Routine ECG Monitoring Research Articles

Results of a survey of anesthesiologists and resuscitation specialists: possible prediction and diagnosis of cardiac complications after non-cardiac surgery

Relevance. A critical task of modern anesthesiology and resuscitation is the prediction and diagnosis of cardiac complications after non-cardiac surgeries. There are clinical guidelines for reducing the incidence of such complications; however, in practice, routine implementation of the full-risk stratification algorithm is not always performed. Objective. To assess the possibility of predicting and diagnosing cardiac complications after non-cardiac surgeries in medical organizations of constituent entities of the Russian Federation with a population of less than 1 million people. Materials and methods. An anonymous online survey of anesthesiologists and resuscitators of one of the constituent entities of the Russian Federation was developed using Yandex Forms.Results. We processed 62 completed questionnaires. Cardiac complications during the postoperative period are registered by 33 (53.2 %) respondents. Cardiac risk indices were used by 10 (16.1 %) physicians and load tests (treadmill, bicycle ergometry) by 9 (14.5 %). Routine ECG monitoring after surgery was performed by 27 (43.5 %) respondents. Cardiac-specific troponin determination is available to 60 (96.8 %) physicians; however, only 6 (9.7 %) respondents measured it routinely before surgery and 4 (6.5 %) respondents measured it after surgery. Natriuretic peptide or its prohormone determination is available to 19 (30.6 %) physicians; however, only 3 (4.8 %) prescribe it before surgery and 0 after surgery. The possibility of performing echocardiography before and after surgery was noted by 54 (87.1 %) respondents. Only 9 (14.5 %) respondents reported that their hospital could perform coronary angiography.Conclusions. The results of this survey revealed that many cardiac complications could have been missed because of insufficient preoperative prognosis and postoperative diagnostic data.

The effect of intravenous ondansetron on QT interval in the emergency department

ObjectiveOndansetron, a 5HT3 receptor antagonist, is commonly used in emergency departments to treat nausea and vomiting. In 2011, the Food and Drug Administration (FDA) issued a warning that this medicine may cause QT prolongation, potentially leading to deadly arrhythmias. The objective of this study was to characterize the QT interval prolongation associated with ondansetron use in the Emergency Department. MethodsThis was a prospective, observational cohort study of adult patients who presented to the emergency department during a one-year period and were treated with intravenous ondansetron. We investigated the QT prolongation associated with dosages. ECGs were obtained before the medication and 5, 15, and 30 minutes after IV drug administration. Every QT measurement was recorded and compared to the zero point. The severity of drug-induced QT prolongation was determined according to the recommendations of the International Conference on Compliance (ICH). QTc prolongation was categorized as ‘negligible’ (<5 ms), ‘significant’ (>20 ms), ‘potential concern’ (>30 ms), or ‘definitely worrying’ (>60 ms). ResultsOf the 435 patients enrolled in the study, 60% (261 patients) were female and the mean age was 39 (±18). The QT prolongation peaked at the fifth minute and remained consistent at the fifteenth and thirty-first minutes. The maximum prolongation of the mean QT duration occured at the fifth minute (7.9 ± 18.1 ms). No patient revealed any problems with cardiac conduction. The prolonged QT interval was not related to the dose of ondansetron, but QT measurements were higher in the 30th minute in patients treated with 8 mg of ondansetron. The effect of ondansetron administration on QT prolongation was found to be above the ‘negligible’ but below the ‘significant’ value, according to the ICH recommendations. DiscussionIn this study, QT prolongation due to ondansetron administration was below the ‘important’ value according to the recommendations of the ICH. No cases of cardiac arrhythmia were reported in any of the partients. Thus, routine ECG monitoring in patients given ondansetron due to the risk of QTc prolongation does not seem cost-effective when evaluated together with additional factors such as its negative impact on emergency patient flow, waste of personnel and time, and increase in healthcare costs. In the absence of a known risk of cardiac arrhythmia, IV administration of 4 mg and 8 mg of ondansetron doses no risk of QT prolongation in the emergency population.

