Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology

The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services’ (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms

Feasibility and Compliance with Daily Home ECG Monitoring of the QT Interval in Heart Transplant Recipients

Background: Recent evidence suggests that acute allograft rejection after heart transplantation causes an increased QT interval on electrocardiogram (ECG). The aims of this pilot study were to (1) determine whether heart transplant recipients could achieve compliance in transmitting a 30-second ECG every day for 1 month using a simple ECG device and their home telephone, (2) evaluate the ease of device use and acceptability by transplant recipients, and (3) evaluate the quality of transmitted ECG tracings for QT-interval measurement. Methods: A convenience sample of adult heart transplant recipients were recruited and trained to use the device (HeartOne, Aerotel Medical Systems, Holon, Israel). Lead II was used with electrodes that were easy to slip on and off (expandable metal wrist watch-type electrode for right wrist and C-shaped band electrode for left ankle). Patients used a toll-free number with automated voice prompts to guide their ECG transmission to the core laboratory for analysis. Results: Thirty-one subjects (72% were male; mean age of 52 ± 17 years; 37% were nonwhite) achieved an ECG transmission compliance of 73.4% (daily) and 100% (weekly). When asked, how difficult do you think it was to record and transmit your ECG by phone, 90% of subjects replied “somewhat easy” or “extremely easy.” Of the total 644 ECGs that were transmitted by subjects, 569 (89%) were acceptable quality for QT-interval measurement. The mean QTc was 448 ± 44 ms (440 ± 41 ms for male subjects and 471 ± 45 ms for female subjects). Eleven subjects (35%) had an extremity tremor, and 19 subjects (55%) had ≥ 1+ left leg edema. Neither of these conditions interfered with ECG measurements. Conclusion: Transplant recipients are compliant with recording and transmitting daily and weekly ECGs

Remote noninvasive allograft rejection monitoring for heart transplant recipients: study protocol for the novel evaluation with home electrocardiogram and remote transmission (NEW HEART) study

Background: Acute allograft rejection is a major cause of early mortality in the first year after heart transplantation in adults. Although endomyocardial biopsy (EMB) is not a perfect "gold standard" for a correct diagnosis of acute allograft rejection, it is considered the best available test and thus, is the current standard practice. Unfortunately, EMB is an invasive and costly procedure that is not without risk. Recent evidence suggests that acute allograft rejection causes delays in ventricular repolarization and thereby increases the cellular action potential duration resulting in a longer QT interval on the electrocardiogram (ECG). No prospective study to date has investigated whether such increases in the QT interval could provide early detection of acute allograft rejection. Therefore, in the Novel Evaluation With Home Electrocardiogram And Remote Transmission (NEW HEART) study, we plan to investigate the potential benefit of daily home QT interval monitoring to predict acute allograft rejection. Methods/design: The NEW HEART study is a prospective, double-blind, multi-center descriptive research study. A sample of 325 adult heart transplant recipients will be recruited within six weeks of transplant from three sites in the United States. Subjects will receive the HeartView™ ECG recorder and its companion Internet Transmitter, which will transmit the subject's ECG to a Core Laboratory. Subjects will be instructed to record and transmit an ECG recording daily for 6 months. An increase in the QTC interval from the previous day of at least 25 ms that persists for 3 consecutive days will be considered abnormal. The number and grade of acute allograft rejection episodes, as well as all-cause mortality, will be collected for one year following transplant surgery. Discussion: This study will provide "real world" prospective data to determine the sensitivity and specificity of QTC as an early non invasive marker of cellular rejection in transplant recipients during the first post-transplant year. A non-invasive indicator of early allograft rejection in heart transplant recipients has the potential to limit the number and severity of rejection episodes by reducing the time and cost of rejection surveillance and by shortening the time to recognition of rejection. Trial Registration: ClinicalTrials.gov: NCT0136580

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD

Prevalence of and Predictors for QT interval Prolongation and Adverse Outcomes in an Acutely Ill Cohort: The QTIP Study.

