1
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Smith SW, Meyers HP. ST Elevation is a poor surrogate for acute coronary occlusion. Let's Replace STEMI with Occlusion MI (OMI)!! Int J Cardiol 2024; 407:131980. [PMID: 38513733 DOI: 10.1016/j.ijcard.2024.131980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Stephen W Smith
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States; Department of Emergency Medicine, Hennepin Healthcare and The University of Minnesota School of Medicine, United States.
| | - H Pendell Meyers
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States
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2
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McLaren JTT, Meyers HP, Smith SW, Chartier LB. Emergency department Code STEMI patients with initial electrocardiogram labeled "normal" by computer interpretation: A 7-year retrospective review. Acad Emerg Med 2024; 31:296-300. [PMID: 37620163 DOI: 10.1111/acem.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, North Carolina, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Kashou AH, Noseworthy PA, Beckman TJ, Anavekar NS, Cullen MW, Angstman KB, Sandefur BJ, Shapiro BP, Wiley BW, Kates AM, Sadhu J, Thakker P, Huneycutt D, Braisted A, Smith SW, Baranchuk A, Grauer K, O'Brien K, Kaul V, Gambhir HS, Knohl SJ, Restrepo D, May AM. EDUCATE: An international, randomized controlled trial for teaching electrocardiography. Curr Probl Cardiol 2024; 49:102409. [PMID: 38232918 PMCID: PMC10922800 DOI: 10.1016/j.cpcardiol.2024.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Despite the critical role of electrocardiograms (ECGs) in patient care, evident gaps exist in ECG interpretation competency among healthcare professionals across various medical disciplines and training levels. Currently, no practical, evidence-based, and easily accessible ECG learning solution is available for healthcare professionals. The aim of this study was to assess the effectiveness of web-based, learner-directed interventions in improving ECG interpretation skills in a diverse group of healthcare professionals. METHODS In an international, prospective, randomized controlled trial, 1206 healthcare professionals from various disciplines and training levels were enrolled. They underwent a pre-intervention test featuring 30 12-lead ECGs with common urgent and non-urgent findings. Participants were randomly assigned to four groups: (i) practice ECG interpretation question bank (question bank), (ii) lecture-based learning resource (lectures), (iii) hybrid question- and lecture-based learning resource (hybrid), or (iv) no ECG learning resources (control). After four months, a post-intervention test was administered. The primary outcome was the overall change in ECG interpretation performance, with secondary outcomes including changes in interpretation time, self-reported confidence, and accuracy for specific ECG findings. Both unadjusted and adjusted scores were used for performance assessment. RESULTS Among 1206 participants, 863 (72 %) completed the trial. Following the intervention, the question bank, lectures, and hybrid intervention groups each exhibited significant improvements, with average unadjusted score increases of 11.4 % (95 % CI, 9.1 to 13.7; P<0.01), 9.8 % (95 % CI, 7.8 to 11.9; P<0.01), and 11.0 % (95 % CI, 9.2 to 12.9; P<0.01), respectively. In contrast, the control group demonstrated a non-significant improvement of 0.8 % (95 % CI, -1.2 to 2.8; P=0.54). While no differences were observed among intervention groups, all outperformed the control group significantly (P<0.01). Intervention groups also excelled in adjusted scores, confidence, and proficiency for specific ECG findings. CONCLUSION Web-based, self-directed interventions markedly enhanced ECG interpretation skills across a diverse range of healthcare professionals, providing an accessible and evidence-based solution.
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Affiliation(s)
- Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas J Beckman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael W Cullen
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Kurt B Angstman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Benjamin J Sandefur
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Brandon W Wiley
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrew M Kates
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Justin Sadhu
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Prashanth Thakker
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | | | | | - Stephen W Smith
- Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | | | - Ken Grauer
- University of Florida, Gainesville, FL, USA
| | | | - Viren Kaul
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | | | - Daniel Restrepo
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Adam M May
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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4
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Herman R, Meyers HP, Smith SW, Bertolone DT, Leone A, Bermpeis K, Viscusi MM, Belmonte M, Demolder A, Boza V, Vavrik B, Kresnakova V, Iring A, Martonak M, Bahyl J, Kisova T, Schelfaut D, Vanderheyden M, Perl L, Aslanger EK, Hatala R, Wojakowski W, Bartunek J, Barbato E. International evaluation of an artificial intelligence-powered electrocardiogram model detecting acute coronary occlusion myocardial infarction. Eur Heart J Digit Health 2024; 5:123-133. [PMID: 38505483 PMCID: PMC10944682 DOI: 10.1093/ehjdh/ztad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/13/2023] [Accepted: 11/02/2023] [Indexed: 03/21/2024]
Abstract
Aims A majority of acute coronary syndromes (ACS) present without typical ST elevation. One-third of non-ST-elevation myocardial infarction (NSTEMI) patients have an acutely occluded culprit coronary artery [occlusion myocardial infarction (OMI)], leading to poor outcomes due to delayed identification and invasive management. In this study, we sought to develop a versatile artificial intelligence (AI) model detecting acute OMI on single-standard 12-lead electrocardiograms (ECGs) and compare its performance with existing state-of-the-art diagnostic criteria. Methods and results An AI model was developed using 18 616 ECGs from 10 543 patients with suspected ACS from an international database with clinically validated outcomes. The model was evaluated in an international cohort and compared with STEMI criteria and ECG experts in detecting OMI. The primary outcome of OMI was an acutely occluded or flow-limiting culprit artery requiring emergent revascularization. In the overall test set of 3254 ECGs from 2222 patients (age 62 ± 14 years, 67% males, 21.6% OMI), the AI model achieved an area under the curve of 0.938 [95% confidence interval (CI): 0.924-0.951] in identifying the primary OMI outcome, with superior performance [accuracy 90.9% (95% CI: 89.7-92.0), sensitivity 80.6% (95% CI: 76.8-84.0), and specificity 93.7 (95% CI: 92.6-94.8)] compared with STEMI criteria [accuracy 83.6% (95% CI: 82.1-85.1), sensitivity 32.5% (95% CI: 28.4-36.6), and specificity 97.7% (95% CI: 97.0-98.3)] and with similar performance compared with ECG experts [accuracy 90.8% (95% CI: 89.5-91.9), sensitivity 73.0% (95% CI: 68.7-77.0), and specificity 95.7% (95% CI: 94.7-96.6)]. Conclusion The present novel ECG AI model demonstrates superior accuracy to detect acute OMI when compared with STEMI criteria. This suggests its potential to improve ACS triage, ensuring appropriate and timely referral for immediate revascularization.
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Affiliation(s)
- Robert Herman
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | | | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Dario T Bertolone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Konstantinos Bermpeis
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Michele M Viscusi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Marta Belmonte
- Department of Advanced Biomedical Sciences, University of Naples Federico II, C.so Umberto I, 40, 80138 Naples, Italy
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | | | - Vladimir Boza
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Faculty of Mathematics, Physics and Informatics, Comenius University in Bratislava, Bratislava, Slovakia
| | - Boris Vavrik
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Viera Kresnakova
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Department of Cybernetics and Artificial Intelligence, Technical University of Kosice, Kosice, Slovakia
| | - Andrej Iring
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Michal Martonak
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Jakub Bahyl
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
| | - Timea Kisova
- Powerful Medical, Bratislavska 81/37, 931 01 Samorin, Slovakia
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry, London, UK
| | - Dan Schelfaut
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Marc Vanderheyden
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petah Tikvah, Israel
| | - Emre K Aslanger
- Department of Cardiology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Robert Hatala
- Department of Arrhythmia and Pacing, National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Jozef Bartunek
- Cardiovascular Centre Aalst, OLV Hospital, Moorselbaan 164, Aalst 9300, Belgium
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Lindow T, Mokhtari A, Nyström A, Koul S, Smith SW, Ekelund U. Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction. Int J Cardiol 2024; 395:131569. [PMID: 37931659 DOI: 10.1016/j.ijcard.2023.131569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. METHODS The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. RESULTS In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). CONCLUSIONS Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.
