Electrocardiographic scores of severity and acuteness of myocardial ischemia predict myocardial salvage in patients with anterior ST-segment elevation myocardial infarction.

BACKGROUND: Terminal "QRS distortion" on the electrocardiogram (ECG) (based on Sclarovsky-Birnbaum's Grades of Ischemia Score) is a sign of severe ischemia, associated with adverse cardiovascular outcome in ST-segment elevation myocardial infarction (STEMI). In addition, ECG indices of the acuteness of ischemia (based on Anderson-Wilkins Acuteness Score) indicate myocardial salvage potential. We assessed whether severe ischemia with or without acute ischemia is predictive of infarct size (IS), myocardial salvage index (MSI) and left ventricular ejection fraction (LVEF) in anterior versus inferior infarct locations. METHODS: In STEMI patients, the severity and acuteness scores were obtained from the admission ECG. Based on the ECG patients were assigned with severe or non-severe ischemia and acute or non-acute ischemia. Cardiac magnetic resonance (CMR) was performed 2-6days after primary percutaneous coronary intervention (pPCI). LVEF was measured by echocardiography 30days after pPCI. RESULTS: ECG analysis of 85 patients with available CMR resulted in 20 (23%) cases with severe and non-acute ischemia, 43 (51%) with non-severe and non-acute ischemia, 17 (20%) with non-severe and acute ischemia, and 5 (6%) patients with severe and acute ischemia. In patients with anterior STEMI (n=35), ECG measures of severity and acuteness of ischemia identified significant and stepwise differences in myocardial damage and function. Patients with severe and non-acute ischemia had the largest IS, smallest MSI and lowest LVEF. In contrast, no difference was observed in patients with inferior STEMI (n=50). CONCLUSIONS: The applicability of ECG indices of severity and acuteness of myocardial ischemia to estimate myocardial damage and salvage potential in STEMI patients treated with pPCI, is confined to anterior myocardial infarction.

Appropriateness of anteroseptal myocardial infarction nomenclature evaluated by late gadolinium enhancement cardiovascular magnetic resonance imaging.

BACKGROUND: In traditional literature, it appears that "anteroseptal" MIs with Q waves in V1-V3 involve basal anteroseptal segments although studies have questioned this belief. METHODS: We studied patients with first acute anterior Q-wave (>30ms) MI. All underwent late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (MRI). RESULTS: Those with Q waves in V1-V2 (n=7) evidenced LGE >50% in 0%, 43%, 43%, 57%, and 29% of the basal anteroseptal, mid anteroseptal, apical anterior, apical septal segments, and apex, respectively. Patients with Q waves in V1-V3 (n=14), evidenced involvement was 14%, 43%, 43%, 50%, and 7% of the same respective segments. In those with extensive anterior Q waves (n=7), involvement was 0%, 71%, 57%, 86%, and 86%. CONCLUSIONS: Q-wave MI in V1-V2/V3 primarily involves mid- and apical anterior and anteroseptal segments rather than basal segments. Data do not support existence of isolated basal anteroseptal or septal infarction. "Anteroapical infarction" is a more appropriate term than "anteroseptal infarction."

Algorithm for the automatic computation of the modified Anderson-Wilkins acuteness score of ischemia from the pre-hospital ECG in ST-segment elevation myocardial infarction.

