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BACKGROUND: COMPARATIVE ANALYSIS OF MORPHOLOGICAL EKG CHANGES AND DOOR-TO-BALLOON TIME IN STEMI Mercy P. Chandrasekaran, Jeffrey Cook, Raj Marok, Carlos.

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Presentation on theme: "BACKGROUND: COMPARATIVE ANALYSIS OF MORPHOLOGICAL EKG CHANGES AND DOOR-TO-BALLOON TIME IN STEMI Mercy P. Chandrasekaran, Jeffrey Cook, Raj Marok, Carlos."— Presentation transcript:

1 BACKGROUND: COMPARATIVE ANALYSIS OF MORPHOLOGICAL EKG CHANGES AND DOOR-TO-BALLOON TIME IN STEMI Mercy P. Chandrasekaran, Jeffrey Cook, Raj Marok, Carlos Arrieta-Garcia, Kathleen Magurany, Peter Stecy, Lloyd W. Klein Departments of Internal Medicine & Cardiology COMPARATIVE ANALYSIS OF MORPHOLOGICAL EKG CHANGES AND DOOR-TO-BALLOON TIME IN STEMI Mercy P. Chandrasekaran, Jeffrey Cook, Raj Marok, Carlos Arrieta-Garcia, Kathleen Magurany, Peter Stecy, Lloyd W. Klein Departments of Internal Medicine & Cardiology History, clinical presentation, and EKG should be used in combination for earliest possible detection of STEMI (1). Early detection is crucial to decrease mortality in by decreasing door-to-balloon (DTB) time (2). Rapid and accurate EKG diagnosis of MI is a challenge (3) is often reader dependent, especially as changes may be dynamic. Reciprocal ST segment depression, convex morphology, and degree/ number leads elevated, have been reported to assist in the differentiation of non infarction causes of STE from AMI-related STE (4). METHODS: CONCLUSIONS: RESULTS: REFERENCES: >250 STEMI PTS (2004-2005) TRANSFER PATIENTS 209 STEMI PATIENTS (FROM EMR) NOT DIRECTLY TO CATH LAB FROM ED 209 STEMI PATIENTS (FROM EMR) PROCEDURAL SUCCESS EKG CHANGES ED TO CATH TIME EKG CHANGES EARLY DETECTION? Q WAVES STE DEGREE LEADS INVOLVED MORPHOLOGY EARLY DTB TIME? 1. Braunwald E, et al. Unstable angina: diagnosis and management. 2. Rathore S, et al BMJ 2009;338: b1807 3. Brady WJ et al Acad Emerg Med. 2001 Apr;8(4):349-60. Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians. 4. Brady WJ et al Electrocardiographic ST segment elevation: a comparison of AMI and non-AMI ECG syndromes. 5. www.projectupstart.com 6. Zimetbaum PJ, Josephson ME., 935. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003;348:934 7. IC Rokos et al Am Heart J. 2010 Dec;160(6):995-1003, 1003.e1-8 8. ACC/AHA STEMI guidelines 9. Jacobs A, et al. Circulation. 2007;116:217. VARIABLE DTB>90 MIN (A) N=142 DTB<90 MIN (B) N=67 DTB<60 MIN (C) N=12 DEMOGRAPHICS Mean Age (with SD)58 +/-1460+/-14 (p=0.3362)62 +/-8 (p=0.3314) Age >7522 (15.5%)7(10.4%) p=0.32471(8.3%) p=0.5042 Male*111(78.1%)58(86.6%) p=0.149711(91.7%) p=0.2684 Tobacco51 (35.9%)24(35.8%) p=14(33.3%) p=0.8580 Diabetes40 (28.2%)19(28.4%) p=0.97483 (25.0%) p=0.8146 Hypertension98 (69.0%)53(79.1%) p=0.128410(83.8%) p=0.2980 Hyperlipidemia75(52.8%)36(53.7%) p=0.90258(66.7%) p=0.3554 History of CAD40(28.2%)19(28.4%) p=0.97484(33.3%) p=0.7034 History of CABG5(3.5%)3(4.5%) p=0.73681(8.3%) p=0.4082 History of PCI30(21.1%)13(19.4%) p=0.77332(16.7%) p=0.7143 BMI27.9+/-5.429.5+/-7.5 (p=0.0806)32.4+/-10.1(p=0.0117) Earlier DTB were achieved in patient with EKG’s presenting with: 1. reciprocal changes 2. inferior/posterior MI 3. greater degrees of ST elevation and distribution This indicates that some EKG morphologies increase early recognition of STEMI. On the other hand, Anterior MI was not as quickly recognized. These findings raise the questions: 1. What is the value of EKGs in early detection of STEMI ? 