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Biomedical subjects

F M Fesmire

Publications and source records attributed to F M Fesmire.

At least 19 recordsLinked to original sources
PubMed2001

Selective dual nuclear scanning in low-risk patients with chest pain to reliably identify and exclude acute coronary syndromes.

STUDY OBJECTIVE: We sought to determine the use in routine clinical practice of selective dual nuclear cardiac scanning (rest and stress) in low-risk patients with chest pain for identifying and excluding acute coronary syndromes (ACSs) during the initial emergency department evaluation. METHODS: A prospective observational study was conducted over 13 months in 1,775 low-risk patients with chest pain who had intermediate- and high-risk ACSs ruled out by means of our 2-hour protocol, which consists of automated serial 12-lead ECG monitoring in conjunction with baseline and 2-hour creatine kinase (CK) MB and troponin I (cTnI) measurements. At the completion of the 2-hour evaluation period, low-risk patients were stratified by means of physician judgment into 1 of 2 categories: category III, possible ACS; and category IV, probable non-ACS chest pain. Level III patients underwent immediate dual nuclear scanning (rest thallium and stress sestamibi scanning), and level IV patients were discharged directly from the ED unless another serious non-ACS medical condition was thought to exist. Rest and stress scans were interpreted by a board-certified radiologist contemporaneous with patient evaluation. All patients were followed up for 30-day ACS, which was defined as acute myocardial infarction, percutaneous transluminal coronary angioplasty/coronary artery bypass grafting, coronary arteriography revealing stenosis of the major coronary artery of 70% or greater not amenable to percutaneous transluminal coronary angioplasty/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. RESULTS: A total of 2,206 ED patients with chest pain were evaluated for ACS during the study period. Four hundred thirty-one patients were excluded for having 1 or more of the following findings: initial ECG diagnostic of injury; baseline CK-MB level, cTnI level, or both diagnostic of acute myocardial infarction; 2-hour DeltaCK-MB level of +1.5 ng/mL or greater; 2-hour DeltacTnI level of +0.2 ng/mL or greater; injury or new or evolving ischemia on serial 12-lead ECG monitoring; or clinical diagnosis of ACS. Of the 1,775 study patients, 805 (45.4%) underwent immediate dual nuclear scanning. A positive stress nuclear scan result was more sensitive (97.3% versus 71.2%, P <.0001) and specific (87.7% versus 72.6%, P <.0001) for 30-day ACS than a positive resting nuclear scan result. The protocol of selective dual nuclear scanning (ie, patients who did not undergo dual nuclear scanning were counted as having a negative test result) had a sensitivity and specificity for 30-day ACS of 93.4% and 94.7%, respectively (positive likelihood ratio 17.6; negative likelihood ratio 0.07). CONCLUSION: Stress nuclear scanning is more sensitive and specific than resting nuclear scanning for identification of ACS in low-risk patients with chest pain. A strategy of using selective dual nuclear scanning once high- and intermediate-risk ACS has been ruled out with our 2-hour evaluation both reliably identifies and reliably excludes 30-day ACS.

Adult↗
PubMed2001

Improved identification of acute coronary syndromes with delta cardiac serum marker measurements during the emergency department evaluation of chest pain patients.

Current findings from the American College of Emergency Physicians (ACEP) are that no serum marker reliably identifies or excludes acute myocardial infarction (AMI) within 6 h of symptom onset. The ACEP recommends repeat serum marker testing 6-10 h after symptom onset for CK-MB mass and subform, and 8-12 h after symptom onset for cardiac troponin I and T before making an exclusionary diagnosis of non-AMI chest pain. A new approach for identifying myocardial necrosis is to rely on time changes in the serum marker value over an abbreviated time interval (slope or delta values) as opposed to the traditional approach of relying on a value exceeding the threshold of normalcy. As assays become ever more sensitive and precise, this approach has the potential for both reliably identifying and excluding AMI (and subsets of high-risk unstable angina) at earlier time intervals with no loss in specificity. This article discusses some of the experimental evidence for this delta approach and some preliminary evidence for the potential of utilizing second-generation cTnI assays for the identification of acute coronary syndromes. Finally, we discuss a unique way of viewing receiver-operating characteristic (ROC) curves as catalogs of likelihood ratios, which we believe will be more useful to the clinician in the proper interpretation of serum marker values.