BACKGROUND: The acuteness score (based on the modified Anderson-Wilkins score) estimates the acuteness of ischemia based on ST-segment, Q-wave and T-wave measurements obtained from the electrocardiogram (ECG) in patients with ST Elevation Myocardial Infarction (STEMI). The score (range 1 (least acute) to 4 (most acute)) identifies patients with substantial myocardial salvage potential regardless of patient reported symptom duration. However, due to the complexity of the score, it is not used in clinical practice. Therefore, we aimed to develop a reliable algorithm that automatically computes the acuteness score. METHODS: We scored 50 pre-hospital ECGs from STEMI patients, manually and by the automated algorithm. We assessed the reliability test between the manual and automated algorithm by interclass correlation coefficient (ICC) and Bland-Altman plot. RESULTS: The ICC was 0.84 (95% CI 0.72-0.91), P<0.0001. The mean difference between manual and automated acuteness score was 0.17±0.66. In only two cases, there was a major disagreement between the two scores. There was an excellent agreement between the scores for the remaining 48 ECGs, all within the upper (1.46) and lower (-1.12) limits of agreement. CONCLUSION: In conclusion, we have developed an automated algorithm for measurement of the modified Anderson-Wilkins ECG acuteness score from the pre-hospital ECG in STEMI patients. This automated algorithm is highly reliable, can be applied in daily practice for research purposes and may be implemented in commercial automated ECG analysis programs to achieve practical use for decision support in the acute phase of STEMI.

Myocardium at risk assessed by electrocardiographic scores and cardiovascular magnetic resonance - a MITOCARE substudy.

INTRODUCTION: The myocardium at risk (MaR) represents the quantitative ischemic area destined to myocardial infarction (MI) if no reperfusion therapy is initiated. Different ECG scores for MaR have been developed, but there is no consensus as to which should be preferred. OBJECTIVE: Comparisons of ECG scores and Cardiac Magnetic Resonance (CMR) for determining MaR. METHODS: MaR was determined by 3 different ECG scores, and by CMR in ST-segment elevation MI (STEMI) patients from the MITOCARE cardioprotection trial. The Aldrich score (AL) is based on the number of leads with ST-elevation for anterior MI and the sum of ST-segment elevation for inferior MI on the admission ECG. The van Hellemond score (VH) considers both the ischemic and infarcted component of the MaR by adding the AL and the QRS score, which is an estimate of final infarct size. The Hasche score is based on the maximal possible infarct size determined from the QRS score on the baseline ECG. RESULTS: Ninety-eight patients (85% male, mean age 61years) met STEMI criteria on their admission ECG and underwent CMR within 3-5days after STEMI. Mean MaR by CMR was 41.2±10.2 and 30.3±7.2 for anterior and inferior infarcts, respectively. For both anterior and inferior infarcts the Aldrich (18.2±5.1 and 18.6±6.0) and Hasche (25.3±9.8 and 26.4±8.8) scores significantly underestimated MaR compared to MaR measured by CMR. In contrast, MaR by the van Hellemond score (37.0±14.2 and 31.7±12.8) was comparable to CMR. CONCLUSION: We tested the performance of the electrocardiographic estimation of myocardium area at risk by Aldrich, Hasche and van Hellemond ECG scores in comparison to MaR measured by CMR in STEMI patients. MaR by the van Hellemond score and CMR were comparable, while Aldrich and Hasche underestimated MaR.

Prehospital electrocardiographic acuteness score of ischemia is inversely associated with neurohormonal activation in STEMI patients with severe ischemia.

BACKGROUND: Elevated levels of N-terminal pro brain natriuretic peptide (NT-proBNP) are associated with adverse cardiovascular outcome after ST elevation myocardial infarction (STEMI). We hypothesized that decreasing acuteness-score (based on the electrocardiographic score by Anderson-Wilkins acuteness score of myocardial ischemia) is associated with increasing NT-proBNP levels and the impact of decreasing acuteness-score on NT-proBNP levels is substantial in STEMI patients with severe ischemia. METHODS: In 186 STEMI patients treated with primary percutaneous coronary intervention (pPCI), the severity of ischemia (according to Sclarovsky-Birnbaum severity grades of ischemia) and the acuteness-score were obtained from prehospital ECG. Patients were classified according to the presence of severe ischemia or non-severe ischemia and acute ischemia or non-acute ischemia. Plasma NT-proBNP (pmol/L) was obtained after pPCI within 24hours of admission and was correlated with the acuteness-score. RESULTS: NT-proBNP levels were median (25th-75th interquartile) 112 (51-219) pmol/L in patients with non-severe ischemia (71.5%) and 145 (79-339) in patients with severe ischemia (28.5%) (p=0.074). NT-proBNP levels were highest in patients with severe and non-acute ischemia compared to those with severe and acute ischemia (182 (98-339) pmol/L vs 105 (28-324) pmol/L, p=0.012). There was a negative correlation between acuteness-score and log(NT-proBNP) in patients with severe ischemia (r=0.395, p=0.003), which remained significant in multilinear regression analysis (ß=-0.155, p=0.007). No correlation was observed between the acuteness-score and log(NT-proBNP) in patients with non-severe ischemia (p=0.529) or in the entire population (p=0.187). CONCLUSION: In STEMI patients with severe ischemia, neurohormonal activation is inversely associated with ECG patterns of acute myocardial ischemia.

