Bethlehem, Pennsylvania
| | - Yugandhar Manda
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, The Heart Institute of East Texas, Lufkin, Texas
| | - Huseng Vefali
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, New York – Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Sahil Agrawal
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, St. Francis Hospital, Tulsa, Oklahoma
| | - Abdullah Quddus
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, Franciscan Health System, Michigan City, Indiana
| | | | - Melinda Shoemaker
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Jill Stoltzfus
- Biostatistics, St. Luke’s University Hospital, Bethlehem, Pennsylvania, USA
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6
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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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7
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Abstract
Coronavirus disease 2019 (COVID-19) can cause a wide range of cardiovascular diseases, including ST-segment elevation myocardial infarction (STEMI) and STEMI-mimickers (such as myocarditis, Takotsubo cardiomyopathy, among others). We performed a systematic review to summarize the clinical features, management, and outcomes of patients with COVID-19 who had ST-segment elevation. We searched electronic databases from inception to September 30, 2020 for studies that reported clinical data about COVID-19 patients with ST-segment elevation. Differences between patients with and without obstructive coronary artery disease (CAD) on coronary angiography were evaluated. Forty-two studies (35 case reports and seven case series) involving 161 patients were included. The mean age was 62.7 ± 13.6 years and 75% were men. The most frequent symptom was chest pain (78%). Eighty-three percent of patients had obstructive CAD. Patients with non-obstructive CAD had more diffuse ST-segment elevation (13% versus 1%, p = 0.03) and diffuse left ventricular wall-motion abnormality (23% versus 3%, p = 0.02) compared to obstructive CAD. In patients with previous coronary stent (n = 17), the 76% presented with stent thrombosis. In the majority of cases, the main reperfusion strategy was primary percutaneous coronary intervention instead of fibrinolysis. The in-hospital mortality was 30% without difference between patients with (30%) or without (31%) obstructive CAD. Our data suggest that a relatively high proportion of COVID-19 patients with ST-segment elevation had non-obstructive CAD. The prognosis was poor across groups. However, our findings are based on case reports and case series that should be confirmed in future studies.
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8
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Lindow T, Engblom H, Pahlm O, Carlsson M, Lassen AT, Brabrand M, Lundager Forberg J, Platonov PG, Ekelund U. Low diagnostic yield of ST elevation myocardial infarction amplitude criteria in chest pain patients at the emergency department. SCAND CARDIOVASC J 2021; 55:145-152. [PMID: 33461362 DOI: 10.1080/14017431.2021.1875138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To evaluate the diagnostic yield of the ECG criteria for ST-elevation myocardial infarction in a large cohort of emergency department chest pain patients, and to determine whether extended ECG criteria or reciprocal ST depression can improve accuracy. Design: Observational, register-based diagnostic study on the accuracy of ECG criteria for ST-elevation myocardial infarction. Between Jan 2010 and Dec 2014 all patients aged ≥30 years with chest pain who had an ECG recorded within 4 h at two emergency departments in Sweden were included. Exclusion criteria were: ECG with poor technical quality; QRS duration ≥120 ms; ECG signs of left ventricular hypertrophy; or previous coronary artery bypass surgery. Conventional and extended ECG criteria were applied to all patients. The main outcome was acute myocardial infarction (AMI) and an occluded/near-occluded coronary artery at angiography. Results: Finally, 19932 patients were included. Conventional ECG criteria for ST elevation myocardial infarction were fulfilled in 502 patients, and extended criteria in 1249 patients. Sensitivity for conventional ECG criteria in diagnosing AMI with coronary occlusion/near-occlusion was 17%, specificity 98% and positive predictive value 12%. Corresponding data for extended ECG criteria were 30%, 94% and 8%. When reciprocal ST depression was added to the criteria, the positive predictive value rose to 24% for the conventional and 23% for the extended criteria. Conclusions: In unselected chest pain patients at the emergency department, the diagnostic yield of both conventional and extended ECG criteria for ST-elevation myocardial infarction is low. The PPV can be increased by also considering reciprocal ST depression.
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Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Department of Research and Development, Växjö Central Hospital, Växjö, Sweden.,Clinical Physiology, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Engblom
- Clinical Physiology, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.,Clinical Physiology, Karolinska Institute, Stockholm, Sweden
| | - Olle Pahlm
- Clinical Physiology, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Clinical Physiology, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.,Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | | | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Emergency Medicine, Skåne University Hospital, Department of Clinical Sciences, Lund University, Lund, Sweden
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9
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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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10
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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.
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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
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11
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Lindow T, Wiiala J, Lundager Forberg J, Lassen AT, Brabrand M, Platonov PG, Ekelund U. Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome. J Electrocardiol 2020; 58:165-170. [PMID: 31901697 DOI: 10.1016/j.jelectrocard.2019.12.012] [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] [Received: 11/04/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION In the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients. MATERIAL AND METHODS We included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients. RESULTS In total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20. CONCLUSIONS This study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.