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Affiliation(s)
- Thomas Lindow
- Clinical Physiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Clinical Physiology, Department of Research and Development, Region Kronoberg, Växjö Central Hospital, Växjö, Sweden.
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Axel Nyström
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Stephen W Smith
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ulf Ekelund
- Emergency Medicine, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Emergency Medicine, Skåne University Hospital, Lund, Sweden
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6
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McLaren JTT, Smith SW. A Bayesian approach to acute coronary occlusion. J Electrocardiol 2023; 81:300-302. [PMID: 37951822 DOI: 10.1016/j.jelectrocard.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023]
Abstract
In the STEMI paradigm, the disease (acute coronary occlusion) is defined and named after one element (ST elevation, without regard to the remainder of the QRST) of one imperfect test (the ECG). This leads to delayed reperfusion for patients with acute coronary occlusion whose ECGs don't meet STEMI criteria. In this editorial, we elaborate on the article by Jose Nunes de Alencar Neto about applying Bayesian reasoning to ECG interpretation. The Occlusion MI (OMI) paradigm offers evidencebased advances in ECG interpretation, expert-trained artificial intelligence, and a paradigm shift that incorporates a Bayesian approach to acute coronary occlusion.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Country Medical Centre, Minneapolis, MN, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kashou AH, Noseworthy PA, Beckman TJ, Anavekar NS, Cullen MW, Angstman KB, Sandefur BJ, Shapiro BP, Wiley BW, Kates AM, Huneycutt D, Braisted A, Smith SW, Baranchuk A, Grauer K, O'Brien K, Kaul V, Gambhir HS, Knohl SJ, Albert D, Kligfield PD, Macfarlane PW, Drew BJ, May AM. ECG Interpretation Proficiency of Healthcare Professionals. Curr Probl Cardiol 2023; 48:101924. [PMID: 37394202 DOI: 10.1016/j.cpcardiol.2023.101924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
ECG interpretation is essential in modern medicine, yet achieving and maintaining competency can be challenging for healthcare professionals. Quantifying proficiency gaps can inform educational interventions for addressing these challenges. Medical professionals from diverse disciplines and training levels interpreted 30 12-lead ECGs with common urgent and nonurgent findings. Average accuracy (percentage of correctly identified findings), interpretation time per ECG, and self-reported confidence (rated on a scale of 0 [not confident], 1 [somewhat confident], or 2 [confident]) were evaluated. Among the 1206 participants, there were 72 (6%) primary care physicians (PCPs), 146 (12%) cardiology fellows-in-training (FITs), 353 (29%) resident physicians, 182 (15%) medical students, 84 (7%) advanced practice providers (APPs), 120 (10%) nurses, and 249 (21%) allied health professionals (AHPs). Overall, participants achieved an average overall accuracy of 56.4% ± 17.2%, interpretation time of 142 ± 67 seconds, and confidence of 0.83 ± 0.53. Cardiology FITs demonstrated superior performance across all metrics. PCPs had a higher accuracy compared to nurses and APPs (58.1% vs 46.8% and 50.6%; P < 0.01), but a lower accuracy than resident physicians (58.1% vs 59.7%; P < 0.01). AHPs outperformed nurses and APPs in every metric and showed comparable performance to resident physicians and PCPs. Our findings highlight significant gaps in the ECG interpretation proficiency among healthcare professionals.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Brandon W Wiley
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andrew M Kates
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | | | - Stephen W Smith
- Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
| | | | - Ken Grauer
- University of Florida, Gainesville, Florida
| | | | - Viren Kaul
- SUNY Upstate Medical University, Syracuse, New York
| | | | | | | | - Paul D Kligfield
- New York-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Peter W Macfarlane
- Electrocardiology Core Lab, New Lister Building, Royal Infirmary, Scotland, UK
| | | | - Adam M May
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
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9
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Kashou AH, Noseworthy PA, Beckman TJ, Anavekar NS, Cullen MW, Angstman KB, Sandefur BJ, Thompson CA, Halvorsen AJ, Shapiro BP, Wiley BW, Kates AM, Cosco D, Sadhu JS, Thakker PD, Huneycutt D, Braisted A, Smith SW, Baranchuk A, Grauer K, O'Brien K, Kaul V, Gambhir HS, Knohl SJ, Restrepo D, Kligfield PD, Macfarlane PW, Drew BJ, May AM. Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial. J Electrocardiol 2023; 80:166-173. [PMID: 37467573 DOI: 10.1016/j.jelectrocard.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Electrocardiogram (ECG) interpretation training is a fundamental component of medical education across disciplines. However, the skill of interpreting ECGs is not universal among medical graduates, and numerous barriers and challenges exist in medical training and clinical practice. An evidence-based and widely accessible learning solution is needed. DESIGN The EDUcation Curriculum Assessment for Teaching Electrocardiography (EDUCATE) Trial is a prospective, international, investigator-initiated, open-label, randomized controlled trial designed to determine the efficacy of self-directed and active-learning approaches of a web-based educational platform for improving ECG interpretation proficiency. Target enrollment is 1000 medical professionals from a variety of medical disciplines and training levels. Participants will complete a pre-intervention baseline survey and an ECG interpretation proficiency test. After completion, participants will be randomized into one of four groups in a 1:1:1:1 fashion: (i) an online, question-based learning resource, (ii) an online, lecture-based learning resource, (iii) an online, hybrid question- and lecture-based learning resource, or (iv) a control group with no ECG learning resources. The primary endpoint will be the change in overall ECG interpretation performance according to pre- and post-intervention tests, and it will be measured within and compared between medical professional groups. Secondary endpoints will include changes in ECG interpretation time, self-reported confidence, and interpretation accuracy for specific ECG findings. CONCLUSIONS The EDUCATE Trial is a pioneering initiative aiming to establish a practical, widely available, evidence-based solution to enhance ECG interpretation proficiency among medical professionals. Through its innovative study design, it tackles the currently unaddressed challenges of ECG interpretation education in the modern era. The trial seeks to pinpoint performance gaps across medical professions, compare the effectiveness of different web-based ECG content delivery methods, and create initial evidence for competency-based standards. If successful, the EDUCATE Trial will represent a significant stride towards data-driven solutions for improving ECG interpretation skills in the medical community.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Brandon W Wiley
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrew M Kates
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dominique Cosco
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Justin S Sadhu
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | | | | | | | - Stephen W Smith
- Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | | | - Ken Grauer
- University of Florida, Gainesville, FL, USA
| | | | - Viren Kaul
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | | | - Daniel Restrepo
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul D Kligfield
- New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | | | | | - Adam M May
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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10
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Smith SW, Meyers HP. Hyperacute T-waves Can Be a Useful Sign of Occlusion Myocardial Infarction if Appropriately Defined. Ann Emerg Med 2023; 82:203-206. [PMID: 36872197 DOI: 10.1016/j.annemergmed.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and University of Minnesota School of Medicine, Minneapolis, MN.
