ECG – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Thu, 06 Jan 2022 22:35:06 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png ECG – ClinCaseQuest https://clincasequest.hospital 32 32 Stephen Smith’s formula for Subtle Anterior STEMI online Calculator https://clincasequest.hospital/stephen-smiths-formula/ Tue, 16 Nov 2021 13:39:00 +0000 https://clincasequest.hospital/?p=31467 Differentiates normal variant ST elevation (benign early repolarization) from anterior STEMI, more sensitive than 3-variable version. Dr. Steven Smith has about 90% sensitivity and specificity.…

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]]> Differentiates normal variant ST elevation (benign early repolarization) from anterior STEMI, more sensitive than 3-variable version. Dr. Steven Smith has about 90% sensitivity and specificity.

Stephen Smith’s formula for Subtle Anterior STEMI use in chest pain patients presenting with an ECG that is non-diagnostic but suspicious for anterior MI.

NB! Before using this calculator, make sure the EKG shows ≥1 mm ST elevation (STE) in ≥1 of the precordial leads V2-V4.

If it shows any one of the following, then it is NOT normal variant, and is very likely to be LAD occlusion; such cases were excluded from the study as “obvious” MI:

  • >5 mm STE.
  • Non-concave STE.
  • Inferior reciprocal changes ST in II, III, aVF, V6.
  • Anterior ST depression.
  • Terminal QRS distortion in V2 or V3:
  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography
  • Q waves in any of V2 to V4.
  • Any T wave inversion from V2 to V6.

Bazett-corrected QT interval

QRS amplitude in lead V2
[Please, enter if you want to get the value according to Stephen Smith’s 4-Variable formula for receiving the highest sensitivity and specificity of the calculated values]:

R wave amplitude in lead V4:

ST segment elevation 60 ms after the J point in lead V3:



Score Stephen Smith’s formula Range of values Conclusion
0 0 0 0
Score Stephen Smith’s formula Range of values Conclusion
0 0 0 0

Both benign early repolarization and STEMI cause ST elevation. The challenge is to differentiate the two entities.

Some patients present with subtle ECG changes nondiagnostic for STEMI but still have 100% coronary artery occlusion and benefit from acute percutaneous coronary intervention (PCI).

Using the equation in such cases can lead to timely cath lab activation, or more intensive evaluation.

Stephen Smith’s formula for the diagnosis of “Insidious” anterior ST-segment elevation acute myocardial infarction (4 variables) includes:

  • Interval QTc with Bazett correction, msec
  • Amplitude of QRS in lead V2, mm
  • Amplitude of the R wave in lead V4, mm
  • ST segment elevation 60 ms after the J-point in lead V3 mm

Formula:

3-variable formula for subtle anterior STEMI =   3-variable = (1.196 x STE 60 elevation in V3, mm) + (0.059 x Bazett QTc interval, ms) – (0.326 x R amplitude in lead V4, mm)
4-variable formula for subtle anterior STEMI =   4-variable = (0.052 x Bazett QTc interval, ms) – (0.151 x QRS amplitude in lead V2, mm) – (0.268 x R amplitude in lead V4, mm) + (1.062 x STE 60 elevation in V3, mm)  
  • STE – ST-elevation 60 ms after the J-point in lead V3, in mm;
  • QTc – QT interval corrected relative to heart rate, in ms (according to automatic ECG analysis);
  • RV4 – the amplitude of the R wave in lead V4, in mm;

Interpretation of 3-component formula results:

  • Indicators ≥23.4, probably there is PNA occlusion.
  • Indicators 22-23.4 – the value does not reach the diagnostic threshold of 23.4, but there is a possibility that the patient has PNA occlusion.
  • Indicators <23.4, low probability of PNA occlusion, possible benign early ventricular repolarization.

Interpreting the results of the 4-component formula:

  • Scores ≥18.2 are likely to be for anterior STEMI (sensitivity 83.3%, specificity 87.7%, and diagnostic accuracy 85.9%).
  • Scores <18.2 are likely to indicate early benign repolarization.

