Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina

Bugiardini, Raffaele; Borghi, Alberico; Pozzati, Andrea; Ruggeri, Augusto; Puddu, Paolo; Maseri, Attilio

doi:10.1016/0735-1097(94)00439-w

Cited by 54 publications

(11 citation statements)

References 17 publications

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“…ST-segment monitoring stud-ies of patients hospitalized with unstable angina show that although 80% to 90% of transient ischemic events are asymptomatic, they are nonetheless significant markers for unfavorable short-and long-term outcomes (Table 2). [63][64][65][66][67][68][69][70] Patients Who Present to the ED With Chest Pain or Anginal Equivalent Symptoms It is not uncommon for patients with acute ST-elevation MI to have an initial ECG that is nondiagnostic for acute ischemia. Investigators who use continuous monitoring have shown that the ST segment often is dynamic in the early hours of acute MI.…”

Section: Patients In the Early Phase Of Acute Coronary Syndromes (St-mentioning

confidence: 99%

Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation

Drew

Funk

2006

Critical Care Nursing Clinics of North America

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Abstract-The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide 'best practices' for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, timeframes, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided. Key Words: AHA Scientific Statements Ⅲ pediatrics Ⅲ electrocardiography Ⅲ torsade de pointes Ⅲ myocardial infarction Ⅲ tachyarrhythmias Ⅲ ischemia Ⅲ antiarrhythmic agents Ⅲ long-QT syndrome S ince the introduction of electrocardiographic (ECG) monitoring in hospital units Ͼ40 years ago, 1 the goals of monitoring have expanded from simple tracking of heart rate and basic rhythm to the diagnosis of complex arrhythmias, the detection of myocardial ischemia, and the identification of a prolonged QT interval. During the same 4 decades, major improvements have occurred in cardiac monitoring systems, including computerized arrhythmia detection algorithms, STsegment/ischemia monitoring software, improved noisereduction strategies, multilead monitoring, and reduced lead sets for monitoring-derived 12-lead ECGs with a minimal number of electrodes. 2,3 Despite these advances in technology, the need for human oversight in the interpretation of ECG monitoring data is as important today as it was 40 years ago for the following reasons. First, cardiac monitor algorithms are intentionally set for high sensitivity at the expense of specificity. As a result, numerous false alarms occur that must be evaluated by healthcare professionals so that overtreatment of patients will not occur. Examples of overtreatment are reported in the The American Heart Association makes every effort to avoid any actual or potential co...

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Section: Patients In the Early Phase Of Acute Coronary Syndromes (St-mentioning

confidence: 99%

Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation

Drew

Funk

2006

Critical Care Nursing Clinics of North America

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“…Indeed, continuous ST monitoring analyzes changing patterns of ST recovery and reelevation, which are associated with cyclic flow changes, 18,19 thus allowing a precise estimation of the total ischemic burden of patients with acute coronary syndromes. 22 There is now considerable evidence from multiple Holter studies in several thousand patients that ischemia-related signals detected by ECG monitoring are linked with major cardiovascular events during follow-up, 11,12,22 even in clinically stable patients. 23,24 …”

Section: The Role Of St Monitoringmentioning

confidence: 99%

“…17 Such an approach, however, is questionable, as some low-risk patients with a cardiac origin of their chest pain have a dynamic activity of the ST segment, 18,19 with most episodes of myocardial ischemia occurring in the absence of symptoms. 11,12 Therefore, standard 60 electrocardiography may miss ST changes when they are not associated with symptoms suggesting a cardiac origin. As a consequence, the optimal sampling interval for ECG tracings is unclear, as is the diagnostic and prognostic contribution of using single-lead or two-or three-lead ECG monitoring.…”

Section: Commonly Used Diagnostic Toolsmentioning

confidence: 99%

“…11 The presence of symptoms correlates infrequently with the presence of ischemia, and anginal score has low specificity and sensitivity in patients with chest pain presenting at an emergency department. 12 Current guidelines suggest the use of ECG monitoring in patients with acute ischemic syndromes, but not in patients with chest pain classified at low risk. 10 The implications of these findings, however, remain unclear.…”

Section: Introductionmentioning

confidence: 99%

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Continuous 12‐lead st‐segment monitoring improves identification of low‐risk patients with chest pain and a worse in‐hospital outcome

