Electrocardiogram Screening Research Articles

P4457Cardiac screening is improved by the addition of vectorcardiography

Abstract Background The most common cause of sudden cardiac death in the United State of America is hypertrophic cardiomyopathy, while other causes such as left ventricular hypertrophy, ion-channelopathies, and other causes are also significant. Screening programs typically involve electrocardiograms with mainly false positive results. Little data regarding EKG and echocardiographic screening combined have been published. Methods During 2016–2019, over 15000 patients were screened by the Heartfelt Cardiac screening program. Screening electrocardiograms and echocardiograms including parasternal short/long axis, 4-chamber views, coronary assessment with color doppler and subcostal views with color doppler for assessment of septal defects, were performed. Results 15,329 patients were screened under 35 years of age, mean age 17 years, with 36 hypertrophic cardiomyopathy patients, 61 borderline left ventricular hypertrophy patients noted, 30 patients with left ventricular dysfunction were noted, 47 patients with mitral valve prolapse, 27 patients with atrial septal defects, 39 patients with Wolf-Parkinson-White, 21patients with ideopathic dilated cardiomyopathy were discovered. Screening electrocardiography was helpful for Wolf-Parkinson-White identification, while echocardiogram was most helpful for detection of the above other defects. Screening EKG only identified 45% of those patients with myocardial disease (per above) with the modified Seattle Screening and ESC screening criteria. Conclusion Screening echocardiogram adds value for screening athletes under 35 years at risk for sudden cardiac death. Consideration of cost-effective echo screening should be considered as part of routine screening.

P308Utility of a prominent R wave in lead V1 of a resting electrocardiogram for detecting significant cardiac pathology in an unselected population of young males

Abstract Background Pre-participation electrocardiogram (ECG) screening is proposed as a means to detect cardiac pathology in asymptomatic individuals, and to select individuals for further cardiac investigation. Isolated ECG finding of Right Ventricular Hypertrophy (RVH) does not require further investigation based on the recent 2017 International Criteria. However, a prominent R wave in V1 has been described in cardiac abnormalities such as Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, cardiomyopathy in Duchenne muscular dystrophy, arrhythmogenic right ventricular cardiomyopathy (ARVC), atrial septal defect and pulmonary hypertension. Purpose We sought to examine the utility of a prominent R wave in V1 as a screening criterion in an asymptomatic young male population of predominantly non-athletes, to detect significant structural cardiac pathology. Methods As part of the Singapore Armed Forces Electrocardiographic and Echocardiographic (SAFE) Protocol Study, pre-military enlistment screening ECG data was collected from 144,346 males between the ages of 16 to 22 from November 2009 to December 2014. Patients with ECGs with a prominent R wave, defined as an R wave ≥0.5mV in lead V1 with an R/S ratio of ≥1, were sent to a tertiary medical facility for a detailed transthoracic echocardiogram and subsequent cardiologist review. Any cardiac pathology identified was deemed significant if it led to the patient being excluded from participation in vigorous physical activity. Results 1,144 patients with an isolated prominent R wave in V1 were studied. The mean age was 18.2±1.09 years and 81% were of Chinese ethnicity. None of the patients had echocardiographic evidence of RVH, 5 patients had a dilated right ventricle and 3 individuals had an elevated pulmonary artery systolic pressure. 11 patients (0.96%) had significant structural heart disease known to be associated with a prominent R wave in V1 that excluded them from participation in physical activity. These included large atrial septal defects (n=8), pulmonary stenosis (n=1), total anomalous pulmonary venous return (n=1) and hypertrophic cardiomyopathy (n=1). The test has a sensitivity of 21.6%, specificity of 93.4%, positive predictive value of 0.96% and negative predictive value of 99.8%, Performance As Screening Criteria Number of Patients With Cardiac Pathology In Those Tested Positive Number of Patients With Cardiac Pathology In Those Tested Negative Positive Predictive Value (%) Negative Predictive Value (%) Sensitivity (%) Specificity (%) 11 40 0.96 99.8 21.6 93.4 Significant Cardiac Pathology Identified Conclusion A prominent R in V1 is not associated with echocardiographic RVH, or ARVC even in a large predominantly non-athletic male population. However, 0.96% of such patients would have other significant cardiac pathologies such as a large atrial septal defect.