Pre-hospital electrocardiographic severity and acuteness scores predict left ventricular function in patients with ST elevation myocardial infarction.

OBJECTIVES: System delay (time from first medical contact to primary percutaneous coronary intervention) is associated with heart failure and mortality in patients with ST segment elevation myocardial infarction (STEMI). We evaluated the impact of system delay on left ventricular function (LVF) according to the combination of ischemia severity (Sclarovsky-Birnbaum grades) and acuteness (Anderson-Wilkins scores) in the pre-hospital electrocardiogram (ECG). METHODS: In a predefined secondary analysis of a prospective study, the severity and acuteness scores were performed on the pre-hospital ECG. Patients were assessed with respect to 4 classifications which were not mutually exclusive: severe ischemia (+SI) or non-severe ischemia (-SI) and acute ischemia (+AI) or non-acute ischemia (-AI). LVF was assessed by global longitudinal strain (GLS) within 48hours of admission. Adjusted linear regression investigated the association of system delay with GLS in each group. RESULTS: In total 262 patients were eligible for analysis of the ECG, which resulted in 42 (16%) with (+SI, -AI), 110 (42%) with (-SI, -AI), 90 (34%) with (-SI, +AI), and 20 (8%) patients with (+SI, +AI). Although system delay did not differ between groups, patients with severe and non-acute ischemia had the most impaired LVF. System delay correlated weakly with GLS in the entire population (r=0.133, p=0.031), and well with GLS in the (+SI, +AI) group (r=0.456, p=0.04), while there was no correlation in the other groups. By adjusted analysis, system delay predicted impaired GLS only in the (+SI, +AI) group (ß=0.578, p=0.002). CONCLUSION: Pre-hospital risk stratification by ECG identifies patients with acute and severe ischemia who are at increased risk for reduced ventricular function (assessed by GLS) after STEMI. Optimizing reperfusion delays in these patients can therefore be of particular benefit in improving clinical outcome after STEMI.

Evaluation of acute ischemia in pre-procedure ECG predicts myocardial salvage after primary PCI in STEMI patients with symptoms >12hours.

BACKGROUND: Primary percutaneous coronary intervention (pPCI) is recommended in patients with ST Elevation Myocardial Infarction (STEMI) and symptom duration <12hours. However, a considerable amount of myocardium might still be salvaged in STEMI patients with symptom durations >12hours (late-presenters). The Anderson-Wilkin's score (AW-score) estimates the acuteness of myocardial ischemia from the electrocardiogram (ECG) in STEMI patients. We hypothesized that the AW-score is superior to symptom duration in identifying substantial salvage potential in late-presenters. METHODS: The AW-score (range 1-4) was obtained from the pre-pPCI ECG in 55 late-presenters and symptoms 12-72 hours. Myocardial perfusion imaging was performed to assess area at risk before pPCI and after 30days to assess myocardial salvage index (MSI). We correlated both the AW-score and pain-to-balloon with MSI and determined the salvage potential (MSI) according to AW-score ≥3 (acute ischemia) and AW-score <3 (late ischemia). RESULTS: Late-presenters had median MSI 53% (inter quartile range (IQR) 27-89). The AW-score strongly correlated with MSI (ß=0.60, R(2)=0.36, p<0.0001), while pain-to-balloon time did not (ß=-0.21, R(2)=0.04, p=0.14). Patients with AW-score ≥3 (n=16) compared to those with AW-score <3 (n=27) had significant larger MSI (82.7% vs 41.5%, p=0.014). MSI>median was observed in 79% in patients with AW-score ≥3 vs 32% in patients with AW-score <3 (adjusted OR 6.74 [95% CI 1.35-33.69], p=0.02). CONCLUSION: AW-score was strongly associated with myocardial salvage while pain-to-balloon time was not. STEMI patients with symptom duration between 12 -72hours and AW-score ≥3 achieved substantial salvage after pPCI.

