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47 year old male: Holiday Indigestion – Conclusion

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This is the conclusion to 47 year old male: Holiday Indigestion. Thanks go to a long time reader Nicholas Eisele for this holiday case! Editor's Note: sorry for the delay, it helps to press "publish"!

When we left off, our patient was in the back of the truck with a burning sensation radiating to his back. We had run a 12-Lead ECG and our partner was wondering which facility you wanted him to drive to.

To answer that question, we should look at the 12-lead!

Frightful Weather We're Having - 3rd 12-Lead

This 12-Lead shows a normal sinus rhythm at 70 bpm without ectopy or bundle branch block. A case could be made for incomplete right bundle branch block given a QRSd of ~110ms. Strikingly we have ST-depression in I, aVL, and V1-V5 with ST-elevation in lead III. Anytime you see flat or downsloping ST-depression in aVL you should look for elevation in the inferior leads (typically III). When present, it is almost certainly an inferior wall MI.

Frightful Weather We're Having - 3rd 12-Lead - III and aVL Closeup

Many readers commented that the ST-depression in V1-V5 could be either a sign of a posterior wall MI or a "anterior ischemia". It is important to remember that ST-depression from ischemia does not localize! This concept is so important, I'm going to list it again:

ST-depression from ischemia does not localize.

Traditional evaluation of ST-depression has taught that focal ischemia may cause localized ST-depression, however, this is not the case. Subendocardial ischemia causes diffuse ST-depression and will not be found in a localized pattern. Any time you have localized ST-depression you must consider it to be a reciprocal change first!

In our case, we have ST-elevation in lead III which clinches the diagnosis of an inferior wall myocardial infarction with possible posterior extension. A subsequent ECG revealed evolving ST-elevation in the inferior leads:

Frightful Weather We're Having - 4th 12-Lead

Remember, all patients who receive one 12-Lead should at least receive a second 12-Lead! If you were not comfortable activating a STEMI from the first clean tracing, serial 12-Leads provide improved diagnostic sensitivity. A single 12-Lead may only identify ~80% of STEMI patients.

The paramedics in this case recognized this fact, activated a STEMI alert, and transported the patient to their nearest PCI center. The in-hospital ECG showed continued evolution of the IWMI with the most impressive elevation and depression of the patient's clinical course:

Frightful Weather We're Having - In-Hospital 12-Lead

They achieved an impressive 83 minute first medical contact to balloon time with one stent placed in the RCA.

Frightful Weather We're Having - Cath Pictures

We hope you've enjoyed this case as much as we did, but more importantly this case presents some great teaching points:

  • Sometimes STEMI patients will have atypical symptoms.
  • A single ECG is not enough to detect all STEMI patients, serial 12-Lead ECG's should be acquired on all patients who receive one.
  • ST-depression from ischemia does not localize, localized ST-depression should be considered a reciprocal change until proven otherwise.

Appropriate Cardiac Cath Lab Activation: Optimizing ECG interpretation and clinical decision making for acute STEMI

2 comments

An important and useful article has been published that deserves our attention.

Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW (December 2010). “Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction“. Am Heart J 160 (6): 995–1003.e8

Here are some comments from the lead author Ivan Rokos, MD that I received in an email.

You may recall that I published an article with Dr. Rokos entitled “The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance.”

Here’s what Dr. Rokos had to say in his email:

“A big issue for STEMI receiving centers is false positives or inappropriate Cath Lab activations and my goal is to prevent this from becoming the Achilles heel of STEMI systems. Thus we propose a benchmark of less than 5% rate of inappropriate Cath Lab activations in a STEMI system.

Other key points from our recent AHJ paper:

  • Perhaps of primary interest is our group’s efforts to provide a terminology outline that is comprehensive and precise….”classic” STEMI, STEMI-equivalents, STE-mimics, and semi-STEMI
  • Table 1 compares 2004 ACC/AHA guideline recommendations with our group’s proposed updates (note: topic not updated in 2007 or 2009 GL).
  • We have also raised concern regarding “new LBBB” as a Class I-A recommendation….and this manuscript provides the supporting rationale in detail.
  • Isolated Posterior MI is also reviewed….and highlights huge opportunities from improved diagnostic sensitivity.
  • We also describe some esoteric but real conditions….De Winter ST/T waves and STE in lead AVR for acute Left Main occlusion
  • We attempted to provide a strong supporting rationale to bridge STEMI and out-of-hospital cardiac arrest (OHCA) systems and regional networks.
  • Beyond the ECG, clinical decision making is emphasized for “appropriateness” before Cath lab activation.
  • Lastly, SPEED has been a key focus of STEMI systems and much has been accomplished regarding D2B and E2B times. However, I believe the next big challenge is EFFICIENCY and optimizing resource utilization, and that is a primary focus of our AHJ manuscript.”