2. How much do physician deficiencies in interpretation compromise early detection of STEMI? 3. What steps can be taken to improve interpretation? UNIVARIATE ODDS for DTB<90 Q-waves51/67 vs 109/142 OR 0.97 (0.49-1.91) p=ns Anterior20/67 vs 65/142 OR 0.50 (0.27-0.94) p=0.03 Inferior45/67 vs 64/142 OR 2.49 (1.36-4.58) p=0.0032 Lateral2/67 vs 7/142 OR 0.59 (0.12-2.94) p=ns Max STE>/=3mm33/67 vs 49/142 OR 1.84 (1.02-3.32) p=0.042 Reciprocal depression48/67 vs 62/142 OR 3.2 (1.74-6.19) p=0.0002 Convex39/67 vs 80/142 OR 1.1 (0.60-1.94) p=ns Concave26/67 vs 54/142 OR 1.03 (0.57-1.88) p=ns Other leads elevated20/67 vs 36/142 OR 1.25 (0.66-2.39) p=ns RESULTS: MULTIVARIATE ODDS RATIO P VALUEHR RECIPROCAL CHANGES 0.0013.504 CI (1.760 6.977) INFERIOR WALL VS. ANTERIOR WALL 0.0012.462 CI (1.665 -3.642) Presence of reciprocal changes on EKG resulted in earlier mean DTB (110 vs 143 mins, p<.001) as well as earlier mean door-to-cath (DTC) times (66 vs 104 mins, p=.0001). The involvement of >1 ischemic distribution resulted in earlier DTB (82 vs 106 mins, p= 0.046) and DTC (71 vs 88 mins, p=0.0001). Pts presenting with inferior/posterior MI compared with other distribution had earlier DTC (77 vs 87 mins, p=0.0001). Pts with DTB 90, 3.0 +/- 1.5 vs 2.4 +/- 1.4, (p<0.01). Pts with DTB 90, (67.2% vs 45.1%, p=.01), and reciprocal depression (71.6% vs 43.7%, p<.01). When adjusted for other variables, reciprocal depression remained a strong predictor of DTB<90, HR 3.4 (1.76-6.98, p=.001) [SEE MULTIVARIATE TABLE] OTHER VARIABLES Weekend presentation 42(29.6%)13(19.4%) p=0.11902(16.6%) p=0.3417 Off hours presentation* 71(50.0%)14(20.9%) p=0.000063(25.0%) p=0.0960 Mean DTB time*151.1+/-66.970.9+/-14.2 (p=0.0001)48.9+/-8.1 (p=0.0001) ASA30(21.1%)21(31.3%) p=0.1085 5(41.7%) p=0.1030 B-BL32 (22.5%)19(28.4%) p=0.36035(41.7%) p=0.1363 Statin35(24.6%)16(23.9%) p=0.90255(41.7%) p=0.1967 Plavix10(7.0%)6(8.9%) p=0.62712(16.6%) p=0.2324 ACEI32(22.5%)14(20.9%) p=0.78993(25.0%) p=0.8454 EKG CHANGES Anterior MI (By EKG)65(45.8%)20(29.9%) p=0.02873, OR=1.98 2(16.7%) p=0.0508, OR=4.22 Lateral MI7(4.9%)2(3.0%) p=0.5179, OR=1.68 0 p=0.4310, OR=0lk; Inf/ Post MI*64(45.1%)45(67.2%) p=0.0028, OR=0.40 10(83.3%) p=0.0108, OR=0.16 LBBB pattern6(4.2%)0 p=0.0878, OR=00 p=0.4674, OR=0 Reciprocal ST Depression* 62(43.7%)48(71.6%) p=0.00016, OR=0.31 10(83.3%) p=0.0082, OR=0.16 Q-waves on 1 st EKG109(76.8%)51(76.1%) p=0.9203, OR=1.04 10(83.3%) p=0.6020, OR=0.66 Has other leads elevated 36 (25.4%)20(29.9%) p=0.4930, OR=0.80 5(41.7%) p=0.2194, OR=0.48 Mean number leads elevated (with SD) 3.7+/-1.53.8+/-1.4 (p=0.6465)4.3+/-1.4 (p=0.1833) Max STE mean w/Std2.4+/-1.43.0+/-1.5 (p=0.0052)2.6+/-1.3 (p=0.6336) ST Elevations Concave 54(38.0%)26(38.8%) p=0.9128, OR=0.97 5(41.7%) p=0.8034, OR=0.86 Graph 1: DTB Time and Mortality Rathore S S et al. BMJ 2009;338:bmj.b1807 Graph 2: Inferior MI and Reciprocal Depression by DTB Group Key: Green bars indicate inferior MI, blue dots indicate reciprocal depression and *Asterisk indicates statistical significance when compared with group DTB>90

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