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11
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Triska J, George J, Rector G, Alam M, Smith SW, Meyers HP, Birnbaum Y. Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. Ann Emerg Med 2023; 82:219-221. [PMID: 37479399 DOI: 10.1016/j.annemergmed.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 07/23/2023]
Affiliation(s)
- Jeffery Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jerin George
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Graham Rector
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; University of Minnesota Medical Center, Minneapolis, MN
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX
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12
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Al-Zaiti SS, Martin-Gill C, Zègre-Hemsey JK, Bouzid Z, Faramand Z, Alrawashdeh MO, Gregg RE, Helman S, Riek NT, Kraevsky-Phillips K, Clermont G, Akcakaya M, Sereika SM, Van Dam P, Smith SW, Birnbaum Y, Saba S, Sejdic E, Callaway CW. Machine learning for ECG diagnosis and risk stratification of occlusion myocardial infarction. Nat Med 2023; 29:1804-1813. [PMID: 37386246 PMCID: PMC10353937 DOI: 10.1038/s41591-023-02396-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/11/2023] [Indexed: 07/01/2023]
Abstract
Patients with occlusion myocardial infarction (OMI) and no ST-elevation on presenting electrocardiogram (ECG) are increasing in numbers. These patients have a poor prognosis and would benefit from immediate reperfusion therapy, but, currently, there are no accurate tools to identify them during initial triage. Here we report, to our knowledge, the first observational cohort study to develop machine learning models for the ECG diagnosis of OMI. Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated an intelligent model that outperformed practicing clinicians and other widely used commercial interpretation systems, substantially boosting both precision and sensitivity. Our derived OMI risk score provided enhanced rule-in and rule-out accuracy relevant to routine care, and, when combined with the clinical judgment of trained emergency personnel, it helped correctly reclassify one in three patients with chest pain. ECG features driving our models were validated by clinical experts, providing plausible mechanistic links to myocardial injury.
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Affiliation(s)
- Salah S Al-Zaiti
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Zeineb Bouzid
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ziad Faramand
- Department of Emergency Medicine, Northeast Georgia Health System, Gainesville, GA, USA
| | - Mohammad O Alrawashdeh
- School of Nursing, Jordan University of Science and Technology, Irbid, Jordan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Richard E Gregg
- Advanced Algorithm Development Center, Philips Healthcare, Cambridge, MA, USA
| | - Stephanie Helman
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan T Riek
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Murat Akcakaya
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan M Sereika
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter Van Dam
- Division of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Yochai Birnbaum
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Samir Saba
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ervin Sejdic
- Department of Electrical & Computer Engineering, University of Toronto, Toronto, ON, Canada
- Artificial Intelligence for Health Outcomes at Research & Innovation, North York General Hospital, Toronto, ON, Canada
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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13
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Birnbaum Y, Smith SW, Nikus K. New-Onset Left Bundle Branch Block With ST Elevation After Minimally Invasive Aortic Valve Replacement: Differential Diagnosis. Ann Emerg Med 2023; 81:546-549. [PMID: 37085196 DOI: 10.1016/j.annemergmed.2022.08.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 04/23/2023]
Affiliation(s)
- Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and the University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Kjell Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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14
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Fabre-Estremera B, Smith SW, Sandoval Y, Schulz K, Okeson B, Cullen L, Apple FS. Rapid Rule-Out of Myocardial Infarction Using a Single High-Sensitivity Cardiac Troponin I Measurement Strategy at Presentation to the Emergency Department: The SAFETY Study. Clin Chem 2023:7109945. [PMID: 37022774 DOI: 10.1093/clinchem/hvad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Our study addressed the diagnostic performance of the Atellica® IM High-Sensitivity Troponin I (hs-cTnI) assay for the rapid rule-out of myocardial infarction (MI) using a single hs-cTnI measurement at presentation in patients presenting to a US emergency department (ED). METHODS This was a prospective, observational, cohort study of consecutive ED patients with suspected acute coronary syndrome, using 12-lead electrocardiogram and serial hs-cTnI measurements ordered on clinical indication (SAFETY, NCT04280926). ST-segment elevation MI patients were excluded. The optimal threshold required a sensitivity ≥99% and a negative predictive value (NPV) ≥99.5% for MI during index hospitalization as primary outcome. Type 1 MI (T1MI), myocardial injury, and 30-day adverse events were considered secondary outcomes. Event adjudications were established using the hs-cTnI assay used in clinical care. RESULTS In 1171 patients, MI occurred in 97 patients (8.3%), 78.3% of which were type 2 MI. The optimal rule out hs-cTnI threshold was <10 ng/L, which identified 519 (44.3%) patients as low risk at presentation, with sensitivity of 99.0% (95% CI, 94.4-100) and NPV of 99.8% (95% CI, 98.9-100). For T1MI, sensitivity was 100% (95% CI, 83.9-100) and NPV 100% (95% CI, 99.3-100). Regarding myocardial injury, the sensitivity and NPV were 99.5% (95% CI, 97.9-100) and 99.8% (95% CI, 98.9-100), respectively. For 30-day adverse events, sensitivity was 96.8% (95% CI, 94.3-98.4) and NPV 97.9% (95% CI, 96.2-98.9). CONCLUSIONS A single hs-cTnI measurement strategy enabled the rapid identification of patients at low risk of MI and 30-day adverse events, allowing potential discharge early after ED presentation. CLINICALTRIALS.GOV REGISTRATION NUMBER NCT04280926.
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Affiliation(s)
- Blanca Fabre-Estremera
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Madrid, Spain
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
| | - Stephen W Smith
- Department of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, United States
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Brynn Okeson
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, United States
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Departments of Laboratory Medicine & Pathology at Hennepin Healthcare/Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN, United States
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15
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McLaren JTT, Meyers HP, Smith SW. Chest Pain, Paced Rhythm, and 2 Missed Indications for Emergent Reperfusion. JAMA Intern Med 2023:2803496. [PMID: 37010835 DOI: 10.1001/jamainternmed.2023.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre, Minneapolis, Minnesota
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16
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Xiong-Hang K, Schulz K, Sandoval Y, Smith SW, Saenger AK, Apple FS. Analytical performance comparing siemens whole blood point of care Atellica VTLi to the central laboratory plasma Atellica IM high-sensitivity cardiac troponin I assays. Clin Biochem 2023; 114:79-85. [PMID: 36780933 DOI: 10.1016/j.clinbiochem.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
INTRODUCTION This study examined the analytical performance of a whole blood (WB) point of care (POC) hs-cTnI assay compared to a plasma central laboratory hs-cTnI assay in patients presenting with ischemic symptoms to a US emergency department. METHODS Fresh WB specimens collected at 0 and 2 h from 1089 consecutive patients (2152 total from 1076 matched specimens) were analyzed for hs-cTnI using WB on POC Siemens Atellica VTLi assay and plasma on central laboratory Siemens Atellica IM assay. Concordances were determined based on concentrations ranging from < limit of detection (LoD), LoD to overall and sex specific 99th percentiles from both the IFCC manufacturer package inserts and Universal Sample Bank (USB) data, and > 99th percentiles. Method comparisons were calculated using Passing Bablok regression and Bland Altmann plots, and linear regression determined by Pearson correlation coefficient. RESULTS Baseline concentration comparisons showed: POC VTLi < LoD 4-5 %, ≥ LoD 95 %; Atellica IM < LoD 5-7 %, and ≥ LoD 94-95 %. From the 2152 paired 0 and 2-hour samples, based on 99th percentiles, overall concordance was 91-92 % (kappa 0.72-0.77) and discordance 8 %. Passing Bablok regression analysis using 1924 specimens between LoD to 500 ng/L showed: slopes 0.469-0.490; y-intercepts 1.753-2.028; r values 0.631-0.817. Pearson correlation coefficient showed moderate to strong correlation strength, even with up to 53 % cTnI concentrations variance (Passing Bablok slopes) vs 27.0-40.1 % (Bland-Altmann plots). CONCLUSIONS Up to 95 % of measured samples were > LoD for both the POC (Atellica VTLi) and central laboratory (Atellica IM) hs-cTnI assays. Moderate to strong concordance and correlation were observed between assays, despite up to 53 % variances in cTnI concentration.
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Affiliation(s)
- Kang Xiong-Hang
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
| | - Karen Schulz
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Stephen W Smith
- Departments of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center & University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.
