Celina M. Yong

Patterns and prognosis of all components of the J-wave pattern in multiethnic athletes and ambulatory patients

BACKGROUND Despite recent concern about the significance of the J-wave pattern (also often referred to as early repolarization) and the importance of screening in athletes, there are limited rigorous prognostic data characterizing the 3 components of the J-wave pattern (ST elevation, J waves, and QRS slurs). We aim to assess the prevalence, patterns, and prognosis of the J-wave pattern among both stable clinical and athlete populations. METHODS We retrospectively studied 4,041 electrocardiograms from a multiethnic clinical population from 1997 to 1999 at the Veterans Affairs Palo Alto Health Care System. We also examined preparticipation electrocardiograms of 1,114 Stanford University varsity athletes from 2007 to 2008. Strictly defined criteria for components of the J-wave pattern were examined. In clinical subjects, prognosis was assessed using the end point of cardiovascular death after 7 years of follow-up. RESULTS Components of the J-wave pattern were most prevalent in males; African Americans; and, particularly, athletes, with the greatest variations demonstrated in the lateral leads. ST elevation was the most common. Inferior J waves and slurs, previously linked to cardiovascular risk, were observed in 9.6% of clinical subjects and 12.3% of athletes. J waves, slurs, or ST elevation was not associated with time to cardiovascular death in clinical subjects, and ST-segment slope abnormalities were not prevalent enough in conjunction with them to reach significance. CONCLUSIONS J waves, slurs, or ST elevation was not associated with increased hazard of cardiovascular death in our large multiethnic, ambulatory population. Even subsets of J-wave patterns, recently proposed to pose a risk of arrhythmic death, occurred at such a high prevalence as to negate their utility in screening.

Socioeconomic Inequalities in Quality of Care and Outcomes Among Patients With Acute Coronary Syndrome in the Modern Era of Drug Eluting Stents

Background The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES). Methods and Results We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower‐income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non‐STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower‐income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased. Conclusions For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

Prognostic implications of the J wave ECG patterns

Recent studies concerning the J wave/slur pattern have caused confusion among those recommending ECG screening to prevent sudden cardiac death in young athletes in whom “early repolarization” is frequently observed. This is of major importance since we know that 50% of sudden death in young people occurs despite morphologically normal hearts. The available prognostic studies of this and similar ECG patterns have demonstrated differing results, but some suggest that end QRS notching and slurring, particularly in the inferior leads and when accompanied by downward sloping ST segments, have associated risk of sudden death. The differences in the studies appear to be due to terminology and methodological issues as well as design shortcomings. A total of 8 prognostic studies, summarized in Table 1, are available as of February 2013. The major methodological issue in these studies is that each defined early repolarization (ER) and the J point differently. Some defined ER as the presence of ST elevation (classic ER) while others defined it as the presence of J waves or slurs (new ER). Early repolarization was originally recognized in the US because of the higher prevalence of persons of African descent. Because of the unique US experience and the fact that most guidelines are international, an early repolarization definition was never established. Guidelines have addressed however, where the ST level for recognizing ischemia or pericarditis is measured and considered the J-point (or J-junction) to be the beginning of the ST segment. Many subtle but important questions regarding appropriate use of the terminology have since arisen: Is the J point the beginning of the ST segment (the classic J point, as in the guidelines) or is it the top of the J wave or slur (the new J point)? How is the QRS duration measured and are conduction delays included? Does the QRS duration include the J waves/slurs when they are present? Table 2 lists the definitions and measurements made by the eight studies. Even close reading of these studies often

Variability in quantitative and qualitative analysis of intravascular ultrasound and frequency domain optical coherence tomography.

Frequency‐domain optical coherence tomography (FD‐OCT) is an intravascular imaging technique now available in the United States. However, the importance of level of training required for analysis using intravascular ultrasound (IVUS) and FD‐OCT is unclear. The aim of this study was to evaluate inter‐ and intra‐observer variability between expert and beginner analysts interpreting IVUS and FD‐OCT images.

The Electrocardiogram at a Crossroads

The ECG is at a crossroads as to its future integration into modern medical practice. Those most interested in electrocardiography remain the old guard, whose careers evolved with this technology. They remain as enamored by the experiential mythology as by the experimental science of the ECG. Electrophysiologists, who rightly should be carrying on the torch of further ECG development, are too busy with their therapeutic invasive procedures and devices to invest much time in diagnostic decision support. Young physicians in training are too busy learning the plethora of new diagnostic modalities and treatment procedures to even become competent in ECG interpretation. Many of them only have goals to recognize an ST elevation myocardial infarction and atrial fibrillation, and to pass their board examinations. Their understanding of ST elevation myocardial infarction criteria could be easily exposed by asking them to name the contiguous pairs of standard ECG leads. A disappointing number would refer to pairs of leads that are contiguous on the ECG display such as II and III or V1 and V4, rather than the leads separated by 30° going around the surface of the heart as specified in the guidelines.1 Reimbursement provides a further counterincentive: to paraphrase George Bernard Shaw ( The Doctor’s Dilemma , 1926), “the doctor orders the test that pays the most” and that is no longer the ECG, but a panoply of imaging procedures. Examples of the experiential mythology that continue to haunt electrocardiography include the requirement for contiguous or adjacent leads instead of a single lead for fulfilling diagnostic criteria. The contiguous or adjacent lead constraint is a residual from the thick, noisy tracings from the early days of electrocardiography before high-impedance amplifiers, DC coupling, and digital processing produced the high-resolution tracings of today (Figure 1). Applying the criteria to a …