Electrocardiogram interpretation in NCAA athletes: Comparison of the ‘Seattle’ and ‘International’ criteria

BackgroundAccurate electrocardiogram (ECG) interpretation in competitive athletes requires the distinction of physiological adaptations from findings suggestive of a pathological condition. The purpose of this study was to compare the performance of the Seattle Criteria to the International Criteria in a large dataset of NCAA athletes screened with an ECG. MethodsECGs from 5258 NCAA athletes who underwent prior ECG screening were re-examined by two experts in the field of sports cardiology and by ECG interpretation software by Cardea (© 2018 Cardiac Insight Inc.) using the Seattle and International Criteria. Each ECG was classified as normal or abnormal and the specific ECG abnormalities noted. Chi-squared analysis was used for statistical comparisons. ResultsThe total number of ECGs flagged as abnormal by expert over-read decreased from 158 (3.0%) using the Seattle Criteria to 83 (1.6%) using the International Criteria (p<0.0001). Likewise, the total number of abnormal ECGs using ECG interpretation software by Cardea decreased from 278 (5.3%) using Seattle Criteria programming compared to 134 (2.5%) using International Criteria programming (p<0.0001). The most common ECG abnormality by expert over-read using the International Criteria was T wave inversion 40 (48%). The newer definition of pathological Q waves reduced the number of ECGs flagged as abnormal from pathologic Q waves from 69 (Seattle) to 11 (International) (84% reduction; p<0.0001). Expert over-read using both criteria and both Cardea interpretation programs identified all 13 athletes with cardiac pathology associated with sudden cardiac death. Cardea software using the International Criteria had a higher false-positive rate (2.3%) than expert over-read (1.3%) (p=0.0001). ConclusionsUse of the International Criteria for ECG interpretation significantly reduces the total abnormal and false-positive ECG rates compared to the Seattle Criteria without compromising sensitivity. Cardea interpretation software performs well and may be a useful tool to assist clinicians.

Comparison of Electrophysiologic Profiles in Pediatric Patients with Incidentally Identified Pre-Excitation Compared with Wolff-Parkinson-White Syndrome

The rising utilization of screening electrocardiograms has resulted in increased incidental identification of ventricular pre-excitation in pediatric patients. We compared accessory pathways of incidentally identified pre-excitation to Wolff-Parkinson-White Syndrome (WPW) with the aim to identify factors important in preprocedural counseling and planning. This single-center, retrospective study of patients ≤18 years without congenital heart disease identified 227 patients diagnosed with pre-excitation and referred for invasive electrophysiology study between 2008 and 2017. WPW Syndrome was diagnosed in 178 patients, while 49 patients had incidental identification of pre-excitation. Anterograde conduction of incidentally identified accessory pathways was not clinically different between the two cohorts at baseline or upon isoproterenol infusion. However, the proportion of accessory pathways meeting high-risk criteria was significantly lower than in patients diagnosed with WPW, 12% versus 28% (p < 0.05). Retrograde conduction at baseline of incidentally diagnosed accessory pathways was slower with a median block cycle length 365 milliseconds (IQR 260 to 450) versus 290 milliseconds (IQR 260 to 330, p < 0.01). In the incidentally identified cohort, right-sided, paraHisian, and fascicular pathways were more common with fewer attempted ablations (71% vs 94%, p < 0.001) and lower success rate (91% vs 97%, p < 0.001). A binomial logistic regression analysis further indicated patients incidentally identified with pre-excitation were associated with having lower rates of inducible supraventricular tachycardia, atrial fibrillation, and ablations performed, in addition, to having right-sided pathways. In conclusion, as patients with incidentally identified pre-excitation present more frequently for consideration of invasive electrophysiology study, these results impact procedural approaches, technical considerations, patient counseling, and outcome expectations.

ECG-based cardiac screening programs: Legal, ethical, and logistical considerations

