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TELEMEDICINE AND TELEELECTROCARDIOGRAPHYIN CHILE EDGARDO ESCOBAR  MD, FACC, FAHA PROFESSOR OF MEDICINE MEDICAL DIRECTOR IT...
 
 
 
 
 
 
Chilean  Demography <ul><li>POPULATION:  17.000.000 </li></ul><ul><li>NUMBER OF PHYSICIANS:   </li></ul><ul><li>1/559 </li...
TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>55% OF POPULATION HAS A HIGH OR VERY HIGH RISK OF ATHEROSCLEROTIC CARDIOVASCULAR ...
TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>NOT ENOUGH NUMBER OF SPECIALISTS </li></ul><ul><li>NOT ENOUGH MEANS OF TRANSPORTA...
TRILOGY OF TELEMEDICINE SERVICE <ul><ul><ul><ul><ul><li>1. PHYSICIANS </li></ul></ul></ul></ul></ul><ul><ul><li>2.- TELECO...
TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>EQUIPMENTS ARE DISTRIBUTED: </li></ul><ul><li>IN 493 PLACES (381 DEPENDING OF TH...
 
HOW DOES Tele-EKG WORK ? EKG REGISTERED AND SENT  TELEPHONE CALL CENTER RECEIVES EKG,  PARAMEDIC GIVES THE APPROVAL  AND C...
TELE-ELECTROCARDIOGRAPHY IN CHILE
TELE-EKG
 
TELEELECTROCARDIOPRAHY IN CHILE <ul><li>THE REPORT IS MADE ACCORDING TO THE EKG GUIDE USED BY  THE AMERICAN BOARD OF INTER...
TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>ALL EKG DIAGNOSIS ARE CODIFIED AND MOVED TO THE FINAL REPORT JUST MAKING A CLICK...
 
Comparison of some leads between traditional EKG and TeleEKG
 
ECG Hospital del Salvador
 
ALTMAN BLAND METHOD: Comparison of V4  amplitude in traditional EKG and TeleEKG
Altman and  Bland: Logaritmic comparison of  V4 amplitude between traditional EKG and Tele EKG
Teleelectrocardiography in Chile <ul><li>1300 to 1600 ECGs are received daily Monday thru Friday and 600 to 800 during the...
 
ABNORMAL TRACINGS
Nuestra Política de Confidencialidad de la Información VIGESIMO PRIMERO: El soporte médico remoto y/o el apoyo al diagnóst...
ASPECTOS DESTACADOS POR LOS USUARIOS DE ITMS <ul><li>Rapidez de Interpretación y del Informe del Especialista (+/- 5 min.)...
TEACHING AND RESEARCH <ul><li>MEETINGS TO DISCUSS DIFFICULT TRACINGS OR INTERESTING ONES </li></ul><ul><li>STUDIES OF PREV...
Conclusions <ul><li>OUT OF THE 523 371 EKG TRACINGS 3656 SUBEPICARDIAL LESIONS WERE DIAGNOSED. </li></ul><ul><li>GREATER I...
Copyright ©2008 American Heart Association Ting, H. H. et al. Circulation 2008;118:1066-1079 Reperfusion time goals for pa...
CHALLENGES IN CHILE <ul><li>FEW CARDIOLOGISTS </li></ul><ul><li>NOT ENOUGH NUMBER OF WELL EQUIPPED HOSPITALS </li></ul><ul...
AUGE LAW <ul><li>A PATIENT WITH CHEST PAIN SUGGESTIVE OF ISCHEMIC ORIGIN  MUST HAVE AN   EKG TAKEN WITHIN 15 MINUTES  OF C...
TELEMEDICINE AND ITS ALLIANCE WITH THE MINISTRY OF HEALTH <ul><li>SINCE MAY 1 ST  2004 THE MINISTRY OF HEALTH IMPLEMENTED ...
TELEMEDICINE IN THE CASE OF AN ACE Primary Care or ER Rescue Coordination with Reference Hospital Center Coordination with...
AUGE law and AMI <ul><li>Ministry of Health implemented 180 places to perform Thrombolysis, even in rural areas </li></ul>...
Impact of AUGE law in the treatment of AMI <ul><li>GLOBAL MORTALITY DECREASED FROM 12 TO 8.6% ;   OR 0.64 ( adjusted by ag...
Innovative strategies in Chile for treatment of STEMI <ul><li>Existence of a law which compels to have an early diagnosis ...
Servicios actuales de Telemedicina <ul><li>Electrocardiografía </li></ul><ul><li>Monitoreo ambulatorio de la presión arter...
Telemedicina y atención médica <ul><li>Los grandes beneficiados son: </li></ul><ul><li>Los   pacientes:  mejora la accesib...
<ul><li>MUCHAS GRACIAS POR SU ATENCION  </li></ul>
EKG in the diagnosis of an acute coronary event (ACE) <ul><li>“ TWELVE LEAD EKG IT IS IN THE CENTER OF THE DECISION TO EVA...
Subepicardial lesions in Chile (Acute Myocardial Infarction with ST segment elevation) Experience with Telemedicine Escoba...
METHOD <ul><li>523 371 ELECTROCARDIOGRAMS WERE ANALYZED  </li></ul><ul><li>SUBEPICARDIAL LESIONS WERE DEFINED AS ST ELEVAT...
Objectives of treatment of Myocardial Infarction <ul><li>Improvement of symptoms </li></ul><ul><li>Improvement of Survival...
PATIENT WITH SYMPTOMS OF AMI ECG STE or LBBB ECG (+) for ISCHEMIA NSTE  T (-) NORMAL or AMBIGUOUS ADMISSION   ADMISSION AN...
 
 
 
 
Impact of AUGE law in the treatment of AMI <ul><li>3547 patients with AMI were analyzed in 9 hospitals: 2623 pre AUGE and ...
IMPACT OF AUGE LAW <ul><li>IT HAS PRODUCED A CHANGE OF  ATTITUDE IN PHYSICIANS, NURSES AND PARAMEDICAL PERSONNEL OF PRIMAR...
PREVALENCE OF  EKG BRUGADA PATTERN EXPERIENCE IN CHILE E. ESCOBAR, MD;  P.ADRIAZOLA, MD F.BELLO, MD;  M.ORELLANA, MD;  P.T...
METHOD <ul><li>402 947  TRACINGS WERE RECEIVED IN OUR CENTER BETWEEN JAN 2004 AND SEPT 2007 </li></ul><ul><li>TWO GROUPS, ...
CONCLUSIONS <ul><li>IRBB IS PRESENT IN 5.9% OF CHILEAN POPULATION </li></ul><ul><li>BRUGADA PATTERN (1+2+3) : </li></ul><u...
CONCLUSIONS <ul><li>THESE RESULTS ARE SIMILAR TO OTHER STUDIES  </li></ul><ul><li>PREVALENCE OF TYPE 1 (BRUGADA SYNDROME) ...
Prevalence of prolonged QT interval in different electrocardiographic patterns Study by Teleelectrocardigoraphy Orellana M...
Prolonged QTc interval <ul><li>Group 1: 8459 normal tracings </li></ul><ul><li>Group 2: 2647 tracings with complete BBB : ...
RESULTS
Prolonged QTc interval <ul><li>QTc duration of 500 msec or more: </li></ul><ul><li>LVH by voltage criteria…………4.7% </li></...
Prolonged QTc interval:CONCLUSIONS <ul><li>1.- HIGH PREVALENCE OF PROLONGED QTc EVEN IN NORMAL TRACINGS (16%), but more so...
Francesca Bello, Edgardo Escobar, Denisse Lama,  Gabriel Mezzano, Stefania Pavlov ITMS, Telemedicina de Chile
<ul><li>En el presente trabajo se describe la relación contemporánea observada entre el terremoto del 27 de febrero del 20...
Método  <ul><li>Se analizó un total de 280.592 electrocardiogramas recibidos  a través de telemedicina correspondientes a ...
Resultados  <ul><li>Hubo un aumento estadísticamente significativo de las lesiones subepicárdicas (p<0,05) entre el fin de...
Distribución por género  <ul><li>Distribución general </li></ul><ul><li>Distribución 48 horas post terremoto </li></ul>
Porcentaje lesiones subepicárdicas fines de semana
MAPA (27/02): frecuencia cardíaca
MAPA (27/02):PA diastólica
MAPA (27/02): PA sistólica
Conclusiones  <ul><li>Se confirma un aumento significativo de las lesiones subepicárdicas en relación al “stress” producid...
Conclusiones  <ul><li>Este aumento puede estar subestimado ya que a pese a que el servicio de Telemedicina estuvo operativ...
BRUGADA PATTERN
Brugada type 1
 
 
 