Deceleration capacity of heart rate variability as a predictor of sedation related hypotension

High risk and geriatric patients are supposed to suffer higher risks of hypotension underwent painless endoscopic procedures. This study evaluated different biomarkers associated with hypotension in off-site patients and aimed to determine the most relevant risk factors in space and monitoring limited environment. The inclusions of this observational cohort study underwent complex endoscopic procedures were sedated with age-adjusted doses of target-controlled infusion of propofol. The following pre-sedative parameters were analysed: time domain, frequency domain, and Deceleration capacity (DC) of heart rate variability, estimated cardiac output data and the index of cardiac contractility from the cardiometer. Patients were divided into hypotension group (blood pressure < 90 mmHg or a > 35% decrease) and non-hypotension group according to peri-sedative blood pressure, regression analysis is used to examine the association between factors and hypotension. Total data from 178 patients (age range: 33–94 years) were analysed. Age was not significantly different between the hypotension and non-hypotension groups (p = 0.978). Among all the factors, DC was most associated with hypotension (p = 0.05), better than cardiometer, age, and ASA status. In conclusion, DC, which can be interpreted as the indicator of parasympathetic activity and was significantly and negatively correlated with sedation-related hypotension. Pre-sedative measuring DC from routine ECG monitoring is simple and cost-effective and should be added to haemodynamic monitoring in the endoscopic room.

Monitoring oxygen saturation and heart rate during neonatal transition. comparison between two different pulse oximeters and electrocardiography.

To compare the efficacy and reliability of two pulse-oximeters (POx) (Masimo Radical-7 and Nellcor™ Oxymax Bedside) and evaluate the feasibility of routine ECG monitoring during delivery room transition. Prospective observational comparative study. Sixty newborns were connected simultaneously to both POxs and ECG monitor (as a gold standard for HR). Times to achieve a stable signal were compared. Heart rates were compared to simultaneous ECG. A significant difference in times to stable signal was found: Mean, Median (Interquartile range) for Nellcor and Masimo, were 15, 8.5 (6-18) and 27, 12 (9-34) seconds, respectively. Compared to ECG, false bradycardia was displayed in 18 of 55 (35%) newborns by the Masimo POx and in no newborns by the Nellcor POx. Attaching the ECG monitor was feasible but consumed additional resources. The time for achievement of a stable saturation reading in an uncomplicated resuscitation setting differed significantly between POxs.

Invasive strategy for COVID patients presenting with acute coronary syndrome: The first multicenter Italian experience.

ObjectiveTo report our initial experience of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)/acute coronary syndrome (ACS) patients undergoing standard of care invasive management.BackgroundThe rapid diffusion of the SARS‐CoV‐2 together with the need for isolation for infected patients might be responsible for a suboptimal treatment for SARS‐CoV‐2 ACS patients. Recently, the group of Sichuan published a protocol for COVID/ACS infected patients that see the thrombolysis as the gold standard of care.MethodsWe enrolled 31 consecutive patients affected by SARS‐COV‐2 admitted to our emergencies room for suspected ACS.ResultsAll patients underwent urgent coronary angiography and percutaneous coronary intervention (PCI) when required except two patients with severe hypoxemia and unstable hemodynamic condition that were conservatively treated. Twenty‐one cases presented diffuse ST‐segment depression while in the remaining cases anterior and inferior ST‐elevation was present in four and six cases, respectively. PCI was performed in all cases expect two that were diagnosed as suspected myocarditis because of the absence of severe coronary disease and three with apical ballooning at ventriculography diagnostic for Tako‐Tsubo syndromes. Two patients conservatively treated died. The remaining patients undergoing PCI survived except one that required endotracheal intubation (ETI) and died at Day 6. ETI was required in five more patients while in the remaining cases CPAP was used for respiratory support.ConclusionsUrgent PCI for ACS is often required in SARS‐CoV‐2 patients improving the prognosis in all but the most advanced patients. Complete patient history and examination, routine ECG monitoring, echocardiography, and careful evaluation of changes in cardiac enzymes should be part of the regular assessment procedures also in dedicated COVID positive units.

The cardiac diagnostic work-up in stroke patients-A subanalysis of the Find-AFRANDOMISED trial.