Smith’s 4-variable formula is more sensitive than the 3-variable version of the formula.

NB! The authors specifically excluded patients with obvious MI. Using the calculator in cases that were excluded in the study may lead to a wrong result.

Tips for ECG interpretation:

1). Measure STE at 60 ms in lead V3:

  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography

ST elevation at 60 ms after the J-point in lead V3, relative to the PR segment.

  • Measure STE 60 ms (1½ small box after J point).
  • The baseline is the PR segment.
  • In this example, STE 60 = 4 mm.

2). Measure amplitude of R wave in V4:

  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography

In this example, RV4 = 9 mm.

3). Calculate the QTc: QTc is simply read from the computerized interpretation (uses Bazett’s formula).

Corrected QT Interval Bazett’s formula online calculator

Conclusion

Activation of a cath lab team is appropriate in patients with a positive Smith formula in the appropriate clinical context. At the very least, this result should prompt the command of the heart team to carry out repeated ECG recordings, the so-called serial ECG, and echocardiography.

The Smith Formula is best used to identify patients with LAD occlusion, which was initially considered a normal option for early repolarization.

If the Smith formula (4-variable) is negative for STEMI, proceed with caution if STEMI is still suspected.

References:

  1. Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. https://pubmed.ncbi.nlm.nih.gov/22520989/
  2. Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – Adding QRS amplitude of V2 improves the model. J Electrocardiol. 2017;50(5):561-569. https://www.sciencedirect.com/science/article/abs/pii/S0022073617301073
  3. Bozbeyoğlu E, Aslanger E, Yıldırımtürk Ö, et al. A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation. Ann Noninvasive Electrocardiol. 2018;:e12568. https://onlinelibrary.wiley.com/doi/epdf/10.1111/anec.12568

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Unconsciousness and ECG changes in a patient with comorbidities

Tisdale Risk Score for QT Prolongation

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]]> Corrected QT Interval Bazett’s formula online calculator https://clincasequest.hospital/corrected-qt-calculator-bazetts-formula-qtc/ Mon, 15 Nov 2021 08:41:44 +0000 https://clincasequest.hospital/?p=31512 Bazett’s formula The formula should be used in patients with a heart rate of 60 to 100 beats per minute. In cases of tachycardia or…

Сообщение Corrected QT Interval Bazett’s formula online calculator появились сначала на ClinCaseQuest.

]]>

  • Bazett’s formula The formula should be used in patients with a heart rate of 60 to 100 beats per minute. In cases of tachycardia or bradycardia, the values may not be correct.
  • For heart rate below 60 or above 100 beats per minute, the adjusted QT interval should be calculated by the Framingham formula.

Normal values of Corrected QT: 320-430 for men and 320-450 for women.

  • Bazett’s formula The formula should be used in patients with a heart rate of 60 to 100 beats per minute. In cases of tachycardia or bradycardia, the values may not be correct.
  • For heart rate below 60 or above 100 beats per minute, the adjusted QT interval should be calculated by the Framingham formula.

Normal values of Corrected QT: 320-430 for men and 320-450 for women.

Corrected Interval Q-T
  beats / min
Corrected Interval QT  

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]]> Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block https://clincasequest.hospital/msgarbossa/ Sat, 04 Sep 2021 07:12:00 +0000 https://clincasequest.hospital/?p=30111 Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block Concordant ST elevation > 1mm in leads with a positive QRS complex: No Yes Concordant…

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]]> Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block

Concordant ST elevation > 1mm in leads with a positive QRS complex:
No
Yes

Concordant ST depression > 1 mm in V1-V3:
No
Yes

ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave
An ST/S ratio of 0.20 is also very high and almost as specific as a 0.25 ratio:

No
Yes




Result
0 0

Modified Sgarbossa's Criteria for MI in Left Bundle Branch Block

In Normal for LBBB and placed rhythm – ST and T waves in opposite direction to QRS main vector:

It’s often difficult to identify an MI for patients with existing left bundle branch blocks (LBBB). About 1 in 200 patients with MI have LBBB. The Modified Sgarbossa’s Criteria is a well accepted approach at determining which LBBB are having an MI.

