Objectives

We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA).

Methods

OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or >6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA.

Results

152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6).

Conclusions

Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.

中文翻译：

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经验丰富的心电图读取器在诊断院外心脏骤停患者急性血栓性冠状动脉闭塞时的观察者间变异性：代谢环境和血管造影罪魁祸首的影响

目标

我们试图评估经验丰富的心电图 (ECG) 读取器在预测急性血栓性冠状动脉闭塞 (ATCO) 的情况下在院外心脏骤停 (OHCA) 复苏后代谢环境异常 (AMM) 的观察者间一致性。

方法

包括接受有创冠状动脉造影（ICA）的初始可电击节律的 OHCA 患者。AMM 定义为以下之一：pH < 7.1，乳酸 > 2 mmol/L，血清钾 < 2.8 或 >6.0 mEq/L。ROSC 之后但 ICA 之前的初始 ECG 由 2 位经验丰富的读者使用经典 ST 段抬高心肌梗死 [STEMI] 和扩展标准及其组合来预测 ICA 上的 ATCO。

结果

152 名连续患者（平均年龄 58 岁，76% 男性）符合纳入标准。AMM 占 77%；42% 在 ICA 上有 ATCO。使用经典 STEMI 标准的敏感性、特异性、PPV、NPV 分别为 50%、98%、94%、72%（c 统计量 0.74）；而对于组合（STEMI + 扩展）标准，它们分别为 69%、88%、81%、79%（c 统计量 0.79）。经典 STEMI 标准的观察者间一致性 (kappa) 为 0.7，综合标准为 0.66。当 ATCO 缺席和有 NMM（kappa 0.78）时，读者之间的一致性一直较高，但在 AMM 中较低（kappa 0.6）。

结论

尽管有经验丰富的心电图阅读者，但在 OHCA 复苏的情况下预测 ATCO 的总体一致性只有适度的一致性。注意到显着的观察者间差异取决于代谢环境和血管造影 ATCO。这些观察从根本上质疑 12 导联心电图作为 OHCA 患者早期血管造影的主要分类工具的作用。