BRUGADA <ul><li>BRUGADA MORPHOLOGY IN THE EKG IS KNOWN SINCE THE FIFTIES BUT ONLY UNTIL 1992 IT WAS DESCRIBED AS A CLINICA...
BRUGADA <ul><li>BRUGADA SYNDROME HAS THE RISK OF SUDDEN DEATH IN YOUNG ADULTS, AT A MEAN AGE OF 41  ±   15  YEARS   </li><...
BRUGADA <ul><li>Prevalence is estimated to be 5/10 000 people; in Japan and Southeast Asia: 12 to 14/10 000 </li></ul><ul>...
BRUGADA <ul><li>PREVALENCE OF THIS PATTERN HAS NOT BEEN ENOUGH STUDIED WORLDWIDE AND THERE IS NO STUDIES OF THIS MAGNITUDE...
BRUGADA <ul><li>CHILE IS  4500 Kms LONG and 200 Kms WIDE WITH VERY DIFFERENT CLIMATES </li></ul><ul><li>ON THE OTHER HAND ...
DEFINITIONS <ul><li>TYPE 1 :  COVED TYPE ELEVATION ≥ 2 mms FOLLOWED BY NEGATIVE T WAVE  (V1,V2) </li></ul><ul><li>TYPE 2: ...
METHOD <ul><li>INCOMPLETE RIGHT BUNDLE BRANCH BLOCK  (IRBB)  WAS DIAGNOSED WHEN r AND r’ WAVES WERE PRESENT IN V1  AND  V2...
Brugada type 1
Brugada type 2
Brugada type 3
RESULTS  n= 122 000
RESULTS n= 122 000 ( 37 * 10 000 )
RESULTS n= 7 155 ( IRBB )
RESULTS   n= 458 ( Brugada )
RESULTS n= 122 000 ( 4,6 * 10 000 )
BRUGADA PATTERN
<ul><li>STRENGHTS </li></ul><ul><li>- IT IS THE FIRST STUDY OF THIS MAGNITUDE OF PREVALENCE OF BRUGADA IN SOUTH AMERICA </...
PROLONGED  QT INTERVAL <ul><li>PROLONGED QT INTERVAL HAS BEEN PROPOSED AS A RISK FACTOR FOR VENTRICULAR ARRYTHMIAS AND DEA...
Prolonged QT interval   <ul><li>In left ventricular enlargement by ECG and/or echocardiography  prolonged QT has been docu...
Prolonged QT interval   <ul><li>Prolongation of QT interval in relation to QRS duration in complete bundle branch blocks h...
Prolonged QTc interval   <ul><li>Tracings were analyzed with a computer system using Aerotel HRS 6.0 software which allows...
Prolonged QTc interval <ul><li>QT interval was measured in 4 leads: D1, aVL, V5 and V6, agreed by two observers. </li></ul...
Prolonged  QTc interval   <ul><li>Chi square was used for statistical anaylisis </li></ul><ul><li>In cases with BBB correl...
Results   <ul><li>Statistical analysis: </li></ul><ul><ul><li>CLBB vs normal tracings  p<0,001 </li></ul></ul><ul><ul><li>...
QRS and QTc in complete LBBB <ul><li>Pearson 0,311  (0,28 – 0,35) </li></ul><ul><li>R2   0,0971  </li></ul>
QRS and QTc in complete RBBB <ul><li>Pearson 0,181  </li></ul><ul><li>(0,15 – 0,21) </li></ul><ul><li>R2  0,0326   </li></ul>
QRS and QTc at a fixed HR in complete LBBB <ul><li>HR 82 / min </li></ul><ul><li>Pearson 0.32 </li></ul><ul><li>R2  0.102 ...
Complete RBBB: QRS and QTc at a fixed HR  <ul><li>HR 77 / min </li></ul><ul><li>Pearson 0,129 </li></ul><ul><li>R2 0,016 <...
Limitations  and strenghts  <ul><li>We only have the ECG analysis  </li></ul><ul><li>We do not know associated diseases an...
SUBEPICARDIAL LESIONS
NUMBER OF LESIONS BY AGE 0 50 100 150 200 250 300 350 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100 + Age rang...
HOURLY DISTRIBUTION BY GENDER 0 20 40 60 80 100 120 140 160 0 - 1 1 - 2 2 - 3 3 - 4 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 1...
AREA OF SUBEPICARDIAL LESIONS L 0 100 200 300 400 500 600 700 Anterolateral Anteroseptal Anterior wall Inferior Número de ...
Percentage of lesions out of the total of EKGs by region Total EKGs =523371  0,52% 1,20% 1,60% 1,07% 2,72% 1,65% 2,34% 0,4...
MONTHLY DISTRIBUTION 0 50 100 150 200 250 1 2 3 4 5 6 7 8 9 10 11 12 Mes Frecuencia women Men
Antecedentes  <ul><li>La asociación de “stress” y eventos coronarios agudos (ECA) ha sido extensamente estudiada. </li></u...
Antecedentes  <ul><li>El IAM se incrementó 3 veces en población cercana al epicentro del terremoto de Hanshin-Awaji, predo...
STRESS Diferencias individuales (genes, experiencia) Respuesta emocional (depresión, ansiedad, enojo, etc) Respuesta condu...
Método  <ul><li>El diagnóstico de lesión subepicárdica se basó en la elevación nueva del segmento ST igual o mayor de 1 mm...
Método  <ul><li>Se analizó el porcentaje diario de lesiones subepicárdicas </li></ul><ul><li>Se comparó estadísticamente e...
Resultados  <ul><li>El diagnóstico de lesión subepicárdica se realizó en 1.795 trazados de las fechas descritas. </li></ul...
Enero 2009
Febrero 2009
Marzo 2009
Junio 2009
Julio 2009
Agosto 2009
Junio 2010
Julio 2010
Agosto 2010
Enero 2010
Febrero 2010
Marzo 2010
Resultados  <ul><li>Un estado hiperadrenérgico se puede evidenciar indirectamente a través del aumento de la frecuencia ca...
 
FECHA ECG Lesiones  subepicárdicas RIESGO ABSOLUTO p 27 y 28  febrero 352 12 3,41% 2 y 3 ene 2010 705 12 1,70% p<0.05 9 y ...
FECHA ECG Lesiones  subepicárdicas RIESGO ABSOLUTO p 27 y 28  febrero 352 12 3,41% 5 y 6  jun 2010 751 8 1,07% p<0.05 12 y...
FECHA ECG Lesiones  subepicárdicas RIESGO ABSOLUTO p 27 y 28  febrero 352 12 3,41% 3 y 4 ene 2009 590 9 1,53% p<0.05 10 y ...
FECHA ECG Lesiones  subepicárdicas RIESGO ABSOLUTO p 27 y 28  febrero 352 12 3,41% 6 y 7 junio 2009 663 8 1,21% p<0.05 13 ...
Stress and the heart <ul><li>There are extensive data concerning “stressors” contribution to: </li></ul><ul><li>Sudden dea...
Earthquakes are acute stressors and there are data about the increase in the number of  AMI and sudden deaths. TELEMEDICIN...
Earthquake in Chile <ul><li>February 27th at 3:34 AM Chile suffered the most devastating earthquake and tsunami  of its hi...
 
 
Preliminary data <ul><li>194.376 EKG  by TELEMEDICINE were analyzed </li></ul><ul><li>Group 1: First trimester  2009   </l...
Impact of earthquake: daily diagnosis of AMI <ul><li>Group 1   (1 st  trimester ,2009):  </li></ul><ul><li>0,2 - 2.7%;  as...
Daily incidence of AMI: first trimester 2009
Daily incidence of AMI, first trimester 2010 earthquake
Impact of earthquake <ul><li>The number of AMI is underestimated  since communications were interrupted, although Telemedi...
TELE-ELECTROCARDIOGRAPHY IN CHILE. CONCLUSIONS <ul><li>IT HAS POWERFULLY CONTRIBUTED TO THE EARLY TREATMENT OF AMI .  </li...
TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>GREAT SUPPORT TO PRIMARY CARE PHYSICIANS BY SPECIALISTS </li></ul><ul><li>REFERRA...
TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>QUICK RESPONSE ( REPORT IN 5 TO 10 MIN). </li></ul><ul><li>EQUIPMENT EASY TO USE ...
TELECTROCARDIOGRAPHY IN CHILE <ul><ul><ul><li>CONTRIBUTORS </li></ul></ul></ul><ul><ul><ul><li>AT  PRESENT: </li></ul></ul...
THANKS VERY MUCH FOR YOUR ATTENTION
 
ITMS puede contribuir al diagnóstico de SCA a través del informe del ECG y al tratamiento mediante el apoyo telefónico del...
Lesiones subepicárdicas:resumen <ul><li>Se analizaron 523 371 ECG  </li></ul><ul><li>Se detectaron 3656 lesiones </li></ul...
 
 
IMPACT OF AUGE IN THE TREATMENT OF PATIENTS WITH AMI 1.   Thrombolysis 2. Primary PTCA 3. Coronariography 4. Rescue PTCA 5...
 
Servicio de Tele-ECG en apoyo a Eventos Coronarios Agudos SAPU SAMU Hospital de Referencia SAPU o Traslado
ECG
 
<ul><li>Tiempo es Miocardio </li></ul><ul><li>Tiempo “Puerta-a-Tratamiento” </li></ul><ul><li>Tiempo “Llamada-a-Tratamient...
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TOTAL NUMBER OF DIAGNOSIS:  1 522 546 TOTAL NUMBER OF TRACINGS:  838 077  (Sept 1, 2002 up to May 13, 2009)
Telemedicina de Chile <ul><li>Al 11 de Julio del 2006 existen en nuestra base de datos 262 776 electrocardiogramas. </li><...
TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>BETWEEN SEPT.1, 2002 and MAY 13, 2009 </li></ul><ul><li>WE HAVE READ: </li></ul>...
 
Resumen Investigación Dr. Ricardo Villarroel Director Médico H. La Ligua Estudio en Eventos Coronarios Agudos en Hospital ...
Relación Costo Efectividad (Costo Unitario de Traslado) Resumen Investigación Dr. Ricardo Villarroel Director Médico H. La...
TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><ul><ul><li>COWORKERS. </li></ul></ul></ul><ul><ul><ul><li>PHYSICIANS : </li></ul></...
 