Concordant ST elevation >1 mm in leads with a positive QRS complexNo
 Yes
Concordant ST depression > 1 mm in V1-V3No
 Yes
ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave
An ST/S ratio of 0.20 is also very high and almost as specific as a 0.25 ratio		No
 Yes

Modified Sgarbossa’s Criteria are met if any criteria are positive.

To read Sgarbossa’s Criteria for MI in Left Bundle Branch Block:

Sgarbossa’s Criteria for MI in Left Bundle Branch Block

Literature:
1. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996 Feb 22;334(8):481-7. Erratum in: N Engl J Med 1996 Apr 4;334(14):931. PubMed PMID: 8559200. https://pubmed.ncbi.nlm.nih.gov/8559200/
2. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012 Dec;60(6):766-76. doi: 10.1016/j.annemergmed.2012.07.119. Epub 2012 Aug 31. Erratum in: Ann Emerg Med. 2013 Oct;62(4):302. PubMed PMID: 22939607. https://pubmed.ncbi.nlm.nih.gov/22939607/
3. Cai Q, Mehta N, Sgarbossa EB, Pinski SL, Wagner GS, Califf RM, Barbagelata A. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J. 2013 Sep;166(3):409-13. doi: 10.1016/j.ahj.2013.03.032. Epub 2013 Aug 6. PubMed PMID: 24016487. https://pubmed.ncbi.nlm.nih.gov/24016487/

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Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

* Required
VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

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≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
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]]> Sgarbossa’s Criteria for MI in Left Bundle Branch Block https://clincasequest.hospital/sgarbossas/ Sat, 04 Sep 2021 07:02:00 +0000 https://clincasequest.hospital/?p=30107 Criteria to diagnose acute MI in patients with prior LBBB. Concordant ST elevation > 1mm in leads with a positive QRS complex: No Yes Concordant…

Сообщение Sgarbossa’s Criteria for MI in Left Bundle Branch Block появились сначала на ClinCaseQuest.

]]> Criteria to diagnose acute MI in patients with prior LBBB.

Concordant ST elevation > 1mm in leads with a positive QRS complex:
No
Yes

Concordant ST depression > 1 mm in V1-V3:
No
Yes

Excessively discordant ST elevation (or depression) in leads with a negative QRS
In proportion to the preceding S-wave (or R-wave) as determined by 1) at least 1 mm of ST elevation (or depression) AND 2) an ST/S ratio ≤-0.25:
No
Yes




Patient’s score Range Clinical advice
0 0 0

Sgarbossa's Criteria, Sgarbossa, mi, myocardial infarction, LBBB, Left Bundle Branch Block, calculator, online calculator, medical calculator

In Normal for LBBB and placed rhythm – ST and T waves in opposite direction to QRS main vector:

In some cases it is often difficult to identify an MI for patients with existing left bundle branch blocks (LBBB). About 1 in 200 patients with MI have LBBB. Sgarbossa’s is a well accepted approach at determining which LBBB are having an MI.

Patient’s scoreRangeClinical advice
 0-2 pointsIn the original Sgarbossa criteria, a score of <3 typically is not considered diagnostic of acute MI, but also does not rule out MI. In concerning patients, repeating ECGs and cardiac enzymes may be helpful, along with cardiology consultation.

NOTE! the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.
 ≥3 pointsA score of 3 or more is 90% specific for MI.

NOTE! the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.

Addition of the assigned points.

Concordant ST elevation > 1mm in leads with a positive QRS complexYes+5
Concordant ST depression > 1 mm in V1-V3Yes+3
Excessively discordant ST elevation (or depression) in leads with a negative QRS
In proportion to the preceding S-wave (or R-wave) as determined by 1) at least 1 mm of ST elevation (or depression) AND 2) an ST/S ratio ≤-0.25		Yes+2

A score of 3 or more is 90% specific for MI, but not sensitive (36%). Therefore a positive score should be acted upon, but a lower score can not by itself rule out MI – maintain a high index of suspicion if the presentation is consistent with MI.