BackgroundThe cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis.MethodsFind-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring.Results50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001).ConclusionsMost changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials.Trial registrationClinicalTrials.gov NCT01855035

Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients

ObjectivePatients with electrical injury are considered to be at high risk of cardiac arrhythmias. Due to the small number of studies, there is no widely accepted guideline regarding the risk assessment and management of arrhythmic complications after electrical accident (EA). Our retrospective observational study was designed to determine the prevalence of ECG abnormalities and cardiac arrhythmias after EA, to evaluate the predictive value of cardiac biomarkers for this condition and to assess in-hospital and 30-day mortality.MethodsConsecutive patients presenting after EA at the emergency department of our institution between 2011 and 2016 were involved in the current analysis. ECG abnormalities and arrhythmias were analyzed at admission and during ECG monitoring. Levels of cardiac troponin I, CK and CK-MB were also collected. In-hospital and 30-day mortality data were obtained from hospital records and from the national insurance database.ResultsOf the 480 patients included, 184 (38.3%) had suffered a workplace accident. The majority of patients (96.2%) had incurred a low-voltage injury (< 1000 V). One hundred and four (21.7%) patients had a transthoracic electrical injury while 13 (2.7%) patients reported loss of consciousness. The most frequent ECG disorders at admission were sinus bradycardia (< 60 bpm, n = 50, 10.4%) and sinus tachycardia (> 100 bpm, n = 21, 4.4%). Other detected arrhythmias were as follows: newly diagnosed atrial fibrillation (n = 1); frequent multifocal atrial premature complexes (n = 1); sinus arrest with atrial escape rhythm (n = 2); ventricular fibrillation terminated out of hospital (n = 1); ventricular bigeminy (n = 1); and repetitive nonsustained ventricular tachycardia (n = 1). ECG monitoring was performed in 182 (37.9%) patients for 12.7 ± 7.1 h at the ED. Except for one case with regular supraventricular tachycardia terminated via vagal maneuver and one other case with paroxysmal atrial fibrillation, no clinically relevant arrhythmias were detected during the ECG monitoring. Cardiac troponin I was measured in 354 (73.8%) cases at 4.6 ± 4.3 h after the EA and was significantly elevated only in one resuscitated patient. CK elevation was frequent, but CK-MB was under 5% in all patients. Both in-hospital and 30-day mortality were 0%.ConclusionsMost of cardiac arrhythmias in patients presenting after EA can be diagnosed by an ECG on admission, thus routine ECG monitoring appears to be unnecessary. In our patient cohort cardiac troponin I and CK-MB were not useful in risk assessment after EA. Late-onset malignant arrhythmias were not observed.

Abstract WP255: The Role of Echocardiography and ECG in Stroke Patients

Background: The cardiac diagnostic workup of stroke patients, especially the value of echocardiography and prolonged and enhanced Holter-ECG monitoring (EPM), is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis. Methods: Find-AF RANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to EPM or usual stroke unit care. Therapeutic consequences of echocardiography and routine Holter-ECG or EPM, respectively, were compared and one-year mortality was calculated. Results: 50.3% received EPM and 49.7% routine ECG monitoring. 82.9 % underwent transthoracic echocardiography (TTE), 38.9 % transesophageal echocardiography (TEE) and 25.6 % both procedures. 14/90 TEE pathologies and 1/89 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 334, respectively. In comparison, EPM found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively). We found a trend towards a higher one-year mortality in patients with pathologic echocardiographic findings (p = 0.093). Conclusions: Most changes in therapeutic decisions were caused by EPM, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials.

Abnormal QTc syndrome in HIV-infected patients: a systematic review of prevalence and risk factors.

The purpose of this review is to critically analyse data regarding the prevalence and risk factors for developing a prolonged QTc interval and subsequent sudden cardiac death (SCD) in persons living with HIV (PLWH). A systematic literature search using PubMed and Google Scholar databases was performed using the following search terms: 'HIV and prolonged QTc' and 'managing HIV-patients with prolonged QTc'. References within articles of interest were also evaluated. PLWH are at an increased risk of having a prolonged QTc interval. Some risk factors for this include the virus itself, concomitant medications, comorbid conditions, addictions and electrolyte disturbances. PLWH who have an increased HIV RNA viral load or decreased CD4+ T-cell count are at further risk for progressing to sudden cardiac death (SCD). Many medications commonly prescribed in the PLWH population, such as antiretrovirals and antimicrobials used in opportunistic infection prophylaxis, have also been shown to promote QTc prolongation through inhibition of human ether-a-go-go potassium channels or through drug metabolism inhibition of other QTc prolonging drugs. Due to the high number of risk factors associated with QTc prolongation, clinicians should incorporate baseline and routine ECG monitoring for PLWH to potentially lower the increased risk of SCD in PLWH.

