Occurrence of Transient Myocardial Ischemic Events among Non-ST Segment Elevation Acute Coronary Syndrome Patients Before or After Invasive Coronary Angiography.

BACKGROUND: The occurrence of transient myocardial ischemia (TMI) is an important pathology in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), yet studies are scarce regarding when TMI occurs during hospitalization, particularly in relation to invasive coronary angiography (ICA). This study examined: (1) TMI before or after ICA; (2) patient characteristics and ischemic burden by TMI group (before or after ICA); and (3) major in-hospital complications (transfer to critical care, death) and length of stay (LOS) by TMI group (before or after ICA). METHODS: Secondary data analysis in hospitalized NSTE-ACS patients with TMI event(s) identified from 12-lead electrocardiographic (ECG) Holter. Patient records were reviewed to assess ischemic burden (TMI time [minutes] ÷ hours recording duration), outcomes and TMI timing, before or after ICA. RESULTS: In 38 patients, 3 (8%) had TMI before and after ICA. Of the remaining 35 patients (92%), TMI occurred before ICA (16; 46%), and after ICA (9; 26%), and 10 (28%) did not have ICA. Patient characteristics, untoward outcomes, and TMI duration (minutes) did not differ by group. Ischemic burden was higher in patients with TMI after ICA (7.29±8.82 min/hr) compared to before ICA (2.54±2.11 min/hr), p=0.039. Hospital LOS by TMI group was 113±113 (before), 226±244 (after), and 85±65 hr (no ICA); p=0.172. CONCLUSION: Almost half of the sample had TMI before ICA; one-third had TMI but did not have ICA. Patients with TMI after an ICA had higher ischemic burden. Future studies with larger sample sizes are needed to investigate further the short- and long-term clinical significance of TMI among NSTE-ACS patients.

Evaluation of premature ventricular complexes during in-hospital ECG monitoring as a predictor of ventricular tachycardia in an intensive care unit cohort.

In-hospital electrocardiographic (ECG) monitors are typically configured to alarm for premature ventricular complexes (PVCs) due to the potential association of PVCs with ventricular tachycardia (VT). However, no contemporary hospital-based studies have examined the association of PVCs with VT. Hence, the benefit of PVC monitoring in hospitalized patients is largely unknown. This secondary analysis used a large PVC alarm data set to determine whether PVCs identified during continuous ECG monitoring were associated with VT, in-hospital cardiac arrest (IHCA), and/or death in a cohort of adult intensive care unit patients. Six PVC types were examined (i.e., isolated, bigeminy, trigeminy, couplets, R-on-T, and run PVCs) and were compared between patients with and without VT, IHCA, and/or death. Of 445 patients, 48 (10.8%) had VT; 11 (2.5%) had IHCA; and 49 (11%) died. Isolated and run PVC counts were higher in the VT group (p = 0.03 both), but group differences were not seen for the other four PVC types. The regression models showed no significant associations between any of the six PVC types and VT or death, although confidence intervals were wide. Due to the small number of cases, we were unable to test for associations between PVCs and IHCA. Our findings suggest that we should question the clinical relevance of activating PVC alarms as a forewarning of VT, and more work should be done with larger sample sizes. A more precise characterization of clinically relevant PVCs that might be associated with VT is warranted.

Ischemic Pre-Conditioning is Present in Patients with Non-ST Elevation Myocardial Infarction and ECG Derived Moderate Obstructive Sleep Apnea.

Background: Obstructive Sleep Apnea (OSA) is associated with an increased risk of cardiovascular events, including Acute Coronary Syndrome (ACS). There is conflicting evidence that suggests OSA has a cardioprotective effect (i.e., lower troponin), via ischemic pre-conditioning, in patients with ACS. Purpose: This study had two aims: (1) compare peak troponin between non-ST elevation (NSTE) ACS patients with and without moderate OSA identified using a Holter derived respiratory disturbance index (HDRDI); and (2) determine the frequency of transient myocardial ischemia (TMI) between NSTE-ACS patients with and without moderate HDRDI. Method: This was a secondary analysis. OSA events were identified from 12-lead ECG Holter recordings using QRSs, R-R intervals, and the myogram. Moderate OSA was defined as an HDRDI ≥15 events per/hour. TMI was defined as ≥1 millimeter of ST-segment ↑ or ↓, in ≥ 1 ECG lead, ≥ 1 minute. Results: In 110 NSTE-ACS patients, 39% (n=43) had moderate HDRDI. Peak troponin was higher in patients with moderate HDRDI (6.8 ng/ml yes vs. 10.2 ng/ml no; p=0.037). There was a trend for fewer TMI events, but there were no differences (16% yes vs. 30% no; p=0.081). Conclusions: NSTE-ACS patients with moderate HDRDI have less cardiac injury than those without moderate HDRDI measured using a novel ECG derived method. These findings corroborate prior studies suggesting a possible cardioprotective effect of OSA in ACS patients via ischemic pre-condition. There was a trend for fewer TMI events in moderate HDRDI patients, but there was no statistical difference. Future research should explore the underlying physiologic mechanisms of this finding.