Biomarkers↗
PubMed2000

Delta CK-MB outperforms delta troponin I at 2 hours during the ED rule out of acute myocardial infarction.

It has been shown that a rise in creatine kinase MB bank (CK-MB) of > or = + 1.6 ng/mL in 2 hours is more sensitive and equally specific for detection of acute myocardial infarction (AMI) as compared with a 2-hour CK-MB > or = 6 ng/mL during the emergency department (ED) evaluation of chest pain. Because cardiac specific troponin I (cTnI) is thought to have similar early release kinetics as compared with CK-MB mass, we undertook a retrospective cohort study in 578 chest pain patients whose baseline CK-MB and cTnI was less than two times the hospital's upper limits of normal and who underwent a 2-hour CK-MB and cTnI to compare sensitivities and specificities of the 2-hour delta CK-MB (deltaCK-MB) and delta cTnI (delta cTnI) for AMI and 30-day Adverse Outcome (AO). Thirty day AO was defined as AMI, life-threatening complication, death, or percutaneous transluminal coronary angioplasty (PTCA)/coronary artery bypass graft (CABG) within 30 days of ED presentation. Optimum delta values were determined by choosing the smallest cutoff value greater than the assay precision where the deltaCK-MB and delta cTnI had a positive likelihood ratio for 30-day AO of > or = 15. A deltaCK-MB > or = +1.5 ng/mL was more sensitive than a deltaTnI > or = +0.2 ng/mL for AMI (87.7% versus 61.4%; P < .0005) and 30-day AO (56.7% versus 42.3%; P < .005). There were no differences in specificities for AMI and 30-day AO. Combining the two tests (MBdelta > or = +1.5 ng/mL and/or a deltaTnI > or = +0.2 ng/mL) resulted in an incremental increase in sensitivity of 89.5% for AMI and 61.9% for AO (P < .005). Patients with either a rise in CK-MB of > or = +1.5 ng/mL or rise in cTnI of > or = +0.2 ng/mL in 2 hours should receive consideration for aggressive antiischemic therapy and further diagnostic testing before making an exclusionary diagnosis of nonischemic chest pain.

Bias↗
PubMed2000

A rapid protocol to identify and exclude acute myocardial infarction: continuous 12-lead ECG monitoring with 2-hour delta CK-MB.

A prospective observational study was performed in 706 chest pain patients who underwent our chest pain evaluation protocol which consists of continuous 12-lead ST-segment monitoring with automated serial ECG (SECG) and a 2-hour delta (delta) CK-MB level determination before ED physician making final disposition decision to determine the incremental value of our 2-hour protocol for identifying myocardial infarction (MI) as compared with the initial ECG in combination with a baseline CK-MB. The initial ECG was obtained on presentation and considered positive if it revealed injury or ischemia. SECGs were obtained at least every 10 minutes and considered positive if it revealed new injury or ischemia. The baseline CK-MB value was considered positive if it was > or =12 ng/mL and index > or =4%. ACK-MB was defined as a difference between the 2 hour and baseline CK-MB and was considered positive if the value was > or =+1.5 ng/mL. MI was defined as acute myocardial infarction (AMI) or recent AMI (ie, AMI patients presenting on falling curve of CK-MB). The incremental value of the 2 hour protocol (ie, SECG in conjunction with deltaCK-MB) was more sensitive for identification of MI than the baseline protocol (ie, initial ECG in conjunction with the baseline CK-MB) (94.0% versus 55.4%; P < .0001) and reliably both identified (+LR = 14.6) and excluded MI (-LR = 0.06). SECG monitoring in conjunction with the 2 hour deltaCK-MB allows for early identification and exclusion of MI, and can assist the ED physician in making appropriate treatment and disposition decisions.

