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Pelter MM, Xu Y, Fidler R, Xiao R, Mortara DW, Xiao H. Evaluation of ECG algorithms designed to improve detect of transient myocardial ischemia to minimize false alarms in patients with suspected acute coronary syndrome. J Electrocardiol 2017; 51:288-295. [PMID: 29129350 DOI: 10.1016/j.jelectrocard.2017.10.005] [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] [Received: 08/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients hospitalized for suspected acute coronary syndrome (ACS) are at risk for transient myocardial ischemia. During the "rule-out" phase, continuous ECG ST-segment monitoring can identify transient myocardial ischemia, even when asymptomatic. However, current ST-segment monitoring software is vastly underutilized due to false positive alarms, with resultant alarm fatigue. Current ST algorithms may contribute to alarm fatigue because; (1) they are not designed with a delay (minutes), rather alarm to brief spikes (i.e., turning, heart rate changes), and (2) alarm to changes in a single ECG lead, rather than contiguous leads. PURPOSE This study was designed to determine sensitivity, and specificity, of ST algorithms when accounting for; ST magnitude (100μV vs 200μV), duration, and changes in contiguous ECG leads (i.e., aVL, I, - aVR, II, aVF, III; V1, V2, V3, V4, V5, V6, V6, I). METHODS This was a secondary analysis from the COMPARE Study, which assessed occurrence rates for transient myocardial ischemia in hospitalized patients with suspected ACS using 12-lead Holter. Transient myocardial ischemia was identified from Holter using >100μV ST-segment ↑ or ↓, in >1 ECG lead, >1min. Algorithms tested against Holter transient myocardial ischemia were done using the University of California San Francisco (UCSF) ECG algorithm and included: (1)100μV vs 200μV any lead during a 5-min ST average; (2)100μV vs 200μV any lead >5min, (3) 100μV vs 200μV any lead during a 5-min ST average in contiguous leads, and (4) 100μV vs 200μV>5min in contiguous leads (Table below). RESULTS In 361 patients; mean age 63+12years, 63% male, 56% prior CAD, 43 (11%) had transient myocardial ischemia. Of the 43 patients with transient myocardial ischemia, 17 (40%) had ST-segment elevation events, and 26 (60%) ST-segment depression events. A higher proportion of patients with ST segment depression has missed ischemic events. Table shows sensitivity and specificity for the four algorithms tested. CONCLUSIONS Sensitivity was highly variable, due to the ST threshold selected, with the 100μV measurement point being superior to the 200μV amplitude threshold. Of all the algorithms tested, there was moderate sensitivity and specificity (70% and 68%) using the 100μV ST-segment threshold, integrated ST-segment changes in contiguous leads during a 5-min average.
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Affiliation(s)
- Michele M Pelter
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States.
| | - Yuan Xu
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States
| | - Richard Fidler
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States
| | - Ran Xiao
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States
| | - David W Mortara
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States
| | - Hu Xiao
- Department of Physiological Nursing, University of California San Francisco, San Francisco, CA, United States
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Syed S, Gatien M, Perry JJ, Chaudry H, Kim SM, Kwong K, Mukarram M, Thiruganasambandamoorthy V. Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring. CMAJ 2017; 189:E139-E145. [PMID: 28246315 DOI: 10.1503/cmaj.160742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Most patients with chest pain in the emergency department are assigned to cardiac monitoring for several hours, blocking access for patients in greater need. We sought to validate a previously derived decision rule for safe removal of patients from cardiac monitoring after initial evaluation in the emergency department. METHODS We prospectively enrolled adults (age ≥ 18 yr) who presented with chest pain and were assigned to cardiac monitoring at 2 academic emergency departments over 18 months. We collected standardized baseline characteristics, findings from clinical evaluations and predictors for the Ottawa Chest Pain Cardiac Monitoring Rule: whether the patient is currently free of chest pain, and whether the electrocardiogram is normal or shows only nonspecific changes. The outcome was an arrhythmia requiring intervention in the emergency department or within 8 hours of presentation to the emergency department. We calculated diagnostic characteristics for the clinical prediction rule. RESULTS We included 796 patients (mean age 63.8 yr, 55.8% male, 8.9% admitted to hospital). Fifteen patients (1.9%) had an arrhythmia, and the rule performed with the following characteristics: sensitivity 100% (95% confidence interval [CI] 78.2%-100%) and specificity 36.4% (95% CI 33.0%-39.6%). Application of the Ottawa Chest Pain Cardiac Monitoring Rule would have allowed 284 out of 796 patients (35.7%) to be safely removed from cardiac monitoring. INTERPRETATION We successfully validated the decision rule for safe removal of a large subset of patients with chest pain from cardiac monitoring after initial evaluation in the emergency department. Implementation of this simple yet highly sensitive rule will allow for improved use of health care resources.
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Affiliation(s)
- Shahbaz Syed
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Mathieu Gatien
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Jeffrey J Perry
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Hina Chaudry
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Soo-Min Kim
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Kenneth Kwong
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Muhammad Mukarram
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont
| | - Venkatesh Thiruganasambandamoorthy
- Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
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Loreto L, Andrea T, Lucia D, Carla L, Cristina P, Silvio R. Accuracy of EASI 12-lead ECGs in monitoring ST-segment and J-point by nurses in the Coronary Care Units. J Clin Nurs 2016; 25:1282-91. [DOI: 10.1111/jocn.13168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Lancia Loreto
- Department of Health, Life and Environmental Sciences; University of L'Aquila; L'Aquila Italy
| | | | - Dignani Lucia
- Nursing Science; University of L'Aquila; L'Aquila Italy
| | | | - Petrucci Cristina
- Department of Health, Life and Environmental Sciences; University of L'Aquila; L'Aquila Italy
| | - Romano Silvio
- Department of Health, Life and Environmental Sciences; University of L'Aquila; L'Aquila Italy
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