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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

References

REFERENCES

1.Blanc, JJ, L’Her, C, Touiza, A, et al. Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 2002;23:815–20, doi:10.1053/euhj.2001.2975.Google Scholar
2.Sarasin, FP, Louis-Simonet, M, Carballo, D, et al. Prospective evaluation of patients with syncope: a population-based study. Am J Med 2001;111:177–84, doi:10.1016/S0002-9343(01)00797-5.Google Scholar
3.Sun, BC, Emond, JA, Camargo, CA Jr.Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992–2000. Acad Emerg Med 2004;11:1029–34.Google Scholar
4.Quinn, JV, Stiell, IG, McDermott, DA, et al. Derivation of the San Francisco Syncope Rule to predict patients with shortterm serious outcomes. Ann Emerg Med 2004;43:224–32, doi:10.1016/S0196-0644(03)00823-0.Google Scholar
5.Quinn, J, McDermott, D, Stiell, I, et al. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med 2006;47:448–54, doi:10.1016/j.annemergmed.2005.11.019.Google Scholar
6.Birnbaum, A, Esses, D, Bijur, P, et al. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med 2008;52:151–9, doi:10.1016/j.annemergmed.2007.12.007.CrossRefGoogle Scholar
7.Sun, BC, Mangione, CM, Merchant, G, et al. External validation of the San Francisco Syncope Rule. Ann Emerg Med 2007;49:420–7, doi:10.1016/j.annemergmed.2006.11.012.Google Scholar
8.Wasson, JH, Sox, HC, Neff, RK, et al. Clinical prediction rules. Applications and methodological standards. N Engl J Med 1985;313:793–9, doi:10.1056/NEJM198509263131306.Google Scholar
9.Stiell, IG, Wells, GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47, doi:10.1016/S0196-0644(99)70309-4.Google Scholar
10.Laupacis, A, Sekar, N, Stiell, IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997;277:488–94, doi:10.1001/jama.1997.03540300056034.Google Scholar
11.Thiruganasambandamoorthy, V, Hess, EP, Alreesi, A, et al. External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med 2010;55:464–72, doi:10.1016/j.annemergmed.2009.10.001.Google Scholar
12.Colivicchi, F, Ammirati, F, Melina, D, et al. OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) Study Investigators. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J 2003;24:811–9, doi:10.1016/S0195-668X(02)00827-8.Google Scholar
13.Martin, TP, Hanusa, BH, Kapoor, WN. Risk stratification of patients with syncope. Ann Emerg Med 1997;29:459–66, doi:10.1016/S0196-0644(97)70217-8.Google Scholar
14.Sarasin, FP, Hanusa, BH, Perneger, T, et al. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003;10:1312–7, doi:10.1111/j.1553-2712.2003.tb00003.x.Google Scholar
15.Cosgriff, TM, Kelly, AM, Kerr, D. External validation of the San Francisco Syncope Rule in the Australian context. CJEM 2007;9:157–61.CrossRefGoogle ScholarPubMed
16.Pezzullo, JC. Interactive statistics page. 2-Way contingency table analysis. Available at: http://www.statpages.org/ctab2x2.html.Google Scholar
17.Hanley, JA, McNeil, BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983;148:839–43.Google Scholar
18.Gilbert, EH, Lowenstein, SR, Koziol-McLain, J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996;27:305–8, doi:10.1016/S0196-0644(96)70264-0.Google Scholar
19.Worster, A, Bledsoe, RD, Cleve, P, et al. Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med 2005;45:448–51, doi:10.1016/j.annemergmed.2004.11.021.CrossRefGoogle ScholarPubMed
20.Badcock, D, Kelly, AM, Kerr, D, et al. The quality of medical record review studies in the international emergency medicine literature. Ann Emerg Med 2005;45:444–7, doi:10.1016/j.annemergmed.2004.11.011.CrossRefGoogle ScholarPubMed
21.Lowenstein, SR. Medical record reviews in emergency medicine: the blessing and the curse. Ann Emerg Med 2005;45:452–5, doi:10.1016/j.annemergmed.2005.01.032.CrossRefGoogle Scholar
22.Lasser, RP, Haft, JI, Friedberg, CK. Relationship of right bundle-branch block and marked left axis deviation (with left parietal or peri-infarction block) to complete heart block and syncope. Circulation 1968;37:429–37.Google Scholar
23.Tabrizi, F, Rosenqvist, M, Bergfeldt, L, et al. Time relation between a syncopal event and documentation of atrioventricular block in patients with bifascicular block: clinical implications. Cardiology 2007;108:138–43, doi:10.1159/000096038.Google Scholar
24.Huff, JS, Decker, WW, Quinn, JV, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med 2007;49:431–44, doi:10.1016/j.annemergmed.2007.02.001.CrossRefGoogle Scholar
25.Moya, A, Sutton, R, Ammirati, F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631–71, doi:10.1093/eurheartj/ehp290.Google Scholar
26.Grossman, SA, Fischer, C, Lipsitz, LA, et al. Predicting adverse outcomes in syncope. J Emerg Med 2007;33:233–9, doi:10.1016/j.jemermed.2007.04.001.CrossRefGoogle ScholarPubMed
27.Reed, MJ, Newby, DE, Coull, AJ, et al. The Risk stratification Of Syncope in the Emergency department (ROSE) pilot study: a comparison of existing syncope guidelines. Emerg Med J 2007;24:270–5, doi:10.1136/emj.2006.042739.Google Scholar
28.Byrt, T. How good is that agreement? Epidemiology 1996;7:561.Google Scholar
29.Landis, JR, Koch, GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74, doi:10.2307/2529310.Google Scholar