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Affiliation(s)
- T Lindow
- Department of Clinical Physiology, Department of Research and Development, Växjö Central Hospital, Sweden; Clinical Physiology, Clinical Sciences, Lund University, Sweden.
| | - J Wiiala
- Emergency Medicine, Clinical Sciences, Skåne University Hospital, Lund University, Sweden
| | - J Lundager Forberg
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - A T Lassen
- Department of Emergency Medicine, Odense University, Hospital, Odense, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Odense University, Hospital, Odense, Denmark
| | - P G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - U Ekelund
- Emergency Medicine, Clinical Sciences, Skåne University Hospital, Lund University, Sweden
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12
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Hillinger P, Strebel I, Abächerli R, Twerenbold R, Wildi K, Bernhard D, Nestelberger T, Boeddinghaus J, Badertscher P, Wussler D, Koechlin L, Zimmermann T, Puelacher C, Rubini Gimenez M, du Fay de Lavallaz J, Walter J, Geigy N, Keller DI, Reichlin T, Mueller C. Prospective validation of current quantitative electrocardiographic criteria for ST-elevation myocardial infarction. Int J Cardiol 2019; 292:1-12. [DOI: 10.1016/j.ijcard.2019.04.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/06/2019] [Accepted: 04/11/2019] [Indexed: 01/18/2023]
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13
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Ifedili I, Bob-Manuel T, Kadire SR, Heard B, John LA, Zambetti B, Heckle MR, Thomas F, Haji S, Khouzam RN, Reed GL, Ibebuogu UN. Cocaine Positivity in ST-Elevation Myocardial Infarction: A True or False Association. Perm J 2019; 23:18-048. [PMID: 30939276 DOI: 10.7812/tpp/18-048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Every year, more than 500,000 US Emergency Department visits are associated with cocaine use. People who use cocaine tend to have a lower incidence of true ST-elevation myocardial infarction (STEMI). OBJECTIVE To identify the factors associated with true STEMI in patients with cocaine-positive (CPos) findings. METHODS We retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and 2013. True STEMI was defined as having a culprit lesion on coronary angiogram. Multivariate and univariate analyses were used to identify risk factors and create a predictive model. RESULTS A total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2 years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos true STEMI were more likely to be uninsured than those with false STEMI (61.8% vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12 ng/mL, p = < 0.01) with no difference in mean age between the 2 groups (p = 0.24). In multivariate analyses, independent predictors of true STEMI in patients with CPos findings included age older than 65 years (odds ratio [OR] = 19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR = 4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI = 2.6-216.8) (all p < 0.05). A multivariate risk score created with a C-statistic of 82% (95% CI = 71-93) significantly improved the identification of patients with true STEMI. CONCLUSION Among those with suspected STEMI, patients with CPos findings had a higher incidence of false STEMI. Older age, lack of health insurance, and troponin levels outside of defined limits were associated with true STEMI in this group.
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Affiliation(s)
- Ikechukwu Ifedili
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | | | - Siri R Kadire
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Britteny Heard
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Leah A John
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Benjamin Zambetti
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Mark R Heckle
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Fridtjof Thomas
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Showkat Haji
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Rami N Khouzam
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Guy L Reed
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Uzoma N Ibebuogu
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
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14
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Lange DC, Conte S, Pappas-Block E, Hildebrandt D, Nakamura M, Makkar R, Kar S, Torbati S, Geiderman J, McNeil N, Cercek B, Tabak SW, Rokos I, Henry TD. Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 11:e004464. [PMID: 30354373 DOI: 10.1161/circoutcomes.117.004464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCLX) remain a challenging problem. We examined the reasons for CCLX, clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCLX. METHODS AND RESULTS We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCLX was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009). CONCLUSIONS In this study, prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCLX patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCLX and influence clinical outcomes.
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Affiliation(s)
- David C Lange
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (D.C.L.)
| | - Stanley Conte
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Effie Pappas-Block
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - David Hildebrandt
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Mamoo Nakamura
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Raj Makkar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Saibal Kar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Sam Torbati
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joel Geiderman
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Nathan McNeil
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bojan Cercek
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Steven W Tabak
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA Olive View Medical Center, Los Angeles, CA (I.R.)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
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15
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Abstract
BACKGROUND Rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is crucial for appropriate management. Catheterization for a false STEMI activation has risks including exposure to contrast agent and radiation, increased healthcare costs and delay in treatment of the primary medical condition. PATIENTS AND METHODS This was a single center retrospective study including all 'cath alerts' between January 2012 and December 2015. 'Cath alert' is a term used to activate the interventional cardiology team when STEMI is suspected by the emergency department physicians based on review of the initial ECG. We reviewed all STEMI alerts to understand ECG differences between true and false STEMI. RESULTS Our study population (N = 361) included 221 (61%) men and 140 (39%) women, with average age 60 ± 4.2 years. Among the 361 STEMI alerts, 82 (22.7%) did not have acute coronary syndrome. Common ECG causes of misdiagnosis included left ventricular hypertrophy (LVH, found in 40/82, 49%), early repolarization changes (20/82, 24%), right bundle branch block (RBBB) (13/82, 16%), and Brugada pattern (3/82, 4%). Multivariate regression analysis showed that LVH and RBBB were independent predictors of nonacute coronary syndrome false STEMI (odds ratio: 0.54; 95% confidence interval: 0.32-0.93; P = 0.03 for LVH, and odds ratio: 0.26, 95% confidence interval: 0.1-0.62, P = 0.004 for RBBB). CONCLUSION The incidence of false STEMI alerts was almost 23% at our center. This number might be reduced with additional training of emergency department physicians in ECG interpretation, and recognition of common causes of misdiagnosis such as LVH, early repolarization changes, RBBB, and Brugada pattern.