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17
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Vallelonga F, Diella FA, Smith SW. Lead aVR Should Not Be Neglected-Reply. JAMA Intern Med 2023; 183:392. [PMID: 36806797 DOI: 10.1001/jamainternmed.2022.6935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Fabrizio Vallelonga
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy.,Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Francesco A Diella
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis
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18
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Totzkay D, Silk KJ, Thomas B, Walling BM, Smith SW. Women's Understanding of Windows of Susceptibility and the Role of the Environment in Breast Cancer Risk. J Cancer Educ 2023; 38:115-126. [PMID: 34505275 PMCID: PMC8907316 DOI: 10.1007/s13187-021-02086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 06/13/2023]
Abstract
Emerging evidence suggests women who are exposed to harmful environmental exposures, especially during certain critical periods across the lifespan, may increase their breast cancer risk. Such windows of susceptibility (WoS) occur throughout a woman's lifetime, during which she is especially vulnerable to the effects of harmful environmental exposures. This interaction makes the reduction of harmful environmental toxicants during those time periods a priority for community health promotion. Communicating about environmental exposures and their impact on women's health requires an assessment of sense-making around, and understanding of, the link between breast cancer and the environment. To that end, focus groups were conducted to assess the themes that emerge when women make sense of (a) their own breast cancer risk, (b) the environment-cancer connection, and (c) WoS. Results provide insight into how women understand these issues which can inform messaging strategies focused on reducing harmful environmental exposures. Implications are discussed within the context of communication efforts tailored to educate women, particularly mothers with daughters in the prepubertal and pubertal WoS who are particularly vulnerable to harmful environmental exposures.
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Affiliation(s)
- D Totzkay
- West Virginia University, Morgantown, WV, USA
| | - K J Silk
- University of Delaware, Newark, DE, USA
| | - B Thomas
- Michigan State University, East Lansing, MI, USA
| | - B M Walling
- Michigan State University, East Lansing, MI, USA
| | - S W Smith
- Michigan State University, East Lansing, MI, USA.
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19
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McLaren JTT, Meyers HP, Smith SW. Kenichi Harumi Plenary Address at Annual Meeting of the International Society of Computers in Electrocardiology: "What Should ECG Deep Learning Focus on? The diagnosis of acute coronary occlusion!". J Electrocardiol 2023; 76:39-44. [PMID: 36436473 DOI: 10.1016/j.jelectrocard.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
According to the STEMI paradigm, only patients whose ECGs meet STEMI criteria require immediate reperfusion. This leads to reperfusion delays and significantly increases the mortality for the quarter of "non-STEMI" patients with totally occluded arteries. The Occlusion MI (OMI) paradigm has developed advanced ECG interpretation to identify this high-risk group, including examining the ECG in totality and assessing ST/T changes in proportion to the QRS. If neural networks are only developed based on STEMI databases and to identify STEMI criteria, they will simply reinforce a failed paradigm. But if deep learning is trained to identify OMI it could revolutionize patient care. This article reviews the paradigm shift from STEMI and OMI, and examines the potential and pitfalls of deep learning. This is based on the Kenichi Harumi Plenary Address at the Annual Meeting of the International Society of Computers in Electrocardiology, given by OMI expert Dr. Stephen Smith.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada.
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre, Minneapolis, MN, USA.
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20
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Cumming MM, Poling DV, Qiu Y, Pham AV, Daunic AP, Corbett N, Smith SW. A Validation Study of the BRIEF-2 Among Kindergarteners and First Graders At-Risk for Behavior Problems. Assessment 2023; 30:3-21. [PMID: 34423656 DOI: 10.1177/10731911211032289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early identification of executive dysfunction and timely school-based intervention efforts are critical for students at risk for problematic behaviors during early elementary school. The original Behavior Rating Inventory of Executive Functioning (BRIEF) was designed to measure real-world behavioral manifestations of executive functioning, neurocognitive processes critical for school success. With the updated BRIEF-2, independent validation is needed with kindergarten and first grade students at risk for emotional and behavioral disorders. Thus, using item level analyses, we examined the factor structure of the BRIEF-2 Teacher Rating form with 1,112 students. Results indicated little evidence for the original three-index model and supported a modified two-index model, with a Cognitive Regulation Index and an overall Behavior-Emotion Regulation Index. Criterion related validity indicated positive relationships with performance-based executive functioning (Head-Toes-Knees-Shoulders) and later internalizing and externalizing behaviors. We discuss implications of findings for early identification and school-based intervention efforts, as well as future research.
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Affiliation(s)
| | | | - Yuxi Qiu
- Florida International University, Miami, FL, USA
| | - Andy V Pham
- Florida International University, Miami, FL, USA
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21
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Lipták R, Smith SW, Hodosy J. When the ECG Tells the Story, But It is Not Heard. Ann Emerg Med 2023; 81:79-83. [PMID: 36543489 DOI: 10.1016/j.annemergmed.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Róbert Lipták
- Department of Emergency Ružinov, University Hospital in Bratislava, Bratislava, Slovakia; Faculty of Medicine, Institute of Physiology, Comenius University in Bratislava, Bratislava, Slovakia
| | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota Medical Center, and Hennepin County Medical Center, Minneapolis, MN; Professor of Emergency Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - Julius Hodosy
- Department of Emergency Ružinov, University Hospital in Bratislava, Bratislava, Slovakia; Faculty of Medicine, Institute of Physiology, Comenius University in Bratislava, Bratislava, Slovakia
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22
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Doggart P, Kennedy A, Bond R, Finlay D, Smith SW. A two-staged classifier to reduce false positives: On device detection of atrial fibrillation using phase-based distribution of poincaré plots and deep learning. J Electrocardiol 2023; 76:17-21. [PMID: 36395631 DOI: 10.1016/j.jelectrocard.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/30/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Mobile Cardiac Outpatient Telemetry (MCOT) can be used to screen high risk patients for atrial fibrillation (AF). These devices rely primarily on algorithmic detection of AF events, which are then stored and transmitted to a clinician for review. It is critical the positive predictive value (PPV) of MCOT detected AF is high, and this often leads to reduced sensitivity, as device manufacturers try to limit false positives. OBJECTIVE The purpose of this study was to design a two stage classifier using artificial intelligence (AI) to improve the PPV of MCOT detected atrial fibrillation episodes whilst maintaining high levels of detection sensitivity. METHODS A low complexity, RR-interval based, AF classifier was paired with a deep convolutional neural network (DCNN) to create a two-stage classifier. The DCNN was limited in size to allow it to be embedded on MCOT devices. The DCNN was trained on 491,727 ECGs from a proprietary database and contained 128,612 parameters requiring only 158 KB of storage. The performance of the two-stage classifier was then assessed using publicly available datasets. RESULTS The sensitivity of AF detected by the low complexity classifier was high across all datasets (>93%) however the PPV was poor (<76%). Subsequent analysis by the DCNN increased episode PPV across all datasets substantially (>11%), with only a minor loss in sensitivity (<5%). This increase in PPV was due to a decrease in the number of false positive detections. Further analysis showed that DCNN processing was only required on around half of analysis windows, offering a significant computational saving against using the DCNN as a one-stage classifier. CONCLUSION DCNNs can be combined with existing MCOT classifiers to increase the PPV of detected AF episodes. This reduces the review burden for physicians and can be achieved with only a modest decrease in sensitivity.
