Jonathan Lipton

Comprehensive hospital care improvement strategies reduce time to treatment in ST-elevation acute myocardial infarction

BACKGROUND Delay in treatment of patients with ST-elevation acute myocardial infarction (STEMI) has an adverse effect on patient outcomes. Limited data are available on the effectiveness of hospital care improvement strategies (HCIS) to reduce time to reperfusion by percutaneous coronary intervention (PCI). This study evaluated the combined effect of HCIS implementation to reduce door-to-balloon time in patients with STEMI. METHODS Retrospective chart review was done for 95 consecutive patients with STEMI who underwent PCI at Charleston Area Medical Center. Patients with non-STEMI and patients transferred from other medical centers were excluded. Door-to-balloon time was defined as time from emergency department arrival to first PCI balloon inflation. A program of 3 HCIS was implemented: 1) a fast-track catheterization laboratory protocol, 2) feedback to cardiologists on their treatment times, and 3) a weekday 24-hour inhouse catheterization laboratory team. Patients were separated into groups before (n = 46), during (n = 18), and after (n = 31) HCIS implementation. RESULTS Mean age was 60.3 +/- 13 years and 74% were male. The majority (64%) arrived by ambulance; 29% had a prehospital electrocardiogram done. Most patients presented during the day (68%) on weekdays (75%). Symptom onset-to-door time was 289 +/- 393 minutes. No significant differences were found between the groups for these variables. Door-to-PCI time in minutes was reduced in the group after versus the group before HCIS implementation (94.3 +/- 37 vs 133.5 +/- 53; P < 0.0001). CONCLUSION Implementation of HCIS shortened door-to-PCI time for patients with STEMI by 39.2 +/- 10 minutes. Thus, HCIS may be effective in improving patient outcomes.

Detection of stress-induced myocardial ischemia from the depolarization phase of the cardiac cycle—a preliminary study

BACKGROUND Electrocardiogram (ECG)-based detection of ischemia is typically dependent on identifying changes in repolarization. Analysis of high-frequency QRS (HFQRS) components, related to the depolarization phase of the cardiac action potential, has been reported to better identify ischemia. Our aim was to test the hypothesis that HFQRS analysis is both more sensitive and specific than standard ECG for detecting exercise-induced ischemia in patients undergoing exercise myocardial perfusion imaging (MPI). METHODS Exercise MPI was performed in 133 consecutive patients (age, 63 +/- 12; 100 males) and used as the gold standard for ischemia. Patients with QRS duration more than 120 milliseconds (n = 20), technical problems (n = 8), or inconclusive MPI (n = 4) were excluded, leaving 101 patients for analysis. Conventional ECG was combined with high-resolution ECG acquisition that was digitized and analyzed using the HyperQ System (BSP, Tel Aviv, Israel). The relative HFQRS intensity change during exercise was used as an index of ischemia. RESULTS Of the 101 patients who were included in the analysis, 19 exhibited MPI ischemia. The HFQRS index of ischemia was found to be more sensitive (79% vs 41%; P < .05) and more specific (71% vs 57%; P < .05) than conventional ST analysis. CONCLUSIONS The HFQRS analysis was more sensitive and specific than conventional ECG interpretation in detecting exercise-induced ischemia and exhibited enhanced diagnostic performance in both women and men. Thus, it may aid in the noninvasive diagnosis of ischemic heart disease.

Hyperglycemia at admission and during hospital stay are independent risk factors for mortality in high risk cardiac patients admitted to an intensive cardiac care unit

Aims: Hyperglycemia is associated with increased mortality in cardiac patients. However, the predictive value of admission- and average glucose levels in patients admitted to an intensive cardiac care unit (ICCU) has not been described. Methods: Observational study of patients admitted to the ICCU of a tertiary medical center in whom glucose levels were measured at and during admission. Over a 19-month period, 1713 patients were included. Mean age was 63±14 years, 1228 (72%) were male, 228 (17%) had known diabetes. Median (interquartile) glucose levels at admission were 7.9 (6.5–10.1) mmol/l; median glucose levels during ICCU admission (873 patients with three or more measurements) were 7.3 (6.7–8.3) mmol/l. Cox regression analysis was performed including the variables age, gender, admission diagnosis, length of stay, prior (cardio)vascular disease and diabetes. Results: A 1 mmol/l increase in admission glucose level (above 9 mmol/l) was associated with a 10% (95% confidence interval (CI): 7 –13%) increased risk for all-cause mortality. A 1 mmol/l higher average glucose level (above 8 mmol/l) was an additional independent predictor of mortality (HR 1.11, 95% CI: 1.03 – 1.20). At 30 days, 16.8% (97/579) of the patients with an admission glucose level in the highest tertile (>9.8 mmol/L) had died vs 5.2% (59/1134) of those with a lower admission glucose level. Conclusion: In a high risk ICCU population, both high admission glucose levels as well as high average glucose levels during hospitalization were independently associated with increased mortality, even when accounting for other risk factors and parameters of disease severity.