0-2 points. In the original Sgarbossa criteria, a score of <3 typically is not considered diagnostic of acute MI, but also does not rule out MI. In concerning patients, repeating ECGs and cardiac enzymes may be helpful, along with cardiology consultation.

NOTE: the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.

Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block

As mentioned, Sgarbossa’s criteria does not rule out myocardial infarction in patients with pre-existing Left Bundle Branch Block (it is not sufficiently sensitive), but in patients with ≥ 3 points, it is specific for MI.

Literature:
1. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996 Feb 22;334(8):481-7. Erratum in: N Engl J Med 1996 Apr 4;334(14):931. PubMed PMID: 8559200. https://pubmed.ncbi.nlm.nih.gov/8559200/?dopt=Abstract
2. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012 Dec;60(6):766-76. doi: 10.1016/j.annemergmed.2012.07.119. Epub 2012 Aug 31. Erratum in: Ann Emerg Med. 2013 Oct;62(4):302. PubMed PMID: 22939607. https://pubmed.ncbi.nlm.nih.gov/22939607/
3. Cai Q, Mehta N, Sgarbossa EB, Pinski SL, Wagner GS, Califf RM, Barbagelata A. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J. 2013 Sep;166(3):409-13. doi: 10.1016/j.ahj.2013.03.032. Epub 2013 Aug 6. PubMed PMID: 24016487. https://pubmed.ncbi.nlm.nih.gov/24016487/

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Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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]]> TIMI Risk Score for STEMI https://clincasequest.hospital/timi-risk-score-stemi/ Sun, 22 Aug 2021 09:46:00 +0000 https://clincasequest.hospital/?p=29910 TIMI Risk Score for STEMI estimates mortality in patients with STEMI Myocardial Infarction. Age, years: <65 65-74 ≥75 Diabetes, Hypertension or Angina: No Yes Systolic…

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]]> TIMI Risk Score for STEMI estimates mortality in patients with STEMI Myocardial Infarction.

Age, years:
<65
65-74
≥75

Diabetes, Hypertension or Angina:
No
Yes

Systolic BP < 100 mmHg:
No
Yes

Heart rate > 100:
No
Yes

Killip Class II-IV
JVD or any pulmonary exam findings of CHF:
No
Yes

Weight < 67kg (147.7 lbs):
No
Yes

Anterior ST Elevation or LBBB:
No
Yes

Time to treatment > 4 hours:
No
Yes



Patient’s score Risk of all-cause mortality at 30 days
0 0

Addition of the assigned points.

CriteriaValue
Age < 65 years0
Age 65-74+2
Age ≥ 75+3
DM or Hypertension or Angina+1
Systolic BP < 100 mmHg+3
Heart Rate > 100+2
Killip Class II-IV+2
Weight < 67kg (147.7 lbs)+1
Anterior ST Elevation or LBBB+1
Time to Treatment > 4 hours+1

Interpretation of the results:

ScoreRisk of all-cause mortality at 30 days
0 points0.8%
1 points1.6%
2 points2.2%
3 points4.4%
4 points7.3%
5 points12.4%
6 points16.1%
7 points23.4%
8 points26.8%
9-14 points35.9%

The patient’s with an ST-Elevation Myocardial Infarction (STEMI) are already at high risk for complications and adverse outcomes, including death. This score was developed based on outcomes analyses in patient’s after thrombolytic therapy, which likely have worse outcomes when compared to PCI. The TIMI Score for STEMI was developed from the InTIME II trial of 15,000 STEMI patients and was studying these patients for thrombolytics.

The primary endpoint was 30-day all-cause mortality and did not include a placebo arm.

TIMI Risk Score for STEMI should be used in patients with diagnosed STEMI, not to evaluate patients with chest pain.

STEMI patients should receive guidelines recommended treatment, obviously undergo PCI or thrombolysis, depending on availability and standard of care at one’s hospital; risk stratification can be performed only after this most critical first step.