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16
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Improving Electrocardiography Diagnostic Accuracy in Emergency Medical Services Personnel. CJC Open 2019; 1:28-34. [PMID: 32159079 PMCID: PMC7063641 DOI: 10.1016/j.cjco.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/29/2018] [Indexed: 01/06/2023] Open
Abstract
Background Accuracy of electrocardiogram (ECG) interpretation is important for identification of ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) personnel who recognize STEMI in the field and activate the coronary catheterization laboratory. According to previous research, there is improvement in diagnosis of STEMIs for healthcare providers who read an average of > 20 ECGs per week. This study evaluated the effectiveness of online ECG modules on improving diagnostic accuracy. Methods EMS personnel received 25 ECGs per week to interpret via an online program. Diagnostic accuracy was assessed for improvement via completion of an ECG evaluation package before and after the intervention. Job satisfaction data were collected to determine the impact of the educational initiative. Results A total of 64 participants completed the study. Overall, there was an improvement in ECG diagnostic accuracy from 50.8% to 61.2% (95% confidence interval [CI], 7.7-13.2; P < 0.0001). Specifically, there was significant improvement in the diagnosis of STEMI (8.5%; 95% CI, 4.9-12.3; P < 0.003) and supraventricular tachycardia (39.0%; 95% CI, 17.2-60.8; P < 0.008), with a trend toward improvement in all other diagnoses. These effects were sustained to 3 months (9.6%; 95% CI, 6.4-12.7; P < 0.0001). Improvement was seen regardless of employment experience and training. There was no significant impact on job satisfaction. Conclusions ECG exposure remains an important factor in improving the accuracy of ECG diagnosis in EMS personnel. Online education modules provide an easily accessible way of improving ECG interpretation with the opportunity for positive downstream effects on patient outcomes and resource use.
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17
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Heckle MR, Efeovbokhan N, Thomas F, Blumer M, Chumpia M, Ibebuogu U, Reed GL, Khouzam RN. Accurate Prediction of False ST-Segment Elevation Myocardial Infarction: Ready for Prime Time? Curr Probl Cardiol 2018; 43:400-412. [DOI: 10.1016/j.cpcardiol.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Tanguay A, Lebon J, Brassard E, Hébert D, Bégin F. Diagnostic accuracy of prehospital electrocardiograms interpreted remotely by emergency physicians in myocardial infarction patients. Am J Emerg Med 2018; 37:1242-1247. [PMID: 30213475 DOI: 10.1016/j.ajem.2018.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/29/2018] [Accepted: 09/05/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Prehospital 12‑lead electrocardiogram (ECG) is the most widely used screening tool for recognition of ST-segment elevation myocardial infarction (STEMI). However, prehospital diagnosis of STEMI based solely on ECGs can be challenging. OBJECTIVES To evaluate the ability of emergency department (ED) physicians to accurately interpret prehospital 12‑lead ECGs from a remote location. METHODS All suspected prehospital STEMI patients who were transported by EMS and underwent angiography between 2006 and 2014 were included. We reviewed prehospital ECGs and grouped them based on: 1) presence or absence of a culprit artery lesion following angiography; and 2) whether they met the 3rd Universal Definition of Myocardial Infarction. We also described characteristics of ECGs that were misinterpreted by ED physicians. RESULTS A total of 625 suspected STEMI cases were reviewed. Following angiography, 94% (590/625) of patients were found having a culprit artery lesion, while 6% (35/625) did not. Among these 35 patients, 24 had ECGs that mimicked STEMI criteria and 9 had non-ischemic signs. Upon ECG reinterpretation, 92% (577/625) had standard STEMI criteria while 8% (48/625) did not. Among these 48 patients, 35 had ischemic signs ECGs and 13 did not. Characteristics of misinterpreted ECGs included pericarditis, early repolarization, STE > 1 mm (1‑lead only), and negative T-wave. CONCLUSIONS Remote interpretation of prehospital 12‑lead ECGs by ED physicians was a useful diagnostic tool in this EMS system. Even if the rate of ECG misinterpretation is low, there is still room for ED physicians operating from a remote location to improve their ability to accurately diagnose STEMI patients.