Impact of an alerting clinical decision support system for glucose control on protocol compliance and glycemic control in the intensive cardiac care unit

BACKGROUND Glycemic control in patients with acute cardiac conditions is a clinical challenge but may substantially improve patient outcome. The aim of the current study was to evaluate the effect of implementing an automated version of an existing insulin protocol for glucose regulation in the Intensive Cardiac Care Unit (ICCU) on compliance with the protocol and achievement of glycemic targets. METHODS During an 11-month period, data of 667 patients with two or more glucose measurements were evaluated, 425 before and 242 after implementation of the clinical decision support system (CDSS) for glucose control at the Erasmus Medical Center ICCU (Rotterdam, The Netherlands). RESULTS After implementation, compliance with the advised measurement time increased from 40% to 52% (P < 0.001), and compliance regarding insulin dosage increased from 49% to 61% (P < 0.001). Also, more patients had a mean glucose level within the target range of 81-126 mg/dL (31% vs. 43% [P = 0.01]). Monthly evaluation identified reasons for protocol noncompliance (e.g., nutritional status and time of day) and will be used to improve the existing CDSS. CONCLUSIONS The CDSS implementation of an insulin protocol in an ICCU improved compliance, identified targets for further improvement of the protocol, and resulted in improved glucose regulation after implementation.

Abnormal spatial QRS-T angle predicts mortality in patients undergoing dobutamine stress echocardiography for suspected coronary artery disease

ObjectiveTo investigate the association between (cardiac) mortality and spatial QRS-T angle in patients undergoing dobutamine – atropine stress echocardiography (DSE) for evaluation of known or suspected coronary disease. MethodsBetween 1990 and 2003, 2347 patients underwent DSE for evaluation of coronary disease at the Erasmus Medical Center. Echocardiographic images were analyzed offline using a 16-segment, 5-point scoring model for regional function. Twelve-lead resting ECGs were analyzed and patients were grouped in three categories according to their spatial QRS-T angle: normal (0–105°), borderline (105–135°), and abnormal (135–180°). ResultsMean age was 61±13 years, 66% were male, 32% had hypertension, 26% had hypercholesterolemia, 28% were smokers, and 12% were diabetic. During a mean follow-up of 7±3.4 years, 26.5% (623) of the patients died; 15.3% (359) died due to a cardiac cause. Abnormal QRS-T angle (135–180°) was present in 21% of the patients.Abnormal QRS-T angle was a predictor of cardiac death [hazard ratio: 3.2 (2.6–4.1)] and all-cause mortality [hazard ratio: 2.2 (1.8–2.6)]. After multivariate analysis abnormal and borderline QRS-T angle, peak wall motion score, age, male sex, history of diabetes, history of heart failure, smoking, and hypertension were independent predictors of (cardiac) death. ConclusionAbnormal QRS-T angle is an independent predictor of (cardiac) death in patients undergoing DSE. Abnormal QRS-T angle should be considered as a risk factor in stable patients evaluated for coronary disease.

An open source ECG toolkit with DICOM

Unlike the ubiquitous use of DICOM for sharing various medical image modalities, the storage and retrieval of digital 12-lead electrocardiograms across different ECG management systems is often limited to manual file-based export and import using vendor-specific solutions. In addition to SCP-ECG, a number of open standard initiatives have been introduced, such as DICOM-ECG and HL7 aECG. By extending and improving a previously developed ECG toolkit we have explored the capabilities of these open standards in terms of interoperability, filesize and transmission times. The ECG toolkit is almost entirely available under the Apache License Version 2.0.

Implementing a Clinical Decision Support System for Glucose Control for the Intensive Cardiac Care

Adherence to guidelines and protocols in clinical practice can be difficult to achieve. We describe the implementation of a Clinical Decision Support System (CDSS) for glucose control on the Intensive Cardiac Care Unit (ICCU) of the Erasmus MC. An existing paper protocol for glucose control was used for the CDSS rule set. In the first phase we implemented a proof of concept of a CDSS: a web 2.0 AJAX-driven web screen, which resulted in an improved adherence to the glucose guideline. This paper will reflect on the technical implementations and challenges of our experience with this process. The end product will allow: storage of guidelines in a shareable and uniform matter, presentation of guidelines in a more clear way to physicians, a more flexible platform to maintain guidelines, the ability to adjust guidelines to incorporate changes based on collected evidence from the CDSS and/or literature review, and be able to better review the outcome.