Clinical use of the combined Sclarovsky Birnbaum Severity and Anderson Wilkins Acuteness scores from the pre-hospital ECG in ST-segment elevation myocardial infarction.

This review summarizes the electrocardiographic changes during an evolving ST segment elevation myocardial infarction and discusses associated electrocardiographic scores and the potential use of these indices in clinical practice, in particular the ECG scores developed by Anderson and Wilkins estimating the acuteness of myocardial ischemia and Sclarovsky-Birnbaum's grades of ischemia evaluating the severity of ongoing ischemia.

A novel prehospital electrocardiogram score predicts myocardial salvage in patients with ST-segment elevation myocardial infarction evaluated by cardiac magnetic resonance.

OBJECTIVES: We hypothesized that prehopsital ECG scores can identify ST-segment elevation myocardial infarction (STEMI) patients in whom time delay is particularly important for myocardial salvage. METHODS: We evaluated the Anderson-Wilkins (AW) score (which designates the acuteness of ischemia) and grade 3 ischemia (GI3) (which identifies severe ischemia) in the prehospital ECG and compared them to the myocardial salvage index (MSI) assessed by cardiac magnetic resonance. RESULTS: In 150 patients, system delay (alarm to balloon inflation) (ß = -0.304, p < 0.001) and AW score (ß = 0.364, p < 0.001) correlated with MSI. AW scores ≥3 (p < 0.001) and GI3 (p = 0.002) predicted the MSI. We formed 4 subgroups combining AW scores (<3 or ≥3) and grades of ischemia (

Pre-hospital diagnosis and transfer of patients with acute myocardial infarction--a decade long experience from one of Europe's largest STEMI networks.

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is essential. Although primary percutaneous coronary intervention (pPCI) is the preferred revascularization technique, it often involves longer primary transportation or secondary inter-hospital transfers and thus longer system related delays. The current ESC Guidelines state that PCI should be performed within 120 minutes from first medical contact, and door-to-balloon time should be <60 minutes in order to reduce long term mortality. STEMI networks should be established with regionalization of pPCI treatment to address the challenges regarding pre-hospital treatment, triage and transport of STEMI patients and collaborations between hospitals and Emergency Medical Services (EMS). We report on a regional decade long experience from one of Europe's largest STEMI networks located in Eastern Denmark, which serves a catchment area of 2.5 million inhabitants by processing ~4000 prehospital ECGs annually transmitted from 4 EMS systems to a single pPCI center treating 1100 patients per year. This organization has led to a significant improvement of the standard of therapy for acute myocardial infarction (MI) patients leading to historically low 30-day mortality for STEMI patients (<6%). About 70-80% of all STEMI patients are being triaged from the field and rerouted to the regional pPCI center. Significant delays are still found among patients who present to local hospitals and for those who are first admitted to a local emergency room and thus subject to inter-hospital transfer. In the directly transferred group, approximately 80% of patients can be treated within the current guideline time window of 120 minutes when triaged within a 185 km (~115 miles) radius. Since 2010, a Helicopter Emergency Medical Service has been implemented for air rescue. Air transfer was associated with a 20-30 minute decrease from first medical contact to pPCI, at distances down to 90 km from the pPCI center and with a trend toward better survival among air transported patients. The pPCI center also serves a small island in the Baltic Sea, where STEMI patients are rescued via air force helicopters. Based on data from more than 100 patients transferred over the past decade, we have found a similar in-hospital and long term mortality rate compared to the main island inhabitants. In conclusion, with the optimal collaboration within a STEMI network including local hospitals, university clinics, EMS and military helicopters using the same telemedicine system and field triage of STEMI patients, most patients can be treated within the time limits suggested by the current guidelines. These organizational changes are likely to contribute to the improved mortality rate for STEMI patients.