Screening asymptomatic people with a resting electrocardiogram (ECG) has been theorized to detect latent cardiovascular disease. However, resting ECG screening is not recommended for numerous populations, such as asymptomatic middle-aged (sedentary) people, as it is not sufficiently sensitive to detect coronary artery disease. While the issues raised in this article are largely common to all screening programs, this review focuses on 2 distinct programs: (1) screening elite athletes for conditions associated with sudden cardiac death (SCD); and (2) screening people aged ≥65 years for atrial fibrillation (AF). These 2 settings have recently gained attention for their promise and concerns regarding prevention of SCD and stroke, respectively. If screening is to be done, it must be done well. Organizations conducting screening must consider a range of legal, ethical, and logistical responsibilities that arise from the beginning to the end of the process. This includes consideration of who to screen, timing of screening, whether screening is mandatory, consent issues, and auditing systems to ensure quality control. Good infrastructure for interpretation of ECG results according to expert guidelines and follow-up testing for abnormal screening results, including a pathway to treatment, are essential. Finally, there may be significant implications for those diagnosed with cardiac disease, including insurance, employment, the ability to play sport, and mental health issues. There are several legal risks, and the best protective measures are good communication systems, thorough clinical record-keeping, careful handling of eligibility questions for those diagnosed, and reference to expert guidelines as the standard of care.

Abstract P415: Correlation of Screening Electrocardiogram, Transthoracic Echocardiogram, and ASCVD Risk Score to 10 Year ASCVD Outcomes Among Asymptomatic Community Dwelling Women

Background: The efficacy and value of non-traditional screening methods such as electrocardiogram (ECG) and transthoracic echocardiography(TTE) remain unknown. In this study, we examined the correlation between initial ECG and TTE findings, and atherosclerotic cardiovascular disease (ASCVD) 10 year risk score with actual 10-year ASCVD outcomes among asymptomatic women from a community-based screening program cohort at Rush University Medical Center. Methodology: A 10-year follow-up survey was conducted in March-September 2018 from the 355 participants from the initial 2BigHearts community screening program in 2007. Demographics, past medical history, ASCVD outcomes (stroke, non-fatal MI, PAD), and self-reported medication lists were obtained from the 107 participants who responded to the survey. Pearson Chi-square Test was used to determine the association of ECG, TTE, and calculated ASCVD risk score with ASCVD outcomes and heart failure(HF). Results: Amongst the 107 participants (mean age 63±10.6 years, 68.3% (71/104) Caucasian, 18.3% (19/104) African American, 8.6% (9/104) Hispanic, 4.8% (5/104) Asian), 15% (16/107) had baseline TTE abnormality with chamber enlargement as most common while 29.9% (32/107) had baseline ECG abnormality with conduction abnormalities as most common. The mean ASCVD 10 year risk score was 4.02%±4.5%. Of the 107, 11 had ASCVD score ≥ 7.5% of which 2 developed non-fatal MI and PAD. Other co-morbid conditions included 29% (31/107) hyperlipidemia, 22.4% (24/107) hypertension, 8.4% (9/107) diabetes, 6.5% (7/107) obstructive sleep apnea and 12.1% (13/107) any type of cancer. Chi-square testing showed no statistically significant correlation between ECG or TTE abnormality with ASCVD outcome (p=0.251 ECG, p=0.461 TTE). Baseline ASCVD risk score of ≥7.5% was associated with 10-year ASCVD outcome (p=0.003) and abnormal TTE at baseline was associated with heart failure in 10-year follow-up (p=0.017). Conclusion: This study found no association between abnormal screening ECG and TTE findings with 10-year ASCVD outcomes (stroke, non-fatal MI, PAD). However, abnormal TTE findings are associated with HF. ASCVD pooled cohort equation proved to be better than ECG and TTE in predicting ASCVD outcomes.

Deep Learning-Based Electrocardiogram Signal Noise Detection and Screening Model.

ObjectivesBiosignal data captured by patient monitoring systems could provide key evidence for detecting or predicting critical clinical events; however, noise in these data hinders their use. Because deep learning algorithms can extract features without human annotation, this study hypothesized that they could be used to screen unacceptable electrocardiograms (ECGs) that include noise. To test that, a deep learning-based model for unacceptable ECG screening was developed, and its screening results were compared with the interpretations of a medical expert.MethodsTo develop and apply the screening model, we used a biosignal database comprising 165,142,920 ECG II (10-second lead II electrocardiogram) data gathered between August 31, 2016 and September 30, 2018 from a trauma intensive-care unit. Then, 2,700 and 300 ECGs (ratio of 9:1) were reviewed by a medical expert and used for 9-fold cross-validation (training and validation) and test datasets. A convolutional neural network-based model for unacceptable ECG screening was developed based on the training and validation datasets. The model exhibiting the lowest cross-validation loss was subsequently selected as the final model. Its performance was evaluated through comparison with a test dataset.ResultsWhen the screening results of the proposed model were compared to the test dataset, the area under the receiver operating characteristic curve and the F1-score of the model were 0.93 and 0.80 (sensitivity = 0.88, specificity = 0.89, positive predictive value = 0.74, and negative predictive value = 0.96).ConclusionsThe deep learning-based model developed in this study is capable of detecting and screening unacceptable ECGs efficiently.