Biomarkers↗
PubMed2000

Which chest pain patients potentially benefit from continuous 12-lead ST-segment monitoring with automated serial ECG?

A prospective observational study was performed in 678 chest pain patients with suspected acute coronary ischemic syndrome (ACS) and absence of clinical and ECG criteria for emergent reperfusion therapy on presentation to determine how often continuous 12-lead ST-segment monitoring with automated serial ECG (SECG) results in a significant change in therapy during the initial emergency department (ED) evaluation in typical high- and low-risk chest pain patients. After initial history, physical, and ECG were obtained, patients were grouped into high and low risk subgroups based on ED physician's assessment of likelihood of ACS. Significant change in therapy was defined as thrombolytic drug administration, emergent percutaneous coronary angioplasty (PTCA), and intensive anti-ischemic therapy with intravenous heparin and/or intravenous nitroglycerin. SECG monitoring was continued until either the patient was taken for emergent PTCA or until 2-hour serum markers measurements were obtained. A total of 26 patients therapy was changed secondary to SECG monitoring which represented 14.6% of high-risk patients and 1.1% of low-risk patients. New injury (21 patients) and new ischemia (4 patients) were the only SECG findings that led to a change in therapy. SECG monitoring had a 15.2 times increased odds of changing therapy in the high risk patients as compared with the low risk patients (P < .0001; 95% CI 6.1 to 38.2). Chest pain evaluation protocols that exclude these high risk ED patients from SECG monitoring should be reevaluated. Our data also suggests that researchers designing randomized studies to show utility of SECG monitoring should focus on the high-risk patients.

Aged↗
PubMed1998

Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain.

STUDY OBJECTIVE: To determine whether the use of automated serial 12-lead ECG monitoring (SECG) is more sensitive and specific than the initial 12-lead ECG in the detection of injury and ischemia in patients with acute coronary syndromes (ACS) during the initial ED evaluation of patients with chest pain. METHODS: A prospective observational study was performed in 1,000 patients with chest pain who were admitted to a university teaching hospital and who underwent continuous ST-segment monitoring with SECG during the initial ED evaluation. The initial ECG was obtained on presentation, and SECG readings were obtained at least every 20 minutes during the ED evaluation. Diagnostic abnormalities on the initial ECG were defined as injury or ischemia. Diagnostic changes on SECG were defined as evolving injury, evolving ischemia, new injury, or new ischemia. ACS was defined as acute myocardial infarction (AMI), recent myocardial infarction or unstable angina. RESULTS: A diagnostic SECG was more sensitive than a diagnostic initial ECG for detection of AMI (68.1% versus 55.4%; P < .0001) and ACS (34.2% versus 27.5%; P < .0001). A diagnostic SECG was more specific than a diagnostic initial ECG for detection of ACS (99.4% versus 97.1%; P < .01). SECG detected injury in an additional 16.2% of AMI patients compared with the initial ECG (61.8% versus 45.6%; P < .0001; 95% confidence interval for difference of proportions, 10.9% to 21.4%). CONCLUSION: SECG during the initial ED evaluation is more sensitive and more specific than the initial ECG in the identification of ACS. Patients with a diagnostic SECG need intensive antiischemic therapy, evaluation for reperfusion therapy, and admission to an ICU.

Adult↗
PubMed1998

Serial creatinine kinase (CK) MB testing during the emergency department evaluation of chest pain: utility of a 2-hour deltaCK-MB of +1.6ng/ml.