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Affiliation(s)
- Peter Doggart
- PulseAI, 58 Howard Street, Belfast BT1 6PL, United Kingdom; Ulster University, Shore Road, BT37 OQB, United Kingdom.
| | - Alan Kennedy
- PulseAI, 58 Howard Street, Belfast BT1 6PL, United Kingdom; Ulster University, Shore Road, BT37 OQB, United Kingdom.
| | - Raymond Bond
- Ulster University, Shore Road, BT37 OQB, United Kingdom
| | - Dewar Finlay
- Ulster University, Shore Road, BT37 OQB, United Kingdom
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, NM, USA; University of Minnesota, Department of Emergency Medicine, USA
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23
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Apple FS, Smith SW, Greenslade JH, Sandoval Y, Parsonage W, Ranasinghe I, Gaikwad N, Schulz K, Stephensen L, Schmidt CW, Okeson B, Cullen L. Single High-Sensitivity Point-of-Care Whole-Blood Cardiac Troponin I Measurement to Rule Out Acute Myocardial Infarction at Low Risk. Circulation 2022; 146:1918-1929. [PMID: 36314160 DOI: 10.1161/circulationaha.122.061148] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turnaround times can delay patient management. Our primary aim was to identify patients at low risk of index MI using a rapid point-of-care (POC) whole-blood hs-cTnI assay at presentation with potential early patient discharge. METHODS Consecutive patients presenting to the emergency department from 2 prospective observational studies with suspected acute coronary syndrome were enrolled. A POC hs-cTnI assay (Atellica VTLi) threshold using whole blood at presentation, which resulted in a negative predictive value of ≥99.5% and sensitivity of >99% for index MI, was derived (SEIGE [Safe Emergency Department Discharge Rate]) and validated with plasma (SAMIE [Suspected Acute Myocardial Infarction in Emergency]). Event adjudications were established with hs-cTnI assay results from routine clinical care. The primary outcome was MI at 30 days. RESULTS A total of 1086 patients (8.1% with MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole-blood POC hs-cTnI concentration of <4 ng/L provided a sensitivity of 98.9% (95% CI, 93.8%-100%) and negative predictive value of 99.5% (95% CI, 97.2%-100%) for ruling out MI. In the validation cohort, the sensitivity was 98.8% (95% CI, 93.3%-100%), and negative predictive value was 99.8% (95% CI, 99.1%-100%); 17.8% and 41.8%, respectively, were defined as low risk for discharge. The 30-day adverse cardiac events were 0.1% (n=1) for SEIGE and 0.8% (n=5) for SAMIE. CONCLUSIONS A POC whole-blood hs-cTnI assay permits accessible, rapid, and safe exclusion of MI and may expedite discharge from the emergency department. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04772157. URL: https://www.australianclinicaltrials.gov.au/anzctr_feed/form; Unique identifier: 12621000053820.
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Affiliation(s)
- Fred S Apple
- Departments of Laboratory Medicine (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Pathology (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN
| | - Stephen W Smith
- Emergency Medicine (S.W.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN
| | - Jaimi H Greenslade
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C.).,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.)
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - William Parsonage
- Department of Cardiology (W.P., I.R.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Isuru Ranasinghe
- Department of Cardiology (W.P., I.R.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.).,Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Niranjan Gaikwad
- Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Karen Schulz
- Departments of Laboratory Medicine (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Pathology (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Hennepin Healthcare Research Institute, Minneapolis, MN (K.S.)
| | - Laura Stephensen
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C.)
| | - Christian W Schmidt
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - Brynn Okeson
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - Louise Cullen
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.)
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Vallelonga F, Diella FA, Smith SW. High-risk Electrocardiogram Patterns. JAMA Intern Med 2022; 182:1313-1314. [PMID: 36251314 DOI: 10.1001/jamainternmed.2022.4704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This case report describes a patient in their 50s who presented to the emergency department with the presence of typical retrosternal chest pain radiating to the left scapular site.
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Affiliation(s)
- Fabrizio Vallelonga
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy.,Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Francesco A Diella
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy
| | - Stephen W Smith
- Hennepin County Medical Center, Department of Emergency Medicine, University of Minnesota, Minneapolis
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25
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Avdikos G, Michas G, Smith SW. From Q/Non-Q Myocardial Infarction to STEMI/NSTEMI: Why It's Time to Consider Another Simplified Dichotomy; a Narrative Literature Review. Arch Acad Emerg Med 2022; 10:e78 . [PMID: 36426169 PMCID: PMC9676707 DOI: 10.22037/aaem.v10i1.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute coronary syndromes (ACSs) are classified as ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) based on the presence of guideline-recommended ST-segment elevation (STE) criteria on the electrocardiogram (ECG). STEMI is associated with acute total coronary occlusion (ATO) and transmural myocardial necrosis and is managed with emergent reperfusion therapy, and NSTEMI is supposedly synonymous with subendocardial myocardial infarction without ATO. However, coronary angiograms reveal that a significant proportion of patients with NSTEMI have ATO. Here, we review articles that studied the frequency and cardiovascular outcomes of ATO in NSTEMI patients compared with those without ATO. We discuss ECG patterns of patients with suspected acute myocardial infarction that do not fulfill STEMI criteria but are associated with ATO. Under-recognition of these atypical patterns results in delays to reperfusion therapy. We also advocate revision of the current STEMI/NSTEMI paradigm because consideration of STE, by itself, out of context of other clinical and ECG features, leads to the ECG diagnosis of STEMI when the ECG actually represents a mimic ["Pseudo-STEMI"], and suggest renaming the ACSs classification as the Occlusion Myocardial Infarction (OMI)/Non-Occlusion Myocardial Infarction (NOMI) paradigm.
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Affiliation(s)
- Grigorios Avdikos
- Department of Cardiology, Bioiatriki Healthcare Group, 132 Kifisias Ave. & Papada st., 11526, Athens, Greece.,Corresponding author: Grigorios Avdikos; Department of Cardiology, Bioiatriki Healthcare Group, 132 Kifisias Ave. & Papada st., 11526, Athens, Greece. , Tel: +306942906463
| | - George Michas
- Department of Cardiology, “Elpis” General Hospital of Athens, Dimitsanas 7, 11522, Athens, Greece
| | - Stephen W. Smith
- Hennepin Healthcare, University of Minnesota School of Medicine, HCMC ER, R-2, 701 S. Park Ave., Minneapolis, MN 55415, United States of America
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26
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Kennedy A, Doggart P, Smith SW, Finlay D, Guldenring D, Bond R, McCausland C, McLaughlin J. Device agnostic AI-based analysis of ambulatory ECG recordings. J Electrocardiol 2022; 74:154-157. [PMID: 36283253 DOI: 10.1016/j.jelectrocard.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Deep Convolutional Neural Networks (DCNNs) have been shown to provide improved performance over traditional heuristic algorithms for the detection of arrhythmias from ambulatory ECG recordings. However, these DCNNs have primarily been trained and tested on device-specific databases with standardized electrode positions and uniform sampling frequencies. This work explores the possibility of training a DCNN for Atrial Fibrillation (AF) detection on a database of single‑lead ECG rhythm strips extracted from resting 12‑lead ECGs. We then test the performance of the DCNN on recordings from ambulatory ECG devices with different recording leads and sampling frequencies. We developed an extensive proprietary resting 12‑lead ECG dataset of 549,211 patients. This dataset was randomly split into a training set of 494,289 patients and a testing set of the remaining 54,922 patients. We trained a 34-layer convolutional DCNN to detect AF and other arrhythmias on this dataset. The DCNN was then validated on two Physionet databases commonly used to benchmark automated ECG algorithms (1) MIT-BIH Arrhythmia Database and (2) MIT-BIH Atrial Fibrillation Database. Validation was performed following the EC57 guidelines, with performance assessed by gross episode and duration sensitivity and positive predictive value (PPV). Finally, validation was also performed on a selection of rhythm strips from an ambulatory ECG patch that a committee of board-certified cardiologists annotated. On MIT-BIH, The DCNN achieved a sensitivity of 100% and 84% PPV in detecting episodes of AF. and 100% sensitivity and 94% PPV in quantifying AF episode duration. On AFDB, The DCNN achieved a sensitivity of 94% and PPV of 98% in detecting episodes of AF, and 98% sensitivity and 100% PPV in quantifying AF episode duration. On the patch database, the DCNN demonstrated performance that was closely comparable to that of a cardiologist. The results indicate that DCNN models can learn features that generalize between resting 12‑lead and ambulatory ECG recordings, allowing DCNNs to be device agnostic for detecting arrhythmias from single‑lead ECG recordings and enabling a range of clinical applications.
