Mild therapeutic hypothermia improves outcome in patients suffering cardiac arrest from non-shockable rhyhtms (original) (raw)
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European Heart Journal: Acute Cardiovascular Care, 2015
Background: Current guidelines recommend that comatose out-of-hospital cardiac arrest patients with ST-segment elevations (STEs) following return of spontaneous circulation (ROSC) should be referred for an acute coronary angiography. We sought to investigate the diagnostic value of the pre-hospital ROSC-ECG in predicting ST-elevation myocardial infarction (STEMI). Method: ROSC-ECGs of 145 comatose survivors of out-of-hospital cardiac arrest, randomly assigned in the Target Temperature Management trial, were classified according to the current STEMI ECG criteria (third universal definition of myocardial infarction). Results: STEs were present in the pre-hospital ROSC-ECG of 78 (54%) patients. A final diagnosis revealed that 69 (48%) patients had STEMI, 31 (21%) patients had non-STEMI and 45 (31%) patients had no myocardial infarction. STE in ROSC-ECGs had a sensitivity of 74% (95% confidence interval (CI) 62-84), specificity of 65% (95% CI 53-75) and a positive and negative predictive value of 65% (95% CI 54-76) and 73% (95% CI 61-83) in predicting STEMI. Time to ROSC was significantly longer (24 minutes vs. 19 minutes, P=0.02) in STE compared with no STE patients. Percutaneous coronary intervention was successful in 68% versus 36% (P<0.001) of STE compared to no STE patients. No significant difference was found in 180-day mortality rates between STE and no STE patients (36% vs. 30%, P logrank =0.37). Conclusion: The pre-hospital ROSC-ECG is a suboptimal diagnostic tool to predict STEMI and therefore not a sensitive tool for triage to cardiac centres. This supports the incentive of referring all comatose survivors of out-of-hospital cardiac arrest of suspected cardiac origin to a tertiary heart centre with the availability of acute coronary angiography, even in the absence of STEs.
The ECG in acute myocardial infarction
The Journal of Emergency Medicine, 1988
0 Abstract-The initial ECG is the most rapid and readily available tool in the emergency department for the evaluation of patients presenting with suspected myocardial infarction. However, studies have shown that the initial ECG is diagnostic of acute myocardial infarction in only a minority of patients. This paper discusses the importance of the initial ECG and other information in aiding the disposi-.l-_ l,on of patients -with suspected myo~ardiai infarction. ~,as_ sic electrocardiographic descriptions are discussed as well as the newer terminology of Q wave versus non-Q wave infarction and ST segment versus T wave infarction. A brief review is made of the electrophysiology of the ECG changes seen in myocardial infarction. Finally, clinical studies are presented that establish a definite role for the use of the initial ECG.
Criteria for ECG detection of acute myocardial ischemia: Sensitivity versus specificity
Journal of electrocardiology, 2018
Criteria for electrocardiographic detection of acute myocardial ischemia recommended by the Consensus Document of ESC/ACCF/AHA/WHF consist of two parts: The ST elevation myocardial infarction (STEMI) criteria based on ST elevation (ST↑) in 10 pairs of contiguous leads and the other on ST depression (ST↓) in the same 10 contiguous pairs. Our aim was to assess sensitivity (SE) and specificity (SP) of these criteria-and to seek their possible improvements-in three databases of 12‑lead ECGs. We used (1) STAFF III data of controlled ischemic episodes recorded from 99 patients (pts) during percutaneous coronary intervention (PCI) involving either left anterior descending (LAD) coronary artery, right coronary artery (RCA), or left circumflex (LCx) coronary artery. (2) Data from the University of Glasgow for 58 pts with acute myocardial infarction (AMI) and 58 pts without AMI, as confirmed by MRI. (3) Data from Lund University retrieved from a centralized ECG management system for 100 pts w...
Electrocardiogram in Acute Myocardial Infarction: What to Expect?
International Journal of Cardiovascular Sciences, 2016
Background: Cardiovascular diseases are the leading cause of death. The electrocardiogram (ECG) is an accessible and useful tool in the initial evaluation of acute coronary syndromes (ACS). Objective: To identify and correlate electrocardiographic changes in different leads with the location of the intracoronary thrombus in the artery involved in the coronary event. Methods: Retrospective and observational study conducted with 179 patients with ACS. The data were analyzed considering three diagnostic groups: unstable angina (n = 31), non-ST-elevation myocardial infarction (n = 86), and ST-elevation myocardial infarction of the anterior (n = 34) and inferior (n = 28) walls. Data obtained from ECG, coronary angiography, and transthoracic echocardiogram tests were analyzed and compared among the three groups. Results: The sensitivity and specificity of the ECG in detecting the culprit coronary artery were 70.0% and 79.1%, respectively. The positive and negative predictive values for ECG location of the proximal segment of the left anterior descending (LAD) artery were 70.6% and 66.7%, respectively. Regarding the distal segment of the LAD, the positive and negative predictive values were 100.0% and 28.0%, respectively. With ECG analysis, we were able to identify the right coronary (RC) artery as the culprit artery in 88.9% of the cases, with positive and negative predictive values of 90.0% and 14.3%, respectively. Conclusion: The ECG is an indispensable diagnostic method in ACS, even though it fails to locate the culprit artery accurately.
