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Defining abnormal electrocardiography in adult emergency department syncope patients: the Ottawa Electrocardiographic Criteria

Published online by Cambridge University Press:  11 May 2015

Venkatesh Thiruganasambandamoorthy ,
Erik P. Hess ,
Ekaterina Turko ,
My-Linh Tran ,
George A. Wells  and
Ian G. Stiell
Venkatesh Thiruganasambandamoorthy*
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
Erik P. Hess
Affiliation:
Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
Ekaterina Turko
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON
My-Linh Tran
Affiliation:
The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
George A. Wells
Affiliation:
Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
Ian G. Stiell
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
*
The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, 6th Floor, Room F655, Ottawa, ON K1Y 4E9; [email protected].

Abstract

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Background:

Previous studies have indicated that the sub-optimal performance of the San Francisco Syncope Rule (SFSR) is likely due to the misclassification of the “abnormal electrocardiogram (ECG)” variable. We sought to identify specific emergency department (ED) ECG and cardiac monitor abnormalities that better predict cardiac outcomes within 30 days in adult ED syncope patients.

Methods:

This health records review included patients 16 years or older with syncope and excluded patients with ongoing altered mental status, alcohol or illicit drug use, seizure, head injury leading to loss of consciousness, or severe trauma requiring admission. We collected patient characteristics, 22 ECG variables, cardiac monitoring abnormalities, SFSR “abnormal ECG” criteria, and outcome (death, myocardial infarction, arrhythmias, or cardiac procedures) data. Recursive partitioning was used to develop the “Ottawa Electrocardiographic Criteria.”

Results:

Among 505 included patient visits, 27 (5.3%) had serious cardiac outcomes. We found that patients were at risk for cardiac outcomes within 30 days if any of the following were present: second-degree Mobitz type 2 or third-degree atrioventricular (AV) block, bundle branch block with first-degree AV block, right bundle branch with left anterior or posterior fascicular block, new ischemic changes, nonsinus rhythm, left axis deviation, or ED cardiac monitor abnormalities. The sensitivity and specificity of the Ottawa Electrocardiographic Criteria were 96% (95% CI 80–100) and 76% (95% CI 75–76), respectively.

Conclusion:

We successfully identified specific ED ECG and cardiac monitor abnormalities, which we termed the Ottawa Electrocardiographic Criteria, that predict serious cardiac outcomes in adult ED syncope patients. Further studies are required to identify which adult ED syncope patients require cardiac monitoring in the ED and the optimal duration of monitoring and to confirm the accuracy of these criteria.

Keywords

arrhythmiacardiacelectrocardiogramoutcomesrisksyncope
Type
State of the Art • À la fine pointe
Information
Canadian Journal of Emergency Medicine , Volume 14 , Issue 4 , July 2012 , pp. 252 - 262
Copyright
Copyright © Canadian Association of Emergency Physicians 2012

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