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27
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Al-Zaiti S, Macleod R, Dam PV, Smith SW, Birnbaum Y. Emerging ECG methods for acute coronary syndrome detection: Recommendations & future opportunities. J Electrocardiol 2022; 74:65-72. [PMID: 36027675 DOI: 10.1016/j.jelectrocard.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 12/13/2022]
Abstract
Despite being the mainstay for the initial noninvasive assessment of patients with symptomatic coronary artery disease, the 12‑lead ECG remains a suboptimal diagnostic tool for myocardial ischemia detection with only acceptable sensitivity and specificity scores. Although myocardial ischemia affects the configuration of the QRS complex and the STT waveform, current guidelines primarily focus on ST segment amplitude, which constitutes a missed opportunity and may explain the suboptimal diagnostic performance of the ECG. This possible opportunity and the low cost and ease of use of the ECG provide compelling motivation to enhance the diagnostic accuracy of the ECG to ischemia detection. This paper describes numerous computational ECG methods and approaches that have been shown to dramatically increase ECG sensitivity to ischemia detection. Briefly, these emerging approaches can be conceptually grouped into one of the following four approaches: (1) leveraging novel ECG waveform features and signatures indicative of ischemic injury other than the classical ST-T amplitude measures; (2) applying body surface potentials mapping (BSPM)-based approaches to enhance the spatial coverage of the surface ECG to detecting ischemia; (3) developing an inverse ECG solution to reconstruct anatomical models of activation and recovery pathways to detect and localize injury currents; and (4) exploring artificial intelligence (AI)-based techniques to harvest ECG waveform signatures of ischemia. We present recent advances, shortcomings, and future opportunities for each of these emerging ECG methods. Future research should focus on the prospective clinical testing of these approaches to establish clinical utility and to expedite potential translation into clinical practice.
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Affiliation(s)
- Salah Al-Zaiti
- Department of Acute & Tertiary Care, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Robert Macleod
- Department of Biomedical Engineering, University of Utah, Salt Lake, UT, USA
| | - Peter Van Dam
- Department of Cardiology, University Medical Center Utrecht, the Netherlands
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, MN, USA
| | - Yochai Birnbaum
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
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28
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Bracey A, Meyers HP, Smith SW. Emergency physicians should interpret every triage ECG, including those with a computer interpretation of "normal". Am J Emerg Med 2022; 55:180-182. [PMID: 35361516 DOI: 10.1016/j.ajem.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, USA.
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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29
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Gunsolus IL, Schulz K, Sandoval Y, Smith SW, Lindgren B, Okeson B, Apple FS. Diagnostic performance of a rapid, novel, whole blood, point of care high-sensitivity cardiac troponin I assay for myocardial infarction. Clin Biochem 2022; 105-106:70-74. [PMID: 35447148 DOI: 10.1016/j.clinbiochem.2022.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We evaluated the diagnostic performance of a whole blood, point of care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay for myocardial infarction (MI) compared to central laboratory assays. METHODS Consecutive patients presenting to the emergency department with symptoms of ischemia were studied. Serial hs-cTnI testing was based on clinical indication at presentation. Parallel measurements were made using fresh whole blood on Siemens Atellica VTLi POC assay, EDTA plasma on Abbott ARCHITECT i2000 used in practice, and heparin plasma on Siemens Atellica. MI was determined according to the Fourth Universal Definition of MI using 99th percentiles. Sensitivities and negative predictive values (NPV) were calculated using 99th percentile URLs. RESULTS 1089 Patients, 418 females and 671 males, were enrolled. There were 91 (8.4%) MIs. At baseline (0 h), POC hs-cTnI assay had a sensitivity of 65.7% (95% CI 47.8-80.9) for females and 67.9% (54.0-79.7) for males and NPV of 96.4% (93.9-98.1) for females and 96.7% (94.9-98.0) for males. At 2 h, sensitivity improved to 82.9% (66.4-93.4) for females and 80.4% (67.6-89.8) for males, while NPV improved to 98.2% (96.1-99.3) and 97.9% (96.3-99.0), respectively. For central laboratory assays, comparable diagnostics were observed at 2 h: females - sensitivity 94.3% (80.8-99.3) for ARCHITECT and 79.4% (62.1-91.3) for Atellica, and NPV 99.3% (97.6-99.9) and 98.0% (95.8-99.2), respectively; males - sensitivity 87.5% (75.9-94.8) for ARCHITECT and 80.4% (67.6-89.8) for Atellica, NPVs of 98.7% (97.3-99.5) and 97.9% (96.3-99.0), respectively. CONCLUSIONS The POC, whole blood Atellica VTLi hs-cTnI assay demonstrated comparable diagnostic accuracy for MI to central laboratory assays using 99th percentiles.
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Affiliation(s)
- Ian L Gunsolus
- Department of Laboratory Medicine and Pathology, HealthPartners, Minneapolis, MN, USA
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brittany Lindgren
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
| | - Brynn Okeson
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA; Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
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30
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit. Resuscitation 2022; 172:24-31. [PMID: 35041876 DOI: 10.1016/j.resuscitation.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA). METHODS OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA. RESULTS 152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6). CONCLUSIONS Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.
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Affiliation(s)
- Amit Sharma
- Regions Hospital, St. Paul, MN, United States
| | - David F Miranda
- CentraCare Heart and Vascular Center, St. Cloud, United States
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, United States.
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Veterans Affairs Medical Center and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
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31
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McLaren JTT, Meyers HP, Smith SW, Chartier LB. From STEMI to occlusion MI: paradigm shift and ED quality improvement. CAN J EMERG MED 2021; 24:250-255. [PMID: 34967919 PMCID: PMC9001399 DOI: 10.1007/s43678-021-00255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. .,Emergency Department, University Health Network, Toronto, ON, Canada. .,Toronto General Hospital, 200 Elizabeth Street, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON, M5G 2C4, 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, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
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32
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Dodd KW, Zvosec DL, Meyers HP, Smith SW. In Response to The Influence of Serial ECG on the Test Characteristics of the Sgarbossa Criteria in Ventricular Paced Rhythms (published in Annals volume 78, issue 6). Ann Emerg Med 2021; 79:89-90. [PMID: 34949416 DOI: 10.1016/j.annemergmed.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Kenneth W Dodd
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | | | | | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc 2021; 10:e022866. [PMID: 34775811 PMCID: PMC9075358 DOI: 10.1161/jaha.121.022866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.
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Affiliation(s)
- H Pendell Meyers
- Department of Emergency Medicine Carolinas Medical Center Charlotte NC
| | - Alexander Bracey
- Department of Emergency Medicine Albany Medical Center Albany NY
| | - Daniel Lee
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Andrew Lichtenheld
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Wei J Li
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Daniel D Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Zach Rollins
- William Beaumont School of Medicine Oakland University Rochester MI
| | - Jesse A Kane
- Department of Cardiology Stony Brook University Hospital Stony Brook NY
| | - Kenneth W Dodd
- Department of Emergency Medicine Advocate Christ Medical Center Oak Lawn IL
| | - Kristen E Meyers
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Gautam R Shroff
- Division of Cardiology Department of Medicine Hennepin County Medical Center University of Minnesota Medical School Minneapolis MN
| | - Adam J Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Stephen W Smith
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN.,Department of Emergency Medicine University of Minnesota Medical Center Minneapolis MN
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34
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Khawaja M, Thakker J, Kherallah R, Ye Y, Smith SW, Birnbaum Y. Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms. Curr Cardiol Rep 2021; 23:187. [PMID: 34791609 DOI: 10.1007/s11886-021-01613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW A number of criteria have been developed to aid with the diagnosis of occlusion myocardial infarction (OMI) in patients with left bundle branch block (LBBB) and ventricular paced rhythms (VPR). The current guidelines do not provide clear preference for any specific ECG criteria in LBBB and paced rhythm patients. RECENT FINDINGS This review delineates the difficulties of electrocardiographic diagnosis of OMI in both LBBB and VPR patients. We describe the original Sgarbossa and the newer criteria and their diagnostic performances. We highlight the expected changes of newer pacing modalities and how they may interfere with the electrocardiographic diagnosis of OMI. We recommend utilizing the Cai et al. algorithm, which combines clinical assessment with the Smith Modified Sgarbossa ECG criteria, for both LBBB and right ventricular pacing patients with suspected OMI. There is limited data concerning ECG changes of OMI in patients with the newer pacing modalities, such as biventricular, His-bundle, or left bundle branch pacing.