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Affiliation(s)
- Alain Tanguay
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgence (UCCSPU), 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada
| | - Johann Lebon
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgence (UCCSPU), 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada.
| | - Eric Brassard
- Faculté de Médecine Université Laval, 2325 Rue de l'Université, Québec, Québec G1V 0A6, Canada
| | - Denise Hébert
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgence (UCCSPU), 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada
| | - François Bégin
- Centre de Recherche de l'Hôtel-Dieu de Lévis, 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada; Département de Médecine d'Urgence, Hôtel-Dieu de Lévis, 143 Rue Wolfe, Lévis, Québec G6V 3Z1, Canada
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19
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Muhrbeck J, Persson J, Hofman-Bang C. Catheterization laboratory activations and time intervals for patients with pre-hospital ECGs. SCAND CARDIOVASC J 2018; 52:74-79. [DOI: 10.1080/14017431.2018.1430899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Josephine Muhrbeck
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Jonas Persson
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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20
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Andersson HB, Pedersen F, Engstrøm T, Helqvist S, Jensen MK, Jørgensen E, Kelbæk H, Räder SBEW, Saunamäki K, Bates E, Grande P, Holmvang L, Clemmensen P. Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease. Eur Heart J 2017; 39:102-110. [DOI: 10.1093/eurheartj/ehx491] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 08/04/2017] [Indexed: 11/12/2022] Open
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21
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Kim JH, Roh YH, Park YS, Park JM, Joung BY, Park IC, Chung SP, Kim MJ. Risk score to predict false-positive ST-segment elevation myocardial infarction in the emergency department: a retrospective analysis. Scand J Trauma Resusc Emerg Med 2017; 25:61. [PMID: 28666458 PMCID: PMC5493848 DOI: 10.1186/s13049-017-0408-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background The best treatment approach for ST-segment elevation myocardial infarction (STEMI) is prompt primary percutaneous coronary intervention (PCI). However, some patients show ST elevation on electrocardiography (ECG), but do not have myocardial infarction. We sought to identify the frequency of and to develop a prediction model for false-positive STEMI. Methods This study was conducted in the emergency departments (EDs) of two hospitals using the same critical pathway (CP) protocol to treat STEMI patients with primary PCI. The prediction model was developed in a derivation cohort and validated in internal and external validation cohorts. Results Of the CP-activated patients, those for whom ST elevation did not meet the ECG criteria were excluded. Among the patients with appropriate ECG patterns, the incidence of false-positive STEMI in the entire cohort was 16.3%. Independent predictors extracted from the derivation cohort for false-positive STEMI were age < 65 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.35–4.89), no chest pain (OR, 12.04; 95% CI, 5.92–25.63), atypical chest pain (OR, 7.40; 95% CI, 3.27–17.14), no reciprocal change (OR, 4.80; 95% CI, 2.54–9.51), and concave-morphology ST elevation (OR, 14.54; 95% CI, 6.87–34.37). Based on the regression coefficients, we established a simplified risk score. In the internal and external validation cohorts, the areas under the receiver operating characteristic curves for our risk score were 0.839 (95% CI, 0.724–0.954) and 0.820 (95% CI, 0.727–0.913), respectively; the positive predictive values were 40.9% and 22.0%, respectively; and the negative predictive values were 94.9% and 96.7%, respectively. Discussion Our prediction model would help them make rapid decisions with better rationale. Conclusion We devised a model to predict false-positive STEMI. Larger-scale validation studies are needed to validate our model, and a prospective study to determine whether this model is effective in reducing improper primary PCI in actual clinical practice should be performed.
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Affiliation(s)
- Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yun Ho Roh
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Joon Min Park
- Department Emergency Medicine, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, 10380, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Bo Young Joung
- Division of Cardiology, Department of Internal medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - In Cheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea. .,Department of Emergency Medicine, Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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22
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Lange DC, Rokos IC, Garvey JL, Larson DM, Henry TD. False Activations for ST-Segment Elevation Myocardial Infarction. Interv Cardiol Clin 2017; 5:451-469. [PMID: 28581995 DOI: 10.1016/j.iccl.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
First-medical-contact-to-device (FMC2D) times have improved over the past decade, as have clinical outcomes for patients presenting with ST-elevation myocardial infarction (STEMI). However, with improvements in FMC2D times, false activation of the cardiac catheterization laboratory (CCL) has become a challenging problem. The authors define false activation as any patient who does not warrant emergent coronary angiography for STEMI. In addition to clinical outcome measures for these patients, STEMI systems should collect data regarding the total number of CCL activations, the total number of emergency coronary angiograms, and the number revascularization procedures performed.