J wave patterns and ST elevation in women

New data have challenged the benign nature of early repolarization (ER) by suggesting that it may be a prognostic marker of susceptibility to malignant arrhythmia and cardiovascular death. A seminal study in 2008 by Haissaguerre demonstrated an association between the J wave pattern and idiopathic ventricular fibrillation. 2 Subsequently, a Finnish population study with 30-year follow up reported greater risk of arrhythmic deaths associated with inferior lead J wave pattern. However, a number of additional studies since then, riddled with nomenclature inconsistencies, have raised further disagreements about the clinical significance of the J wave pattern. Despite the excitement surrounding this controversy, these studies have dedicated minimal attention to the clinical significance of early repolarization among women. Limited data suggest that not only do substantial differences in prevalence exist by gender, but the clinical significance may be different as well. Besides data from our institution, currently there have been nine other population studies of ST elevation, J waves, and QRS slurs that include women. Of the nine studies, only six report gender-specific data and of those, only three report gender-specific prognostic information. In this paper, we will present our comparison of gender differences in the patterns and prevalence of J waves, terminal QRS slurs, and ST elevation in our populations of Veterans and collegiate athletes. Because of the small numbers of women of African descent, we will consider only non-African Americans in this study (another paper in the symposium will concentrate on African Americans). Only 6 deaths occurred in the clinical population so

Is the J wave or the ST slope malignant…or neither?

Probably no group has done more to make sense of the current confusion regarding early repolarization than our friends from Tel Aviv. Although we agree with their logical conclusions in their recent state-of-the-art paper [(1)][1], we would like to add our own concerns regarding terminology and the

Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study)

Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarins efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.

Justification of an Introductory Electrocardiogram Teaching Mnemonic by Demonstration of its Prognostic Value

OBJECTIVES With diminishing time afforded to electrocardiography in the medical curriculum, we have found Sibbitts simple mnemonic, the Diagonal Line Lead Rule, for a pattern recognition approach to 12-lead electrocardiogram (ECG) interpretation to be appreciated by students. However, it still lacks universal acceptance because its clinical utility has not been documented. The study objective was to demonstrate the clinical utility of the Diagonal Line Lead ECG Teaching Rule. METHODS After excluding ECGs of high-risk patients with Wolff-Parkinson-White syndrome and QRS durations greater than 120 ms, the initial ECGs of the remaining 43,798 patients were scored according to the Diagonal Line Lead Rule. A total of 45,497 patients from the Veterans Affairs Palo Alto Healthcare System were referred for a routine initial resting ECG from 1987 to 1999. We determined cardiovascular mortality with 8 years of follow-up. RESULTS In patients with normal QRS duration, diagnostic Q-wave or T-wave inversions isolated to the diagonal line leads showed no increased risk of cardiovascular death. Q-wave or T-wave inversion in any other lead was significantly associated with cardiovascular death with an age-adjusted Cox hazard of 2.6 (confidence interval, 2.4-2.8; P < .0001) and an annual cardiovascular mortality rate of 3.0%. Leads V4-V6, I, and aVL were especially significant predictors of cardiovascular death, with a Cox hazard greater than 3. CONCLUSIONS Our analysis demonstrates the prognostic power and clinical utility of a simple mnemonic for 12-lead ECG interpretation that can facilitate ECG teaching and interpretation.

Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry

Background It is poorly understood whether insurance type may be a major contributor to the underuse of oral anticoagulation (OAC) among patients with atrial fibrillation (AF), particularly for novel oral anticoagulants (NOACs). Methods We performed a retrospective cohort registry study of patients with insurance, AF, CHA2DS2‐VASc ≥2, and at least one outpatient encounter recorded in the ACC NCDRs PINNACLE Registry between January 1, 2011 and December 31, 2014. We used hierarchical regression, adjusting for patient characteristics and clustering by physician, to evaluate the association of insurance type (Private, Military, Medicare, Medicaid, Other) with receipt of OAC (any OAC, warfarin, or NOAC). Results In 363,309 patients (age 75 ± 10; 48% female), we found a significant difference in proportions of OAC and NOAC prescription across insurance types (OAC: Military 53%, Private 53%, Medicare 52%, Other 41%, Medicaid 41%, P < .001; NOAC: Military 24%, Private 19%, Medicare 17%, Other 17%, Medicaid 8%, P < .001). After adjustment for patient characteristics and facility, private, Medicaid, and other insurance were independently associated with a lower odds of OAC prescription relative to Medicare, but military insured patients were not significantly different. After adjustment, military and private insurance were independently associated with a higher odds of NOAC prescription relative to Medicare, while Medicaid and other insurance were associated with a lower odds of NOAC prescription. Conclusions In a contemporary US AF population, there was significant variation of OAC prescription across insurance plans, with the highest among private and Medicare insured patients. These differences may indicate that insurance plan, and its associated pharmacy benefits, affect the pace of diffusion of new therapies.