Peter Canning is the Man! (was: Paramedics Get Special Cardiac Training)

6 comments

Here’s a great story from WSFB-TV Channel 3 Eyewitness News (Hartford-New Haven) featuring our very own Peter Canning from the Street Watch: Notes of a Paramedic blog!

Watch as Peter calls in a “definite STEMI Alert” and activates the cath lab!

Click HERE for the best quality video without commercials.

Screen shots below.






Review of Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary Intervention

12 comments

I found an interesting article while surfing the internet this morning.

Yamamoto Swan, Pamela BA, Nighswonger, Beverly RN, Boswell, Gregory L RN, & Stratton, Samuel J. MD, MPH. (2009). Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary Intervention. Western Journal of Emergency Medicine, 10(4),

This is a retrospective analysis of 12-lead cases from Orange County California Emergency Medical Services between February 2006 and June 2007.

For those of you who are not aware, in Southern California they use computerized interpretive algorithms to diagnose STEMI in the field. They’ve taken a lot of flack about this from the EMS intelligentsia who interpret it (wrongly) as evidence that fire-based EMS is somehow inferior.

The truth is far more complicated than that.

In the system studied they used three different types of 12-lead monitors.

There were 548 patients who were triaged from the field for primary PCI at a STEMI Receiving Center.

19 cases were excluded from the study for various reasons.

393 patients (74.3%) had PCI with significant coronary lesions found.

The remaining 136 (25.7%) were considered false positives, which included 121 patients (22.9%) who were determined by the ED physician to have no need for PCI, and 15 patients (2.8%) with no culprit artery.

False positive cases were associated with the following variables:

  • A specific brand of one of three monitors used in the system
  • Sinus tachycardia
  • Missing lead recording on 12-lead printout
  • Atrial fibrillation
  • Female gender
  • Poor ECG baseline

A discussion ensues during which the authors make this important statement:

“Poor ECG baseline and failure to record all 12 leads for machine algorithm interpretation are false-positive associated variables that can be addressed by improved quality in field acquisition of 12-leads.”

It can’t be said often enough! That’s why I’m always harping on achieving excellent data quality!

The authors continue:

“Variables more difficult to address are sinus tachycardia and atrial fibrillation, which had a tendency to be wrongly interpreted by machine algorithm as acute MI.”

It would be interesting to know if they are including atrial flutter in with atrial fibrillation. Either way the message is clear. The specificity of the computerized interpretive algorithms is highest when a tachycardia is not present.

Then the authors make this interesting statement:

“An unexpected finding was the association of one type of 12-lead machine with false-positive triage. Once this was re-validated by repeat data analysis, we advised the device manufacturer of the findings. Adjustments and changes to the algorithm for the device have been made and follow-up study is in progress. The type of monitor associated with false-positive 12-leads is not identified in this paper because the oversight Institutional Review Committee for the study requires that a written release from the manufacturer be obtained and such a release was declined.”

A few points here.

First, why in the world would the Institutional Review Committee for the study require a written release from the manufacturer? Research is research and outcomes are outcomes. It’s difficult to escape the conclusion that the IRC was afraid of getting sued.

Second, shame on the device manufacturer for not giving permission for the results to be published. They should just be happy that valuable feedback was given back to the company by the researchers so they can make improvements to their algorithm.

Third, it doesn’t take a rocket scientist to figure out which manufacturer’s 12-lead monitor was associated with a higher rate of false positives!

Let’s think about it. Two of the three use the GE-Marquette 12SL interpretive algorithm (ZOLL and Physio-Control). One of the three uses their own algorithm. Does it really take a college level Introduction to Logic class to connect the dots?

The authors of course admit to some limitations, including this one which I found interesting:

“A more subtle limitation is that our definition of false-positive triage does not take into account patients who were determined by the receiving physicians to lack evidence for an acute STEMI MI, when in fact such an MI was present and PCI could have been a benefit.”

To be honest, I was just amazed that so many activations were canceled by the ED physicians! They acted as gatekeepers, which is extremely important considering the high number of false positive activations triggered by the paramedics in the system.