Intervalo QT prolongado   <ul><li>En el  crecimiento VI por criterio electrocardiográfico y/o  ecocardiográfico se ha docu...
Intervalo QT prolongado   <ul><li>La prolongación del intervalo QT en relación a la duración del QRS  en los bloqueos comp...
Intervalo QTc prolongado   <ul><li>Los trazados fueron analizados con un sistema computacional, utilizando el software Aer...
Intervalo QTc prolongado <ul><li>Se consideró prolongado un  valor de QTc ≥ 440 mseg., en las tres derivaciones. </li></ul...
Intervalo QTc prolongado   <ul><li>Para el análisis estadístico se utilizó la prueba de chi-cuadrado </li></ul><ul><li>En ...
Resultados   <ul><li>El análisis del intervalo QTc mostró diferencias estadísticamente significativas: </li></ul><ul><ul><...
QRS y QTc en BCRD <ul><li>Pearson 0,181  </li></ul><ul><li>(0,15 – 0,21) </li></ul><ul><li>R2  0,0326   </li></ul>
QRS y QTc para frecuencia fija en BCRI <ul><li>FC 82 / min </li></ul><ul><li>Pearson 0.32 </li></ul><ul><li>R2  0.102 </li...
QRS y QTc para frecuencia fija en BCRD   <ul><li>FC 77 / min </li></ul><ul><li>Pearson 0,129 </li></ul><ul><li>R2 0,016 </...
Limitaciones   <ul><li>Sólo tenemos el análisis del trazado electrocardiográfico  </li></ul><ul><li>Desconocemos las patol...
<ul><li>Sin embargo, estos resultados adquieren validez por el alto número de trazados analizados, muy superior a lo descr...
Results
Results
TELE-ELECTROCARDIOGRAPHY IN CHILE
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Presentación ITMS

