Optimizing Electrocardiogram Interpretation and Catheterization Laboratory Activation in ST-Segment Elevation Myocardial Infarction: A Teaching Module for Medical Students Mortada Shams, Alexander Sullivan, Shajidan Abudureyimu, Bassel Hassouna, Vimala Jayanthi, Richard Amdur, P. Jacob Varghese, Marco Mercader Division of Cardiology, The George Washington University, Washington, DC
Learning Objectives Methods- Validation Study Module- Classic STEMI 1. To develop a teaching module to increase the accuracy of We conducted a prospective education validation trial with fourth- cardiac catheterization lab activation year medical students. We administered pre- and post-tests 2. To improve medical student and clinician electrocardiographic comprised of exemplary cases of STEMIs, STEMI-equivalents (ECG) diagnosis of ST-segment elevation myocardial and STEMI-mimics from our case review. Participants studied the infarctions (STEMI), their equivalents, and their mimics module for two weeks and received a didactic module-based lecture prior to the post-test. Students served as their own control. Introduction The primary end point was STEMI recognition, measured by In the last 10 years, cardiovascular mortality has dropped by 30%. appropriate catheterization lab activation. The secondary endpoint This results from various innovations in preventive cardiology, was correct ECG diagnosis. Paired t-tests were used to compare diagnostic testing, and a number of treatment modalities. One of pre- and post-training scores. the most effective interventions has been the 90-minute reperfusion strategy, the so-called “Door-to-Balloon time”. This Results approach has resulted in a 5% 30-day mortality for acute ST- Appropriate catheterization lab activation mean score was 61% Module- STEMI Equivalent segment elevation myocardial infarction (STEMI). (SD 0.14) and improved to 76% on post-test (SD 0.18, p<0.0001). Accurate ECG diagnosis mean score was 59% (SD 0.14) and To achieve the 90-minute reperfusion goal in STEMI care, improved to 74% on post-test (SD 0.16, p<0.0001). A sample size providers must diagnose STEMIs from electrocardiograms of 26 achieved more than 99% power. (ECGs) obtained upon emergency room arrival and appropriately 80 76% activate the catheterization lab. To enhance early STEMI care, we 74% 70 SD 0.18 sought to improve medical student STEMI recognition and SD 0.16 60 61% 59% diagnostic accuracy with a teaching module we designed and SD 0.14 SD 0.14 developed. 50 40
Methods- Literature and Case Review 30 Mean Score (%) Score Mean
An extensive literature review was conducted to compile 20 evidenced-based criteria to identify the following: 10 Module- STEMI Mimic 0 • STEMIs: Classic anterior, inferior, and lateral patterns Appropriate Cath Lab Activation Accurate ECG Diagnosis • STEMI-equivalents: Hyperacute T-waves, STEMI with (p<0.0001) (p<0.0001) existing left bundle branch block (LBBB), and Wellens’ Pre-Test Post-Test syndrome. Figure 1: Bar graph of pre- and post-test scores for cath lab activation and correct ECG diagnosis amongst fourth-year medical students • STEMI-mimics: Known LBBB, pericarditis, ventricular aneurysm, pulmonary embolism, left ventricular hypertrophy, Conclusion hyperkalemia, Brugada syndrome, early repolarization, and The module significantly improved student STEMI recognition, takotsubo cardiomyopathy. appropriate catheterization lab activation and diagnostic accuracy.
Our literature review informed a subsequent case review of cases References seen at the GW Hospital that demonstrate the identified evidence- 1. Bagai A. Acute Coronary Syndromes Compendium. Circulation 2014; 114: 1918-1928. based ECG criteria. The 24 best ECGs were compiled into the 2. Rokos I. Appropriate Cardiac Cath Lab Activation. American Heart Journal 2010; 160: 995-1003. teaching module with clinical information, diagnostic ECG 3. Wagner G. AHA/ACCF/HRS Recommendations For the Standardization and Disclosure of Faculty Relationships- Marco Mercader, MD: Other- criteria, and imaging, including cardiac catheterization, Interpretation of the Electrocardiogram: Part IV: Acute Ischemia/Infarction. Circulation 2009; 119: e262-270. Amazon, Ownership Interest/Partnership/Principal – LuxCath echocardiography and computed tomography. 4. Wang K. ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction. LLC. All others: Nothing to disclose. NEJM 2003; 349: 2128-35.