Telemedicine fighting acute coronary syndromes.

INTRODUCTION: Telemedicine allows exchange of information and has therefore become an important tool for optimizing patient treatment in the field of cardiology. Transmission of electrocardiograms (ECGs) from the prehospital setting to the receiving hospital is the most widespread technology in the prehospital setting. Providing a diagnostic ECG from patients with acute coronary syndromes to health care professionals with decision-making power has proven pivotal for an early diagnosis, ideal triage, and initiation of reperfusion therapy of the large group of patients presenting with ST-elevation myocardial infarction (STEMI). This urgent triage could be expanded to several diagnosis in cardiology, primarily the non-ST-elevation presenters. PURPOSE: The purpose of the present article is to briefly describe the history the teletransmitted ECG and some of the recent results obtained when used in routine practice for acute triage and referral for primary percutaneous coronary intervention. CONCLUSIONS: Transmitting 12-lead ECGs from the community directly to attending cardiologists should become routine. Time to reperfusion in STEMI has decreased, explaining much of the observed decrease in STEMI mortality. This technology allows for increasingly complex and individualized prehospital medical care and could be expanded to a broader number of cardiovascular diagnoses.

Overcoming barriers to developing seamless ST-segment elevation myocardial infarction care systems in the United States: recommendations from a comprehensive Prehospital 12-lead Electrocardiogram Working Group.

BACKGROUND: Reducing time to reperfusion treatment for patients with ST-segment elevation myocardial infarction (STEMI) improves patient outcomes. Few medical systems consistently meet current benchmarks regarding timely access to treatment. Studies have widely demonstrated that prehospital 12-lead electrocardiography can facilitate early catheterization laboratory activation and is the most effective means of decreasing patients' time to treatment. METHODS: We gathered experts to examine the barriers to implementation of prehospital 12-lead electrocardiographic monitoring and transmission to in-hospital cardiologists in creating seamless STEMI care systems (STEMI-CS) and propose multidisciplinary approaches to overcoming these barriers. RESULTS AND CONCLUSIONS: Physicians, hospital systems, and emergency medical services often lack coordination of care delivery and receive fragmented funding and oversight. Clinical and regulatory guidelines do not emphasize local solutions to achieving clinical benchmarks, do not target incentives at all components of the STEMI-CS, and underemphasize risk-based approaches to protecting patient health. Integration of the multiple complex components involved in STEMI-CS is essential to improving care delivery.

Effect on treatment delay of prehospital teletransmission of 12-lead electrocardiogram to a cardiologist for immediate triage and direct referral of patients with ST-segment elevation acute myocardial infarction to primary percutaneous coronary intervention.

Prehospital electrocardiogram (ECG) transmission to hospitals was shown to reduce time to treatment in patients with acute myocardial infarction. However, new technologies allow transmission directly to a mobile unit so an attending physician can respond irrespective of presence within or outside the hospital. The primary study purpose was to determine whether delays could be decreased in an urban area by transmitting a prehospital 12-lead ECG directly to the attending cardiologist's mobile telephone for rapid triage and transport to a primary percutaneous coronary intervention (PCI) center, bypassing local hospitals and emergency departments. A secondary purpose was to describe whether transport would be safe despite longer transport times. During a 2-year period, patients with acute nontraumatic chest pain had their prehospital ECG transmitted directly to a cardiologist's mobile telephone. Time to treatment was compared with historic controls. After ECG evaluation, 168 patients (30%) were referred directly for PCI, and 146 of these (87%) underwent emergent catheterization. In referred patients, median time from 911 call to PCI was significantly shorter than in the control group (74 vs 127 minutes; p <0.001). Accordingly, door-to-PCI time was 63 minutes shorter for referred patients versus controls (34 vs 97 minutes; p <0.001). During transport, 7 patients (4%) experienced ventricular fibrillation; 3 patients (2%), ventricular tachycardia; and 1 patient (0.5%), pulseless electrical activity, including 2 deaths (1%) caused by treatment-resistant arrhythmia. In conclusion, transmission of a prehospital 12-lead ECG directly to the attending cardiologist's mobile telephone decreased door-to-PCI time by >1 hour when patients were transported directly to PCI centers, bypassing local hospitals. Ambulance transport seems safe despite longer transport times.