  1. 1. TELEMEDICINE AND TELEELECTROCARDIOGRAPHYIN CHILE EDGARDO ESCOBAR MD, FACC, FAHA PROFESSOR OF MEDICINE MEDICAL DIRECTOR ITMS-TELEMEDICINE CHILE
  2. 8. Chilean Demography <ul><li>POPULATION: 17.000.000 </li></ul><ul><li>NUMBER OF PHYSICIANS: </li></ul><ul><li>1/559 </li></ul><ul><li>UNEVEN DISTRIBUTION OF PHYSICIANS </li></ul><ul><li>LIMITED NUMBER OF SPECIALISTS </li></ul><ul><li>EXTENSIVE RURALITY </li></ul>
  3. 9. TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>55% OF POPULATION HAS A HIGH OR VERY HIGH RISK OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE </li></ul><ul><li>CARDIOVASCULAR DISEASES ARE THE FIRST CAUSE OF MORTALITY : 29% OF TOTAL MORTALITY </li></ul><ul><li>CORONARY HEART DISEASE RESPONDS FOR 31% OF CARDIOVASCULAR DEATHS </li></ul><ul><li>32% OF CARDIOVASCULAR DEATHS ARE DUE TO CEREBROVASCULAR DISEASES </li></ul>
  4. 10. TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>NOT ENOUGH NUMBER OF SPECIALISTS </li></ul><ul><li>NOT ENOUGH MEANS OF TRANSPORTATION IN RURAL PLACES (Primary care). IT IS IMPORTANT TO AVOID UNNECESSARY TRANSPORTATION OF PATIENTS TO A PLACE OF HIGHER COMPLEXITY </li></ul><ul><li>ON THE OTHER HAND: </li></ul><ul><li>THERE IS A VERY GOOD TECHNOLOGY SUPPORT AND A GOOD LEVEL OF COMMUNICATIONS (TELEPHONE, FAX, AND IN MANY CASES INTERNET) </li></ul>
  5. 11. TRILOGY OF TELEMEDICINE SERVICE <ul><ul><ul><ul><ul><li>1. PHYSICIANS </li></ul></ul></ul></ul></ul><ul><ul><li>2.- TELECOMUNICATION SYSTEMS </li></ul></ul><ul><ul><li>3.- TECHNOLOGY SUPPORT </li></ul></ul><ul><ul><li>(INFORMATIC) </li></ul></ul>
  6. 12. TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>EQUIPMENTS ARE DISTRIBUTED: </li></ul><ul><li>IN 493 PLACES (381 DEPENDING OF THE MINISTRY OF HEALTH) SOME OF THEM VERY REMOTE, INCLUDING EASTERN ISLAND, and </li></ul><ul><li>IN 75 DISTRICTS (MUNICIPALIDADES) </li></ul><ul><li>EKGS ARE CAPTURED WITH VERY SMALL EQUIPMENTS EITHER AEROTEL OR CARDIETTE </li></ul><ul><li>EKG IS SENT EITHER BY PHONE, MOBILE PHONE OR INTERNET AND RECEIVED IN THE CALL CENTER IN A COMPUTER </li></ul><ul><li>WHATEVER THE ORIGINAL SIGNAL IS , IT ENTERS THRU AN INTEGRATED SYSTEM: Integrated platform of Telemedicine (IPT-PIT ) </li></ul><ul><li>MEASUREMENTS OF AMPLITUDES AND INTERVALS ARE MADE WITH AN ELECTRONIC CURSOR AT 25, 50 OR 100mm/sec. </li></ul>
  7. 14. HOW DOES Tele-EKG WORK ? EKG REGISTERED AND SENT TELEPHONE CALL CENTER RECEIVES EKG, PARAMEDIC GIVES THE APPROVAL AND COLLECTS INFORMATION OF A LIST OF SYMPTOMS AND DEMOGRAPHIC DATA GENERAL PRACTITIONER RECEIVES THE REPORT AND EVENTUALLY CALL BACK FOR QUESTIONS EKG IS SENT BACK BY MAIL OR FAX OPERATOR PRINTS EKG AND SAVES THE INFORMATION TO A CENTRAL DATABASE CARDIOLOGISTS MAKES THE REPORT
  8. 15. TELE-ELECTROCARDIOGRAPHY IN CHILE
  9. 16. TELE-EKG
  10. 18. TELEELECTROCARDIOPRAHY IN CHILE <ul><li>THE REPORT IS MADE ACCORDING TO THE EKG GUIDE USED BY THE AMERICAN BOARD OF INTERNAL MEDICINE AND AMERICAN COLLEGE OF CARDIOLOGY . </li></ul><ul><li>REPORT IS MADE BY THE CARDIOLOGIST AND SENT BACK BY FAX OR e-MAIL. </li></ul><ul><li>ADVISE IS GIVEN BY PHONE UPON REQUEST AND ALWAYS IF THERE IS SUBEPICARDIAL LESION </li></ul>
  11. 19. TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>ALL EKG DIAGNOSIS ARE CODIFIED AND MOVED TO THE FINAL REPORT JUST MAKING A CLICK ON IT. THIS MAKES THE PROCEDURE VERY FAST </li></ul><ul><li>(No more than 10 minutes) </li></ul><ul><li>DIAGNOSIS ARE SAVED IN A DATABASE FROM WHERE THEY MAY BE RECOVERED AT ANYTIME. STATISTICAL STUDIES ARE EASY TO PERFORM </li></ul>
  12. 21. Comparison of some leads between traditional EKG and TeleEKG
  13. 23. ECG Hospital del Salvador
  14. 25. ALTMAN BLAND METHOD: Comparison of V4 amplitude in traditional EKG and TeleEKG
  15. 26. Altman and Bland: Logaritmic comparison of V4 amplitude between traditional EKG and Tele EKG
  16. 27. Teleelectrocardiography in Chile <ul><li>1300 to 1600 ECGs are received daily Monday thru Friday and 600 to 800 during the weekends </li></ul><ul><li>There are about 1500 000 electrocardiograms in our data base </li></ul>
  17. 29. ABNORMAL TRACINGS
  18. 30. Nuestra Política de Confidencialidad de la Información VIGESIMO PRIMERO: El soporte médico remoto y/o el apoyo al diagnóstico e informe de electrocardiograma proporcionado por los especialistas de ITMS, no sustituye, en ningún caso la responsabilidad directa que emana de la relación médico-paciente que regula la práctica de la profesión médica en Chile… VIGESIMO: Con el objeto de monitorear la calidad de servicio … ITMS podrá grabar parte o la totalidad de la conversación… manteniendo tales registros en la más estricta reserva, siendo éstos accesibles sólo por el Director Médico de ITMS y el médico representante del Usuario
  19. 31. ASPECTOS DESTACADOS POR LOS USUARIOS DE ITMS <ul><li>Rapidez de Interpretación y del Informe del Especialista (+/- 5 min.) </li></ul><ul><li>Facilidad en manejo del dispositivo y de toma del examen </li></ul><ul><li>Cobertura en cualquier lugar- Portabilidad del equipo </li></ul><ul><li>Evaluación por cardiólogo- Segunda opinión inmediata </li></ul><ul><li>Derivación oportuna en pacientes con ECG alterados </li></ul><ul><li>Disponibilidad permanente </li></ul><ul><li>Se evitan traslados innecesarios </li></ul><ul><li>Sistema eficiente y eficaz – de gran utilidad en Salud Pública por cobertura y bajo costo </li></ul>
  20. 32. TEACHING AND RESEARCH <ul><li>MEETINGS TO DISCUSS DIFFICULT TRACINGS OR INTERESTING ONES </li></ul><ul><li>STUDIES OF PREVALENCE OF SOME ABNORMAL TRACINGS </li></ul>
  21. 33. Conclusions <ul><li>OUT OF THE 523 371 EKG TRACINGS 3656 SUBEPICARDIAL LESIONS WERE DIAGNOSED. </li></ul><ul><li>GREATER INCIDENCE OF STEMI IN MEN (69 vs 31%) AND PRESENTATION IN AN OLDER AGE IN WOMEN ARE CONFIRMED. </li></ul><ul><li>GREATER NUMBER OF STEMI BETWEEN APRIL AND JULY AND </li></ul><ul><li>BETWEEN 09 AM AND 11 PM WITH A PEAK BETWEEN 11 AM AND 1 PM, SIMILARLY IN MEN AND WOMEN. </li></ul><ul><li>7th AND 9th REGIONS HAD THE GREATER INCIDENCE OF STEMI. </li></ul><ul><li>TELEMEDICINE IS A TOOL OF A GREAT VALUE FOR THE EARLY DIAGNOSIS OF AMI AND ITS TREATMENT, PARTICULARLY IN REMOTE AREAS. </li></ul><ul><li>TELEMEDICINE MADE POSSIBLE THE APPLICATION OF THE AUGE LAW </li></ul>
  22. 34. Copyright ©2008 American Heart Association Ting, H. H. et al. Circulation 2008;118:1066-1079 Reperfusion time goals for patients with ST-segment-elevation myocardial infarction
  23. 35. CHALLENGES IN CHILE <ul><li>FEW CARDIOLOGISTS </li></ul><ul><li>NOT ENOUGH NUMBER OF WELL EQUIPPED HOSPITALS </li></ul><ul><li>NOT ENOUGH MEANS OF TRANSPORT AVAILABLE AT PRIMARY CARE LEVEL </li></ul><ul><li>THEREFORE </li></ul><ul><li>PRECISE AND TIMELY DIAGNOSIS ARE IMPORTANT FOR </li></ul><ul><li>EARLY TREATMENT AND TO AVOID UNNECESSARY </li></ul><ul><li>TRANSPORT OF PATIENTS TO A HIGHER COMPLEXITY </li></ul><ul><li>HEALTH CARE PLACE </li></ul>
  24. 36. AUGE LAW <ul><li>A PATIENT WITH CHEST PAIN SUGGESTIVE OF ISCHEMIC ORIGIN MUST HAVE AN EKG TAKEN WITHIN 15 MINUTES OF CONSULTATION. </li></ul><ul><ul><li>RESPONSE TO THIS REQUIREMENT IN MANY PLACES: </li></ul></ul><ul><ul><li>TELEMEDICINE </li></ul></ul><ul><li>THROMBOLYSIS WITH STREPTOKINASE SHOULD BE STARTED, OR PATIENT SHOULD BE REFERRED FOR PRIMARY ANGIOPLASTY, WHICH IS ONLY POSSIBLE IN FEW PLACES </li></ul>
  25. 37. TELEMEDICINE AND ITS ALLIANCE WITH THE MINISTRY OF HEALTH <ul><li>SINCE MAY 1 ST 2004 THE MINISTRY OF HEALTH IMPLEMENTED NATIONAL COVERAGE OF EKG IN PATIENTS CONSULTING WITH CHEST PAIN SUGGESTIVE OF ACE </li></ul><ul><li>TELEMEDICINE WAS RECOGNIZED AS THE DIAGNOSTIC SUPPORT TO PERFORM THROMBOLYSIS 24 HOURS A DAY, EVERY DAY OF THE YEAR, PARTICULARLY IN HOSPITALS OF LOWER COMPLEXITY </li></ul>
  26. 38. TELEMEDICINE IN THE CASE OF AN ACE Primary Care or ER Rescue Coordination with Reference Hospital Center Coordination with Rescue and transfer