Pelliccia

Cianfrocca

Marazzi³

et al. 2002

Clinical Cardiology

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Background: Various strategies have been proposed to improve diagnosis and triage of patients with chest pain at low risk, but uncertainty still exists on the optimal combination of diagnostic tools that should be used in this subset of patients. Hypothesis: The aim of this study was to evaluate the incremental benefit of continuous 12‐lead ST‐segment monitoring over that provided by conventional diagnostic tools in patients with chest pain. Methods: Of 232 consecutive patients referred because of chest pain, 52 were classified as low‐risk according to the Agency for Health Care Policy and Research unstable angina guidelines and observed for 12 h with serial cardiac enzymes and electrocardiograms (ECG) (every 3 h). All patients also underwent both echocardiography at entry and continuous 12‐lead ST‐segment monitoring during the observation period. Results: During a mean hospital stay of 3.7 days (range 1‐14 days), a benign outcome was observed in 37 patients (71%), whereas 15 patients (29%) had major cardiac events or recurrence of chest pain of ischemic origin. Addition of ST‐segment monitoring findings to baseline clinical data as well as to serial enzymes and ECG features added significant incremental prognostic value (p < 0.001). Multivariate analysis showed reproduction of pain by chest pressure (p < 0.05) and presence of ST‐segment changes (≥ 0.1 mV) during 12‐lead ST‐segment monitoring (p < 0.001) as independent predictors of a benign or unfavorable outcome. Conclusions: In low‐risk patients with chest pain, continuous 12‐lead ST‐segment monitoring provides significant incremental diagnostic and prognostic information to currently used clinical, enzymatic, and ECG data, and is helpful in identifying the subset of patients with a worse in‐hospital outcome.

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“…[9][10][11][12] Importantly, many studies have found that patients with ECG-detected ischemia, as compared to patients without such events, were at higher risk for unfavorable outcomes in both the short term [11][12][13] and long term. [14][15][16] Hence, symptoms are an unreliable indicator of ischemia in NSTEMI/UA, which is problematic since treatment decisions for an early invasive strategy or initial medication strategy are often driven by patient symptoms. [2][3][4][5] Further, biomarkers identify NSTEMI/UA patients too late because their presence in the serum indicates that cellular death has already occurred.…”

mentioning

confidence: 99%

A Research Method For Detecting Transient Myocardial Ischemia In Patients With Suspected Acute Coronary Syndrome Using Continuous ST-segment Analysis

Pelter

Kozik

Loranger

et al. 2012

JoVE

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Each year, an estimated 785,000 Americans will have a new coronary attack, or acute coronary syndrome (ACS). The pathophysiology of ACS involves rupture of an atherosclerotic plaque; hence, treatment is aimed at plaque stabilization in order to prevent cellular death. However, there is considerable debate among clinicians, about which treatment pathway is best: early invasive using percutaneous coronary intervention (PCI/ stent) when indicated or a conservative approach (i.e., medication only with PCI/stent if recurrent symptoms occur).There are three types of ACS: ST elevation myocardial infarction (STEMI), non-ST elevation MI (NSTEMI), and unstable angina (UA). Among the three types, NSTEMI/UA is nearly four times as common as STEMI. Treatment decisions for NSTEMI/UA are based largely on symptoms and resting or exercise electrocardiograms (ECG). However, because of the dynamic and unpredictable nature of the atherosclerotic plaque, these methods often under detect myocardial ischemia because symptoms are unreliable, and/or continuous ECG monitoring was not utilized.Continuous 12-lead ECG monitoring, which is both inexpensive and non-invasive, can identify transient episodes of myocardial ischemia, a precursor to MI, even when asymptomatic. However, continuous 12-lead ECG monitoring is not usual hospital practice; rather, only two leads are typically monitored. Information obtained with 12-lead ECG monitoring might provide useful information for deciding the best ACS treatment.Purpose. Therefore, using 12-lead ECG monitoring, the COMPARE Study (electroCardiographic evaluatiOn of ischeMia comParing invAsive to phaRmacological trEatment) was designed to assess the frequency and clinical consequences of transient myocardial ischemia, in patients with NSTEMI/UA treated with either early invasive PCI/stent or those managed conservatively (medications or PCI/stent following recurrent symptoms). The purpose of this manuscript is to describe the methodology used in the COMPARE Study.Method. Permission to proceed with this study was obtained from the Institutional Review Board of the hospital and the university. Research nurses identify hospitalized patients from the emergency department and telemetry unit with suspected ACS. Once consented, a 12-lead ECG Holter monitor is applied, and remains in place during the patient's entire hospital stay. Patients are also maintained on the routine bedside ECG monitoring system per hospital protocol. Off-line ECG analysis is done using sophisticated software and careful human oversight.

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Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina

Abstract: Transient myocardial ischemia detected by Holter monitoring, but not chest pain, is the best predictor of unfavorable short-term clinical outcome. The decision to perform early angiography and revascularization cannot be based on symptoms alone.

Cited by 54 publications

References 17 publications

Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation

Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation

Continuous 12‐lead st‐segment monitoring improves identification of low‐risk patients with chest pain and a worse in‐hospital outcome

A Research Method For Detecting Transient Myocardial Ischemia In Patients With Suspected Acute Coronary Syndrome Using Continuous ST-segment Analysis

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