A Retrospective Analysis of Hospital Electrocardiogram Auto-Populated QT Interval Calculation.

Abstract

BackgroundThe current electrocardiogram (ECG) standard for rate correction of the QT interval (QTc) is a power function known as the Bazett formula (QTcB). QTc formulae are either power functions or linear functions. QTcB is known to lack reliability, as heart rate (HR) rises from or falls below 60 beats per minute (bpm). The American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and the Heart Rhythm Society (HRS) have recommended using other formulae in place of QTcB since 2009. The Epic Electronic Health Record System (Epic Systems Corporation, Verona, WI) automatically populates the Fridericia formula (QTcFri) on hospital ECG reports without any provider calculation.MethodsWe aimed to retrospectively investigate the effect of QTcFri on one year of ECGs in the Epic Electronic Health Record (EHR) at a single tertiary care center. Inclusion criteria for ECG reports specified HR 60-120 bpm without QRS duration > 120 ms. Gathered data from Epic EHR ECG reports included patient age, sex, HR, QRS duration (QRSd), QT interval, QTcB, and QTcFri. EHR documented 61,946 ECG reports for the year, with 44,566 meeting criteria for inclusion. General statistical methods included range, median, mean, and standard deviation. Confidence intervals were assessed to maintain the fidelity of analysis. The normality of data distribution was assessed with Kolmogorov-Smirnov testing. The Wilcoxon rank-sum test was then performed to confirm a statistically significant difference between the Bazett and Fridericia formulae. The ∆QTc analysis was conducted on prolonged QTc (males > 450 ms; females > 460 ms) and severely prolonged QTc > 500 ms data subsets. A value of p<0.05 was interpreted as significant. Statistical analysis was performed using SPSS statistical software (IBM Statistics, v. 26; IBM Corp, Armonk, NY).ResultsThe 44,566 ECG reports demonstrated 57% female gender and a mean age of 57 ± 17.5 years. The mean HR was 83 ± 14.7 bpm and the mean ∆QTc was 23 ± 12.9 ms shorter with QTcFri. Mean data showed minimal variation between sexes: age, heart rate, uncorrected QT, QTcB, QTcFri, and ∆QTc varied by less than 2%. Mean QRS varied by 4% between sexes. The Wilcoxon rank-sum test revealed 44,127 ranks with a negative difference, 0 ranks with a positive difference, and 439 ties, p <0.001 (99% CI: 22.5 ms, 23.0 ms). QTcB identified 37.4% (16665/44566) ECGs prolonged. Using QTcFri, 21% (9371/44566) of the total ECGs corrected to normal QTc (<450 ms (men) and 460 ms (women)). QTcFri use reduced the number of ECG reports with QTc > 500 ms by 57.3%. A total of 125 ECG reports, 117 females and eight males, corrected to normal gender-specific QTc with QTcFri. The mean decrease in QTc with the Fridericia formula when QTcB > 500 ms was 31 ± 14.5 ms (99% CI: 30.4 ms, 31.7 ms).ConclusionOur data from the Wilcoxon rank-sum analysis indicated that the EHR QTcFri analysis yields a statistically significant difference (p < 0.001) in QTc calculation of 22 ms over 44,566 ECG reports. The data showed a 21% reduction in inaccurately documented test results. The utilization of this resource will provide the most accurate and clinically relevant data to inform clinical decision-making. Accurate QT interval calculation will better inform downstream clinical decision-making through a wider scope of therapeutic intervention. This analysis is readily available to clinicians without calculation and its awareness will benefit patient care.