  27. 39. AUGE law and AMI <ul><li>Ministry of Health implemented 180 places to perform Thrombolysis, even in rural areas </li></ul><ul><li>After the procedure is performed high risk patients are referred to a hospital of tertiary level, for further treatment </li></ul>
  28. 40. Impact of AUGE law in the treatment of AMI <ul><li>GLOBAL MORTALITY DECREASED FROM 12 TO 8.6% ; OR 0.64 ( adjusted by age, gender, risks factors, previous MI and Killip score at admission) </li></ul><ul><li>GREATER REDUCTION OF MORTALITY IN PATIENTS OF HIGHER RISK (WOMEN, OLDER THAN 75 YEARS) </li></ul><ul><li>IN PATIENTS TREATED WITH THROMBOLYSIS MORTALITY DECREASED FROM 10.6% TO 6.8% </li></ul><ul><li>(p < 0.005 ) , EVEN IN HOSPITALS OF LOW COMPLEXITY </li></ul><ul><li>SIGNIFICANT INCREASES IN THE PRESCRIPTION OF STATINS, BETABLOCKERS, ACEI, ASPIRIN </li></ul>
  29. 41. Innovative strategies in Chile for treatment of STEMI <ul><li>Existence of a law which compels to have an early diagnosis and treatment of AMI </li></ul><ul><li>Guidelines for the treatment of Acute Myocardial Infarction are “official”, distributed by decision of the State through the public health system </li></ul><ul><li>The support of Telemedicine for early diagnosis </li></ul><ul><li>Implementation to perform thrombolysis, even in rural areas ( although only with streptokinase) </li></ul>
  30. 42. Servicios actuales de Telemedicina <ul><li>Electrocardiografía </li></ul><ul><li>Monitoreo ambulatorio de la presión arterial de 24 horas (MAPA) </li></ul><ul><li>Monitoreo ambulatorio del electrocardiograma de 24 horas (Holter de arritmias) </li></ul><ul><li>Espirometría </li></ul><ul><li>Teleradiología </li></ul>
  31. 43. Telemedicina y atención médica <ul><li>Los grandes beneficiados son: </li></ul><ul><li>Los pacientes: mejora la accesibilidad, la coberturta y la equidad de la atención </li></ul><ul><li>Los médicos de atención primaria , que pueden contar con elementos de diagnóstico que les permite resolver de inmediato muchos problemas que en otra forma habrían sido postergados. El médico se siente así apoyado en una atención médica de suyo difícil en nuestro país. </li></ul><ul><li>Los especialistas a quienes se refirarán pacientes que antes no hubieran tenido oportunidad de conocer </li></ul>
  32. 44. <ul><li>MUCHAS GRACIAS POR SU ATENCION </li></ul>
  33. 45. EKG in the diagnosis of an acute coronary event (ACE) <ul><li>“ TWELVE LEAD EKG IT IS IN THE CENTER OF THE DECISION TO EVALUATE AND TO TREAT PATIENTS WITH CHEST PAIN..........” (ACC/AHA) </li></ul><ul><li>ISCHEMIC CHANGES IN THE EKG ARE EVOLUTIVE. CONFOUNDERS ARE STATIC </li></ul><ul><li>SUFFICIENT EVIDENCE THAT PREHOSPITAL EKG SPEEDS STEMI PATIENTS ’ ROUTE TO TREATMENT, DECREASING DOOR- TO-DRUG TIME AND DOOR TO BALLOON TIME . </li></ul><ul><li>“ TIME IS MYOCARDIUM” </li></ul><ul><li>TELEMEDICINE ALLOWS THE DIAGNOSIS OF AMI IN THE FIELD, CAPTURING A DIAGNOSTIC QUALITY 12 LEAD ELECTROCARDIOGRAM </li></ul>
  34. 46. Subepicardial lesions in Chile (Acute Myocardial Infarction with ST segment elevation) Experience with Telemedicine Escobar E, Vèjar M, del Pino R Rev. Chilena Cardiol 2009:28,73-80
  35. 47. METHOD <ul><li>523 371 ELECTROCARDIOGRAMS WERE ANALYZED </li></ul><ul><li>SUBEPICARDIAL LESIONS WERE DEFINED AS ST ELEVATION OF AT LEAST 1mm IN 2 OR MORE CONSECUTIVE LEADS. </li></ul><ul><li>AMBIGUOUS LESIONS AS WELL AS NON EVOLUTIVE WERE DISCARDED. </li></ul>
  36. 48. Objectives of treatment of Myocardial Infarction <ul><li>Improvement of symptoms </li></ul><ul><li>Improvement of Survival </li></ul><ul><li>Decrease of Myocardial damage (“Time is myocardium”) </li></ul>
  37. 49. PATIENT WITH SYMPTOMS OF AMI ECG STE or LBBB ECG (+) for ISCHEMIA NSTE T (-) NORMAL or AMBIGUOUS ADMISSION ADMISSION ANTI ISCHEMIC THERAPY ECG ENZYMES ECHO ANTI ISCHEMIC THERAPY THROMBOLYSIS or PCI EVIDENCE of ISCHEMIA NO OTHER DIAGNOSIS YES
  38. 54. Impact of AUGE law in the treatment of AMI <ul><li>3547 patients with AMI were analyzed in 9 hospitals: 2623 pre AUGE and 924 after AUGE law </li></ul><ul><li>Time between initiation of symptoms and admission was 4 hours in both periods (only 25% before 3 hours) </li></ul><ul><li>Time between admission and thrombolysis was 31 min. </li></ul>
  39. 55. IMPACT OF AUGE LAW <ul><li>IT HAS PRODUCED A CHANGE OF ATTITUDE IN PHYSICIANS, NURSES AND PARAMEDICAL PERSONNEL OF PRIMARY CARE FACING NEW CHALLENGES IN THE TREATMENT OF AMI </li></ul><ul><li>IT HAS POWERFULLY CONTRIBUTED TO THE EARLY TREATMENT OF AMI </li></ul>
  40. 56. PREVALENCE OF EKG BRUGADA PATTERN EXPERIENCE IN CHILE E. ESCOBAR, MD; P.ADRIAZOLA, MD F.BELLO, MD; M.ORELLANA, MD; P.TREJO, MD ITMS, TELEMEDICINE, CHILE
  41. 57. METHOD <ul><li>402 947 TRACINGS WERE RECEIVED IN OUR CENTER BETWEEN JAN 2004 AND SEPT 2007 </li></ul><ul><li>TWO GROUPS, ONE FROM JAN 2004 TO MAY 2005 AND THE OTHER ONE FROM MARCH 2007 TO SEPT 2007, INCLUDING 1430 CHILDREN UNDER 15 YEARS OF AGE, WERE ANALYZED, MAKING A TOTAL OF </li></ul><ul><li>122 000 TRACINGS </li></ul>
  42. 58. CONCLUSIONS <ul><li>IRBB IS PRESENT IN 5.9% OF CHILEAN POPULATION </li></ul><ul><li>BRUGADA PATTERN (1+2+3) : </li></ul><ul><li>-IT HAS A PREVALENCE OF 37/10 000 </li></ul><ul><li>-REPRESENT 6.4% OF IRBB </li></ul><ul><li>-IT IS MORE FREQUENT IN MEN (2.3/1) AND BETWEEN THE 4 TH AND 6 TH DECADES </li></ul><ul><li>OF AGE </li></ul>
  43. 59. CONCLUSIONS <ul><li>THESE RESULTS ARE SIMILAR TO OTHER STUDIES </li></ul><ul><li>PREVALENCE OF TYPE 1 (BRUGADA SYNDROME) IS 4.6/10 000 </li></ul><ul><li>PATIENTS WITH BRUGADA TYPE 1 AND THEIR FAMILIES SHOULD BE CLOSELY FOLLOWED UP </li></ul><ul><li>TELEMEDICINE PROVIDES AN EXCELLENT TOOL FOR THIS KIND OF STUDIES </li></ul>
  44. 60. Prevalence of prolonged QT interval in different electrocardiographic patterns Study by Teleelectrocardigoraphy Orellana M, Bello F , Escobar E. Adriazola P,Trejo P, Gonzalez P Rev.Chilena Cardiol 2009 28:349-356
  45. 61. Prolonged QTc interval <ul><li>Group 1: 8459 normal tracings </li></ul><ul><li>Group 2: 2647 tracings with complete BBB : </li></ul><ul><li>532 with LBBB + 2115 with RBBB </li></ul><ul><li>Group 3: 2503 tracings with left ventricular enlargment: </li></ul><ul><li>377 by voltage criteria + 1083 by voltage and ST-T changes + 1043 only by ST-T changes </li></ul>
  46. 62. RESULTS
  47. 63. Prolonged QTc interval <ul><li>QTc duration of 500 msec or more: </li></ul><ul><li>LVH by voltage criteria…………4.7% </li></ul><ul><li>LVH by voltage + ST-T changes..7,9% </li></ul><ul><li>LVH by ST-T changes only……...8,3% </li></ul>
  48. 64. Prolonged QTc interval:CONCLUSIONS <ul><li>1.- HIGH PREVALENCE OF PROLONGED QTc EVEN IN NORMAL TRACINGS (16%), but more so in </li></ul><ul><li>COMPLETE LBBB (51,5%) </li></ul><ul><li>COMPLET RBBB (25%) </li></ul><ul><li>LVH by voltage + ST-T changes(42%) </li></ul><ul><li>LVH by voltage criteria(28%) </li></ul><ul><li>LVH by ST-T changes (29%) </li></ul><ul><li>2.-NO CORRELATION BETWEEN QRS DURATION AND QTc IN COMPLETE BBBs WAS OBSERVED </li></ul><ul><li>3.-PROGNOSTIC IMPACT OF PROLONGED QTc IN COMPLETE BBB NEEDS TO BE STUDIED </li></ul>
  49. 65. Francesca Bello, Edgardo Escobar, Denisse Lama, Gabriel Mezzano, Stefania Pavlov ITMS, Telemedicina de Chile
  50. 66. <ul><li>En el presente trabajo se describe la relación contemporánea observada entre el terremoto del 27 de febrero del 2010 y el diagnóstico de lesión subepicárdica, en electrocardiogramas recibidos en ITMS, Telemedicina de Chile </li></ul>
  51. 67. Método <ul><li>Se analizó un total de 280.592 electrocardiogramas recibidos a través de telemedicina correspondientes a los meses de: </li></ul><ul><ul><li>Enero, Febrero, Marzo del año 2009 y los mismos meses del año 2010 </li></ul></ul><ul><ul><li>Junio, Julio, Agosto del año 2009 y los mismos meses del año 2010 </li></ul></ul>