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Affiliation(s)
- David C Lange
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Ivan C Rokos
- Department of Emergency Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Lee Garvey
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - David M Larson
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
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Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion - Adding QRS amplitude of V2 improves the model. J Electrocardiol 2017; 50:561-569. [PMID: 28460689 DOI: 10.1016/j.jelectrocard.2017.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Precordial normal variant ST elevation (NV-STE), previously often called "early repolarization," may be difficult to differentiate from subtle ischemic STE due to left anterior descending (LAD) occlusion. We previously derived and validated a logistic regression formula that was far superior to STE alone for differentiating the two entities on the ECG. The tool uses R-wave amplitude in lead V4 (RAV4), ST elevation at 60 ms after the J-point in lead V3 (STE60V3) and the computerized Bazett-corrected QT interval (QTc-B). The 3-variable formula is: 1.196 x STE60V3 + 0.059 × QTc-B - 0.326 × RAV4 with a value ≥23.4 likely to be acute myocardial infarction (AMI). HYPOTHESIS Adding QRS voltage in V2 (QRSV2) would improve the accuracy of the formula. METHODS 355 consecutive cases of proven LAD occlusion were reviewed, and those that were obvious ST elevation myocardial infarction were excluded. Exclusion was based on one straight or convex ST segment in V2-V6, 1 millimeter of summed inferior ST depression, any anterior ST depression, Q-waves, "terminal QRS distortion," or any ST elevation >5 mm. The NV-STE group comprised emergency department patients with chest pain who ruled out for AMI by serial troponins, had a cardiologist ECG read of "NV-STE," and had at least 1 mm of STE in V2 and V3. R-wave amplitude in lead V4 (RAV4), ST elevation at 60 ms after the J-point in lead V3 (STE60V3) and the computerized Bazett-corrected QT interval (QTc-B) had previously been measured in all ECGs; physicians blinded to outcome then measured QRSV2 in all ECGs. A 4-variable formula was derived to more accurately classify LAD occlusion vs. NV-STE and optimize area under the curve (AUC) and compared with the previous 3-variable formula. RESULTS There were 143 subtle LAD occlusions and 171 NV-STE. A low QRSV2 added diagnostic utility. The derived 4-variable formula is: 0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3. The 3-variable formula had an AUC of 0.9538 vs. 0.9686 for the 4-variable formula (p = 0.0092). At the same specificity as the 3-variable formula [90.6%, at which cutpoint (≥23.4), 123 of 143 MI were correctly classified for 86% sensitivity], the sensitivity of the new formula at cutpoint ≥17.75 is 90.2%, with 129/143 correctly classified MI, identifying an additional 6 cases. The cutpoint with the highest accuracy (92.0%) was at a cutoff value ≥18.2, with 88.8% sensitivity, 94.7% specificity, and a positive and negative likelihood ratio of 16.9 (95% CI: 8.9-32) and 0.12 (95% CI: 0.07-0.19). At this cutpoint, it correctly classified an additional 11 cases (289 of 315, vs. 278 of 315): 127/143 for MI (an additional 4 cases) and 162/171 for NV-STE (an additional 7 cases). CONCLUSION On the ECG, a 4-variable formula was derived which adds QRSV2; it differentiates subtle LAD occlusion from NV-STE better than the 3-variable formula. At a value ≥18.2, the formula (0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3) was very accurate, sensitive, and specific, with excellent positive and negative likelihood ratios. This formula needs to be validated.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ayesha Khalil
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Timothy Henry
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Faraz Kazmi
- Department of Medicine, Cardiology of Division, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Amina Adil
- Department of Medicine, Cardiology Division, Aurora St. Luke's Medical Center, Milwaukee, WI
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
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Tanguay A, Brassard E, Lebon J, Bégin F, Hébert D, Paradis JM. Effectiveness of a Prehospital Wireless 12-Lead Electrocardiogram and Cardiac Catheterization Laboratory Activation for ST-Elevation Myocardial Infarction. Am J Cardiol 2017; 119:553-559. [PMID: 27939226 DOI: 10.1016/j.amjcard.2016.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/29/2022]
Abstract
The aim of the study was to determine the prevalence of false-positive and inappropriate cardiac catheterization laboratory (CCL) activation in patients suspected with ST-elevation myocardial infarction (STEMI) diverted to a percutaneous coronary intervention (PCI) facility after paramedics wireless 12-lead electrocardiogram transmission to an emergency physician at an online medical control center. This retrospective study collected data from medical records of patients with suspected STEMI from 2006 to 2014. It included demographics, coronaropathic risk factors, cardiac biomarkers, time from the first medical contact to treatment, and final diagnosis. Primary outcome was the rate of false-positive and inappropriate CCL activation. As secondary outcomes, we compared patient characteristics between cases of appropriate and inappropriate CCL activation, and we assessed the presence of cardiac biomarkers, time from first medical contact to start of PCI, and final diagnosis. Overall, 673 patients with suspected STEMI were included in the analysis. A total of 640 patients (95%) had coronarography, of which 10% (62 of 640) did not have a culprit coronary artery (false positive). Angiography was canceled for 5% (33 of 673) of patients. The total false-positive and inappropriate CCL activation rate was 14% (95 of 673). Average time from the first medical contact to the start of PCI was 47 ± 18.1 minutes. Unwanted CCL activations were more likely to involve men aged >65 years and patients with a history of coronary artery disease. In conclusion, our system of transmitted prehospital electrocardiography and STEMI interpretation by emergency physicians at an online medical control center showed a total false-positive and inappropriate CCL activation rate of 14% over the 8-year study period.
