Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study.

OBJECTIVES: Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN: Multicenter retrospective observational study. SETTING: Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS: Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS: In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.

Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest.

BACKGROUND: Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. METHODS: We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. RESULTS: We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. CONCLUSIONS: Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

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.

Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients.

BACKGROUND: The benefit of red blood cell (RBC) transfusion in anemic critically-ill patients with cardiovascular disease is uncertain, as is the optimal threshold at which RBC transfusion should be considered. We sought to examine the association between RBC transfusion and mortality stratified by nadir Hgb level and admission diagnosis among cardiac intensive care unit (CICU) patients. METHODS: Retrospective single-center cohort of 11,754 CICU patients admitted between 2007 and 2018. The association between RBC transfusion and hospital mortality at each nadir Hgb (<8 g/dL, 8-9.9 g/dL, ≥10 g/dL) was assessed using multivariable logistic regression adjusted for the propensity to receive RBC transfusion. RESULTS: The study population had a mean age of 68±15 years, including 38% females; 1,134 (11.4%) received RBC transfusion. Admission diagnoses included: acute coronary syndrome , 42%; heart failure, 50%; cardiac arrest , 12%; and cardiogenic shock , 12%. Patients who received RBC transfusion had higher crude hospital mortality (19% vs. 8%, P<.001). RBC transfusion was associated with lower adjusted hospital mortality in patients with nadir Hgb <8 g/dL after propensity adjustment, including subgroups with acute coronary syndrome, cardiac arrest, or cardiogenic shock (all P <.01). RBC transfusion was not associated with lower adjusted hospital mortality in any subgroup of patients with nadir Hgb ≥8 g/dL. CONCLUSIONS: These observational data suggest the use of a Hgb threshold <8 g/dL for RBC transfusion in most CICU patients, although we could not exclude a potential benefit of RBC transfusion at a nadir Hgb of 8 to 9.9 g/dL; we did not observe any benefit from RBC transfusion at a nadir Hgb ≥10 g/dL.

The ß-Adrenergic Agonist Albuterol Improves Pulmonary Vascular Reserve in Heart Failure With Preserved Ejection Fraction.

RATIONALE: Pulmonary vascular resistance fails to decrease appropriately during exercise in patients with heart failure with preserved ejection fraction (HFpEF). Interventions that enhance pulmonary vasodilation might be beneficial in this cohort but could also worsen left atrial hypertension, exacerbating lung congestion. Intravenous ß-agonists reduce pulmonary vascular resistance but are not suitable for chronic use. OBJECTIVE: We hypothesized that the inhaled ß-adrenergic agonist albuterol would improve pulmonary vasodilation during exercise in patients with HFpEF, without increasing left heart filling pressures. METHODS AND RESULTS: We performed a randomized, double-blind, placebo-controlled trial testing the effects of inhaled albuterol on resting and exercise hemodynamics in subjects with HFpEF using high-fidelity micromanometer catheters and expired gas analysis. The primary end point was pulmonary vascular resistance during exercise. Subjects with HFpEF (n=30) underwent resting and exercise hemodynamic assessment and were then randomized 1:1 to inhaled, nebulized albuterol or placebo. Rest and exercise hemodynamic testing was then repeated. Albuterol improved the primary end point of exercise pulmonary vascular resistance as compared with placebo (-0.6±0.5 versus +0.1±0.7 WU; P=0.003). Albuterol enhanced cardiac output reserve and right ventricular pulmonary artery coupling, reduced right atrial and pulmonary artery pressures, improved pulmonary artery compliance, and enhanced left ventricular transmural distending pressure (all P <0.01), with no increase in pulmonary capillary hydrostatic pressures. CONCLUSIONS: Albuterol improves pulmonary vascular reserve in patients with HFpEF without worsening left heart congestion. Further study is warranted to evaluate the chronic efficacy of ß-agonists in HFpEF and other forms of pulmonary hypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02885636.

Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock.