BACKGROUND: Traditional methods of using creatinine kinase (CK)-MB to diagnose acute myocardial necrosis rely on the total CK-MB exceeding a threshold of normalcy before being considered diagnostic. Because the CK-MB rapid immunoassay is both sensitive and precise, a small difference between two serial samples over an appropriate time interval may result in an increased sensitivity for acute myocardial infarction (AMI) compared with traditional methods if an appropriate cutoff value is chosen. METHODS AND RESULTS: Baseline and 2-hour CK-MB immunoassay measurements were performed in 710 patients with chest pain whose baseline CK-MB was less than two times upper limits of normal (<12 ng/ml) to determine whether a rise in CK-MB > or =+1.6 ng/ml is more sensitive and specific than an abnormal 2-hour CK-MB in the detection of patients with AMI during the initial emergency department evaluation of chest pain. The baseline (MBO) or 2-hour (MB2) CK-MB was considered positive if the CK-MB level was > or =6 ng/ml. MBdelta was defined as the difference of MB2 and MBO and was considered positive if the value was > or =+1.6 ng/ml. A positive MB2 was more sensitive for the detection of AMI (75.2% vs 17.7%; p < 0.0001) than a positive MBO. A positive MBdelta was more sensitive for the detection of AMI (93.8% vs 75.2%; p < 0.0001 ) than a positive MB2. There were no statistically significant differences in specificities for AMI for any test modality. CONCLUSIONS: A rise in CK-MB of > or =+ 1.6 ng/ml in 2 hours is a useful marker of AMI during the initial emergency department evaluation of patients with chest pain.

Adult↗
PubMed1995

Instability of ST segments in the early stages of acute myocardial infarction in patients undergoing continuous 12-lead ECG monitoring.

Many patients presenting to the emergency department with suspected acute myocardial infarction (AMI) have an initial 12-lead electrocardiogram (ECG) nondiagnostic for acute injury and thus do not meet any accepted ECG criteria for thrombolytic therapy. Early studies in the use of intracoronary thrombolytic therapy documented that cyclic variations in ST segment magnitudes between normalcy and injury are common during the early phase of AMI and correspond to spontaneous intermittent coronary opening and reocclusion. The reliance on a single ECG to diagnose AMI may mean that many patients with AMI are missed if the initial ECG is obtained during a window of ST segment normalcy. We present 3 patients with AMI who underwent continuous 12-lead ST segment monitoring with frequent serial ECGs whose ST segments periodically normalized during the acute injury phase. We believe continuous 12-lead ST segment monitoring with frequent serial ECGs can aid the physician in identifying patients with AMI who may benefit from thrombolytic therapy and other urgent revascularization techniques.

Adult↗
PubMed1995

ECG diagnosis of acute myocardial infarction in the presence of left bundle-branch block in patients undergoing continuous ECG monitoring.

It is common knowledge that the ECG diagnosis of completed myocardial infarction in the presence of left bundle-branch block (LBBB) is extremely difficult and often impossible. More than 50 rules have been proposed as criteria for interpreting Q-wave equivalents superimposed on the QRS complex in the presence of LBBB. However, because of misinterpretation of the available literature, physicians frequently recommend that patients with chest pain in the presence of LBBB receive thrombolytic therapy or urgent coronary arteriography on the basis of the assumption that acute injury and ischemia cannot be interpreted in the presence of LBBB. Unfortunately, many physicians fail to realize that although completed infarction is difficult to confirm in the presence of LBBB, ongoing ischemia and injury can be detected in the presence of LBBB and may be seen as often as they are in the presence of normal cardiac conduction. A deflection of the J point (and ST segment) in the direction of the major QRS complex or an elevation of the ST segment of more than 7 to 8 mm opposite the direction of the major QRS complex has been demonstrated to have a sensitivity of more than 50% in detecting acute injury, with a specificity of more than 90%. During the first half of an ongoing prospective study of the use of continuous 12-lead ECG monitoring in the emergency department, we encountered five patients with final diagnoses of acute myocardial infarction in the presence of LBBB who demonstrated significant ECG changes while undergoing continuous ST-segment monitoring with frequent serial ECGs. The five different locations of the infarcts in these five patients were posterior, posterolateral, inferior, anterior, and anterolateral. We present these patients' cases to demonstrate the ECG characteristics of acute injury in the presence of LBBB.