Routine ECG monitoring for patients with cystic fibrosis: physiotherapists be aware!

Routine ECG monitoring for patients with cystic fibrosis: physiotherapists be aware!

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

The cumulative incidence of new onset atrial fibrillation (AF) in patients undergoing cardiac resynchronization therapy (CRT) is substantial, exceeding 25% in multiple recent studies. Although AF patients undergoing CRT show improved echocardiographic parameters, functional status, and quality of life in, they benefit to a lesser degree than do patients in normal sinus rhythm. They also exhibit a trend toward increased mortality. Understanding the barriers to response from CRT among AF patients is critical to addressing the needs of growing populations of patients with AF and HF. Foremost among these are suboptimal biventricular pacing, often characterized by fusion or pseudo-fusion complexes, leading to inefficient CRT delivery. Furthermore, AF increases the risk of inappropriate shocks, which lead to substantial psychiatric morbidity, increased risk of heart failure hospitalization, and may also increase mortality. Assiduous rate control is reasonable for all AF patients receiving CRT, but there is a paucity of data regarding specific antiarrhythmic drug therapy recommendations. For patients with permanent AF and severe symptoms, atrioventricular junction ablation appears effective in improving response by ensuring biventricular capture and reducing implantable cardioverter-defibrillator shock burden in selected patients. Catheter-based techniques such as pulmonary vein isolation appear more attractive and in the future may offer further advantages and lower risks, particularly for patients with paroxysmal AF.

Can we improve delivery room monitoring for newborns? A novel photoplethysmographic heart rate monitor evaluated among stable nicu infants

BackgroundHeart rate (HR) is considered the most reliable indicator of successful newborn resuscitation. Current recommended assessment is by auscultation but this is subject to human error1 and can interrupt resuscitation....

Electrocardiographic changes in HIV-infected, drug experienced patients treated with atazanavir

After reading the case study of 75 HIV infected patients treated with atazanavir-based therapy reported by Gianotti et al. [1], we express concerns regarding the methodology used to measure ECG intervals in this report. In particular, we note that automated measurement by ECG recording machines was used. This is in contrast to the current industry standard for ECG interval measurements to be digitally measured with electronic calipers or confirmed by experienced reviewers. In our view, the absence of digital overreading resulted in inadequate quality control for the QRS interval measurements and a false-positive finding of QRS prolongations in patients treated with atazanavir [1]. The authors report a median increase in QRS duration of 5 ms [interquartile range (IQR) = 0–9 ms; P < 0.0001] on atazanavir after 51 weeks of follow-up (range = 36–89.9 weeks) compared with pretreatment values. In particular, the authors report 14 patients with pretreatment QRS 100 ms or less who experienced an end-of-study QRS interval greater than 100 ms. One of these patients (patient #1) appeared to experience a marked increase in QRS duration (baseline QRS of 88 ms compared with end-of-study QRS of 145 ms). The authors report involvement of a cardiologist in the ECG review. However, because of the possibility of unrecognized ECG machine error, we requested further information from the site. Dr Gianotti et al. graciously supplied photocopies of the actual baseline and end-of-treatment ECGs for the 75 patients in the original report [1]. All of the 150 paper copies (75 patient sets) were electronically scanned using a standard HP Digital Scanner at 300 dpi and then transferred to Scan ECG (AMPS, New York, New York, USA), by Cardiocore (Bethesda, Maryland, USA). Due to poor quality, 16 of the 75 sets could not be interpreted due to unsuccessful digitization. Using electronic calipers, 59 sets of ECGs were measured for QRS width. This technique, often referred to as semiautomatic over-reading, is the industry standard and involves expert review. In the set of 59 digitized samples, we found that only four patients experienced an increase in QRS duration of greater than 10 ms, compared with 15 patients as determined by machine interrogation. Furthermore, no patient experienced QRS duration greater than 116 ms. We found significant discrepancies for two patients reported to have QRS greater than 120 ms in the original report, including the one with the marked increase at end-of-study, patient #1, with corrected values, as shown in Table 1.Table 1: Comparison of QRS values.The machine versus digital-caliper discrepancy is very likely due to random error by the machine algorithm, which can be affected by the variability in rate of change of the tracing as is commonly found with artifact. The end-of-study tracing for patient #1 shows a significant degree of artifact. Taking the 59 digitally measured sets altogether, the median baseline to end-of-study QRS change was 1.0 ms (IQR =–2 to–4; P = 0.246) The corresponding machine-calculated median change was 5 ms (IQR = 1–10; P < 0.001) in the same set of 59 patients. Because the QRS width is difficult to gauge with the human eye using manual calipers (with a likely error of ±15–20 ms) and because the machine QRS calculation is affected by artifact, the conclusions of Gianotti et al.[1] should be regarded with caution. Overreading using digital calipers represents the gold-standard technique. Although we were only able to investigate 80% of the originally reported ECG set, the uncorrected median value of 5 ms for this subset compares closely to the originally reported uncorrected median value of 5 ms for the whole cohort [1]. Furthermore, as the subset includes the extremely anomalous result for patient #1, our reanalysis is likely to be relevant. As such, we note that the corrected median QRS change of 1 ms in these 59 sample sets is likely to have very little clinical relevance. We respectfully disagree with the QRS results and the conclusions presented by Gianotti et al.[1], including their recommendation for routine ECG monitoring with regard to QRS as well as their proposed association between QRS changes and bundle branch block effects. We note that one patient experienced resolution of bundle branch block findings while on atazanavir. As we show here, the study would have been better served by digital collection of ECG tracings with intervals determined by the digital caliper overread technique. We are grateful to the authors for sharing the ECG data.