Despite decades of research, the mortality rate of sepsis and septic shock remains unacceptably high. Delays in diagnosis, identification of an infectious source, and the challenge of providing patient-tailored resuscitation measures routinely result in suboptimal patient outcomes. Bedside ultrasound improves a clinician's ability to both diagnose and manage the patient with sepsis. Indeed, multiple point-of-care ultrasound (POCUS) protocols have been developed to evaluate and treat various subsets of critically ill patients. These protocols mostly target patients with undifferentiated shock and have been shown to improve clinical outcomes. Other studies have shown that POCUS can improve a clinician's ability to identify a source of infection. Once a diagnosis of septic shock has been made, serial POCUS exams can be used to continuously guide resuscitative efforts. In this review, we advocate that the patient with suspected sepsis or septic shock undergo a comprehensive POCUS exam in which sonographic information across organ systems is synthesized and used in conjunction with traditional data gleaned from the patient's history, physical exam, and laboratory studies. This harmonization of information will hasten an accurate diagnosis and assist with hemodynamic management.

The haemodynamic basis of lung congestion during exercise in heart failure with preserved ejection fraction.

AIMS: Increases in extravascular lung water (EVLW) during exercise contribute to symptoms, morbidity, and mortality in patients with heart failure and preserved ejection fraction (HFpEF), but the mechanisms leading to pulmonary congestion during exercise are not well-understood. METHODS AND RESULTS: Compensated, ambulatory patients with HFpEF (n = 61) underwent invasive haemodynamic exercise testing using high-fidelity micromanometers with simultaneous lung ultrasound, echocardiography, and expired gas analysis at rest and during submaximal exercise. The presence or absence of EVLW was determined by lung ultrasound to evaluate for sonographic B-line artefacts. An increase in EVLW during exercise was observed in 33 patients (HFpEFLW+, 54%), while 28 (46%) did not develop EVLW (HFpEFLW-). Resting left ventricular function was similar in the groups, but right ventricular (RV) dysfunction was two-fold more common in HFpEFLW+ (64 vs. 31%), with lower RV systolic velocity and RV fractional area change. As compared to HFpEFLW-, the HFpEFLW+ group displayed higher pulmonary capillary wedge pressure (PCWP), higher pulmonary artery (PA) pressures, worse RV-PA coupling, and higher right atrial (RA) pressures during exercise, with increased haemoconcentration indicating greater loss of water from the vascular space. The development of lung congestion during exercise was significantly associated with elevations in PCWP and RA pressure as well as impairments in RV-PA coupling (area under the curve values 0.76-0.84). CONCLUSION: Over half of stable outpatients with HFpEF develop increases in interstitial lung water, even during submaximal exercise. The acute development of lung congestion is correlated with increases in pulmonary capillary hydrostatic pressure that favours fluid filtration, and systemic venous hypertension due to altered RV-PA coupling, which may interfere with fluid clearance. CLINICAL TRIAL REGISTRATION: NCT02885636.

Changes in comorbidities, diagnoses, therapies and outcomes in a contemporary cardiac intensive care unit population.

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. METHODS: We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. RESULTS: We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis. CONCLUSIONS: We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

Beamforming algorithms for endocardial border detection.

BACKGROUND: Software-based beamforming which utilizes delay and standard beamforming is a signal processing technique that temporarily stores data from each probe element to improve specular reflections to improve the image resolution. We compared a software algorithm which uses delay and standard beamforming with delay and sum beamforming in standard, hardware to evaluate endocardial borders and need for echo contrast. METHODS: In this prospective study, eligible participants were ≥18 years of age referred clinically for transthoracic echocardiograms. A limited study consisting of three views (apical 4, apical 3, and apical 2 chamber) was performed with the software-based beamforming and standard platform. Number and quality of segments visualized were evaluated using a 17-segment model. Quality of segments was graded as 0 = not visualized, 1 = incompletely visualized, or 2 = completely visualized. Overall quality score for each study (0 = poor, 1 = adequate, 2 = good) was reported. The need for contrast was determined by ASE guidelines. RESULTS: A total of 101 patients (mean age 61 ± 16 years, males 52%) were enrolled. Mean number of segments visualized in apical 4- (6.28 vs 5.65, P < .001), apical 3- (6.27 vs 5.54, P < .001), and apical 2-chamber views (6.26 vs 5.72 P < .001) was higher with the software vs standard platform. The average overall score for image quality was significantly better for the software platform vs standard (1.4 vs 0.9, P =< .001). With the software platform, 23% were judged as requiring contrast as compared with 45% for the standard platform (P < .001). CONCLUSIONS: Delay and standard beamforming in software platform identified more segments with better image quality when compared to the standard high-end platform, decreasing the need for contrast usage.