Aged↗
PubMed1994

ST-segment instability preceding simultaneous cardiac arrest and AMI in a patient undergoing continuous 12-lead ECG monitoring.

Little data exist concerning the actual onset time (time zero) in sudden death (SD) and acute myocardial infarction (AMI). Most studies have focused on describing the warning arrhythmias that occur before SD and AMI and have relied on retrospective analyses of fortuitous data obtained from patients who experience these adverse outcomes while undergoing routine ambulatory holter monitoring. Because of the limitations of holter monitoring, little information is known concerning the actual incidence of ST-segment changes preceding SD and AMI. The first case of simultaneous onset of silent SD and AMI occurring in a patient undergoing continuous 12-lead electrocardiograph (ECG) monitoring during his initial emergency department evaluation is reported. Analyses of the serial 12-lead electrocardiographs showed extensive transient silent ST-segment elevations and depressions preceding cardiac arrest and AMI and provided insight in the pathogenesis of SD and AMI. Continuous 12-lead ECG monitoring can identify patients at high risk for SD and AMI and allow physicians to intervene before the development of life-threatening conditions.

Arrhythmias, Cardiac↗
PubMed1993

Continuous 12-lead electrocardiograph monitoring in the emergency department.

Many patients presenting to the emergency department with suspected acute myocardial infarction have an initial electrocardiogram (ECG) non-diagnostic for acute injury or ischemia. Continuous ST segment monitoring devices have been used by physicians in the past to diagnose ischemia in the ambulatory outpatient population and to identify coronary occlusion in postthrombolytic and postsurgical patients. We report three patients with suspected acute myocardial infarction who underwent real-time continuous 12-lead ST segment monitoring with frequent serial ECGs on a microprocessor-controlled device during their initial emergency department evaluation. Continuous 12-lead ECG monitoring revealed significant changes on the ECG in all three cases presented, with a resultant change in emergency department therapy. Interestingly, all of these patients had significant ECG changes in the absence of recurrence of chest pain. We believe real-time continuous 12-lead ST segment monitoring with frequent serial ECGs can identify patients with an initially nondiagnostic or atypical ECG who may benefit from early interventional therapy.

Acute Disease↗
PubMed1991

Diagnostic and prognostic importance of comparing the initial to the previous electrocardiogram in patients admitted for suspected acute myocardial infarction.

Two hundred fifty-eight patients were admitted to the hospital for suspected acute myocardial infarction. Electrocardiograms recorded on admission (initial ECG) and the most recent available electrocardiogram recorded before admission (previous ECG) were compared to determine whether changes from the previous to initial ECG predicted acute myocardial infarction or complications of coronary artery disease. Initial ECGs were classed as either positive or negative, with positive indicating either infarction, injury, ischemia, strain, left ventricular hypertrophy, left bundle branch block, or paced rhythm. Negative ECGs were those that did not include any of the positive criteria. Positive and negative ECGs were subgrouped as showing change or no change from previous ECG. We found that patients with a negative initial ECG that had changed from the previous ECG had a 2.1 times greater risk for requiring interventions than those patients whose ECGs were unchanged. We also found that patients with a positive initial ECG that had changed from the previous ECG had a greater risk for interventions (2.0 times), complications (2.6 times), life-threatening complications (4.2 times), and acute myocardial infarction (6.6 times) than the sum of patients in all other ECG categories. We conclude that change is a useful predictor for interventions in patients with negative initial ECGs and a useful predictor for interventions, complications, and acute myocardial infarction in patients with positive initial ECGs.

Coronary Disease↗