Literature:
David A. Morrow, et. al. TIMI Risk Score for ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clinical Score for Risk Assessment at Presentation: An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy Circulation. 2000; 102: 2031-2037 doi: 10.1161/01.CIR.102.17.2031 https://pubmed.ncbi.nlm.nih.gov/11044416/
Morrow DA, Antman EM, Parsons L, et al. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA. 2001;286(11):1356-9. https://pubmed.ncbi.nlm.nih.gov/11560541/
Bradshaw PJ, Ko DT, Newman AM, Donovan LR, Tu JV. Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients. Can J Cardiol. 2007;23(1):51-6. https://pubmed.ncbi.nlm.nih.gov/17245483/
Silveira DS, Jaeger CP et al. Validation of TIMI risk score for STEMI. International Journal of Cardiovascular Sciences. 2016;29(3):189-197. http://www.onlineijcs.org/sumario/29/pdf/en_v29n3a06.pdf

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Related interactive simulators:

Assessment the degree of ST segment elevation on the ECG, J-point

Сообщение TIMI Risk Score for STEMI появились сначала на ClinCaseQuest.

]]> TIMI Risk Score for unstable angina/NSTEMI https://clincasequest.hospital/timi-ua-nstemi/ Sun, 22 Aug 2021 08:09:00 +0000 https://clincasequest.hospital/?p=29916 Estimates mortality for patients with unstable angina and non-ST elevation MI. Can be used to help risk stratify patients with presumed ischemic chest pain. However,…

Сообщение TIMI Risk Score for unstable angina/NSTEMI появились сначала на ClinCaseQuest.

]]> Estimates mortality for patients with unstable angina and non-ST elevation MI.

Can be used to help risk stratify patients with presumed ischemic chest pain. However, it was originally derived in patients with confirmed unstable angina or non-ST elevation myocardial infarction.

Unstable angina /NSTEMI can sometimes be missed. Traditionally, the TIMI Risk Score for UA/NSTEMI can correlate the risk of adverse outcome in chest pain patients.

Age ≥65:
No
Yes

≥3 CAD risk factors
Hypertension, hypercholesterolemia, diabetes, family history of CAD, or current smoker:
No
Yes

Known CAD (stenosis ≥50%):
No
Yes

ASA use in past 7 days:
No
Yes

Severe angina (≥2 episodes in 24 hrs):
No
Yes

EСG ST changes ≥0.5mm:
No
Yes

Positive cardiac marker:
No
Yes

NB!!!
A TIMI Risk Score of 0 does not equate to zero risk of adverse outcome.



Patient’s score Risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization
0 0

TIMI UA/NSTEMI assessment as addition of the selected points:

CriteriaValue
Age ≥65+1
≥3 CAD risk factors*+1
Known CAD (stenosis ≥50%)+1
ASA use in past 7 days+1
Severe angina (≥2 episodes in 24 hrs)+1
EKG ST changes ≥0.5mm+1
Positive cardiac marker+1

*Risk factors for CAD: Family history of CAD, hypertension, hypercholesterolemia, diabetes, or current smoker (thanks to Jeff Geske at Mayo for this update!)

Interpretation of results:

NB!!! A TIMI Risk Score of 0 does not equate to zero risk of adverse outcome.

ScoreRisk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization
0 points4,7%
1 points5%
2 points8%
3 points13%
4 points20%
5 points26%
6 points41%
7 points41%

A TIMI risk score of 0 or 1 does not equal zero risk of adverse outcome. The original study showed 4.7% of patients with a score of 0 or 1 had adverse outcomes within 14 days. Validation studies showed 1.7 to 2.1% of patients with a score of 0 still had adverse outcomes within 30 days.

Patients with a score of 0 or 1 point are at lower risk of adverse outcome (death, MI, urgent revascularization) compared to patients with a higher risk score. However, the risk is not zero.

Patients who have a higher risk score may require more aggressive medical or procedural intervention.

TIMI Risk Score for unstable angina/NSTEMI was developed as one of the earliest chest pain decision rules that was widely implemented. Originally derived with patients with known unstable angina or NSTEMI.

