THIS PRESENTATION ADDRESSES THE EFFECTIVENESS OF TWO DIAGNOSTIC TESTS ELECTROCARDIOGRAMS AND BLOOD TESTS AND DISTINGUISHES WHAT TEST IS BETTER IN DIAGNOSING ACUTE MYOCARDIAL INFARCTIONS. BY: NATHAN GRISWOLD PICO Question Addressed: Are (Is) Electrocardiogram’s (ECG’s) more accurate in diagnosing Acute myocardial infarctions (MI’s) compared with blood tests?

RESULTS: ECG’s and Blood test are both used collectively in diagnosing Acute Myocardial Infarctions. The sources used to collect articles and literature are Google, PubMed,, Journal of Cardiovascular and Thoracic Research, and The Journal of the American Medical Association (JAMA). Key words- Myocardial Infarction (MI), Electrocardiograms (ECGs), blood test, cardiac biomarkers and Heart attack. Cardiac biomarkers can be used for screening acute chest pains, also shows cost effectiveness of using cardiac biomarkers, appropriate specificity and sensitivity can guarantee their usefulness in emergency room (Vahdati et ak. 2014). It is mentioned that serial enzyme measurements as one of the three criteria for diagnosis of (MIs), the other two being ECG changes and clinical features such as chest pain Vahdati et el. (2014). According to Hathaway et el. (1998) “The initial ECG of patients who present with myocardial infarction and ST-segment elevation contains valuable prognosis information mostly related to heart rate, ST-segment deviations, QRS duration, and infarct location. This information adds to the known clinical predictors of mortality and should be valuable in early diagnosis, when mortality is greatest.”

Articles Referenced Hathaway WR, Peterson ED, Wagner GS, et al. Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction. JAMA. 1998;279(5): doi: /jama Shams-Vahdati, S., Vand-Rajavpour, Z., Paknezhad, S., Piri, R., Moghaddasi- Ghezeljeh, E., Mirabolfathi, S., et al. (2014, March 21). Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain. National Center for Biotechnology Information. Retrieved October 5, 2014, from po=

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” It shows that statistical data that cardiac biomarkers done in the ED when triaging of patients with acute chest pain by means of rapid testing for CTnI And cTnT, it was concluded that positive or negative bedside tests for Troponins have demonstrated high rate for the detection of acute MI. Discussed that with negative results was associated with low risk and safe discharge of client with an episode of acute chest pain. Immense amount of quantitative and statistical data Provides statistical data that the initial ECG of patients who present with myocardial infarction symptoms and ST-segment elevation contains valuable prognostic information mostly related to heart rate, ST- segment deviations, QRS duration, and infarct location. The statistical data shows that early ECGs test may help in assessing outcomes adjusted for patient risks. Immense amount of quantitative and statistical data that proves this. Rationale

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” Theory: There is not a specific theory with this study. All of the results and finding are based off of statistical data and other quantitative studies. Type of study: Quantitative study it discusses the relevance, usefulness, and cost- effectiveness of biomarker testing in diagnosis a Acute myocardial Infarctions (MI) in patients. Theory: In this research article there is not a specific theory. But the had a objective to see the independent value of the initial ECG for short- term risk stratification during and after acute myocardial infarction. Type of study: Quantitative study discusses and use statistical data using patients that come into the hospital setting that present with chest pain and ST- elevation and use the data gathered to see the effectiveness of the initial ECG in predicting the overall 30 day mortality rate. Theory & Type of Study

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” Design: This study is trying to link the effectiveness of cardiac biomarkers and their usefulness in the emergency department screening acute chest pains, also cost effectiveness of cardiac biomarkers in patients admitted to the ED. Method: It is a descriptive-analytic study conducted on patients who were asked for troponin I and CK- MB. Consisted of patients referred to ED in a specific medical center January 2012 to July the All patient where documented in terms of gender, age, ethnicity, and Chief complaint. Design: Clinical trial: This is the Global Utilization of Streptokinase and t-PA (alteplase) for Occluded Coronary Arteries (GUSTO-I) clinical trial data base. which enrolled patients with acute myocardial infarction from December 1990 to February 1993 from 1081 hospitals in 15 countries. Method: The characteristics are presented in percentages, and continuous measures are summarized with medians an interquartile ranges. The relation of each factor to 30-day mortality was tested with the log-likelihood ratio χ2 test. In relating the factor of the initial ECG factors an to ECGs factors to 30 day mortality. Design & Methods of Studies

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain.” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction.” Findings: “Shows that sensitivity of cardiac biomarkers’ test in diagnosing Acute Coronary Syndrome (ACS) disease was calculated as 44.8% and its specificity was 86.6%. For diagnosing Acute Myocardial Infarction (AMI), sensitivity of cardiac biomarkers’ test was 72.2% and its specificity was 86% Vadhdati et al (2014)”. Researchers concluded: that cardiac biomarkers can be helpful in screening acute chest pains. Also, has a decrease in cost the use of cardiac biomarkers. Has a High success rate in for diagnosis of a (AMI). Findings: Most ECG variables in the study were associated with 30-day mortality in a univariable analysis. In a multivariable analysis merging the initial ECG variables and clinical predictors of mortality an found a significance of the initial ECGs for assessing (AMIs). Researchers concluded: “The initial ECG of patients who present with myocardial infarction and ST- segment elevation contains valuable prognostic information mostly related to heart rate, ST-segment deviations, QRS duration, and infarct location Hathaway et al. (1998)”. Research findings

Research Findings of Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” “The findings show that Compared with those excluded from analysis, the sub-study population had a slightly higher proportion of patients who had anterior infarctions. Most patients were male and white, and 16% had experienced a prior infarction. Patients who were excluded from the ECG sub- study had a 21% higher mortality rate at 30 days than those included in the sub- study (8.2% vs 6.8%) Vahdati et al (2014).