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Affiliation(s)
- Alain Tanguay
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada
| | - Eric Brassard
- Faculté de Médecine Université Laval, Québec, Québec, Canada
| | - Johann Lebon
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada; Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada.
| | - François Bégin
- Centre de Recherche de l'Hôtel-Dieu de Lévis, Québec, Québec, Canada; Faculté de Médecine Université Laval, Québec, Québec, Canada
| | - Denise Hébert
- Unité de Coordination Clinique des Services Préhospitaliers d'Urgences (UCCSPU), Québec, Québec, Canada
| | - Jean-Michel Paradis
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada
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Lu J, Bagai A, Buller C, Cheema A, Graham J, Kutryk M, Christie JA, Fam N. Incidence and characteristics of inappropriate and false-positive cardiac catheterization laboratory activations in a regional primary percutaneous coronary intervention program. Am Heart J 2016; 173:126-33. [PMID: 26920605 DOI: 10.1016/j.ahj.2015.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 10/29/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The implementation of regional primary percutaneous coronary intervention (PCI) programs has been critical in achieving timely intervention in patients with ST-segment elevation myocardial infarction (STEMI). However, 1 consequence has been inappropriate and false-positive cardiac catheterization laboratory (CCL) activations where either angiography is cancelled or no culprit lesion is found, respectively. METHODS We performed a retrospective cohort study of 1,391 patients referred for primary PCI to a single academic center from November 2007 to August 2013. Our purpose was to determine the incidence and characteristics of inappropriate and false-positive CCL activations by emergency departments (EDs) or emergency medical services (EMS), and the effect of a quality improvement (QI) initiative to reduce such events implemented during this period. RESULTS During the study period, there were 37 (2.7%) inappropriate and 206 (14.8%) false-positive CCL activations. There was no difference between the ED and EMS rates of inappropriate activation (2.1% vs 3.8%, P = .06). Among patients who proceeded to angiography, the false-positive rate for ED CCL activation was 16.9% compared to 11.5% for EMS (P = .01). Although there was no difference comparing inappropriate activation or false-positive rates before and after the QI initiative (P = .22), we observed an encouraging year-to-year trend. CONCLUSIONS Emergency department activation of the CCL is associated with a higher false-positive rate than activation by EMS. Further QI efforts are required to improve communication between interventional cardiologists, emergency physicians, and paramedics to improve the specificity of CCL activation while taking care not to sacrifice sensitivity and rapidity of diagnosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Neil Fam
- St Michael's Hospital, Toronto, ON, Canada.
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El Khoury C, Bochaton T, Flocard E, Serre P, Tomasevic D, Mewton N, Bonnefoy-Cudraz E. Five-year evolution of reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction in France. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:573-582. [PMID: 26680780 DOI: 10.1177/2048872615623065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess 5-year evolutions in reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction. METHODS AND RESULTS Using data from the French RESCUe network, we studied patients with ST-segment elevation myocardial infarction treated in mobile intensive care units between 2009 and 2013. Among 2418 patients (median age 62 years; 78.5% male), 2119 (87.6%) underwent primary percutaneous coronary intervention and 299 (12.4%) pre-hospital thrombolysis (94.0% of whom went on to undergo percutaneous coronary intervention). Use of primary percutaneous coronary intervention increased from 78.4% in 2009 to 95.9% in 2013 ( Ptrend<0.001). Median delays included: first medical contact to percutaneous coronary intervention centre 48 minutes; first medical contact to balloon inflation 94 minutes; and percutaneous coronary intervention centre to balloon inflation 43 minutes. Times from symptom onset to first medical contact and first medical contact to thrombolysis remained stable during 2009-2013, but times from symptom onset to first balloon inflation, and first medical contact to percutaneous coronary intervention centre to first balloon inflation decreased ( P<0.001). Among patients with known timings, 2146 (89.2%) had a first medical contact to percutaneous coronary intervention centre delay ⩽90 minutes, while 260 (10.8%) had a longer delay, with no significant variation over time. Primary percutaneous coronary intervention use increased over time in both delay groups, but was consistently higher in the ⩽90 versus >90 minutes delay group (83.0% in 2009 to 97.7% in 2013; Ptrend<0.001 versus 34.1% in 2009 to 79.2% in 2013; Ptrend<0.001). In-hospital (4-6%) and 30-day (6-8%) mortalities remained stable from 2009 to 2013. CONCLUSION In the RESCUe network, the use of primary percutaneous coronary intervention increased from 2009 to 2013, in line with guidelines, but there was no evolution in early mortality.
