“False-Positive” Cardiac Catheterization Laboratory Activation Among Patients With Suspected ST-Segment Elevation Myocardial Infarction

Abstract Background Fatigue and sleepiness contribute to medical errors, although the effect of circadian disruption and fatigue on diagnostic reasoning skills is largely unknown. Objective To determine whether circadian disruption and fatigue negatively affect the emergency medicine (EM) resident's ability to make important clinical decisions based on electrocardiogram (ECG) interpretation. Methods Senior EM residents at 2 programs completed a questionnaire consisting of various measures of fatigue followed by an ECG test packet of ST-segment elevation myocardial infarction (STEMI) and STEMI mimics. Participants were asked to examine each ECG and determine whether cardiac catheterization laboratory activation (CLA) was indicated, and to report their confidence in their decision making on an 11-point, numeric rating scale. The primary outcome measured was a pairwise difference in accuracy of CLA between daytime and overnight testing. Results A total of 23 residents were enrolled in 2011 and 2012. Subjects demonstrated significant differences in multiple measures of sleepiness and fatigue during overnight periods. The median (interquartile range [IQR]) accuracy of CLA was not significantly different between daytime and overnight (70% [IQR, 50–80] versus 70% [IQR, 60–70], P = .82). There were no significant differences in the median number of overcalls (CLA when not a STEMI) and undercalls (no CLA when a STEMI was present; P = .57 and .37, respectively). Diagnostic confidence and confidence in CLA were not statistically different between daytime and overnight. Conclusions Despite a measurable degree of fatigue, senior EM residents experienced no decrease in their ability to accurately make CLA decisions based on ECG interpretation.

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Abstract 19059: Thermodilution-derived Coronary Blood Flow Pattern Immediately After Coronary Intervention as a Predictor of Long-term Clinical Outcomes in Patients With ST-segment Elevation Myocardial Infarction

Circulation ◽

10.1161/circ.130.suppl_2.19059 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Masashi Fukunaga ◽

Kenichi Fujii ◽

Machiko Nishimura ◽

Tetsuo Horimatsu ◽

Ten Saita ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Intervention ◽

St Segment Elevation ◽

Catheterization Laboratory ◽

Cardiac Catheterization Laboratory ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Temperature Time ◽

Thermodilution Curve

Background: We reported that coronary blood flow (CBF) can be evaluated by analyzing thermodilution curve that is measured with a single pressure sensor/thermistor-tipped guidewire in the cardiac catheterization laboratory during percutaneous coronary intervention (PCI). Bimodal shape of thermodilution curve was associated with microvascular damage and predictors of left ventricular functional recovery after ST-segment elevation myocardial infarction (STEMI). However it is unknown whether the bimodal shape of thermodilution curve predicts mortality and re-hospitalization for heart failure in long term period for patients experiencing STEMI. Methods: Between September 2009 and August 2012, 97 consecutive patients with a first STEMI were prospectively enrolled in this study. Using a pressure sensor/thermistor-tipped guidewire, CBF pattern was assessed from the thermodilution-curves after successful PCI at maximum hyperemia. CBF pattern was classified into 3 groups according to the shape of thermodilution curve: a narrow unimodal (a rapid fall and rise of temperature-time curves) (n=47), a wide unimodal (a gradual fall and rise of temperature-time curves) (n=33), or bimodal (two populations with valley deeper than 20% of peak temperature drop) (n=17). Major adverse cardiac events (MACE) were defined as cardiac death and/or heart failure re-hospitalization within this study period. Results: Median follow-up period was 2.4 years. Although patients in the narrow-unimodal group and the wide unimodal group had a significantly lower incidence of MACE, patients in bimodal group had a higher risk of MACE during this study period (71, 15, 21%, p<0.001). Multivariate analysis revealed that bimodal shape of the thermodilution-curve was the only independent predictor of MACE after STEMI (hazard ratio, 8.38; 95% confidence interval, 2.13-33.00; P=0.0023). Conclusions: A bimodal shape of the thermodilution curve is associated with the poor long-term clinical outcomes. This easily assessable coronary flow pattern is useful in clinical risk stratification for STEMI patients in the cardiac catheterization laboratory immediately after PCI.

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