Referral of patients with ST-segment elevation acute myocardial infarction directly to the catheterization suite based on prehospital teletransmission of 12-lead electrocardiogram.

BACKGROUND: Time from symptom onset to reperfusion is essential in patients with ST-segment elevation acute myocardial infarction. Prior studies have indicated that prehospital 12-lead electrocardiogram (ECG) transmission can reduce time to reperfusion. PURPOSE: Determine 12-lead ECG transmission success rates, and time saved by referring patients directly to primary percutaneous coronary intervention (pPCI) bypassing local hospitals and emergency departments. METHODS: Prehospital 12-lead ECG was recorded in patients with symptoms suggesting acute coronary syndrome during a 1-year pilot phase and transmitted to the attending cardiologist's mobile phone. Transmission success rates were determined, and prehospital and hospital delays were recorded and compared to historic controls. RESULTS: Transmission was attempted in 152 patients and was successful in 89%. Twenty-seven patients were referred directly for pPCI. Median hospital arrival to pPCI was 22 vs 94 minutes in the control group (P < .01). CONCLUSIONS: Transmission of prehospital ECG is technically feasible and reduces time to pPCI in ST-segment elevation acute myocardial infarction patients.

Automatic electrocardiographic algorithm for assessing severity of ischemia in ST-segment elevation myocardial infarction.

BACKGROUND: Terminal QRS distortion on the electrocardiogram (ECG) is a sign of severe ischemia in patients with STEMI and can be quantified by the Sclarovsky-Birnbaum Severity of Ischemia. Due to score complexity, it has not been applied in clinical practice. Automatic scoring of digitally recorded ECGs could facilitate clinical application. We aimed to develop an automatic algorithm for the severity of ischemia. METHODS: Development set: 50 STEMI ECGs were manually (Manual-score) and automatically (Auto-score) scored by our designed algorithm. The agreement between Manual- and Auto-score was assessed by kappa statistics. Test set: ECGs from 199 STEMI patients were assigned a severity grade (severe or non-severe ischemia) by the Auto-score. Infarct size estimated by median peak Troponin T (TnT) and Creatinine Kinase Myocardial Band (CKMB) was tested between the groups. RESULTS: The agreement between Manual- and Auto-score was 0.83 ((95% CI 0.55-1.00), p < 0.0001), sensitivity 75% and specificity 100%, PPV 100% and NPV 94.6%. In the test set 152 (76%) patients were male, mean age 61 ±â€¯12 years. The Auto-score designated severe ischemia in 42 (21%) and non-severe ischemia in 157 (79%) patients. Patients with ECG signs of severe vs. non-severe ischemia had significantly higher levels of biomarkers of infarct size. In multiple linear regression, ECG sign of severe ischemia was an independent predictor for higher TnT and CKMB levels. CONCLUSION: The automatic ECG algorithm for severity of ischemia in STEMI performs adequately for clinical use. Severe ischemia obtained by the Auto-score was associated with biomarker estimated larger infarct size.

Timing of ischemic onset estimated from the electrocardiogram is better than historical timing for predicting outcome after reperfusion therapy for acute anterior myocardial infarction: a DANish trial in Acute Myocardial Infarction 2 (DANAMI-2) substudy.