EDUCATE: An international, randomized controlled trial for teaching electrocardiography.

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.

Echocardiographic findings in cardiogenic shock due to acute myocardial infarction versus heart failure.

BACKGROUND: Acute myocardial infarction (AMI) is the prototypical cause of cardiogenic shock (CS), yet CS due to heart failure (HF-CS) is increasingly common. Little is known regarding cardiac function in AMI-CS versus HF-CS. We compared transthoracic echocardiography (TTE) findings in AMI-CS versus HF-CS and identified predictors of mortality in AMI-CS patients. METHODS: We performed a single-center, retrospective analysis of CS admissions between 2007 and 2018. We compared baseline demographic and TTE parameters in patients with AMI-CS and HF-CS as well as ST elevation myocardial infarction (STEMI)-CS versus non-ST elevation myocardial infarction (NSTEMI)-CS. RESULTS: We included 893 unique patients, including 581 (65%) with AMI-CS. AMI-CS patients were older but had lower illness severity and non-cardiac comorbidity burden. AMI-CS patients had better left ventricular function (LVEF 35% versus 28%), lower biventricular filling pressures, and higher stroke volume versus those with HF-CS. Among TTE measurements, myocardial contraction fraction had the highest discrimination for mortality in AMI-CS (AUC: 0.64); AUC values for LVEF and SOFA score were 0.61 and 0.65, respectively. Differences in TTE findings between STEMI-CS versus NSTEMI-CS were modest. There were no significant differences in unadjusted or adjusted in-hospital mortality between AMI-CS and HF-CS (31% versus 35%) or STEMI-CS and NSTEMI-CS (31% versus 30%) groups (all p > 0.05). CONCLUSIONS: Patients with HF-CS and AMI-CS differ in terms of clinical and TTE variables yet have similar prognoses. TTE is useful in determining prognosis of patients admitted with AMI-CS and may allow for early triage and directed therapy.

Echocardiographic parameters and hemodynamic instability at the initiation of continuous kidney replacement therapy.

OBJECTIVE: Investigate the association of echocardiographic parameters with hemodynamic instability after initiating continuous kidney replacement therapy (CKRT) in a cohort of intensive care unit (ICU) patients requiring CKRT. METHODS: Historical cohort study of consecutive adults admitted to the ICU at a tertiary care hospital from December 2006 through November 2015 who underwent CKRT and had an echocardiogram done within seven days before CKRT initiation. The primary outcome was hypotension within one hour of CKRT initiation. RESULTS: We included 980 patients, 804 (82%) with acute kidney injury (AKI) and 176 (18%) with end-stage kidney disease (ESKD). Median patient age was 63 (± 14) years, and median Sequential Organ Failure Assessment (SOFA) score on the day of CKRT initiation was 12 (IQR 10-14). Multivariable analysis showed that Left (OR 2.01, 95% CI 1.04-3.86), and Right (OR 1.5, 95% CI 1.04-2.25) moderate and severe ventricular enlargement, Vasoactive-Inotropic Score (VIS) one hour before CKRT initiation (OR 1.18 per 10 units increase, 95% CI 1.09-1.28) and high bicarbonate fluid replacement (OR 2.52, 95% CI 1.01-6.2) were associated with hypotension after CKRT initiation. CONCLUSION: Right and left ventricular enlargement are risk factors associated with hypotension after CKRT initiation.

Impact of Computer-Interpreted ECGs on the Accuracy of Healthcare Professionals.