Noise Rejection for Wearable ECGs Using Modified Frequency Slice Wavelet Transform and Convolutional Neural Networks

Progress in wearable techniques makes the long-term daily electrocardiogram (ECG) monitoring possible. However, the long-term wearable ECGs can be significantly contaminated by various noises, which affect the detection and diagnosis of cardiovascular diseases (CVDs). The situation becomes more serious for wearable ECG screening, where the data are huge, and doctors have no way to visually check the signal quality episode-by-episode. Therefore, automatic and accurate noise rejection for the wearable big-data ECGs is craving. This paper addressed this issue and proposed a noise rejection method for wearable ECGs based on the combination of modified frequency slice wavelet transform (MFSWT) and convolutional neural network (CNN). Wearable ECGs were recorded using the newly developed 12-lead Lenovo smart ECG vest with a sample rate of 500 Hz and a resolution of 16 bit. One thousand 10-s ECG segments were picked up and were manually labeled into three quality types: clinically useful segments with good signal quality (type A), clinically useful segments with poor signal quality (type B), and clinically useless segments (pure noises, type C). Each of the 1,000 10-s ECG segments were transformed into a 2-D time-frequency (T-F) image using the MFSWT, with a pixel size of $200\times 50$ . Then, the 2-D grayscale images from MFSWT were fed into a 13-layer CNN model for training the classification models. Results from the standard 5-folder cross-validation showed that the proposed combination method of MFSWT and CNN achieved a highest classification accuracy of 86.3%, which was higher than the comparable methods from continuous wavelet transform (CWT) and artificial neural networks (ANN). The combination of MFSWT and CNN also had a good calculation efficiency. This paper indicated that the combination of MFSWT and CNN is a potential method for automatic identification of noisy segments from wearable ECG recordings.

Opportunistic Electrocardiogram Screening for Atrial Fibrillation to Prevent Stroke

Opportunistic Electrocardiogram Screening for Atrial Fibrillation to Prevent Stroke

Eligibility for subcutaneous implantable cardioverter defibrillators in the adult congenital heart disease population.

Patients with adult congenital heart disease (ACHD) have an increased risk of arrhythmic and sudden cardiac death. The subcutaneous implantable cardioverter defibrillator (S-ICD) provides a potentially safer alternative to transvenous ICDs in ACHD. Suitability for S-ICD depends on the surface electrocardiogram (ECG), which is often abnormal in ACHD patients. This study investigates the proportion of ACHD patients who meet the screening criteria for S-ICD implantation. A standard screening ECG was performed in 102 patients with complex ACHD (Tetralogy of Fallot, Fontan circulation, and transposition of the great arteries). This process was repeated postexercise for patients who also had an exercise test. Three quarters (75.4%) of ACHD patients meet screening criteria for an S-ICD with at least one suitable vector. The most common number of acceptable vectors in the eligible group was two (35% of total population). In only 12% of total population, all three vectors were suitable while only one vector was suitable in 28% of total population. The primary vector (equivalent of ECG lead III) was the most common suitable vector, found in 62% of participants who had appropriate sensing vectors. Twenty-five (24.5%) patients failed to meet the S-ICD screening criteria. Of these, 14 had repaired tetralogy of Fallot. A total of 92% of patients with a Fontan circulation met ECG screening criteria. Of those who had the protocol repeated following their cardiopulmonary exercise test (n=14), only one additional patient failed to meet the eligibility criteria. A quarter of ACHD patients do not meet the eligibility criteria for the S-ICD. However, more than 90% of patients with a Fontan circulation are suitable for an S-ICD.

Accuracy Screening for ST Elevation Myocardial Infarction in a Task-switching Simulation.