  52. 68. Resultados <ul><li>Hubo un aumento estadísticamente significativo de las lesiones subepicárdicas (p<0,05) entre el fin de semana del terremoto y todos los fines de semana de los meses analizados </li></ul>
  53. 69. Distribución por género <ul><li>Distribución general </li></ul><ul><li>Distribución 48 horas post terremoto </li></ul>
  54. 70. Porcentaje lesiones subepicárdicas fines de semana
  55. 71. MAPA (27/02): frecuencia cardíaca
  56. 72. MAPA (27/02):PA diastólica
  57. 73. MAPA (27/02): PA sistólica
  58. 74. Conclusiones <ul><li>Se confirma un aumento significativo de las lesiones subepicárdicas en relación al “stress” producido por el terremoto del 27/02/2010 </li></ul><ul><li>Se invierte la relación porcentual de infartos entre hombres y mujeres </li></ul><ul><li>Esto coincide con un aumento de frecuencia cardíaca y presión arterial, especialmente diastólica </li></ul>
  59. 75. Conclusiones <ul><li>Este aumento puede estar subestimado ya que a pese a que el servicio de Telemedicina estuvo operativo en los primeros 20 min del evento hubo interrupción de comunicaciones desde las zonas más afectadas y la mayoría de los exámenes se recibieron desde la RM, V y VI regiones. </li></ul><ul><li>Este es el primer estudio realizado con Telemedicina en estas circunstancias </li></ul>
  60. 76. BRUGADA PATTERN
  61. 77. Brugada type 1
  62. 81. BRUGADA <ul><li>BRUGADA MORPHOLOGY IN THE EKG IS KNOWN SINCE THE FIFTIES BUT ONLY UNTIL 1992 IT WAS DESCRIBED AS A CLINICAL ENTITY </li></ul><ul><li>BRUGADA SYNDROME IS DEFINED AS AN EKG WITH A IRBB BUT WITH CHARACTERISTIC COVED-TYPE ST SEGMENT ELEVATION IN V1 and V2 (sometimes in V3) AND A HIGH INCIDENCE OF SUDDEN DEATH WITHOUT STRUCTURAL HEART DISEASE </li></ul>
  63. 82. BRUGADA <ul><li>BRUGADA SYNDROME HAS THE RISK OF SUDDEN DEATH IN YOUNG ADULTS, AT A MEAN AGE OF 41 ± 15 YEARS </li></ul><ul><li>ALTHOUGH IS A POTENTIAL CAUSE OF SEVERE ARRYTHMIAS BRUGADA PATTERN IT IS NOT WELL KNOWN BY PHYSICIANS </li></ul>
  64. 83. BRUGADA <ul><li>Prevalence is estimated to be 5/10 000 people; in Japan and Southeast Asia: 12 to 14/10 000 </li></ul><ul><li>It is dynamic (Fever, large meal) </li></ul><ul><li>It may umasked by moving V1 to an upper intercostal space or by NA CHANNEL BLOCKERS: ajmaline, flecainide, procainamide </li></ul><ul><li>MUTATION OF ALFA SUBUNIT OF NA CHANNEL GENE SCN5A </li></ul><ul><li>PROGRAMMED VENTRICULAR STIMULATION </li></ul>
  65. 84. BRUGADA <ul><li>PREVALENCE OF THIS PATTERN HAS NOT BEEN ENOUGH STUDIED WORLDWIDE AND THERE IS NO STUDIES OF THIS MAGNITUDE IN SOUTHAMERICA </li></ul><ul><li>TELEMEDICINE SYSTEM PROVIDES US WITH AN EXCELLENT TOOL TO HAVE INFORMATION EVEN FROM REMOTE AREAS </li></ul><ul><li>IN THE CASE OF CHILE THE SYSTEM SERVES ALL THE COUNTRY INCLUDING THE EASTERN ISLAND </li></ul>
  66. 85. BRUGADA <ul><li>CHILE IS 4500 Kms LONG and 200 Kms WIDE WITH VERY DIFFERENT CLIMATES </li></ul><ul><li>ON THE OTHER HAND ALTHOUGH THE GREAT MAJORITY OF THE POPULATION IS OF EUROPEAN ANCESTRY WE HAVE SOME DIVERSITY: SMALL GROUPS OF PEOPLE OF INDIAN ORIGIN IN THE NORTH AND SOUTH AND POLYNESIANS IN EASTERN ISLAND </li></ul><ul><li>THEREFORE: </li></ul><ul><li>IT IS A REPRESENTATIVE POPULATION TO STUDY THE PREVALENCE OF DIFFERENT DISEASES </li></ul>
  67. 86. DEFINITIONS <ul><li>TYPE 1 : COVED TYPE ELEVATION ≥ 2 mms FOLLOWED BY NEGATIVE T WAVE (V1,V2) </li></ul><ul><li>TYPE 2: SADDLE BACK-TYPE ST ELEVATION ≥ 2mms, THROUGH DISPLAYING ≥ 1mm, AND (+) OR BIPHASIC T WAVE (V1,V2) </li></ul><ul><li>TYPE 3: THE SAME AS 2 BUT WITH ST ELEVATION < 1mm </li></ul>
  68. 87. METHOD <ul><li>INCOMPLETE RIGHT BUNDLE BRANCH BLOCK (IRBB) WAS DIAGNOSED WHEN r AND r’ WAVES WERE PRESENT IN V1 AND V2 </li></ul><ul><li>ANALYSIS OF THESE TRACINGS WAS PERFORMED AT LEAST BY TWO OF THE AUTHORS AND TYPES 2 AND 3 WERE CONSIDERED AS A WHOLE </li></ul>
  69. 88. Brugada type 1
  70. 89. Brugada type 2
  71. 90. Brugada type 3
  72. 91. RESULTS n= 122 000
  73. 92. RESULTS n= 122 000 ( 37 * 10 000 )
  74. 93. RESULTS n= 7 155 ( IRBB )
  75. 94. RESULTS n= 458 ( Brugada )
  76. 95. RESULTS n= 122 000 ( 4,6 * 10 000 )
  77. 96. BRUGADA PATTERN
  78. 97. <ul><li>STRENGHTS </li></ul><ul><li>- IT IS THE FIRST STUDY OF THIS MAGNITUDE OF PREVALENCE OF BRUGADA IN SOUTH AMERICA </li></ul><ul><li>- ANALYSIS WAS MADE IN A SIGNIFICANT NUMBER OF EKG TRACINGS (122 000) FROM ALL OVER THE COUNTRY </li></ul><ul><li>-IT IS A REPRESENTATIVE POPULATION </li></ul><ul><li>-ALERTS PRIMARY CARE PHYSICIANS ABOUT THE DIAGNOSIS </li></ul><ul><li>LIMITATIONS </li></ul><ul><li>- LACK OF ENOUGH CLINICAL DATA </li></ul><ul><li>-NO FAMILY HISTORY OR FOLLOW UP </li></ul>
  79. 98. PROLONGED QT INTERVAL <ul><li>PROLONGED QT INTERVAL HAS BEEN PROPOSED AS A RISK FACTOR FOR VENTRICULAR ARRYTHMIAS AND DEATH IN POST AMI PATIENTS, DIABETICS AND EVEN IN APPARENTLY HEALTHY POPULATION. </li></ul><ul><ul><ul><li>Circulation 2003;108:1985-1989 </li></ul></ul></ul>
  80. 99. Prolonged QT interval <ul><li>In left ventricular enlargement by ECG and/or echocardiography prolonged QT has been documented. </li></ul><ul><ul><ul><li>J of Hypertension 2001;19:1883-1991 </li></ul></ul></ul><ul><ul><li> Am J Cardiol 2000;86:1117–1122 </li></ul></ul><ul><ul><li> Circulation 2003;107:1764-1769 </li></ul></ul>
  81. 100. Prolonged QT interval <ul><li>Prolongation of QT interval in relation to QRS duration in complete bundle branch blocks has been a matter of discussion. </li></ul><ul><ul><li>Am J Cardiol. 1992;70:628–629 </li></ul></ul><ul><ul><li>J Electrocardiol. 1990;23:49–52 </li></ul></ul><ul><ul><li>Circulation 2003;108:1985-1989 </li></ul></ul>
  82. 101. Prolonged QTc interval <ul><li>Tracings were analyzed with a computer system using Aerotel HRS 6.0 software which allows measurements of different intervals at 10mm/sec at100 mm/seg. </li></ul>
  83. 102. Prolonged QTc interval <ul><li>QT interval was measured in 4 leads: D1, aVL, V5 and V6, agreed by two observers. </li></ul><ul><li>The system automatically corrects by the square root of heart rate (QTc). </li></ul><ul><li>Prolonged QTc was defined by a value of > 440 mseg, in all four leads. </li></ul><ul><li>The most prolonged value was chosen for further analysis. </li></ul>
  84. 103. Prolonged QTc interval <ul><li>Chi square was used for statistical anaylisis </li></ul><ul><li>In cases with BBB correlation analysis was used to evaluate the relationship between QRS and QTc durations </li></ul>
  85. 104. Results <ul><li>Statistical analysis: </li></ul><ul><ul><li>CLBB vs normal tracings p<0,001 </li></ul></ul><ul><ul><li>CRBB vs normal tracings p<0,001 </li></ul></ul><ul><ul><li>LVH by voltage criteria + negative T wave vs normal tracings p<0,001 </li></ul></ul>
  86. 105. QRS and QTc in complete LBBB <ul><li>Pearson 0,311 (0,28 – 0,35) </li></ul><ul><li>R2 0,0971 </li></ul>
  87. 106. QRS and QTc in complete RBBB <ul><li>Pearson 0,181 </li></ul><ul><li>(0,15 – 0,21) </li></ul><ul><li>R2 0,0326 </li></ul>
  88. 107. QRS and QTc at a fixed HR in complete LBBB <ul><li>HR 82 / min </li></ul><ul><li>Pearson 0.32 </li></ul><ul><li>R2 0.102 </li></ul>
  89. 108. Complete RBBB: QRS and QTc at a fixed HR <ul><li>HR 77 / min </li></ul><ul><li>Pearson 0,129 </li></ul><ul><li>R2 0,016 </li></ul>
  90. 109. Limitations and strenghts <ul><li>We only have the ECG analysis </li></ul><ul><li>We do not know associated diseases and the possible use of medications </li></ul><ul><li>We do not have a follow up </li></ul><ul><li>HOWEWER: </li></ul><ul><li>The results are valid due to the high number of tracings analyzed, far above other studies </li></ul>
  91. 110. SUBEPICARDIAL LESIONS
  92. 111. NUMBER OF LESIONS BY AGE 0 50 100 150 200 250 300 350 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100 + Age range Número de Lesiones WOMEN MEN
  93. 112. HOURLY DISTRIBUTION BY GENDER 0 20 40 60 80 100 120 140 160 0 - 1 1 - 2 2 - 3 3 - 4 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11 11 - 12 12 - 13 13 - 14 14 - 15 15 - 16 16 - 17 17 - 18 18 - 19 19 - 20 20 - 21 21 - 22 22 - 23 23 - 0 Rango de Hora Número de Lesiones Women Men