Annals of Noninvasive Electrocardiology, 2014
The electrocardiogram (ECG) is the most widely used imaging tool helping in diagnosis and initial management of patients presenting with symptoms compatible with acute coronary syndrome. Acute ischemia affects the configuration of the QRS complexes, the ST segments and the T waves. The ECG should be read along with the clinical assessment of the patient. ST segment elevation (and ST depression in leads V 1-V 3) in patients with active symptoms usually indicates acute occlusion of an epicardial artery with ongoing transmural ischemia. These patients should be triaged for emergent reperfusion therapy per current guidelines. However, many patients have ST segment elevation secondary to nonischemic causes. ST depression in leads other than V 1-V 3 usually are indicative of subendocardial ischemia secondary to subocclusion of the epicardial artery, distal embolization to small arteries or spasm supply/demand mismatch. ST depression may also be secondary to nonischemic etiologies, such as left ventricular hypertrophy, cardiomyopathies, etc. Knowing the clinical scenario, comparison to previous ECG and subsequent ECGs (in cases that there are changes in the quality or severity of symptoms) may add in the diagnosis and interpretation in difficult cases. This review addresses the different ECG patterns, typically seen in patients with active symptoms, after resolution of symptoms and the significance of such changes when seen in asymptomatic patients.
Use of the Electrocardiogram in Acute Myocardial Infarction
he electrocardiogram remains a crucial tool in the identification and management of acute myocardial infarction. A detailed analysis of patterns of ST-segment elevation may influence decisions regarding the use of reperfusion therapy. The early and accurate identification of the infarct-related artery on the electrocardiogram can help predict the amount of myocardium at risk and guide decisions regarding the urgency of revascularization. Electrocardiographic signs of re-perfusion represent an important marker of microvascular blood flow and consequent prognosis. The electrocardiogram is also crucial for identifying new conduction abnormalities and arrhythmias that influence both short-and long-term outcome. In this review , we discuss approaches to the interpretation of the electrocardiogram in the clinical management of patients during the first 24 hours after a myocardial infarction. The specificity of the electrocardiogram in acute myocardial infarction is limited by large individual variations in coronary anatomy as well as by the presence of preexisting coronary artery disease, particularly in patients with a previous myocardial infarction, collateral circulation, or previous coronary-artery bypass surgery. The electrocardiogram is also limited by its inadequate representation of the posterior, lateral, and apical walls of the left ventricle. Despite these limitations, the electrocardiogram can help in identifying proximal occlusion of the coronary arteries, which results in the most extensive and most severe myocardial infarctions. inferior myocardial infarction
Resuscitation, 2011
Diagnosis of acute myocardial infarction (AMI) in out-of-hospital cardiac arrest (OHCA) patients is important because immediate coronary angiography with coronary angioplasty could improve outcome in this setting. However, the value of acute post-resuscitation electrocardiographic (ECG) data for the detection of AMI is debatable. We assessed the diagnostic characteristics of post-resuscitation ECG changes in a retrospective single centre study evaluating several ECG criteria of selection of patients undergoing AMI, in order to improve sensitivity, even at the expense of specificity. Immediate post resuscitation coronary angiogram was performed in all patients. AMI was defined angiographically using coronary flow and plaque morphology criteria. We included 165 consecutive patients aged 56 (IQR 48-67) with sustained return of spontaneous circulation after OHCA between 2002 and 2008. 84 patients had shockable, 73 non-shockable and 8 unknown initial rhythm; 36% of the patients had an AM...
ECG diagnosis and classification of acute coronary syndromes
2014
In acute coronary syndromes, the electrocardiogram (ECG) provides important information about the presence, extent, and severity of myocardial ischemia. At times, the changes are typical and clear. In other instances, changes are subtle and might be recognized only when ECG recording is repeated after changes in the severity of symptoms. ECG interpretation is an essential part of the initial evaluation of patients with symptoms suspected to be related to myocardial ischemia, along with focused history and physical examination. Patients with ST-segment elevation on their electrocardiogram and symptoms compatible with acute myocardial ischemia/infarction should be referred for emergent reperfusion therapy. However, it should be emphasized that a large number of patients may have ST-elevation without having acute ST-elevation acute coronary syndrome, while acute ongoing transmural ischemia due to an abrupt occlusion of an epicardial coronary artery may occur in patients with ST-elevation less than the thresholds defined by the guidelines. Upsloping ST-segment depression with positive T waves is increasingly recognized as a sign of regional subendocardial ischemia associated with severe obstruction of the left anterior descending coronary artery. Widespread ST-segment depression, often associated with inverted T waves and ST-segment elevation in lead aVR during episodes of chest pain, may represent diffuse subendocardial ischemia caused by severe coronary artery disease. In case of hemodynamic compromise, urgent coronary angiography has been increasingly recommended for these patients.