False Positive Cath Lab Activatin C R T Version


Published on


Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

False Positive Cath Lab Activatin C R T Version

  1. 1. False Positive ST Elevation in Patients Undergoing Direct Percutaneous Coronary Intervention David M. Larson MD, Katie M. Menssen, BS,, Scott W Sharkey MD, James Harris MD, Jeffrey T. Meland, MD Robert Schwartz MD, Barbara T Unger RN, Timothy D. Henry MD, Ridgeview Medical Center, Waconia, Minnesota and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
  2. 2. Introduction <ul><li>Previous data shows that up to 11% of STEMI patients treated with thrombolysis did not have a Myocardial Infarction (MI) </li></ul><ul><li>ACC/AHA guidelines recommend that the Emergency physician make the decision regarding reperfusion therapy for STEMI </li></ul><ul><li>There is limited data reporting the rate of “false positive” ECGs in STEMI patients treated with Percutaneous Coronary Intervention. </li></ul>
  3. 3. Objective <ul><li>To determine the incidence and etiologies of “false positive” ECGs, defined as: no culprit coronary vessel and negative cardiac markers (no MI), from a non-selected cohort of STEMI patients. </li></ul><ul><li>To determine the incidence of “true false positive” ECGs defined as no culprit, no significant coronary disease and negative cardiac markers. </li></ul>
  4. 4. Methods <ul><li>Minneapolis Heart Institute/Abbott Northwestern Hospital (ANW) – a tertiary cardiac center with referral relationships with 30 community hospitals (CH) in Minnesota and Wisconsin – instituted the “MHI Level 1 MI Program” in 2003. </li></ul>
  5. 6. Methods <ul><li>Level 1 MI Protocol: Includes STEMI (ST elevation or new Left Bundle Branch Block) with symptom < 24hrs. Diagnosis and decision to activate the cath lab is made by the Emergency Physician at the presenting hospital. Transferred patients go directly to cath lab for Primary or Facilitated PCI </li></ul><ul><li>Data obtained from a prospective registry of all “Level 1 MI” patients that includes clinical, laboratory, ECG, angiographic and follow up data. </li></ul>
  6. 7. What is the prevalence and etiology of “False Positive” Cath Lab Activation? STEMI Larson, DM et al JAMA 2007;298(23):2754-2760
  7. 8. The Clinical Challenge Denying Reperfusion Falsely Declaring an Emergency Larson, DM et al JAMA 2007;298(23):2754-2760
  8. 9. Definitions of “False Positive” Cardiac Cath Lab Activation <ul><li>No culprit </li></ul><ul><li>No significant coronary disease </li></ul><ul><li>Negative cardiac biomarkers </li></ul>Larson, DM et al JAMA 2007;298(23):2754-2760
  9. 10. Results from the Level 1 MI Program <ul><li>From 3/03 to 11/06, 1,345 STEMI patients enrolled in Level 1 MI program including 1,048 transferred from 30 rural or community hospitals. </li></ul><ul><li>149 (11.2%) had normal cardiac biomarker levels. </li></ul>Larson, DM et al JAMA 2007;298(23):2754-2760
  10. 11. “ False Positive” Cath lab Activations STEMI Diagnosis N=1,345 Angiography N=1,335 5 died prior to angio 5 Case canceled Multiple potential culprits N=10 (0.7%) Clear culprit N=1138 (85.3% No Angiographic Culprit N=187 (14%) Larson, DM et al JAMA 2007
  11. 12. No Significant CAD N = 127 (9.5%) Positive Cardiac Markers N= 48 (38%) Negative Cardiac Markers N = 44 (73%) No Culprit N=187 (14%) Mod-Severe CAD N =60 (4.5%) Positive Cardiac Markers N= 16 (27%) Negative Cardiac Markers N = 79 (62%)
  12. 13. With a culprit Multiple Potential Culprits N=10 Positive Cardiac Markers N= 10 Negative Cardiac Markers N = 26 Clear culprit N=1138 Positive Cardiac Markers N= 1112 Negative Cardiac Markers N = 0 Larson, DM et al JAMA 2007
  13. 14. Positive Cardiac Markers N= 64 (4.8%) Negative Cardiac Markers N = 123 (9.2%) No Angiographic Culprit N=187 (14%) Larson, DM et al JAMA 2007 Early repolarization 25 Non-diagnostic ECG 21 Pericarditis 20 Prior MI 20 LBBB 11 LVH 8 Vasospasm 4 Tachycardia related 3 RBBB 3 Pacemaker 3 Brugada syndrome 1 Aortic dissection 1 Unknown 3 Stress Cardiomyopathy 17 Myocarditis 15 Prior MI 9 STEMI –embolic/spasm 9 LBBB 4 NSTEMI 2 Pulmonary embolus 2 Aortic neoplasm 1 Severe aortic stenosis 1 Drug overdose 1 Unknown 3
  14. 15. No culprit and negative markers by Hospital ED Volume ED visits/year Not significant Larson, DM et al JAMA 2007
  15. 16. Left Bundle Branch Block <ul><li>New or presumed new LBBB observed in 36 (2.6%) of patients </li></ul><ul><ul><li>No culprit: 16 (44%) </li></ul></ul><ul><ul><li>No significant CAD: 10 (27%) </li></ul></ul><ul><ul><li>Negative cardiac biomarkers: 13 (36%) </li></ul></ul><ul><li>30 day mortality in those with new LBBB was 8.3% </li></ul>Larson, DM et al JAMA 2007;298(23):2754-2760
  16. 17. Gender differences <ul><li>381 (28.3%) women enrolled in Level 1 registry </li></ul><ul><ul><li>No culprit: 17.1% women vs 12.7% men (p=0.04) </li></ul></ul><ul><ul><li>No significant CAD: 13.6% women vs 7.9% men (p=0.001) </li></ul></ul><ul><ul><li>Negative biomarkers: 12.3% women vs 10.6% men (p=0.36) </li></ul></ul><ul><li>Stress cardiomyopathy may account for differences </li></ul>Larson, DM et al JAMA 2007;298(23):2754-2760
  17. 18. Summary: Incidence of “False Positive” Cath Lab Activation <ul><li>No culprit: 14% </li></ul><ul><li>Normal or Minimal CAD: 9.5% </li></ul><ul><li>Negative cardiac markers: 11.2% </li></ul><ul><li>Combination of no culprit and negative biomarkers: 9.2% </li></ul>Larson, DM et al JAMA 2007;298(23):2754-2760
  18. 19. Conclusions <ul><li>The incidence of “false positive” ECGs in STEMI patients treated with Primary PCI is similar to previous data in patients treated with thrombolytic therapy. </li></ul><ul><li>Patients presenting with “False Positive” ST elevation are a heterogeneous group, many with other serious cardiac conditions. </li></ul>