IntroductionInterruptions in the emergency department (ED) are associated with clinical errors, yet are important when providing care to multiple patients. Screening triage electrocardiograms (ECG) for ST-segment elevation myocardial infarction (STEMI) represent a critical interrupting task that emergency physicians (EP) frequently encounter. To address interruptions such as ECG interpretation, many EPs engage in task switching, pausing their primary task to address an interrupting task. The impact of task switching on clinical errors in interpreting screening ECGs for STEMI remains unknown.MethodsResident and attending EPs were invited to participate in a crossover simulation trial. Physicians first completed a task-switching simulation in which they viewed patient presentations interrupted by clinical tasks, including screening ECGs requiring immediate interpretation before resuming the patient presentation. Participants then completed an uninterrupted simulation in which patient presentations and clinical tasks were completed sequentially without interruption. The primary outcome was accuracy of ECG interpretation for STEMI during task switching and uninterrupted simulations.ResultsThirty-five participants completed the study. We found no significant difference in accuracy of ECG interpretation for STEMI (task switching 0.89, uninterrupted 0.91, paired t-test p=0.21). Attending physician status (odds ratio [OR] [2.56], confidence interval [CI] [1.66–3.94], p<0.01) and inferior STEMI (OR [0.08], CI [0.04–0.14], p<0.01) were associated with increased and decreased odds of correct interpretation, respectively. Low self-reported confidence in interpretation was associated with decreased odds of correct interpretation in the task-switching simulation, but not in the uninterrupted simulation (interaction p=0.02).ConclusionIn our simulation, task switching was not associated with overall accuracy of ECG interpretation for STEMI. However, odds of correct interpretation decreased with inferior STEMI ECGs and when participants self-reported low confidence when interrupted. Our study highlights opportunities to improve through focused ECG training, as well as self-identification of “high-risk” screening ECGs prone to error during interrupted clinical workflow.

Prevalence of subcutaneous implantable cardioverter-defibrillator based on template ECG screening and ineligible surface ECG predicting factors in patients with hypertrophic cardiomyopathy in China.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) may provide comparable protection while avoiding the disadvantage of transvenous lead, but the abnormal features of the hypertrophic cardiomyopathy (HCM) electrocardiogram (ECG) make it a challenge for S-ICD template screening. We aimed to investigate S-ICD eligibility according to the S-ICD manufacturer's surface ECG screening template in China, and further analyze its corresponding ineligible predicting factors in 12-lead suface ECG. A total of 179 HCM patients (114 males; mean age: 45 ± 14years) underwent S-ICD screening at rest and on exercise, among which 91 patients (50.8%) were eligible for S-ICD. Among the patients who passed screening, 43 (47.3%) had 3 vectors eligibility; 64 (70.3%) screening qualified on both sides; 10 patients (11.0%) passed the screening while the electrodes located only on the left parasternal line versus 17 patients (18.7%) moved to the right line. The secondary sensing vector (Lead III) was mostly appropriate (53.6%), followed by the primary sensing vector (lead II, 53.1%) and the alternate sensing vector (Lead I, 46.9%). Higher R wave was the major cause, accounted for 70.5%, for screening failure. There existed significant difference in T wave in lead II, aVF, V5 and V6, adds R/T ratio in lead V5 and V6, between the screening success group (group A) and screening failure group (group B) at rest and on exercise. A multivariable logistic regression analysis was performed to identify that R/T ≤ 3.5 in lead V5 was the independent factor to predict the screening ineligibility, with odds ratio 3.648. S-ICD screening success is 50.8% in HCM patients, which is much lower than that in other studies. R/T ≤ 3.5 in lead V5 in 12-lead surface ECG was an independent predicting factor for screening failure.

Abstract 17082: ECG Screening in North Texas High School Students: A Randomized, Pilot Feasibility Study