BACKGROUND: Acute treatment strategy and subsequently prognosis are influenced by the duration of ischemia in patients with ST-elevation acute myocardial infarction (AMI). However, timing of ischemia may be difficult to access by patient history (historical timing) alone. We hypothesized that an electrocardiographic acuteness score is better than historical timing for predicting myocardial salvage and prognosis in patients with anterior AMI treated with fibrinolysis or primary percutaneous coronary intervention. METHODS: One hundred seventy-five patients with anterior infarct without electrocardiogram (ECG) confounding factors were included. The ECG method for estimating timing of AMI was calculated using core laboratory measurements from the initial 12-lead ECG. Historical timing was recorded as time from symptom onset to initiation of reperfusion therapy. Myocardial salvage was determined by ECG, using the Aldrich score to determine the initially predicted myocardial infarct size and the Selvester score to determine the final QRS-estimated myocardial infarct size. RESULTS: The mean amount of myocardium salvage depended on ECG timing (43% [+/-38%] for "early" vs 1% [+/-56%] for "late"; P < .001), whereas myocardial salvage was independent of historical timing (P = .9). One-year mortality was predicted from ECG timing (P = .04). CONCLUSIONS: The ECG method of timing was superior to historical timing in predicting myocardial salvage and prognosis after reperfusion therapy. This study suggests that ECG estimated duration of ischemia might provide a better and objective means to select acute reperfusion therapy rather than the subjective patient history, which could preclude proper reperfusion in some patients with salvageable myocardium.

Detection of acute ischemia from the EASI-derived 12-lead electrocardiogram and from the 12-lead electrocardiogram acquired in clinical practice.

ST-segment measurements in the standard 12-lead electrocardiogram (ECG) of patients with acute coronary syndromes are crucial for these patients' management. Our objective was to determine whether the 12-lead ECG derived from the 3-lead EASI system can attain a level of diagnostic performance similar to that of the Mason-Likar (ML) 12-lead ECG acquired in clinical practice (CP) by paramedics and emergency department technicians. Using 120-lead body surface potential maps recorded before and during balloon inflation angioplasty from 88 patients (divided into "responders" and "nonresponders"), and electrode placement data from 60 applications of precordial leads in CP, we generated for the "nonischemic" and "ischemic" states of each patient the following lead sets: the ML 12-lead ECG, the EASI-derived 12-lead ECG, and 60 sets of 12-lead CP ECGs. We extracted ST deviations at J + 60 milliseconds, summed them for all 12 leads of each lead set to obtain SigmaST, and, by using the bootstrap method, determined the mean sensitivity and specificity for recognizing the "ischemic" state at various thresholds of SigmaST. Results were displayed as receiver operating characteristics, and the area under these curves (AUC) +/- SE was used as the measure of diagnostic performance. AUC +/- SE for all patients were ML ECG, 0.66 +/- 0.03; EASI ECG, 0.64 +/- 0.03; and CP ECG, 0.67 +/- 0.03. Corresponding results for responders only were 0.81 +/- 0.04 for ML ECG, 0.78 +/- 0.04 for EASI ECG, and 0.81 +/- 0.04 for CP ECG. The differences between the AUCs for the different lead sets were not significant (P > .05). Thus, the EASI-derived 12-lead ECG is as good for detecting acute ischemia as is the 12-lead ECG acquired in CP.

Usefulness of quantitative baseline ST-segment elevation for predicting outcomes after primary coronary angioplasty or fibrinolysis (results from the DANAMI-2 trial).

The DANAMI-2 trial showed a 40% decrease in the composite end point with primary coronary angioplasty versus fibrinolysis. This result was primarily driven by a decrease in reinfarction, with no significant difference in mortality or stroke rates. The objective of this study was to determine the prognostic value of the sum ST-segment elevation (SigmaST) on baseline electrocardiography in patients who were randomized to receive primary coronary angioplasty versus fibrinolysis. In the DANAMI-2, 1,450 patients had baseline ST-segment deviation measurements and were assigned to quartiles according to SigmaST: 0 to 6.5, 7.0 to 9.5, 10.0 to 14.5, and 15.0 to 70.5 mm. The composite and component end-point rates at 30 days were determined for each quartile and chi-square for trend statistic was used to compare end-point rates across quartiles of SigmaST. The composite end point occurred more often with increasing SigmaST (p = 0.05). With regard to component end points, only mortality increased significantly with SigmaST (p = 0.03), whereas reinfarction and stroke rates did not. By multivariate analysis, only SigmaST and age were independent predictors of mortality. The relative benefit of primary coronary angioplasty was similar for all SigmaST quartiles. In conclusion, the magnitude of SigmaST correlates with increased mortality at 30 days, thus driving the composite end point rate. Regardless of SigmaST, patients had a lower composite end-point rate with primary coronary angioplasty than with fibrinolysis.