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Affiliation(s)
- Carlos El Khoury
- 1 Emergency Department and RESCUe Network, Lucien Hussel Hospital, France
| | | | | | - Patrice Serre
- 4 Emergency Department and RESCUe Network, Fleyriat Hospital, France
| | | | - Nathan Mewton
- 5 Centre d'Investigation Clinique (CIC) de Lyon, Louis Pradel Hospital, France
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Zhu T, Huitema A, Alemayehu M, Allegretti M, Chomicki C, Yadegari A, Lavi S. Clinical presentation and outcome of patients with ST-segment elevation myocardial infarction without culprit angiographic lesions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:217-20. [DOI: 10.1016/j.carrev.2015.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 01/12/2023]
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Salam I, Hassager C, Thomsen JH, Langkjær S, Søholm H, Bro-Jeppesen J, Bang L, Holmvang L, Erlinge D, Wanscher M, Lippert FK, Køber L, Kjaergaard J. Editor’s Choice-Is the pre-hospital ECG after out-of-hospital cardiac arrest accurate for the diagnosis of ST-elevation myocardial infarction? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:317-26. [DOI: 10.1177/2048872615585519] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/08/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Idrees Salam
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Christian Hassager
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Sandra Langkjær
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Helle Søholm
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lia Bang
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lene Holmvang
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Sweden
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia 4142, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | - Lars Køber
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology 2142, Copenhagen University Hospital Rigshospitalet, Denmark
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Groot HE, Wieringa WG, Mahmoud KD, Lexis CP, Hiemstra B, van der Harst P, Lipsic E. Characteristics of patients with false- ST-segment elevation myocardial infarction diagnoses. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:339-46. [PMID: 25872973 DOI: 10.1177/2048872615581500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 03/22/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND A subgroup of patients presenting with suspected ST-elevation myocardial infarction (STEMI) have no culprit lesion during coronary angiography (false-positive STEMI). Little is known about patient- and system-related factors that are associated with false-positive STEMI. We evaluated the incidence, correlates, delay, final diagnosis, and outcome of patients with false-positive STEMI. METHODS We studied 827 consecutive patients presenting with suspected STEMI between January 2011-September 2012. RESULTS A false positive STEMI activation was identified in 68 patients (8.2%). Patients with false-positive STEMI were younger (57 vs 63 year; p=0.020), less often had hypercholesterolemia (19 vs 43%; p=0.001), and had a higher heart rate (82 vs 75 bpm; p=0.014). The association between these factors and false-positive STEMI activation persisted in multivariate analysis. The duration of symptoms to call was longer in false-positive STEMI patients (128 vs 83 min; p=0.030), although this did not reach statistical significance in multivariate analysis. Final diagnosis in patients with false-positive STEMI activation was particularly from unknown origin (41%). There were no significant differences in mortality at 30 days and one year between patients with STEMI and false-positive STEMI. CONCLUSION The incidence of false-positive STEMI was 8.2% in patients suspected of STEMI. Patients with false-positive STEMI differ from STEMI patients in certain baseline characteristics and in patient delay. Interestingly, absence of coronary disease did not translate into better clinical outcome.
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Affiliation(s)
- Hilde E Groot
- Department of Cardiology, University of Groningen, The Netherlands
| | | | - Karim D Mahmoud
- Department of Cardiology, University of Groningen, The Netherlands
| | - Chris Ph Lexis
- Department of Cardiology, University of Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Cardiology, University of Groningen, The Netherlands
| | | | - Erik Lipsic
- Department of Cardiology, University of Groningen, The Netherlands
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Huitema AA, Zhu T, Alemayehu M, Lavi S. Diagnostic accuracy of ST-segment elevation myocardial infarction by various healthcare providers. Int J Cardiol 2014; 177:825-9. [PMID: 25465827 DOI: 10.1016/j.ijcard.2014.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aimed to compare the accuracy of ECG interpretation for diagnosis of STEMI by different groups of healthcare professionals involved in the STEMI program at our institution. METHODS We selected 21 ECGs from patients with typical symptoms of MI that were diagnosed with STEMI, and 10 ECGs of STEMI mimics. STEMI mimic ECGs were repeated in the package with a story of typical and atypical chest pain. ECGs were interpreted to diagnose STEMI and identify need for initiation of the cardiac catheterization lab (CCL). Participants identified confidence in STEMI recognition, and average number of ECGs read per week. RESULTS A total of 64 participants completed the study package. Cardiologists were more likely to provide correct interpretation compared to other groups. False positive diagnoses were more likely made by paramedics when compared to cardiologists (p < 0.01). There was a positive correlation between increased exposure to ECGs and accurate STEMI diagnosis (r = 0.482, p < 0.001). A threshold of ≥ 20 ECGs read per week showed a statistically significant improvement in accuracy (p < 0.001). Self-reported confidence correlated positively with accuracy (r = 0.402, p =< 0.001). Changing the ECG narrative of the STEMI mimic ECGs had a significant effect on interpretation between groups (p = 0.043). CONCLUSIONS Our study showed that healthcare profession and number of ECGs reviewed per week are predictive of the accuracy of ECG interpretation of STEMI. Cardiologists are the most accurate diagnosticians, and are the least likely to falsely activate the CCL. Weekly exposure of ≥ 20 ECGs may improve diagnostic accuracy regardless of underlying experience.