Electroconvulsive Therapy in Patients with Cardiac Pacemakers

There are few contraindications to electroconvulsive therapy and it is generally well tolerated. However, electroconvulsive therapy in elderly patients with cardiac pacemakers in situ theoretically presents an increased risk of complications. We undertook a retrospective audit of all patients who received anaesthesia for electroconvulsive therapy between January 1999 and September 2005. There were ten patients who had cardiac pacemakers in situ. They underwent a total of 147 electroconvulsive therapy treatments. In 146 out of the 147 treatments, the anaesthesia proceeded uneventfully. The findings suggest that provision of anaesthesia and electroconvulsive therapy in patients with cardiac pacemakers, including rate-responsive pacemakers, is a safe undertaking, with no extra precautions being needed except for routine ECG monitoring.

Guías de práctica clínica de la Sociedad Española de Cardiología en la angina inestable/infarto sin elevación ST

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

Hyperpotassemia During Massive Blood Transfusions

Comment: Ever since Mazze et al1 in 1969 pointed out the dangers of hyperkalemia, practicing anesthetists have been unduly concerned regarding either hypo- or hyperkalemia. This report serves as another reminder that, even in this day of routine ECG monitoring, blood component transfusions, and improved blood banking procedures, more than 10-unit blood transfusions of old blood rapidly infused in hypovolemic patients can cause cardiovascular collapse. However, vigilance and control of any of the above should avoid any such calamity.

The Effect of Transtracheal Aspiration on Cardiac Rate and Rhythm: A Prospective Study

To determine the effect of transtracheal aspiration (TTA) on cardiac rate and rhythm, we prospectively monitored by electrocardiography 14 cases before, during, and after the procedure. No serious or life-threatening arrhythmias occurred; sinus tachycardia was virtually a routine occurrence. Cardiac rate increased significantly from an average of 96 beats/min before the procedure to an average of 121/min during the procedure (P less than 0.001). The incidence of premature ventricular or atrial contractions did not change significantly before, during, or after the procedure. Before TTA, all patients had PaO2 measurements equal to or greater than 70 mm Hg; none had CO2 retention or an unstable cardiac status. Patients with significant COPD (mean FEV1/FVC% = 48) were not at increased risk for cardiac arrhythmias during or immediately after TTA. Our results imply the following: (1) routine ECG monitoring in patients such as ours undergoing TTA does not appear to be necessary; and (2) premedication with narcotics, sedatives, or atropine does not appear to be warranted.