Research Gathered Data: Research Findings of Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” This table shows. “In a multivariable analysis of the ECG variables faster heart rate, longer QRS duration, ECG evidence of prior infarction, and sum of the absolute ST-segment deviation were most highly associated with 30-day mortality Hathaway et al (1998).

Research Gathered Data: Research Findings of Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction” This table that the significant initial ECG and clinical predictors of mortality, the sum ECG abnormalities and the evidence of prior infarction remained the strongest of the ECG predictors. Confirming that ECGs are good in diagnosing acute (MIs).

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain.” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction.” In this particular article the study protocol was approved by the Ethics Committee of TUMS, which was in compliance with Helsinki Declaration. This study took into context all data gathered form the (ED). Not just using certain people but people of all gender, age, and ethnicity. This article does not discriminate results. Also fully discloses all tests and gets their consent to be in the study. Ethical Considerations

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain.” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction.” The topic and subject matter of this article are relevant to topic of study in assessing of cardiac biomarkers are good in screening for acute myocardial infarctions. The finding are stated without bias opinions. The gathered data is very precise. The data gather is very accurate and provided the data to show the trends that prove their point clearly. The data is organized proving that the cardiac biomarkers are effective in diagnosing acute myocardial infarctions. The topic and subject matter of this article is relevant to their topic of study in finding that the initial ECG admitted to the (ED) is able to asses all cause of mortality at 30 day post (MI). The gathered data is very precise and organized by using table and graphs in showing the trends of ECGs being a predictor of 30-day mortality. The article is also, accurate in all findings and has strong subject matter. Article Strength

Article 1: “Cost-Effectiveness of Cardiac Biomarkers as Screening Test in Acute Chest Pain.” Article 2: “Prognostic Significance of the Initial Electrocardiogram in Patients With Acute Myocardial Infarction.” This article is published by Journal of Cardiovascular and Thoracic Research. It is a peer-reviewed international open-access journal on cardiovascular Science. The research in this article was use in other peer-reviewed articles. Author has accredited affiliations. With universities, hospitals, and committees. Has high level of research and is accurate in in stating only facts form their study conducted. Was published by the The of the Journal American Medical Association. Which is consortium of peer-reviewed print and online medical publications. Article is used in other peer-reviewed articles. Authors have accredited affiliation in this case the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. In forming research for them. The article has high level of research and is accurate and provided adequately in proving their point. Article Quality

Articles Creditability. Both of the Articles are scholarly journals and peer- reviewed. In both articles both authors had affiliations with a significant University, hospital, and/or, committees. Both articles are directed toward a scholarly personnel. Both are relevant on their specific topics. The articles also list references of other scholarly article used in their article. It also lists their credentials of the authors. Both pieces fall under EBP meeting the specific criteria Both articles are based upon research, and other research studies and both articles use quantitative research.

Articles Relevance to Clinical Practice The findings of these articles studies would be use for education for emergency department health care workers. It would be use to educate them on the success of the patients outcomes in implementing both cardiac biomarker tests and Electrocardiograms to get a rapid and correct diagnosis of a acute myocardial Infarctions. There really is no change in practice when it come to plan of care for a MI because when patients come into the (ED) with chest pain health care personnel administer a ECG and get blood test as a part of protocol. But for a long time bloods test took longer to produce but know we can produce them sooner and we know what to look for on the test to even make a more rapid diagnosis. So we can educate healthcare personnel that work in the (ED) about what bio markers to look for to confirm a acute (MI) with the (ECG) results also. Potential barriers for these studies is health care workers lack of knowledge and education on the topic, Hospitals policy, Health professionals such as Doctors, PA’s, NP’s, RN’s & etc. way of thinking on what works best when diagnosing (MI). An additional PICO question that could de derived form these studies could be: In a emergency situation, What diagnostics test are the best for getting a rapid diagnosis of an Acute myocardial Infarction.

Conclusion Each article focused on a different diagnostic test for diagnosis an Acute myocardial Infarction. But both articles proved and showed how Electrocardiograms and Cardiac Biomarker test are crucial in getting a rapid result in a emergent situation if a patient is have a acute myocardial infarction. By having this statistical data show that both electrocardiograms and specific cardiac markers in blood test have a major significant in diagnosing acute myocardial infarctions. We can now educate more emergency care professionals on the significance of the specific cardiac markers combine with the electrocardiograms to get a rapids diagnosis of a patient having a (AMI). Also having rapid not only decrease the risk of mortality in patients but also patients have less incorrect diagnosis's of (AMIs), shorter hospital stays, and saves the hospitals money. There is valid statistical scientific evidence that confirms The effectiveness of Both Electrocardiograms and Specific cardiac Biomarker test for improving the the rapids diagnosis of (AMI) and proper care given to patient.