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Affiliation(s)
- Ashlay A Huitema
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Tina Zhu
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Shahar Lavi
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
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Min MK, Ryu JH, Kim YI, Park MR, Park YM, Park SW, Yeom SR, Han SK, Kim YW. Does cardiac catheterization laboratory activation by electrocardiography machine auto-interpretation reduce door-to-balloon time? Am J Emerg Med 2014; 32:1305-10. [DOI: 10.1016/j.ajem.2014.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/24/2014] [Accepted: 07/26/2014] [Indexed: 11/30/2022] Open
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Minimizing false activation of cath lab for STEMI — A realistic goal? Int J Cardiol 2014; 172:e91-3. [DOI: 10.1016/j.ijcard.2013.12.132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 12/22/2013] [Indexed: 11/24/2022]
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Positive predictive value of clinically suspected ST-segment elevation myocardial infarction using angiographic verification. Am J Cardiol 2013; 112:923-7. [PMID: 23768460 DOI: 10.1016/j.amjcard.2013.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 11/23/2022]
Abstract
Fibrinolysis has not been used for the treatment of ST-segment elevation myocardial infarction (STEMI) in Denmark since 2005. We aimed to assess the positive predictive value of clinically suspected STEMI among consecutive patients in a real-world setting where all patients with suspected STEMI undergo acute coronary angiography. We evaluated the clinical diagnosis of consecutive patients with suspected STEMI admitted to Aarhus University Hospital between September 1, 2010, and August 31, 2011. Conclusive STEMI was defined as a patient with an identifiable culprit lesion by angiography. Of 615 patients with suspected STEMI, 483 (79%) had conclusive STEMI, and 132 (21%) did not have an identifiable culprit lesion. A higher proportion of patients with conclusive STEMI were men, whereas patients without conclusive STEMI were more likely to have diabetes mellitus (16% vs 10%; p = 0.04), left bundle branch block (24% vs 2%; p <0.001), hypertension (48% vs 36%; p = 0.01), or a history of coronary artery bypass surgery (8% vs 2%; p = 0.001). Compared with the overall 79% with conclusive STEMI, patients with left bundle branch block or a history of coronary artery bypass surgery had positive predictive values of only 26% and 41%, respectively. Our findings thus indicate that a substantial number of patients would have received fibrinolysis, without any potential benefit but with the inherent risk of bleeding complications, if acute angiography had not been an option.
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Chung SL, Lei MH, Chen CC, Hsu YC, Yang CC. Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED. Am J Emerg Med 2013; 31:825-9. [DOI: 10.1016/j.ajem.2013.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 01/29/2013] [Accepted: 02/04/2013] [Indexed: 11/26/2022] Open
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Patankar GR, Choi JW, Schussler JM. Reverse takotsubo cardiomyopathy: two case reports and review of the literature. J Med Case Rep 2013; 7:84. [PMID: 23510078 PMCID: PMC3668300 DOI: 10.1186/1752-1947-7-84] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 01/16/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Reverse takotsubo cardiomyopathy is a rare variant of classic takotsubo cardiomyopathy that presents within a different patient profile and with its own hemodynamic considerations. Its recognition is important for prognostic, evaluation and treatment considerations. Case presentation Case 1: A 69-year-old Caucasian woman presented with substernal chest pain following a motor vehicle accident. During her evaluation, she was found to have positive results for cardiac enzymes and underwent left heart cardiac catheterization. The results of the catheterization demonstrated no significant coronary stenosis. However, her ventriculogram showed basal and anterior akinesis. Case 2: A 62-year-old Caucasian woman began having substernal chest pain that radiated to her shoulder blades. She was taken to a local area hospital where she was found to have elevated troponins. A left heart catheterization showed an ejection fraction of 35% with hypokinesis of the anterior and posterobasal walls of her heart, with 30% stenosis of her left anterior descending artery but no other significant coronary artery stenosis. Conclusion The cases in this report illustrate a lesser-known variant of takotsubo cardiomyopathy.
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Affiliation(s)
- Gautam R Patankar
- Baylor University Medical Center, 621 North Hall Street Suite 500, Dallas, Texas 75226, USA.
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Jeong HC, Ahn Y. False Positive ST-Segment Elevation Myocardial Infarction. Korean Circ J 2013; 43:368-9. [PMID: 23882284 PMCID: PMC3717418 DOI: 10.4070/kcj.2013.43.6.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Hae Chang Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
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