Introduction: The death of young athletes is devastating to families and communities. Despite routine pre-participation screening, 80–100/yr die or suffer cardiac arrest, with 65% occurring in high school athletes. AHA/ACC recommendations for pre-participation screening do not include routine electrocardiogram (ECG), in contrast to some international guidelines. Methods: We designed a pilot study to test feasibility of a larger trial, scaled to 1% of the estimated 800,000 participants required to power for detection of sudden death/arrest. Athletes and band members enrolled in eight high schools in two Texas school districts were randomized in block fashion to standard screening alone versus the addition of ECG. ECGs were interpreted using CardeaScreen software, over-read by an independent expert. Students with abnormal ECGs received cardiology evaluation at no cost. Text messages assessing for cardiac events or hospitalizations were sent to both groups biannually. Results: Of the ~8,000 eligible students, the intervention group enrolled 847 students who received ECG (21%); the non-intervention group enrolled 655 students (16%). CardeaScreen identified 20 of 847 ECGs as abnormal (2.4%) and the expert identified 19 as abnormal (2.2%) Six of 20 ECGs (30%) identified as abnormal by CardeaScreen were over-read as normal, and 5 of 827 ECGs (0.6%) identified as normal by CardeaScreen were over-read as abnormal (PPV 70%, NPV 99.4%). Twenty-five follow up visits were attempted, 22 were completed (88%), and specialist referrals were sent for 6 (29%). New diagnoses included Wolf-Parkinson-White syndrome, coronary anomaly, and depressed LV function. Follow up with SMS surveys yielded 737 responses at 6 months and 441 responses at 16 months. No sudden cardiac death or arrest was reported. Conclusion: Randomized ECG testing and follow-up of high school students is feasible, though with low enrollment and relatively low yield. Automated ECG interpretation is viable but leads to significant false + results. Low participation in enrollment and follow up present challenges to a large-scale ECG screening study powered for clinical events. Possible solutions include an “opt-out” enrollment strategy and use of alternate follow up methods such as social media.

Usefulness of Focused Screening Echocardiography for Collegiate Athletes

Sudden cardiac death in a young healthy athlete is a rare but catastrophic event. The American Heart Association preparticipation screening guidelines recommend a focused history and physical without routine imaging or electrocardiogram screening. We hypothesized that a focused echocardiogram can identify structural abnormalities that may lead to sudden cardiac death in athletes, which might otherwise go undetected by history and physical. We retrospectively reviewed the charts of all incoming collegiate athletes at a single university from 2005 to 2013, all of whom had undergone a focused, 5-minute echocardiogram along with a guideline-based preparticipation history and physical (PPS H&P). Abnormal findings prompted further testing or referral. We report the prevalence of abnormal findings and the relation between an abnormal PPS H&P and screening echocardiogram. A total of 2,898 athletes were screened and 159 (5%) had findings. Forty athletes underwent further testing and evaluation. Of these athletes, 3 had newly diagnosed abnormalities that warranted restriction of participation: 1 apical-variant hypertrophic cardiomyopathy, 1 large bidirectional atrial septal defect with right ventricular dysfunction, and 1 dilated ascending aorta. Two of these athletes had a normal PPS H&P. Conversely, of the 661 athletes with an abnormal PPS H&P, only 1 (0.15%) had an abnormal screening echocardiogram. In conclusion, although the overall number was low, the 5-minute screening echocardiogram detected athletes at risk for sudden cardiac death not discovered on PPS H&P.

195 Screening Electrocardiograms in Cocaine-Positive Chest-Pain-Free Psychiatric Patients Requiring Medical Clearance

Current practice at our large, public, urban academic emergency department (ED) is to obtain a screening electrocardiogram (ECG) as part of the medical clearance process on all patients who require transfer to an inpatient psychiatric facility and test positive for cocaine on a urine toxicology screen regardless of the presence or absence of chest pain. The purpose of this retrospective quality improvement study is to examine the utility and impact of a screening ECG for patients with urine toxicology screening positive for cocaine who are chest-pain-free and require medical clearance prior to transfer to an inpatient psychiatric facility. An institutional review board-approved, retrospective chart review between January 2014 - December 2015 was performed of all ED patients (1) over 18 years of age, (2) without chest pain documented in the medical record, (3) who required medical clearance in the ED prior to transfer to an inpatient psychiatric facility, (4) who tested positive for cocaine on a screening urine toxicology test, and (5) for whom a screening ECG was obtained. All ECGs were interpreted by an attending physician. Abnormal ECGs were defined as: nonspecific ST changes, T wave inversions, sinus tachycardia, ST elevation, or ST depression. All abnormal ECGs were compared to prior ECGs if available, and if no change noted then these were categorized as normal. Primary outcome was disposition of the patient to an inpatient psychiatric facility versus inpatient medical admission. Secondary outcomes were rates of a subsequent cardiac workup, including inpatient medical admission, cardiac enzymes, stress testing, cardiology consultation, and cardiac catheterization. During the study period, 1968 ED patients tested positive for cocaine on a urine toxicology screen and 853 met inclusion criteria. ECGs were normal in 809 (95%, 95% CI [93%, 96%]) patients, and abnormal in 44 (5%, 95% CI [4%, 7%]) patients. Of the 44 patients with abnormal ECGs, 4 were admitted for a cardiac workup. Two patients had positive troponins in the ED. Two patients had cardiology consultations and 3 had further cardiac stress testing performed, all of which were negative or non-diagnostic. No cardiac catheterizations were performed on any patients. Based on the results of our study, the majority of ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority of patients with an abnormal ECG, there were no cases of acute myocardial ischemia or infarction identified in the absence of chest pain. Therefore, a screening ECG in patients without chest pain simply because of a cocaine-positive urine toxicology test does not appear to identify any cases of myocardial ischemia or infarction and may, in fact, lead to over-testing, increased admission, misuse of resources, and increased cost. Limitations of this study include its retrospective, chart review design. Additionally, there is the possibility of a patient not being forthcoming regarding the presence or absence of chest pain and being categorized incorrectly.