The fact that only 2.8% of patients who were cathed had no culprit artery is extremely impressive to me. I’m not even convinced that a canceled STEMI Alert (or whatever they call it in Southern California) should be called a “false positive”.

They also state:

“While left bundle branch block was analyzed within the study population 12-leads, there was not an association of this finding with false-positive triage; on the other hand the study was limited in that we did not test for false-positive association with left ventricular hypertrophy, pericarditis, left ventricular aneurysm, and early repolarization.”

This is in startling contrast to the study by Larson et al. that showed almost half of patients with LBBB had no culprit artery! Who knows, maybe the ED physicians in Southern California use Sgarbossa’s Criteria. On the other hand, the authors admit they didn’t study false negatives, so it’s entirely possible they just aren’t cathing the LBBBs the way used to in Minnesota.

I say “used to” because it was Dr. Smith et al. that came up with excessive discordance as a marker of acute STEMI in LBBB.

Overall, a very interesting and worthwhile article. This is exactly the type of research that needs to be happening right now!

False Positive Cardiac Cath Lab Activations

2 comments

Here are some highlights from Larson, Menssen, Sharkey et al “False-Positive” Cardiac Catheterization Laboratory Activation Among Patients With Suspected ST-Segment Elevation Myocardial Infarction, JAMA 2007;298(23):2754-2760.

The false positive rates (suspected STEMI patients with ST-segment elevation but no clear culprit coronary artery, no significant coronary artery disease, and negative cardiac biomarker results) were analyzed at the Minneapolis Heart Institute at Abbott Northwestern Hospital in Minneapolis, Minnesota (a tertiary cardiovascular center with referral relationships with community hospitals throughout Minnesota and western Wisconsin).

First the authors note:

“Time to reperfusion is a major determinant of outcome in patients presenting with an ST-segment elevation myocardial infarction (STEMI). The American College of Cardiology/American Heart Association STEMI guidelines recommend that the emergency department physician make the decision regarding reperfusion therapy within 10 minutes of interpreting the initial diagnostic ECG, which may be challenging because clinical decisions are often made without a previous ECG result for comparison or time to observe evolutionary ST-segment changes or cardiac biomarker results…

Here’s the bombshell:

Of the 1335 patients who underwent angiography, 187 (14%) did not have a clear culprit coronary artery, 10 patients (0.7%) had multiple potential culprit arteries (severe 3-vessel disease and positive cardiac biomarker results), and 1138 (85.3%) had a clear culprit artery. Patients with a culprit artery were treated with percutaneous coronary intervention (94%), coronary artery bypass surgery (4%), or medical management (2%). Retrospective review of the index ECG indicated that 24 atients (1.8%) did not have diagnostic ST-segment elevation but instead had ST-segment depression, T-wave inversion, or nonspecific ST-T changes, including 3 patients with positive biomarker results (2 with non-STEMI and 1 with a drug overdose) and 21 with negative cardiac biomarker results. These patients were included in the no-culprit artery group. The prevalence of false-positive catheterization laboratory activation with the no-culprit coronary artery criteria was 14%…

The authors then pose a difficult question:

“Achieving door-to-balloon times in less than 90 minutes is an important quality metric that is tied to pay for performance and has been the focus of recent quality improvement initiatives such as the American College of Cardiology’s D2B Alliance and the American Heart Association’s Mission: Lifeline. Upstream activation of the cardiac catheterization laboratory by the emergency department physician is one of the key strategies to reducing door-to balloon times. A major challenge for the emergency department physician is the patient who presents with nonspecific symptoms or subtle ST-segment elevation or QRS repolarization abnormalities that obscure or mimic ST segment elevation. In these cases, is it best to immediately activate the catheterization laboratory, considering the consequences of a false alarm, or take the time to obtain additional data, such as from serial ECGs, biomarkers, or an echocardiogram?

One final note that I found interesting:

“Patients with new or presumably new left bundle-branch block had an inordinately high prevalence of false positive catheterization laboratory activation (almost half did not have a culprit artery). Patients with a previous myocardial infarction or previous coronary bypass surgery had a significantly higher prevalence of no culprit artery, likely because of abnormal baseline ECG results.”

It would be interesting to know whether or not the false positive LBBB patients met Sgarbossa’s criteria. The authors don’t say it, but I can’t help but wonder if the patients with previous MI “and abnormal baseline ECG results” had persistent ST segment elevation similar to (what we think of as) left ventricular aneurysm.

See also:

The problem of ST segment elevation

False positive cardiac cath lab activations – PowerPoint