  94. 113. AREA OF SUBEPICARDIAL LESIONS L 0 100 200 300 400 500 600 700 Anterolateral Anteroseptal Anterior wall Inferior Número de Lesiones Women Men
  95. 114. Percentage of lesions out of the total of EKGs by region Total EKGs =523371 0,52% 1,20% 1,60% 1,07% 2,72% 1,65% 2,34% 0,44% 0,43% 0,90% 1,21% 0,79% 0,11% 0,0% 0,5% 1,0% 1,5% 2,0% 2,5% 3,0% 1 2 3 4 5 6 7 8 9 10 11 12 13 Region
  96. 115. MONTHLY DISTRIBUTION 0 50 100 150 200 250 1 2 3 4 5 6 7 8 9 10 11 12 Mes Frecuencia women Men
  97. 116. Antecedentes <ul><li>La asociación de “stress” y eventos coronarios agudos (ECA) ha sido extensamente estudiada. </li></ul><ul><li>Se ha documentado la relación entre terremotos y ECA. </li></ul><ul><li>Se ha establecido una relación entre la intensidad del terremoto, la hora de ocurrencia, la época del año y el riesgo de un ECA. </li></ul>Kloner, Leor: Natural disaster plus wake-up time: a deadly combination of triggers. AmHeart J. 1999; 137: 779-781 Ogawa, K; Tsuji, I; Shiono, K; Hisamichi, S. Increased acute myocardial infarction mortality following the 1995 great Hanshin-Awaji earthquake in Japan. Int J Epidemiol. 2000; 29:449-455. Ching-Hong, T; For-Wey, L; Shing-Yaw, W. The 1999 Ji-Ji (Taiwan) Earthquake as a Trigger for Acute Myocardial Infarction. Psychosomatics. 2004; 45:477-482
  98. 117. Antecedentes <ul><li>El IAM se incrementó 3 veces en población cercana al epicentro del terremoto de Hanshin-Awaji, predominantemente en mujeres. </li></ul><ul><li>Se documentó la asociación de enfermedad cardiovascular a través de cambios hemodinámicos y factores trombogénicos. </li></ul>Kario, K; Mc Ewen, B; Pickering, G. Disasters and the Heart: a Review of the Effects of Earthquake-Induced Stress on Cardiovascular Disease. Hypertens Res. 2003; 26: 355-367.
  99. 118. STRESS Diferencias individuales (genes, experiencia) Respuesta emocional (depresión, ansiedad, enojo, etc) Respuesta conductual (insomnio, OH, etc) Respuesta fisiológica Eje Hipotálamo-hipófisis Factores de riesgo crónicos: HTA, DM, Dislipidemia ATE Enfermedad cardiovascular silente Sistema nervioso simpático Factores de riesgo agudos: Incremento en PA, disfunción endotelial, incremento en viscosidad sanguínea, activación plaquetaria y hemostática Variación periódca Condición predisponente Modificado de Kario et al: Earthquakeand Cardiovascular Disease , Hypertens Res. 20003. Vol. 26, No. 5
  100. 119. Método <ul><li>El diagnóstico de lesión subepicárdica se basó en la elevación nueva del segmento ST igual o mayor de 1 mm en dos o más derivaciones contiguas. Trazados dudosos no fueron considerados </li></ul>
  101. 120. Método <ul><li>Se analizó el porcentaje diario de lesiones subepicárdicas </li></ul><ul><li>Se comparó estadísticamente el porcentaje de lesiones subepicárdicas registradas en el periodo posterior al terremoto (sábado 27 y domingo 28 de febrero de 2010) y se compararon con los fines de semana de los meses descritos (años 2009 y 2010) </li></ul>
  102. 121. Resultados <ul><li>El diagnóstico de lesión subepicárdica se realizó en 1.795 trazados de las fechas descritas. </li></ul><ul><li>El promedio de edad de presentación fue de 62 años (mujeres 67,7 años; hombres 60 años). </li></ul><ul><li>48 horas post terremoto el promedio de edad fue de 67 años (mujeres 70,6 años; hombres 59,7 años). </li></ul>
  103. 122. Enero 2009
  104. 123. Febrero 2009
  105. 124. Marzo 2009
  106. 125. Junio 2009
  107. 126. Julio 2009
  108. 127. Agosto 2009
  109. 128. Junio 2010
  110. 129. Julio 2010
  111. 130. Agosto 2010
  112. 131. Enero 2010
  113. 132. Febrero 2010
  114. 133. Marzo 2010
  115. 134. Resultados <ul><li>Un estado hiperadrenérgico se puede evidenciar indirectamente a través del aumento de la frecuencia cardiaca y de la presión arterial observada en otros pacientes en el mismo día a la hora de la catástrofe </li></ul>
  116. 136. FECHA ECG Lesiones subepicárdicas RIESGO ABSOLUTO p 27 y 28 febrero 352 12 3,41% 2 y 3 ene 2010 705 12 1,70% p<0.05 9 y 10 ene 2010 670 6 0,90% p<0.05 16 y 17 ene 2010 694 8 1,15% p<0.05 23 y 24 ene 2010 739 9 1,22% p<0.05 30 y 31 ene 2010 598 9 1,51% p<0.05 6 y 7 feb 20100 590 8 1,36% p<0.05 13 y 14 feb 2010 717 5 0,70% p<0.05 20 y 21 feb 2010 749 7 0,93% p<0.05 6 y 7 mar 2010 605 8 1,32% p<0.05 13 y 14 mar 2010 595 8 1,34% p<0.05 20 y 21 mar 2010 633 11 1,74% p<0.05 27 y 28 mar 2010 632 11 1,74% p<0.05
  117. 137. FECHA ECG Lesiones subepicárdicas RIESGO ABSOLUTO p 27 y 28 febrero 352 12 3,41% 5 y 6 jun 2010 751 8 1,07% p<0.05 12 y 13 jun 2010 823 13 1,58% p<0.05 19 y 20 jun 2010 750 6 0,80% p<0.05 26 y 27 jun 2010 795 8 1,01% p<0.05 3 y 4 jul 2010 757 13 1,72% p<0.05 10 y 11 jul 2010 696 7 1,01% p<0.05 17 y 18 jul 2010 660 11 1,67% p<0.05 24 y 25 jul 2010 778 10 1,29% p<0.05 31 jul/01 ago 2010 712 9 1,26% p<0.05 07 y 08 ago 2010 752 7 0,93% p<0.05 14 y 15 ago 2010 721 10 1,39% p<0.05 21 y 22 ago 2010 834 10 1,20% p<0.05 28 y 29 ago 2010 757 7 0,92% p<0.05
  118. 138. FECHA ECG Lesiones subepicárdicas RIESGO ABSOLUTO p 27 y 28 febrero 352 12 3,41% 3 y 4 ene 2009 590 9 1,53% p<0.05 10 y 11 ene 2009 582 6 1,03% p<0.05 17 y 18 ene 2009 645 10 1,55% p<0.05 24 y 25 ene 2009 585 12 2,05% p<0.05 31 ene/ 01 feb 2009 618 10 1,62% p<0.05 7 y 8 feb 2009 647 11 1,70% p<0.05 14 y 15 feb 2009 624 7 1,12% p<0.05 21 y 22 feb 2009 611 12 1,96% p<0.05 28 feb / 01 mar 2009 671 7 1,04% p<0.05 7 y 8 mar 2009 670 11 1,64% p<0.05 14 y 15 mar 2009 638 11 1,72% p<0.05 21 y 22 mar 2009 580 6 1,03% p<0.05 28 y 29 mar 2009 596 5 0,84% p<0.05
  119. 139. FECHA ECG Lesiones subepicárdicas RIESGO ABSOLUTO p 27 y 28 febrero 352 12 3,41% 6 y 7 junio 2009 663 8 1,21% p<0.05 13 y 14 junio 2009 610 9 1,48% p<0.05 20 y 21 junio 2009 535 9 1,68% p<0.05 27 y 28 junio 2009 602 9 1,50% p<0.05 4 y 5 julio 2009 701 12 1,71% p<0.05 11 y 12 julio 2009 695 9 1,29% p<0.05 18 y 19 julio 2009 638 8 1,25% p<0.05 25 y 26 julio 2009 667 7 1,05% p<0.05 1 y 2 ago 2009 754 8 1,06% p<0.05 8 y 9 ago 2009 735 12 1,63% p<0.05 15 y 16 ago 2009 656 9 1,37% p<0.05 22 y 23 ago 2009 832 13 1,56% p<0.05 29 y 30 ago 2009 807 14 1,73% p<0.05
  120. 140. Stress and the heart <ul><li>There are extensive data concerning “stressors” contribution to: </li></ul><ul><li>Sudden death </li></ul><ul><li>Myocardial infarction and myocardial ischemia </li></ul><ul><li>Changes in sympathetic activity and hemostasis </li></ul>
  121. 141. Earthquakes are acute stressors and there are data about the increase in the number of AMI and sudden deaths. TELEMEDICINE has allowed us to study the impact of an earthquake on the number of AMI
  122. 142. Earthquake in Chile <ul><li>February 27th at 3:34 AM Chile suffered the most devastating earthquake and tsunami of its history, 8,8 of Richter`s scale. </li></ul><ul><li>Great destruction from the 5th to the 9th regions (center of the country, including Santiago, the capital) </li></ul>
  123. 145. Preliminary data <ul><li>194.376 EKG by TELEMEDICINE were analyzed </li></ul><ul><li>Group 1: First trimester 2009 </li></ul><ul><li>Group 2: Second trimester 2009 </li></ul><ul><li>Group 3 : First trimester 2010 </li></ul><ul><li>1323 subepicardial lesions were diagnosed </li></ul><ul><li>Daily distribution of lesions of group 3 was compared with groups 1 and 2 </li></ul>
  124. 146. Impact of earthquake: daily diagnosis of AMI <ul><li>Group 1 (1 st trimester ,2009): </li></ul><ul><li>0,2 - 2.7%; asimmetry coefficient: 1.08 </li></ul><ul><li>Group 2 (2 nd trimester, 2009): </li></ul><ul><li>0,2 - 3.0%; asimmetry coefficient : 1,14 </li></ul><ul><li>Group 3 (1 st trimester 2010): </li></ul><ul><li>0 - 4.8%; asimmetry coefficient: 2,8 </li></ul>
  125. 147. Daily incidence of AMI: first trimester 2009
  126. 148. Daily incidence of AMI, first trimester 2010 earthquake