Electrocardiogram screening of deaf children for long QT syndrome: An Egyptian experience.

Jervell and Lange-Nielsen syndrome is an autosomal recessive form of long QT syndrome (LQTS), clinically manifested by long QT interval and bilateral sensorineural hearing loss (SNHL) with the highest prevalence in Norway and Sweden. No data are available about the prevalence of such syndrome in Egypt. This study aimed to assess by electrocardiogram (ECG) the prevalence of LQTS among Egyptian children with SNHL. One thousand and twelve patients, aged ≤ 10 years (mean age 5.8±2.6), were included in this study, 578 male patients (57%) and 434 female patients (43%). A 12-lead ECG was recorded for all patients and the corrected QT interval (QTc) was calculated by Bazett's formula. The probability of LQTS was evaluated by Schwartz criteria and laboratory investigations were done on all patients with long QT interval. In the current study, the mean QTc interval was 411.7±25.3ms (range 343-675ms). Twenty-one patients (2.1 %) had probable LQTS; of these, 11 patients had intermediate probability (Schwartz score 1.5-3 points) and 10 patients had high probability (Schwartz score ≥ 3.5 points). This study shows that 2.1% of Egyptian children with SNHL in a tertiary care setting have LQTS.

Retinal Vascular Geometry and the Prevalence of Atrial Fibrillation and Heart Failure in a Clinic-Based Sample

We aimed to examine the cross-sectional association between a range of retinal vascular geometric variables and the prevalence of atrial fibrillation (AF) and heart failure. The Australian Heart Eye Study (AHES) surveyed 1,680 participants presenting to a tertiary referral hospital for the evaluation of potential coronary artery disease by coronary angiography. Retinal vascular geometric variables (tortuosity, branching, and fractal dimension) were measured from retinal photographs using a computer-assisted program (Singapore I Vessel Assessment). Atrial fibrillation was determined based on a combination of: self-reported history of AF; self-reported use of rate-control and anti-arrhythmic medications; and/or screening electrocardiogram. Self-reported echocardiography-confirmed heart failure was also documented. A total of 1,169 participants had complete information on retinal vascular geometric variables and AF and of these 104 (8.9%) had AF. Participants in the second tertile of fractal dimension (Df) compared to those in the highest tertile (reference group), had 92% increased likelihood of having AF after multivariable adjustment. A threshold effect for Df was identified, and participants below versus those above a Df threshold value of 1.472, had greater odds of having AF: multivariable-adjusted OR 1.85 (95% CI 1.03-3.31). Measures of retinal tortuosity and branching were not associated with AF. Retinal vascular geometric variables were also not associated with prevalence of heart failure. A sparser retinal microvascular network (lower Df) was independently associated with greater likelihood of AF. Further studies are needed to investigate whether temporal changes to the retinal vascular geometry are predictive of AF in the longer term.

Tentative Screening Criteria for Short QT Interval in Children and Adolescents.

While the prevalence of short QT syndrome (SQTS) in children and adolescents is low, early detection is important because SQTS can cause life-threatening arrhythmia. The aim of this study was to determine the tentative screening criteria for short QT interval in children and adolescents. Methods and Results: A total of 75,040 digitally stored electrocardiograms (ECG) of participants in a school-based ECG screening program were obtained between 2009 and 2013 in Kagoshima, Japan. ECG with a corrected QT interval (QTc) below the 10th percentile for each grade and sex were selected: 2,581 first graders (M/F, 1,296/1,285); 2,792 7th graders (M/F, 1,400/1,392); and 2018 10th graders (M/F, 979/1,039). Three consecutive QT/RR intervals were manually measured and corrected using Bazett's formula. The prevalence of SQTS was estimated at 1/30,000-1/10,000, which was set compared with the prevalence of long QT syndrome, then the screening points of the prevalence of short QT interval were assumed to be between 1/5,000 and 1/2,000 to exclude the possibility of false negative. We obtained the following tentative criteria based on frequency distribution charts: 325, 315 and 305 ms for male 1st, 7th and 10th graders, respectively; and 320 ms for female 1st, 7th, and 10th graders. For primary SQTS screening of children and adolescents, the QTc values for short QT interval should be adapted according to grade and sex.