Premature ventricular complexes during continuous electrocardiographic monitoring in the intensive care unit: Occurrence rates and associated patient characteristics.

AIMS AND OBJECTIVES: This study examined the occurrence rate of specific types of premature ventricular complex (PVC) alarms and whether patient demographic and/or clinical characteristics were associated with PVC occurrences. BACKGROUND: Because PVCs can signal myocardial irritability, in-hospital electrocardiographic (ECG) monitors are typically configured to alert nurses when they occur. However, PVC alarms are common and can contribute to alarm fatigue. A better understanding of occurrences of PVCs could help guide alarm management strategies. DESIGN: A secondary quantitative analysis from an alarm study. METHODS: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed. Seven PVC alarm types (vendor-specific) were described, and included isolated, couplet, bigeminy, trigeminy, run PVC (i.e. VT >2), R-on-T and PVCs/min. Negative binomial and hurdle regression analyses were computed to examine the association of patient demographic and clinical characteristics with each PVC type. RESULTS: A total of 797,072 PVC alarms (45,271 monitoring hours) occurred in 446 patients, including six who had disproportionately high PVC alarm counts (40% of the total alarms). Isolated PVCs were the most frequent type (81.13%) while R-on-T were the least common (0.29%). Significant predictors associated with higher alarms rates: older age (isolated PVCs, bigeminy and couplets); male sex and presence of PVCs on the 12-lead ECG (isolated PVCs). Hyperkalaemia at ICU admission was associated with a lower R-on-T type PVCs. CONCLUSIONS: Only a few distinct demographic and clinical characteristics were associated with the occurrence rate of PVC alarms. Further research is warranted to examine whether PVCs were associated with adverse outcomes, which could guide alarm management strategies to reduce unnecessary PVC alarms. RELEVANCE TO CLINICAL PRACTICE: Targeted alarm strategies, such as turning off certain PVC-type alarms and evaluating alarm trends in the first 24 h of admission in select patients, might add to the current practice of alarm management.

Thoracic Impedance Pneumography-Derived Respiratory Alarms and Associated Patient Characteristics.

BACKGROUND: Respiratory rate (RR) alarms alert clinicians to a change in a patient's condition. However, RR alarms are common occurrences. To date, no study has examined RR alarm types and associated patient characteristics, which could guide alarm management strategies. OBJECTIVES: To characterize RR alarms by type, frequency, duration, and associated patient demographic and clinical characteristics. METHODS: A secondary data analysis of alarms generated with impedance pneumography in 461 adult patients admitted to either a cardiac, a medical/surgical, or a neurological intensive care unit (ICU). The RR alarms included high parameter limit (≥30 breaths/min), low parameter limit (≤5 breaths/min), and apnea (no breathing ≥20 s). The ICU type; total time monitored; and alarm type, frequency, and duration were evaluated. RESULTS: Of 159 771 RR alarms, parameter limit alarms (n = 140 975; 88.2%) were more frequent than apnea alarms (n = 18 796; 11.8%). High parameter limit alarms were most frequent (n = 131 827; 82.5%). After ICU monitoring time was controlled for, multivariate analysis showed that alarm rates were higher in patients in the cardiac and neurological ICUs (P = .001), patients undergoing mechanical ventilation (P = .005), and patients without a ventricular assist device or pacemaker (P = .02). Male sex was associated with low parameter limit (P = .01) and apnea (P = .005) alarms. CONCLUSION: High parameter limit RR alarms were most frequent. Factors associated with RR alarms included monitoring time, ICU type, male sex, and mechanical ventilation. Although these factors are not modifiable, these data could be used to guide management strategies.