  127. 149. Impact of earthquake <ul><li>The number of AMI is underestimated since communications were interrupted, although Telemedicine system restarted within 20 min. </li></ul><ul><li>This is the first study performed using Telemedicine under this situation </li></ul>
  128. 150. TELE-ELECTROCARDIOGRAPHY IN CHILE. CONCLUSIONS <ul><li>IT HAS POWERFULLY CONTRIBUTED TO THE EARLY TREATMENT OF AMI . </li></ul><ul><li>IT HAS FACILITADED TREATMENT OF OTHER CARDIAC EMERGENCIES </li></ul><ul><li>IT HAS ALLOWED THE STUDY OF PREVALENCE OF SOME EKG PATTERNS </li></ul>
  129. 151. TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>GREAT SUPPORT TO PRIMARY CARE PHYSICIANS BY SPECIALISTS </li></ul><ul><li>REFERRAL OF NEW AND/OR COMPLICATED PATIENTS TO CARDIOLOGISTS </li></ul><ul><li>INCREASES EFFICIENCY OF MEDICAL PRACTICE </li></ul><ul><li>IT IS A TOOL FOR PREVENTION PROGRAMS </li></ul>
  130. 152. TELEELECTROCARDIOGRAPHY IN CHILE <ul><li>QUICK RESPONSE ( REPORT IN 5 TO 10 MIN). </li></ul><ul><li>EQUIPMENT EASY TO USE </li></ul><ul><li>POSSIBILITY TO USE EVEN IN REMOTE PLACES </li></ul><ul><li>SECOND OPINION BY THE SPECIALIST AT ANY TIME </li></ul><ul><li>FACILITATES DECISION MAKING: AVOIDS UNNECESSARY TRANSFER OF PATIENTS; ACCELERATES </li></ul><ul><li>THE ONES NEEDED; ALLOWS TO INITIATE IMMEDIATE TREATMENT </li></ul><ul><li>EXTENSIVE COVERAGE AND LOW COST </li></ul><ul><li>FEEDBACK OF USERS: </li></ul>
  131. 153. TELECTROCARDIOGRAPHY IN CHILE <ul><ul><ul><li>CONTRIBUTORS </li></ul></ul></ul><ul><ul><ul><li>AT PRESENT: </li></ul></ul></ul><ul><li>PATRICIA ADRIAZOLA ARTURO ARRIBADA WALTER KUHNE FRANCESCA BELLO ROBERTO DEL PINO </li></ul><ul><li>MIRTA ORELLANA JOSE DE HORTA PATRICIO CASTRO </li></ul><ul><li>GUILLERMO DE LA CUADRA MIGUEL BENEDIKT </li></ul><ul><li>ENRIQUE ALMAGRO MARCELO LINDH LEONEL VARGAS </li></ul><ul><li>ALVARO SEP ÚLVEDA CARLOS PIEDRA HERNÁN NOGUERA </li></ul><ul><li>JOSÉ LIPCHENKA ALBERTO COHEN </li></ul>
  132. 154. THANKS VERY MUCH FOR YOUR ATTENTION
  133. 156. ITMS puede contribuir al diagnóstico de SCA a través del informe del ECG y al tratamiento mediante el apoyo telefónico del especialista
  134. 157. Lesiones subepicárdicas:resumen <ul><li>Se analizaron 523 371 ECG </li></ul><ul><li>Se detectaron 3656 lesiones </li></ul><ul><li>69% hombres. 31% mujeres </li></ul><ul><li>Mujeres en edades más tardías </li></ul><ul><li>Mayor frecuencia entre Abril y Julio </li></ul><ul><li>Mayor frecuencia entre las 9 y 18 horas con un máximo entre las 11 y 13 horas </li></ul><ul><li>Mayor número entre la 7 y 9 regiones </li></ul>(1) Rev.Chilena de Cardiologìa 2009;28:73-80
  135. 160. IMPACT OF AUGE IN THE TREATMENT OF PATIENTS WITH AMI 1. Thrombolysis 2. Primary PTCA 3. Coronariography 4. Rescue PTCA 5. Delayed PTCA P. CAMPOS ET AL . REV CHIL CARDIOL. VOL 26 2007.
  136. 162. Servicio de Tele-ECG en apoyo a Eventos Coronarios Agudos SAPU SAMU Hospital de Referencia SAPU o Traslado
  137. 163. ECG
  138. 165. <ul><li>Tiempo es Miocardio </li></ul><ul><li>Tiempo “Puerta-a-Tratamiento” </li></ul><ul><li>Tiempo “Llamada-a-Tratamiento” </li></ul><ul><li>Infarto pequeño significa menor número de complicaciones </li></ul>
  139. 184. TOTAL NUMBER OF DIAGNOSIS: 1 522 546 TOTAL NUMBER OF TRACINGS: 838 077 (Sept 1, 2002 up to May 13, 2009)
  140. 185. Telemedicina de Chile <ul><li>Al 11 de Julio del 2006 existen en nuestra base de datos 262 776 electrocardiogramas. </li></ul><ul><li>212 542 en plataforma HRS y 50 234 en plataforma Rems. </li></ul>
  141. 186. TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><li>BETWEEN SEPT.1, 2002 and MAY 13, 2009 </li></ul><ul><li>WE HAVE READ: </li></ul><ul><li>838 707 TRACINGS </li></ul><ul><li>REPRESENTING 1 522 546 DIAGNOSIS </li></ul>
  142. 188. Resumen Investigación Dr. Ricardo Villarroel Director Médico H. La Ligua Estudio en Eventos Coronarios Agudos en Hospital La Ligua. (Oct. 2003 – Mayo 2004 basado en informes de telemedicina) Sensibilidad 98% Especificidad 100% Resultado Test Enfermedad Presente Enfermedad Ausente POSITIVO 67 0 NEGATIVO 1 582
  143. 189. Relación Costo Efectividad (Costo Unitario de Traslado) Resumen Investigación Dr. Ricardo Villarroel Director Médico H. La Ligua Móvil (240 Km) $25.000 Personal ( sin hrs. Médicas ) $ 8.000 Insumos $ 4.000 Otros (mantención equipos, etc) $ 1.000 Total $38.000
  144. 190. TELE-ELECTROCARDIOGRAPHY IN CHILE <ul><ul><ul><li>COWORKERS. </li></ul></ul></ul><ul><ul><ul><li>PHYSICIANS : </li></ul></ul></ul><ul><li>PATRICIA ADRIAZOLA ARTURO ARRIBADA RAFAEL MENDEZ </li></ul><ul><li>MARGARITA VEJAR WALTER KUHNE JORGE LARROSA </li></ul><ul><li>FRANCESCA BELLO ROBERTO DEL PINO </li></ul><ul><li>MIRTA ORELLANA JOSE DE HORTA </li></ul><ul><li>PAMELA TREJO VICTOR ROSSEL </li></ul><ul><li>LEONOR VILLALBA PATRICIO CASTRO </li></ul><ul><li>BARBARA CLERICUS ROBERTO CONCEPCION </li></ul><ul><li>MARIANELA SEGUEL GUILLERMO DE LA CUADRA </li></ul><ul><li>SOLANGE DONOSO MIGUEL BENEDIKT </li></ul><ul><li>MARCELO LINDH ENRIQUE ALMAGRO </li></ul><ul><li>ENGINEERS : </li></ul><ul><li>FRANCISCO FERNANDEZ HUGO LEON </li></ul><ul><li>JORGE ARAVENA FERNANDO FIGUEROA </li></ul>
  145. 192. Intervalo QT prolongado <ul><li>En el crecimiento VI por criterio electrocardiográfico y/o ecocardiográfico se ha documentado una asociación con intervalo QT prolongado. </li></ul><ul><ul><ul><li> J of Hypertension 2001;19:1883-1991 </li></ul></ul></ul><ul><ul><li> Am J Cardiol 2000;86:1117–1122 </li></ul></ul><ul><ul><li> Circulation 2003;107:1764-1769 </li></ul></ul>
  146. 193. Intervalo QT prolongado <ul><li>La prolongación del intervalo QT en relación a la duración del QRS en los bloqueos completos de rama ha sido motivo de discusión. </li></ul><ul><ul><li>Am J Cardiol. 1992;70:628–629 </li></ul></ul><ul><ul><li>J Electrocardiol. 1990;23:49–52 </li></ul></ul><ul><ul><li>Circulation 2003;108:1985-1989 </li></ul></ul>
  147. 194. Intervalo QTc prolongado <ul><li>Los trazados fueron analizados con un sistema computacional, utilizando el software Aerotel HRS 6.0, que permite efectuar mediciones de los diferentes intervalos a una velocidad de 100 mm/seg. </li></ul>
  148. 195. Intervalo QTc prolongado <ul><li>Se consideró prolongado un valor de QTc ≥ 440 mseg., en las tres derivaciones. </li></ul><ul><li>Se eligió para el análisis posterior el valor más prolongado. </li></ul>
  149. 196. Intervalo QTc prolongado <ul><li>Para el análisis estadístico se utilizó la prueba de chi-cuadrado </li></ul><ul><li>En los bloqueos de rama se utilizó análisis de correlación para evaluar la relación entre la duración del QRS y el QTc </li></ul>
  150. 197. Resultados <ul><li>El análisis del intervalo QTc mostró diferencias estadísticamente significativas: </li></ul><ul><ul><li>BCRI vs trazados normales p<0,001 </li></ul></ul><ul><ul><li>BCRD vs trazados normales p<0,001 </li></ul></ul><ul><ul><li>CVI por criterio de voltaje vs trazados normales p<0,001 </li></ul></ul>
  151. 198. QRS y QTc en BCRD <ul><li>Pearson 0,181 </li></ul><ul><li>(0,15 – 0,21) </li></ul><ul><li>R2 0,0326 </li></ul>
  152. 199. QRS y QTc para frecuencia fija en BCRI <ul><li>FC 82 / min </li></ul><ul><li>Pearson 0.32 </li></ul><ul><li>R2 0.102 </li></ul>
  153. 200. QRS y QTc para frecuencia fija en BCRD <ul><li>FC 77 / min </li></ul><ul><li>Pearson 0,129 </li></ul><ul><li>R2 0,016 </li></ul>
  154. 201. Limitaciones <ul><li>Sólo tenemos el análisis del trazado electrocardiográfico </li></ul><ul><li>Desconocemos las patologías asociadas de estos pacientes y el uso eventual de medicamentos </li></ul><ul><li>No conocemos la evolución clínica posterior </li></ul>
  155. 202. <ul><li>Sin embargo, estos resultados adquieren validez por el alto número de trazados analizados, muy superior a lo descrito en la literatura. </li></ul>
  156. 203. Results
  157. 204. Results
  158. 205. TELE-ELECTROCARDIOGRAPHY IN CHILE

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