The interpretation of electrocardiograms (ECGs) involves a dynamic interplay between computerized ECG interpretation (CEI) software and human overread. However, the impact of computer ECG interpretation on the performance of healthcare professionals remains largely unexplored. The aim of this study was to evaluate the interpretation proficiency of various medical professional groups, with and without access to the CEI report. Healthcare professionals from diverse disciplines, training levels, and countries sequentially interpreted 60 standard 12-lead ECGs, demonstrating both urgent and nonurgent findings. The interpretation process consisted of 2 phases. In the first phase, participants interpreted 30 ECGs with clinical statements. In the second phase, the same 30 ECGs and clinical statements were randomized and accompanied by a CEI report. Diagnostic performance was evaluated based on interpretation accuracy, time per ECG (in seconds [s]), and self-reported confidence (rated 0 [not confident], 1 [somewhat confident], or 2 [confident]). A total of 892 participants from various medical professional groups participated in the study. This cohort included 44 (4.9%) primary care physicians, 123 (13.8%) cardiology fellows-in-training, 259 (29.0%) resident physicians, 137 (15.4%) medical students, 56 (6.3%) advanced practice providers, 82 (9.2%) nurses, and 191 (21.4%) allied health professionals. The inclusion of the CEI was associated with a significant improvement in interpretation accuracy by 15.1% (95% confidence interval, 14.3-16.0; P < 0.001), decrease in interpretation time by 52 s (-56 to -48; P < 0.001), and increase in confidence by 0.06 (0.03-0.09; P = 0.003). Improvement in interpretation accuracy was seen across all professional subgroups, including primary care physicians by 12.9% (9.4-16.3; P = 0.003), cardiology fellows-in-training by 10.9% (9.1-12.7; P < 0.001), resident physicians by 14.4% (13.0-15.8; P < 0.001), medical students by 19.9% (16.8-23.0; P < 0.001), advanced practice providers by 17.1% (13.3-21.0; P < 0.001), nurses by 16.2% (13.4-18.9; P < 0.001), allied health professionals by 15% (13.4-16.6; P < 0.001), physicians by 13.2% (12.2-14.3; P < 0.001), and nonphysicians by 15.6% (14.3-17.0; P < 0.001).CEI integration improves ECG interpretation accuracy, efficiency, and confidence among healthcare professionals.

Predictors of ECG Interpretation Proficiency in Healthcare Professionals.

Accurate ECG interpretation is vital, but variations in skills exist among healthcare professionals. This study aims to identify factors contributing to ECG interpretation proficiency. Survey data and ECG interpretation test scores from participants in the EDUCATE Trial were analyzed to identify predictors of performance for 30 sequential 12-lead ECGs. Nonmodifiable factors (being a physician, clinical experience, patient care impact) and modifiable factors (weekly interpretation volume, training hours, expert supervision frequency) were analyzed. Bivariate and multivariate analyses were used to generate a Comprehensive Model (incorporating all factors) and Actionable Model (incorporating modifiable factors only). Among 1206 participants analyzed, there were 72 (6.0%) primary care physicians, 146 (12.1%) cardiology fellows-in-training, 353 (29.3%) resident physicians, 182 (15.1%) medical students, 84 (7.0%) advanced practice providers, 120 (9.9%) nurses, and 249 (20.7%) allied health professionals. Among them, 571 (47.3%) were physicians and 453 (37.6%) were nonphysicians. The average test score was 56.4% ± 17.2%. Bivariate analysis demonstrated significant associations between test scores and >10 weekly ECG interpretations, being a physician, >5 training hours, patient care impact, and expert supervision but not clinical experience. In the Comprehensive Model, independent associations were found with weekly interpretation volume (9.9 score increase; 95% CI, 7.9-11.8; P < 0.001), being a physician (9.0 score increase; 95% CI, 7.2-10.8; P < 0.001), and training hours (5.7 score increase; 95% CI, 3.7-7.6; P < 0.001). In the Actionable Model, scores were independently associated with weekly interpretation volume (12.0 score increase; 95% CI, 10.0-14.0; P < 0.001) and training hours (4.7 score increase; 95% CI, 2.6-6.7; P < 0.001). The Comprehensive and Actionable Models explained 18.7% and 12.3% of the variance in test scores, respectively. Predictors of ECG interpretation proficiency include nonmodifiable factors like physician status and modifiable factors such as training hours and weekly ECG interpretation volume.

ECG Interpretation Proficiency of Healthcare Professionals.