Outcomes of patients calling emergency medical services for suspected acute cardiovascular disease.

Adequate health care is increasingly dependent on prehospital systems and cardiovascular (CV) disease remains the most common cause for hospital admission. However the prevalence of CV dispatches of emergency medical services (EMS) is not well reported and survival data described in clinical trials and registries are subject to selection biases. We aimed to describe the prevalence and prognosis of acute CV disease and the effect of invasive treatment, in an unselected and consecutive prehospital cohort of 3,410 patients calling the national emergency telephone number from 2005 to 2008 with follow-up in 2013. Individual-level data from national registries were linked to the dedicated EMS database of primary ambulance dispatches supported by physician-manned emergency units. Outcome data were obtained from the Central Population Registry, the National Patient Registry, and the National Registry of Causes of Death. In patients calling the national emergency telephone number, a CV related ambulance alarm code was given in 2,541 patients of 3,410 patients (74.5%) resulting in 2,056 of 3,410 primary CV discharge diagnoses (60.3%) with a 30-day and 5-year all-cause mortality of 24.5% and 46.4%, respectively. Stroke, acute heart failure, and ST-segment elevation myocardial infarction (STEMI) carried a 25- to 50-fold adjusted mortality hazard during the first 4 days. In patients with suspected STEMI, 90.5% had an acute angiography performed. Nontransferred, nonreperfused patients with STEMI (9.1%) carried 80% short-term mortality. Noninvasive management of non-ST-segment elevation myocardial infarction was common (37.9%) and associated with an increased adjusted long-term mortality hazard (hazard ratio 4.17 [2.51 to 8.08], p <0.001). Survival in 447 out-of-hospital cardiac arrest patients (13.1%) was 11.6% at 30 days. In conclusion, patients with a CV ambulance alarm call code and a final CV discharge diagnosis constitute most patients handled by EMS with an extremely elevated short-term mortality hazard and a poor long-term prognosis. Although co-morbidities and frailty may influence triage, this study emphasizes the need for an efficient prehospital phase with focus on CV disease and proper triage of patients suitable for invasive evaluation if the outcomes of acute heart disease are to be improved further in the current international context of hospitals merging into highly specialized entities resulting in longer patient transfers.

Update: Innovation in cardiology (II). Telecardiology: past, present and future.

Technological advances over the past decades have allowed improved diagnosis and monitoring of patients with acute coronary syndromes as well as patients with advanced heart failure. High-quality digital recordings transmitted wirelessly by cellular telephone networks have augmented the prehospital use of transportable electrocardiogram machines as well as implantable devices for arrhythmia monitoring and therapy. The impact of prehospital electrocardiogram recording and interpretation in patients suspected of acute myocardial infarction should not be underestimated. It enables a more widespread access to rapid reperfusion therapy, thereby reducing treatment delay, morbidity and mortality. Further, continuous electrocardiogram monitoring has improved arrhythmia diagnosis and dynamic ST-segment changes have been shown to provide important prognostic information in patients with acute ST-elevation myocardial infarction. Likewise, remote recording or monitoring of arrhythmias and vital signs seem to improve outcome and reduce the necessity of re-admissions or outpatient contacts in patients with heart failure or arrhythmias. In the future telemonitoring and diagnosis is expected to further impact the way we practice cardiology and provide better care for the patient with cardiovascular disease.