Agreement between respiratory rate measurement using a combined electrocardiographic derived method versus impedance from pneumography.

BACKGROUND: Impedance pneumography (IP) is the current device-driven method used to measure respiratory rate (RR) in hospitalized patients. However, RR alarms are common and contribute to alarm fatigue. While RR derived from electrocardiographic (ECG) waveforms hold promise, they have not been compared to the IP method. PURPOSE: Study examined the agreement between the IP and combined-ECG derived (EDR) for normal RR (≥12 or ≤20 breaths/minute [bpm]); low RR (≤5 bpm); and high RR (≥30 bpm). METHODOLOGY: One-hundred intensive care unit patients were included by RR group: (1) normal RR (n = 50; 25 low RR and 25 high RR); (2) low RR (n = 50); and (3) high RR (n = 50). Bland-Altman analysis was used to evaluate agreement. RESULTS: For normal RR, a significant bias difference of -1.00 + 2.11 (95% CI -1.60 to -0.40) and 95% limit of agreement (LOA) of -5.13 to 3.13 was found. For low RR, a significant bias difference of -16.54 + 6.02 (95% CI: -18.25 to -14.83) and a 95% LOA of -28.33 to - 4.75 was found. For high RR, a significant bias difference of 17.94 + 12.01 (95% CI: 14.53 to 21.35) and 95% LOA of -5.60 to 41.48 was found. CONCLUSION: Combined-EDR method had good agreement with the IP method for normal RR. However, for the low RR, combined-EDR was consistently higher than the IP method and almost always lower for the high RR, which could reduce the number of RR alarms. However, replication in a larger sample including confirmation with visual assessment is warranted.

Diagnostic and prognostic significance of premature ventricular complexes in community and hospital-based participants: A scoping review.

BACKGROUND: While there are published studies that have examined premature ventricular complexes (PVCs) among patients with and without cardiac disease, there has not been a comprehensive review of the literature examining the diagnostic and prognostic significance of PVCs. This could help guide both community and hospital-based research and clinical practice. METHODS: Scoping review frameworks by Arksey and O'Malley and the Joanna Briggs Institute (JBI) were used. A systematic search of the literature using four databases (CINAHL, Embase, PubMed, and Web of Science) was conducted. The review was prepared adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR). RESULTS: A total of 71 relevant articles were identified, 66 (93%) were observational, and five (7%) were secondary analyses from randomized clinical trials. Three studies (4%) examined the diagnostic importance of PVC origin (left/right ventricle) and QRS morphology in the diagnosis of acute myocardial ischemia (MI). The majority of the studies examined prognostic outcomes including left ventricular dysfunction, heart failure, arrhythmias, ischemic heart diseases, and mortality by PVCs frequency, burden, and QRS morphology. CONCLUSIONS: Very few studies have evaluated the diagnostic significance of PVCs and all are decades old. No hospital setting only studies were identified. Community-based longitudinal studies, which make up most of the literature, show that PVCs are associated with structural and coronary heart disease, lethal arrhythmias, atrial fibrillation, stroke, all-cause and cardiac mortality. However, a causal association between PVCs and these outcomes cannot be established due to the purely observational study designs employed.

ECG alarms during left ventricular assist device (LVAD) therapy in the ICU.

BACKGROUND: In hospitalized patients with left ventricular assist device (LVAD), electrical interference and low amplitude QRS complexes are common, which could impact the accuracy of electrocardiographic (ECG) arrhythmia detection and create technical alarms. This could contribute to provider alarm fatigue and threaten patient safety. OBJECTIVES: We examined three LVAD patients in the cardiac intensive care unit (ICU) to determine: 1) the frequency and accuracy of audible arrhythmia alarms; 2) occurrence rates of technical alarms; and 3) alarm burden (# alarms/hour of monitoring) METHODS: Secondary analysis. RESULTS: During 593 h, there were 549 audible arrhythmia alarms and 98% were false. There were 25,232 technical alarms and 93% were for artifact, which was configured as an inaudible text alert. CONCLUSION: False-arrhythmia and technical alarms are frequent in LVAD patients. Future studies are needed to identify both clinical and algorithm-based strategies to improve arrhythmia detection and reduce technical alarms in LVAD patients.