In memory of Professor Galen S. Wagner M.D., Ph.D. (1939-2016) : Our mentor, colleague and friend

Galen S. Wagner M.D., Ph.D., the Editor-in-Chief of the Journal of Electrocardiology, passed away on July 13, 2016, in Durham, NC, USA. He was a passionate and tireless clinician–scientist and mentor, devoted father, husband, loyal friend and colleague. (See Fig. 1.) Galen Wagner was born in Connellsville, PA, on December 25, 1939. He started his professional career as an Intern-Resident in medicine at Duke University Medical Center Durham, NC, (1965–1967) and cardiology fellow (1967–1970). Duke University was his place of work throughout his entire professional life where he served in a variety of leadership roles. Being active as the director of the Cardiac Care Unit of the Duke University Medical Center (1968–81), he was instrumental in the development of the world renowned Duke Cardiovascular Databank. He was deeply involved in research and mentoring students as an Associate in Medicine, Duke University (1970–1972), Assistant Professor of Medicine, Duke University (1972–1976) and Acting Chief, Cardiovascular Division, Duke University Medical Center (1976–1977), and as Associate Professor of Medicine, Duke University (1977–2016). He received an honorary Ph.D. from Lund University in Sweden for the extensive mentoring Galen volunteered to both students and colleagues alike in international research. During the years (1977–1982) he was Director of the Duke Cardiology Fellowship Program and Assistant Dean of Medical Education. He was a founder and Co-Director of the Duke University Cooperative Cardiovascular Society (DUCCS) (1986–1997) and Director (1997–1998, and 2003–2008). DUCCS is a consortium of current and former Duke Cardiology Fellows, researchers from many institutions worldwide, and industry sponsors. Galen leaves a legacy as clinician–scientist, mentor, colleague and friend that spans many countries and numerous publications. He was an author on 701 published manuscripts, 8 books, and for the past 11 years, has been the Editor in Chief of the Journal of Electrocardiology. He has also been on the Editorial Boards of Circulation and the American Journal of Cardiology. But the profes-

Evaluation of a clinical decision support system for glucose control: impact of protocol modifications on compliance and achievement of glycemic targets.

Treating hyperglycemia may improve patient outcome, but is a clinical challenge. Three variations of a computerized insulin protocol were compared with regard to protocol compliance and achievement of glucose target levels. In group 1, the existing protocol was applied, in group 2 the protocol was modified to account for decreasing glucose values; group 3 had a higher threshold for initiating insulin, wider glucose target ranges, and included instructions to regulate glucose around mealtimes. From July 28, 2008 until February 1, 2010, data from 1255 patients admitted to our Intensive Cardiac Care Unit with at least 2 glucose measurements were analyzed. Mean age was 64 +/- 15 years, 66% were male, 21% had diabetes. Groups 1 to 3 included 269, 814, and 142 patients, respectively. Protocol compliance in group 2 was lower with 44% of the glucose measurements performed on time versus 51% in group 1 (P < 0.001), and insulin was dosed correctly in 57% versus 67% (P < 0.001). In group 3, compliance increased, 52% of the measurements were done on time, and insulin was dosed correctly in 71%. Average glucose levels increased in group 3 due to a higher threshold for starting insulin and a wider target range: 70% (group 1), 66% (group 2), and 61% (group 3) had an average glucose of <8 mmol/L (P < 0.001). Also, we observed a decreasing trend in incidence of hypoglycemia and reporting of noncompliance. Further improvements in glucose measurement technology and protocols are needed to optimally treat hyperglycemia in the Intensive Cardiac Care Unit.

The role of insulin therapy and glucose normalisation in patients with acute coronary syndrome

Patients with acute myocardial infarction (AMI) and diabetes mellitus, as well as patients admitted with elevated blood glucose without known diabetes, have impaired outcome. Therefore intensive glucose-lowering therapy with insulin (IGL) has been proposed in diabetic or hyperglycaemic patients and has been shown to improve survival and reduce incidence of adverse events. The current manuscript provides an overview of randomised controlled trials investigating the effect of IGL. Furthermore, systematic glucose–insulin–potassium infusion (GIK) has been studied to improve outcome after AMI. In spite of positive findings in some early studies, GIK did not show any beneficial effects in recent clinical trials and thus this concept has been abandoned. While IGL targeted to achieve normoglycaemia improves outcome in patients with AMI, achievement of glucose regulation is difficult and carries the risk of hypoglycaemia. More research is needed to determine the optimal glucose target levels in AMI and to investigate whether computerised glucose protocols and continuous glucose sensors can improve safety and efficacy of IGL.