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Affiliation(s)
- Muzamil Khawaja
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Janki Thakker
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Riyad Kherallah
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Yumei Ye
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and the University of Minnesota School of Medicine, 701 S. Park Ave. Minneapolis, Minnesota, MN, 55415, USA.
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, MS: BCM620. One Baylor Plaza, Houston, TX, 77030, USA.
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35
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Dodd KW, Zvosec DL, Hart MA, Glass G, Bannister LE, Body RM, Boggust BA, Brady WJ, Chang AM, Cullen L, Gómez-Vicente R, Huis In 't Veld MA, Karim RM, Meyers HP, Miranda DF, Mitchell GJ, Reynard C, Rice C, Salverda BJ, Stellpflug SJ, Tolia VM, Walsh BM, White JL, Smith SW. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Ann Emerg Med 2021; 78:517-529. [PMID: 34172301 DOI: 10.1016/j.annemergmed.2021.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/11/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.
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Affiliation(s)
- Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | | | - Michael A Hart
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN; Minneapolis Heart Institute, Minneapolis, MN
| | - George Glass
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA
| | - Laura E Bannister
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard M Body
- Department of Emergency Medicine, Central Manchester University Hospital, Manchester, United Kingdom
| | - Brett A Boggust
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - William J Brady
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA
| | - Anna M Chang
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Rafael Gómez-Vicente
- Department of Cardiology, Central Defense Hospital, Alcala University, Madrid, Spain
| | | | - Rehan M Karim
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - H Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - David F Miranda
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN; Minneapolis Heart Institute, Minneapolis, MN
| | - Gary J Mitchell
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Charles Reynard
- Department of Emergency Medicine, Central Manchester University Hospital, Manchester, United Kingdom
| | - Clifford Rice
- Department of Emergency Medicine, NorthShore University HealthSystem, Evanston, IL
| | | | | | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Brooks M Walsh
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, CT
| | - Jennifer L White
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
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36
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Gregg RE, Yang T, Smith SW, Babaeizadeh S. ECG reading differences demonstrated on two databases. J Electrocardiol 2021; 69S:75-78. [PMID: 34544590 DOI: 10.1016/j.jelectrocard.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Many studies that rely on manual ECG interpretation as a reference use multiple ECG expert interpreters and a method to resolve differences between interpreters, reflecting the fact that experts sometimes use different criteria. The aim of this study was to show the effect of manual ECG interpretation style on training automated ECG interpretation. METHODS The effect of ECG interpretation style or differing ECG criteria on algorithm training was shown in this study by careful analysis of the changes in algorithm performance when the algorithm was trained on one database and tested on a different database. Morphology related ECG interpretation was summarized in eleven abnormalities such as left bundle branch block (LBBB) and old anterior myocardial infarction (MI). Each of the two databases used in the study had a reference interpretation mapped to those eleven abnormalities. F1 algorithm performance scores across abnormalities were compared for four cases. First, the algorithm was trained and tested on randomly split database A and then trained on the training set of database A and tested on randomly chosen test set of database B. The previous two test cases were repeated for opposite databases, train and test on database B and then train on database B and test on the test set of database A. RESULTS F1 scores across abnormalities were generally higher when training and testing on the same database. F1 scores were high for bundle branch blocks (BBB) no matter the training and testing database combination. Old anterior MI F1 score dropped for one cross-database comparison and not the other suggesting a difference in manual interpretation. CONCLUSION For some abnormalities, human experts appear to have used different criteria for ECG interpretation, as evident by the difference between cross-database and within-database performance. Bundle branch blocks appear to be interpreted in a consistent manner.
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Affiliation(s)
- Richard E Gregg
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA.
| | - Ting Yang
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
| | | | - Saeed Babaeizadeh
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, USA
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37
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Birnbaum Y, Ye Y, Smith SW, Jneid H. Rapid Diagnosis of STEMI Equivalent in Patients With Left Bundle-Branch Block: Is It Feasible? J Am Heart Assoc 2021; 10:e023275. [PMID: 34514811 PMCID: PMC8649538 DOI: 10.1161/jaha.121.023275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yochai Birnbaum
- Section of CardiologyDepartment of MedicineBaylor College of MedicineHoustonTX
| | - Yumei Ye
- The Department of Biochemistry and Molecular BiologyUniversity of Texas Medical BranchGalvestonTX
| | - Stephen W. Smith
- Department of Emergency MedicineHennepin Healthcare and the University of Minnesota School of MedicineMinneapolisMN
| | - Hani Jneid
- Section of CardiologyDepartment of MedicineBaylor College of MedicineHoustonTX
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38
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Aslanger EK, Meyers HP, Smith SW. Recognizing electrocardiographically subtle occlusion myocardial infarction and differentiating it from mimics: Ten steps to or away from cath lab. Turk Kardiyol Dern Ars 2021; 49:488-500. [PMID: 34523597 DOI: 10.5543/tkda.2021.21026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
It is increasingly evident that the ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI paradigm that equates STEMI with acute coronary occlusion (ACO) is deceptive. This unfortunate paradigm, adhered to by the current guidelines, misses at least one-fourth of the ACOs, and unnecessarily over-triages a similar fraction of the patients to the catheterization laboratory. Accordingly, we have been calling for a new paradigm, the occlusion/nonocclusion MI (OMI/NOMI). Although this new OMI/NOMI paradigm is not limited to an electrocardiogram (ECG), the ECG will remain the cornerstone of this new paradigm because of its speed, repeatability, noninvasive nature, wide availability, and high diagnostic power for OMI. This review provides a step-by-step approach to ECG for the diagnosis of OMI.
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Affiliation(s)
- Emre K Aslanger
- Department of Cardiology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota Hennepin Healthcare, Minneapolis, Minnesota, USA
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39
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Daunic AP, Corbett NL, Smith SW, Algina J, Poling D, Worth M, Boss D, Crews E, Vezzoli J. Efficacy of the social-emotional learning foundations curriculum for kindergarten and first grade students at risk for emotional and behavioral disorders. J Sch Psychol 2021; 86:78-99. [PMID: 34051919 DOI: 10.1016/j.jsp.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 01/07/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Abstract
Researchers have shown that children's social-emotional growth is inextricably connected to academic learning. We developed the Social-Emotional Learning Foundations (SELF) intervention, a Grade K-1 curriculum merging social-emotional learning (SEL) and literacy instruction, to promote language supported self-regulation, specifically for primary grade children at early risk for emotional or behavioral difficulties. We report findings from a pretest-posttest cluster randomized efficacy trial with one fixed between-subjects factor to test the effects of teacher-delivered SEL instruction against those of business as usual (BAU). We recruited 163 kindergarten (K) and 141 first grade teachers from 52 schools across 11 school districts within one southeastern state. Our student sample (n = 1154) consisted of 627 kindergarteners and 527 first graders identified by teachers as at risk for internalizing or externalizing emotional and behavioral problems using the Systematic Screening for Behavioral Disorders; 613 of these students participated in the SELF condition and 541 participated in the BAU condition. We randomly assigned schools to SELF or BAU and used a multilevel model with three levels (i.e., children, classrooms, schools) to analyze data on subscales of six (four teacher-report and two direct) assessments related to self-regulation, social-emotional learning, social-emotional vocabulary, and general behavioral functioning. We found positive main effects of SELF compared to BAU on all but one measure, with effect sizes (calculated using Hedges' g) ranging from 0.20 to 0.65. Findings provide evidence for guiding future SEL intervention research and informing practice to improve student outcomes, particularly for children at risk for behavior problems.
