Physician Accuracy in Interpreting Potential ST‐Segment Elevation Myocardial Infarction Electrocardiograms

Background: With adoption of telemedicine, physicians are increasingly asked to diagnose ST‐segment elevation myocardial infarctions (STEMIs) based on electrocardiograms (ECGs) with minimal associated clinical information. We sought to determine physicians' diagnostic agreement and accuracy when interpreting potential STEMI ECGs. Methods and Results: A cross‐sectional survey was performed consisting of 36 deidentified ECGs that had previously resulted in putative STEMI diagnoses. Emergency physicians, cardiologists, and interventional cardiologists participated in the survey. For each ECG, physicians were asked, “based on the ECG above, is there a blocked coronary artery present causing a STEMI?” The reference standard for ascertaining the STEMI diagnosis was subsequent emergent coronary arteriography. Responses were analyzed with generalized estimating equations to account for nested and repeated measures. One hundred twenty‐four physicians interpreted a total of 4392 ECGs. Among all physicians, interreader agreement (kappa) for ECG interpretation was 0.33, reflecting poor agreement. The sensitivity to identify “true” STEMIs was 65% (95% CI: 63 to 67) and the specificity was 79% (95% CI: 77 to 81). There was a 6% increase in the odds of accurate ECG interpretation for every 5 years of experience since medical school graduation (OR 1.06, 95% CI: 1.02 to 1.10, P=0.01). After adjusting for experience, there was no significant difference in the odds of accurate interpretation by specialty—Emergency Medicine (reference), General Cardiology (AOR 0.97, 95% CI: 0.79 to 1.2, P=0.80), or Interventional Cardiology physicians (AOR 1.24, 95% CI: 0.93 to 1.7, P=0.15). Conclusions: There is significant physician disagreement in interpreting ECGs with features concerning for STEMI. Such ECGs lack the necessary sensitivity and specificity to act as a suitable “stand‐alone” diagnostic test

Sex‐Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/1/jah32481-sup-0001-TableS1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/2/jah32481.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/3/jah32481_am.pd

Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery

BackgroundAlthough major noncardiac surgery is common, few large-scale studies have examined the incidence and consequences of post-operative atrial fibrillation (POAF) in this population. We sought to define the incidence of POAF and its impact on outcomes after major noncardiac surgery.MethodsUsing administrative data, we retrospectively reviewed the hospital course of adults who underwent major noncardiac surgery at 375 US hospitals over a 1-year period. Clinically significant POAF was defined as atrial fibrillation occurring during hospitalization that necessitated therapy.ResultsOf 370,447 patients, 10,957 (3.0%) developed clinically significant POAF while hospitalized. Of patients with POAF, 7,355 (67%) appeared to have pre-existing atrial fibrillation and 3,602 (33%) had newly diagnosed atrial fibrillation. Black patients had a lower risk of POAF (adjusted odds ratio, 0.53; 95% CI, 0.48-0.59; P < .001). Patients with POAF had higher mortality (adjusted odds ratio, 1.72; 95% CI, 1.59-1.86; P < .001), markedly longer length of stay (adjusted relative difference, +24.0%; 95% CI, +21.5% to +26.5%; P < .001), and higher costs (adjusted difference, +$4,177; 95$3,764 to +$4,590; P < .001). These findings did not differ by whether POAF was a recurrence of pre-existing atrial fibrillation, or a new diagnosis.ConclusionPOAF following noncardiac surgery is not uncommon and is associated with increased mortality and cost. Our study identifies risk factors for POAF, which appear to include race. Strategies are needed to not only prevent new POAF, but also improve management of patients with pre-existing atrial fibrillation

Perioperative atrial fibrillation and the long-term risk of ischemic stroke

IMPORTANCE: Clinically apparent atrial fibrillation increases the risk of ischemic stroke. In contrast, perioperative atrial fibrillation may be viewed as a transient response to physiological stress, and the long-term risk of stroke after perioperative atrial fibrillation is unclear. OBJECTIVE: To examine the association between perioperative atrial fibrillation and the long-term risk of stroke. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using administrative claims data on patients hospitalized for surgery (as defined by surgical diagnosis related group codes), and discharged alive and free of documented cerebrovascular disease or preexisting atrial fibrillation from nonfederal California acute care hospitals between 2007 and 2011. Patients undergoing cardiac vs other types of surgery were analyzed separately. MAIN OUTCOMES AND MEASURES: Previously validated diagnosis codeswere used to identify ischemic strokes after discharge from the index hospitalization for surgery. The primary predictor variable was atrial fibrillation newly diagnosed during the index hospitalization, as defined by previously validated present-on-admission codes. Patients were censored at postdischarge emergency department encounters or hospitalizations with a recorded diagnosis of atrial fibrillation. RESULTS: Of 1 729 360 eligible patients, 24 711 (1.43%; 95%CI, 1.41%-1.45%) had new-onset perioperative atrial fibrillation during the index hospitalization and 13 952 (0.81%; 95%CI, 0.79%-0.82%) experienced a stroke after discharge. In a Cox proportional hazards analysis accounting for potential confounders, perioperative atrial fibrillation was associated with subsequent stroke both after noncardiac and cardiac surgery. (Table Presented) The association with stroke was significantly stronger for perioperative atrial fibrillation after noncardiac vs cardiac surgery (P < .001 for interaction). CONCLUSIONS AND RELEVANCE: Among patients hospitalized for surgery, perioperative atrial fibrillation was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery. Copyright 2014 American Medical Association. All rights reserved