One quarter of total myocardial infarctions are silent manifestation in patients with type 2 diabetes mellitus

BackgroundSilent events with newly developed Q waves in electrocardiogram (ECG) [silent myocardial infarction (MI)] in diabetic patients is reported to be independently associated with an increased risk of fatal MI. However, the incidence rate of silent MI in diabetic patients has yet to be clarified. We sought to determine the incidence rate of first symptomatic MI and silent MI in diabetic patients. MethodsWe conducted a prospective cohort study on patients enrolled in the Japanese primary prevention of atherosclerosis with aspirin for diabetes (JPAD) trial which was started in 2002. It is a randomized controlled trial to examine the efficacy of low-dose aspirin therapy for the primary prevention of atherosclerotic events in type 2 diabetic patients. No patients had Q waves in their ECG before entry to the JPAD trial. We followed-up 1825 patients until July 2015 after completion of the JPAD trial in 2008. The median follow-up period was 10.3 years. We collected 1648 patients’ ECGs to identify patients with silent MI. ResultsSymptomatic MI occurred in 65 patients and silent MI occurred in 22 patients. The incidence rate of symptomatic MI was 4.26 per 1000 patient-years and 1.44 for silent MI in diabetic patients. Thus, 25% of total MIs were silent. Cause-specific Cox proportional hazard model indicated that age (hazard ratio 1.06, 95% confidence interval; 1.03–1.10, p=0.0004) and long history of diabetes (1.00, 1.01–1.07, p=0.01) were independently associated with symptomatic MI, but these were not associated with silent MI. ConclusionsWe demonstrated that incidence rate of first silent MI and that proportion of silent MI to all MIs was 25% in diabetic patients without a history of atherosclerotic events. Diabetic patients frequently need ECG screening for detection of silent MI.

Cardiovascular Screening Practices and Attitudes From the NCAA Autonomous "Power" 5 Conferences.

Background:The development of athlete-specific electrocardiogram (ECG) interpretation standards, along with recent rates of sudden cardiac death (SCD) in athletes being higher than previously estimated, has heightened the debate in the sports medicine community regarding cardiovascular screening of the college athlete, including whether certain high-risk subsets, such as male basketball athletes, should undergo more intensive screening.Hypothesis:ECG and/or echocardiography screening in National Collegiate Athletic Association Autonomous 5 Division I (A5DI) schools will be more common than previous reports, and there will be more frequent use of noninvasive cardiac screening for men’s basketball players than the general athlete population.Study Design:Cross-sectional, quantitative study.Level of Evidence:Level 4.Methods:The head team physician for each of the 65 schools in the A5DI conferences was contacted to complete an anonymous survey regarding cardiovascular screening practices at their institution. The survey inquired about current screening protocols, whether SCD epidemiology (SCD-E) was considered in establishing those practices, and whether awareness of present epidemiology altered physician attitudes toward screening.Results:A total of 45 of the 65 team physicians (69%) responded. All schools reported performing history and a physical evaluation. While 17 (38%) perform only history and physical, 26 (58%) also include an ECG, and 12 (27%) include echocardiography for all student-athletes. Specifically for male basketball athletes, 10 (22%) schools perform only history and physical, 32 (71%) include ECG, and 20 (45%) include echocardiography. Additionally, 64% reported using SCD-E in developing their screening protocol. Those that had not considered SCD-E indicated they were unlikely to change their screening protocol when presented with current SCD-E.Conclusion:The majority (62%) of A5DI institutions include ECG and/or echocardiography as part of their cardiovascular screening of all athletes, increasing to 78% when specifically analyzing male basketball athletes.Clinical Relevance:A5DI institutions, presumably with greater resources, have largely implemented more intensive cardiovascular screening than just history and physical for all student-athletes and specifically for men’s basketball—the athlete group at greatest risk.