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Affiliation(s)
- Ann P Daunic
- University of Florida, United States of America.
| | | | | | | | - Daniel Poling
- Appalachian State University, United States of America
| | - Megan Worth
- University of Florida, United States of America
| | | | - Emily Crews
- University of Florida, United States of America
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40
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Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc 2021; 33:100767. [PMID: 33912650 PMCID: PMC8065286 DOI: 10.1016/j.ijcha.2021.100767] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.
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Key Words
- ACS, Acute coronary syndrome
- AMI, acute myocardial infarction
- Acute coronary syndromes
- ECG, Electrocardiogram
- ED, Emergency department
- Electrocardiography
- LBBB, Left Bundle Branch Block
- MIRO, Myocardial Infarction Ruled Out
- MSC, Modified Sgarbossa Criteria
- NOMI, Non-occlusion myocardial infarction
- NSTEMI, Non-ST-segment elevation myocardial infarction
- OMI, Occlusion myocardial infarction
- Occlusion myocardial infarction
- ST elevation myocardial infarction
- STD, ST-segment depression
- STE, ST-segment elevation
- STEMI, ST-segment elevation myocardial infarction
- VPR, Ventricular Paced Rhythm
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Affiliation(s)
- H. Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Albany Medical Center, Albany NY, USA
| | - Daniel Lee
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrew Lichtenheld
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Wei J. Li
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Daniel D. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Zach Rollins
- William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | - Jesse A. Kane
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Kenneth W. Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kristen E. Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Gautam R. Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stephen W. Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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41
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Sandoval Y, Smith SW, Sexter A, Schulz K, Apple FS. Incidence and Prognostic Impact of Infection in Patients with Type 1 and 2 Myocardial Infarction. Clin Chem 2021; 66:1240-1241. [PMID: 32712646 DOI: 10.1093/clinchem/hvaa138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN
| | - Anne Sexter
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN
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42
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med 2021; 60:273-284. [DOI: 10.1016/j.jemermed.2020.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023]
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Abstract
The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.
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Affiliation(s)
- Emre K Aslanger
- Department of Cardiology, Marmara University Pendik Training and Research Hospital; İstanbul-Turkey
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte; North Carolina-United States of America
| | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota, Hennepin County Medical Center, Minneapolis; Minnesota-United States of America
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44
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Aslanger EK, Meyers HP, Bracey A, Smith SW. The STEMI/NonSTEMI Dichotomy needs to be replaced by Occlusion MI vs. Non-Occlusion MI. Int J Cardiol 2021; 330:15. [PMID: 33577907 DOI: 10.1016/j.ijcard.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Emre K Aslanger
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey.
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, United States of America.
| | - Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, United States of America.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN, United States of America.
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45
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Wereski R, Chapman AR, Lee KK, Smith SW, Lowe DJ, Gray A, Mills NL. High-Sensitivity Cardiac Troponin Concentrations at Presentation in Patients With ST-Segment Elevation Myocardial Infarction. JAMA Cardiol 2021; 5:1302-1304. [PMID: 32785613 PMCID: PMC7675101 DOI: 10.1001/jamacardio.2020.2867] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | | | - David J Lowe
- University of Glasgow, School of Medicine, Glasgow, Scotland
| | - Alasdair Gray
- Royal Infirmary of Edinburgh, Emergency Medicine Research Group, Edinburgh, Scotland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
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46
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Kavsak PA, Hammarsten O, Worster A, Smith SW, Apple FS. Cardiac Troponin Testing in Patients with COVID-19: A Strategy for Testing and Reporting Results. Clin Chem 2021; 67:107-113. [PMID: 33045044 PMCID: PMC7665403 DOI: 10.1093/clinchem/hvaa225] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged late in 2019 causing COVID-19 (coronavirus disease-2019) may adversely affect the cardiovascular system. Publications from Asia, Europe, and North America have identified cardiac troponin as an important prognostic indicator for patients hospitalized with COVID-19. We recognized from publications within the first 6 months of the pandemic that there has been much uncertainty on the reporting, interpretation, and pathophysiology of an increased cardiac troponin concentration in this setting. CONTENT The purpose of this mini-review is: a) to review the pathophysiology of SARS-CoV-2 and the cardiovascular system, b) to overview the strengths and weaknesses of selected studies evaluating cardiac troponin in patients with COVID-19, and c) to recommend testing strategies in the acute period, in the convalescence period and in long-term care for patients who have become ill with COVID-19. SUMMARY This review provides important educational information and identifies gaps in understanding the role of cardiac troponin and COVID-19. Future, properly designed studies will hopefully provide the much-needed evidence on the path forward in testing cardiac troponin in patients with COVID-19.
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Affiliation(s)
| | | | | | - Stephen W Smith
- Hennepin Healthcare/Hennepin County Medical Center and Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
| | - Fred S Apple
- Hennepin Healthcare/Hennepin County Medical Center and Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
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47
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Bracey A, Meyers HP, Smith SW. Post-arrest wide complex rhythm: What is the cause of death? Am J Emerg Med 2021; 45:683.e5-683.e7. [PMID: 33353817 DOI: 10.1016/j.ajem.2020.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old man presented to the ED following witnessed cardiac arrest. After return of spontaneous circulation, an ECG was performed which demonstrated a wide complex rhythm with "shark fin" morphology. With careful examination it is possible to identify the J point and determine that the electrocardiogram (ECG) findings actually represent massive ST-elevation indicative of occlusion myocardial infarction (OMI). Initial troponin was undetectable. The patient underwent emergent cardiac catheterization and had a 100% proximal LAD occlusion that was successfully stented. The patient was discharged home neurologically intact several days later. This case highlights the importance of careful ECG interpretation and the limitations of troponin assays in the evaluation of acute coronary syndrome. Most importantly, we demonstrate how to evaluate for ST elevation in the context of a widened QRS complex.
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Affiliation(s)
- Alexander Bracey
- Albany Medical Center, Department of Emergency Medicine, Albany, NY, USA.
| | - H Pendell Meyers
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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48
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Smith SW, Strobel AM, Saenger AK, Apple FS. Laboratory findings in a child with SARS-CoV-2 (COVID-19) multisystem inflammatory syndrome. Clin Chem Lab Med 2021; 59:e259-e261. [PMID: 33554562 DOI: 10.1515/cclm-2020-1699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Stephen W Smith
- Departments of Emergency Medicine, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Ashley M Strobel
- Departments of Emergency Medicine, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Amy K Saenger
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
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49
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Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. Respone to: "Limitations of Retrospective Chart Reviews to Determine Rare Events, and the Unknown Relative Risk of Droperidol". West J Emerg Med 2020; 22:396-397. [PMID: 33856329 PMCID: PMC7972375 DOI: 10.5811/westjem.2020.9.49870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jon B Cole
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota.,Minnesota Poison Control System, Minneapolis, Minnesota.,Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | | | - Marc L Martel
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota.,Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Stephen W Smith
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota.,Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Michelle H Biros
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
| | - James R Miner
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota.,Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
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Aslanger EK, Smith SW. Response to: "A new electrocardiographic pattern indicating inferior myocardial infarction". J Electrocardiol 2020; 73:148-149. [PMID: 33243464 DOI: 10.1016/j.jelectrocard.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Emre K Aslanger
- Marmara University, Pendik Training and Research Hospital, Department of Cardiology, Istanbul, Turkey.
| | - Stephen W Smith
- University of Minnesota, Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota, United States of America.
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