QT interval prolongation on the electrocardiogram is a marker of abnormal ventricular repolarization and is associated with Torsades de Pointes, sudden death, and all-cause mortality in outpatient samples. This is the first inpatient study of acutely ill adults performed to determine the: 1) need for QT monitoring as outlined in American Heart Association (AHA) guidelines, 2) prevalence and predictors of QT prolongation, 3) association of QT prolongation with hospital length of stay and all-cause mortality and 4) ability of acute care nurses to perform accurate QT measurement by routine manual methods. Methods: Special study software (Philips Healthcare, Andover, MA) was installed to measure the QT and heart-rate-corrected QT (QTc) interval every minute in all patients admitted to 5 hospital units over a 2-month period. Patient data were abstracted directly from the medical record. Nurses' knowledge and skills were assessed by pre-post tests conducted during QT-related classes repeated 44 times on all nursing shifts. Nurses were taught how to measure the QT interval from a rhythm strip using hand-held calipers and to calculate the QTc using the Bazett formula. Results: Patients. 67,648 hours of QT data were obtained from 1039 patients. 73% of patients had at least 1 AHA indication for QT monitoring. 24% had an episode of dangerous QT interval prolongation > 500 milliseconds lasting 15 minutes or more. In a multivariate logistic regression analysis, predictors of QT prolongation were female sex, number of proarrhythmic drugs, low potassium or calcium, high glucose or creatinine, and history of stroke or hypothyroidism. An episode of QT prolongation was associated with longer length of stay (11.53 v 5.52 days, p <.0005) and greater all-cause mortality (8.7% v 2.6%, Fishers exact p < .0005). Patients with QT prolongation had 3 times the odds for all-cause mortality than those without (OR 2.99; 95% C.I., 1.1 - 8.1). Nurses. 391 participated in the classes (81.5% response rate). Education improved nurses' QT knowledge scores (44% v 77%, p <.0005). Nurses ability to calculate the QTc interval also improved (5.6% v 51.9%, p <.0005). Conclusion. A majority (73%) of acutely ill patients need QT monitoring and a significant proportion (24%) develop dangerous QT prolongation. QT prolongation is associated with longer hospitalization and 3 times the odds for mortality. With education, nurses' ability to perform QT measurement improves; however, an unacceptably high proportion (48%) is still unable to correctly measure the QTc interval. These data suggest that the need for QT monitoring is high and that software added to hospital cardiac monitors may be valuable to identify high risk patients who may warrant closer follow-up

Hyperglycemia Is Associated With Corrected QT Prolongation and Mortality in Acutely Ill Patients

BackgroundThe QT interval on an electrocardiogram represents ventricular repolarization time. Increased length of this interval, known as corrected QT (QTc) prolongation, can be a precursor to torsade de pointes, a potentially life-threatening ventricular dysrhythmia. An association exists between blood glucose and QTc interval in ambulatory populations. Because both hyperglycemia and QTc prolongation are common in critically ill patients, we sought to examine the relationship between blood glucose, QTc interval prolongation, and all-cause mortality in critically ill patients.MethodsWe studied adult patients admitted to cardiac monitoring units. Blood glucose and other clinical variables were abstracted from the medical record. Corrected QT measurements were automatically derived from continuous bedside cardiac monitoring systems.ResultsTwenty-five percent (233/940) of the patients had QTc prolongation, and 53% had elevated blood glucose (>140 mg/dL) during hospitalization. Adjusted odds for QTc prolongation were 2.1 (95% confidence interval, 1.5-3.1) for moderately elevated blood glucose (140-180 mg/dL) and 3.7 (95% confidence interval, 2.5-5.4) for severely elevated blood glucose (>180 mg/dL). Mortality rate was highest (16%) in patients experiencing both severely elevated blood glucose (>180 mg/dL) and QTc interval prolongation.ConclusionsHyperglycemia is linked with QTc prolongation, and both are associated with increased odds of mortality in critically ill patients. Further studies are needed to extrapolate the relationship between glucose and ventricular repolarization, as well as appropriate glucose control parameters and QTc interval monitoring in critical care units