Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial.

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.

Assessment of left ventricular filling pressure with Doppler velocities across the patent foramen ovale.

BACKGROUND: The utility of Doppler velocities across the patent foramen ovale (PFO) to estimate left ventricular (LV) filling pressure is not well known. METHODS: The best cut-off value of peak interatrial septal velocity across a transeptal puncture site measured by transesophageal echocardiography for estimating high mean left atrial (LA) pressure (≥ 15 mmHg) was determined in 17 patients. This cut-off value was subsequently applied to 67 patients with a PFO undergoing transthoracic echocardiography (TTE) for assessing the value of PFO velocity in determining LV filling pressure. RESULTS: The peak systolic interatrial septal velocities significantly correlated with directly measured mean LA pressures during transcatheter mitral valve procedure (r = 0.77, P < 0.001). The best cut-off value was 1.7 m/s for predicting high LA pressure (AUC 0.91; sensitivity 90%, specificity 86%). When this cut-off was applied to patients undergoing TTE, peak PFO velocity ≥ 1.7 m/s correlated with reduced e', higher E/e', and higher tricuspid regurgitation velocity (P < 0.01). LV filling pressure according to the 2016 diastolic guideline was compared with peak PFO velocity in 51 patients. Among patients with high filling pressure according to the guidelines (n = 20), peak PFO velocity ≥ 1.7 m/s was present in 60% of patients. In patients with normal filling pressure per the guidelines (n = 31), PFO velocity < 1.7 m/s was present 84%. Sensitivity and specificity were 75% and 92%, respectively, in patients with sinus rhythm, but were only 50% and 57%, respectively, among patients with atrial fibrillation. CONCLUSIONS: Doppler-derived peak PFO velocities could be valuable in the assessment of increased LV filling pressure using 1.7 m/s as the cut-off value.

Noninvasive Hemodynamic Assessment of Shock Severity and Mortality Risk Prediction in the Cardiac Intensive Care Unit.

OBJECTIVES: This study sought to define the 2-dimensional and Doppler echocardiographic hemodynamics associated with each Society for Cardiovascular Angiography and Interventions (SCAI) stage, and to determine their association with mortality. BACKGROUND: The SCAI shock stages classification stratifies mortality risk in cardiac intensive care unit (CICU) patients, but the echocardiographic and hemodynamic parameters that define these SCAI shock stages are unknown. METHODS: Unique CICU patients admitted from 2007 to 2015 who had a transthoracic echocardiogram within 1 day of CICU admission were included. Echocardiographic variables were evaluated as a function of SCAI shock stage. Multivariable logistic regression determined the association between echocardiographic parameters with adjusted hospital mortality. RESULTS: We included 5,453 patients with a median age of 69.3 years (interquartile range: 58.2 to 79.0 years) (37% women), and a median left ventricular ejection fraction (LVEF) of 50% (interquartile range: 35% to 61%). Higher SCAI shock stages were associated with lower LVEF and worse systemic hemodynamics. Hospital mortality was higher in patients with LVEF <40%, cardiac index <1.8 l/min/m2, stroke volume index <35 ml/m2, cardiac power output <0.6 W, or medial early mitral valve inflow velocity to early diastolic annular velocity (E/e') ratio >15 (particularly in SCAI shock Stages A to C). After multivariable adjustment, only stroke volume index <35 ml/m2 (adjusted odds ratio: 2.0; 95% confidence interval: 1.4 to 3.0; p < 0.001) and E/e' ratio >15 (adjusted odds ratio: 1.52; 95% confidence interval: 1.04 to 2.23; p = 0.03) remained associated with higher hospital mortality. CONCLUSIONS: Noninvasive 2-dimensional and Doppler echocardiographic parameters correlate with the SCAI shock stages and improve risk stratification for hospital mortality in CICU patients. Low stroke volume index and high E/e' ratio demonstrated the strongest association with hospital mortality.

Role of Doppler echocardiography for cardiac output assessment in Fontan patients.

BACKGROUND: To determine (1) correlation between Doppler stroke volume index (SVI) and cardiac magnetic resonance imaging (CMRI) SVI and (2) association between Doppler SVI and Fontan-associated diseases (FAD) and Fontan failure. METHODS: Review of Fontan patients who underwent same-day CMRI and transthoracic echocardiography (TTE), 2005 to 2015. We defined FAD as cardiac thrombus, protein-losing enteropathy, arrhythmia, and hospitalization for heart failure. Fontan failure was defined as Fontan conversion or revision, heart transplantation or listing, or death. RESULTS: Fifty-three patients with systemic left ventricle (LV) underwent 86 sets of TTE/CMRI. Mean (SD) age 31 (6) years. SVI (45 [16] vs 42 [13] mL/m2), CI (3.0 [1.1] vs 2.8 [0.8] L min-1 m-2), and ejection fraction (53 [4]% vs 51 [5]%) were similar for both modalities (P>.05 for all). Doppler SVI correlated with CMRI (r=0.68; P<.001). Sixteen patients had cirrhosis, and these patients had a higher CI (3.9 [0.9] vs 2.8 [1.0] L min-1 m-2; P<.01). Among the 37 patients without cirrhosis, Doppler SVI <39 mL/m2 was associated with FAD (odds ratio [OR], 2.11; 95% confidence limit, 1.26-3.14; P=.02); Fontan failure was more common in patients with CI was <2.5 L min-1 m-2 (3/9 [33%] vs 0/28 [0%], P=.01). Another 11 patients with systemic right ventricle (RV) underwent 17 sets of TTE/CMRI, mean (SD) age 17 (3) years, and CMRI SVI also correlated with Doppler SVI (r=0.75; P<.001). CONCLUSION: Doppler SVI correlated with CMRI SVI in patients with systemic LV and systemic RV. The association between output measures (SVI and CI) and FAD were seen only in single LV patients (single RV patients not assessed for this outcome due to small numbers). An association between low Doppler CI and Fontan failure was suggested in a small number of single LV patients.

Revascularization in Patients With Severe Left Ventricular Dysfunction: Is the Assessment of Viability Still Viable?

Myocardial viability assessment is typically reserved for patients with coronary artery disease and significant left ventricular dysfunction. In this setting, there is myocardial adaptation to an altered physiological state that is potentially reversible. Imaging can characterize different parameters of cardiac function; however, despite previously published appraisals of different imaging modalities, there is still uncertainty regarding the role of these tests in clinical practice. The purpose of this review is to reflect on the physiological basis of myocardial viability, discuss the imaging tests available that characterize myocardial viability, and summarize the current published reports on the use of these tests in clinical practice.