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.

Exploring Factors Influencing ECG Interpretation Proficiency of Medical Professionals.

The electrocardiogram (ECG) is a crucial diagnostic tool in medicine with concerns about its interpretation proficiency across various medical disciplines. Our study aimed to explore potential causes of these issues and identify areas requiring improvement. A survey was conducted among medical professionals to understand their experiences with ECG interpretation and education. A total of 2515 participants from diverse medical backgrounds were surveyed. A total of 1989 (79%) participants reported ECG interpretation as part of their practice. However, 45% expressed discomfort with independent interpretation. A significant 73% received less than 5 hours of ECG-specific education, with 45% reporting no education at all. Also, 87% reported limited or no expert supervision. Nearly all medical professionals (2461, 98%) expressed a desire for more ECG education. These findings were consistent across all groups and did not vary between primary care physicians, cardiology FIT, resident physicians, medical students, APPs, nurses, physicians, and nonphysicians. This study reveals substantial deficiencies in ECG interpretation training, supervision, and confidence among medical professionals, despite a strong interest in increased ECG education.

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity.

BACKGROUND: Echocardiographic findings vary with shock severity, as defined by the Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Left ventricular stroke work index (LVSWI) measured by transthoracic echocardiography (TTE) can predict mortality in the cardiac intensive care unit (CICU). We sought to determine whether LVSWI could refine mortality risk stratification by the SCAI shock classification in the CICU. METHODS: We included consecutive CICU patients from 2007 to 2015 with TTE data available to calculate the LVSWI, specifically the mean arterial pressure, stroke volume index and medial mitral E/e' ratio. In-hospital mortality as a function of LVSWI was evaluated across the SCAI shock stages using logistic regression, before and after multivariable adjustment. RESULTS: We included 3635 unique CICU patients, with a mean age of 68.1 ± 14.5 years (36.5% females); 61.1% of patients had an acute coronary syndrome. The LVSWI progressively decreased with increasing shock severity, as defined by increasing SCAI shock stage. A total of 203 (5.6%) patients died during hospitalization, with higher in-hospital mortality among patients with lower LVSWI (adjusted OR 0.66 per 10 J/m2 higher) or higher SCAI shock stage (adjusted OR 1.24 per each higher stage). A LVSWI <33 J/m2 was associated with higher adjusted in-hospital mortality, particularly among patients with shock (SCAI stages C, D and E). CONCLUSIONS: The LVSWI by TTE noninvasively characterizes the severity of shock, including both systolic and diastolic parameters, and can identify low-risk and high-risk patients at each level of clinical shock severity.

Biventricular Function and Shock Severity Predict Mortality in Cardiac ICU Patients.

BACKGROUND: Ventricular function, including left ventricular systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and biventricular dysfunction (BVD), contribute to shock in cardiac ICU (CICU) patients, but the prognostic usefulness remains unclear. RESEARCH QUESTION: Do patients with ventricular dysfunction have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage? STUDY DESIGN AND METHODS: We identified patients in the CICU admitted with available echocardiography data. LVSD was defined as left ventricular ejection fraction < 40%, RVSD as moderate or greater systolic dysfunction by semiquantitative measurement, and BVD as the presence of both. Multivariate logistic regression determined the relationship between ventricular dysfunction and adjusted in-hospital mortality as a function of SCAI stage. RESULTS: The study population included 3,158 patients with a mean ± SD age of 68.2 ± 14.6 years, of which 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and BVD in 16.4%. After adjustment for SCAI shock stage, no difference in in-hospital mortality was found between patients with LVSD or RVSD and those without ventricular dysfunction (P > .05), but BVD was associated independently with higher in-hospital mortality (adjusted hazard ratio, 1.815; 95% CI, 1.237-2.663; P = .0023). The addition of ventricular dysfunction to the SCAI staging criteria increased discrimination for hospital mortality (area under the receiver operating characteristic curve, 0.784 vs 0.766; P < .001). INTERPRETATION: Among patients admitted to the CICU, only BVD was associated independently with higher hospital mortality. The addition of echocardiography assessment to the SCAI shock criteria may facilitate improved clinical risk stratification.