Unclear if this risk score can be used in patients with chest pain in the setting of cocaine use.

Newer chest pain risk scores such as the HEART Score have been shown to better stratify risk than the TIMI Score, particularly in the undifferentiated chest pain patient.

If patients are in the 0 or 1 point group, they should be further risk stratified using another risk score or one’s own institutional practices, as risk is not low enough to safely discharge from the hospital. Many guidelines recommend higher risk levels receiving more aggressive medical intervention and/or receiving early invasive management.

Newer chest pain risk scores such as the HEART Score have been shown to better stratify risk than the TIMI Score, particularly in the undifferentiated chest pain patient.

Literature:
Antman EM, Cohen M, Bernink PJLM, McCabe CH, Hoacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making JAMA. 2000;284(7):835-42. https://pubmed.ncbi.nlm.nih.gov/10938172/
Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006;13(1):13-18. http://www.cardiocast.net/ohds/TIMI_Score.pdf
Scirica BM, Cannon CP, Antman EM, Murphy SA, Morrow DA, Sabatine MS, McCabe CH, Gibson CM, Braunwald E. Validation of the thrombolysis in myocardial infarction (TIMI) risk score for unstable angina pectoris and non-ST-elevation myocardial infarction in the TIMI III registry. Am J Cardiol. 2002;90(3):303-5. https://pubmed.ncbi.nlm.nih.gov/12127617/
Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med. 2006;48(3):252-9. https://pubmed.ncbi.nlm.nih.gov/16934646/
Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012;59(23):2091-8. https://pubmed.ncbi.nlm.nih.gov/22578923/

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]]> Tisdale Risk Score for QT Prolongation https://clincasequest.hospital/tisdale-risk-score-for-qt-prolongation-online-calculator/ Tue, 25 May 2021 08:48:29 +0000 https://clincasequest.hospital/?p=29127 Tisdale Risk Score for QT Prolongation predicts risk of QT prolongation greater than 500 msec in hospitalized patients. QT interval prolongation increases the risk of…

Сообщение Tisdale Risk Score for QT Prolongation появились сначала на ClinCaseQuest.

]]> Tisdale Risk Score for QT Prolongation predicts risk of QT prolongation greater than 500 msec in hospitalized patients.

QT interval prolongation increases the risk of Torsade de pointes (TdP), a type of polymorphic ventricular tachycardia which is life-threatening and often fatal.

Age ≥68 years:
Yes
No

Sex:
Male
Female

Patient on loop diuretic:
Yes
No

Potassium ≤3.5 mEq/L (mmol/L). (Potassium should be potassium determined closest to EСG timing):
Yes
No

Admission QTc ≥450 msec (QTc – corrected QT interval (relative to heart rate):
Yes
No

Being admitted for acute myocardial infarction:
Yes
No

Being admitted for sepsis:
Yes
No

Being admitted for heart failure:
Yes
No

Number of QTc-prolonging drugs given:
None
1 QTc-prolonging drug
≥2 QTc-prolonging drugs


Tisdale Risk Score Risk for QT prolongation Clinical recommendation
0 0 0

Many hospitalized patients have increased risk of QT prolongation due to medical conditions they are facing (myocardial infarction, sepsis, heart failure with reduced enjection fraction for example), as well as medications they may be prescribed in order to treat these conditions (antibiotics, antivirals, antifungals, or anti-arrhythmics, for example) or continue outpatient medications (like psychotropic medications, methadone, or tamoxifen, for example).

This risk score can assess risk of QT prolongation for a physician or pharmacist managing a patient in the hospital.

  • There are many known factors that can cause the risk of QT prolongation; the ones included in this score were found to be the most predictive, but others should not be ignored. Some of the other common risks include:
    • Other electrolyte abnormalities like hypomagnesemia or hypocalcemia
    • Inadequate dose adjustment for patients with acute or chronic kidney dysfunction
    • Drug-drug interactions
  • CredibleMeds.org also provides a comprehensive list of drugs that may cause QT prolongation.
  • Drug-drug interactions should always be considered when prescribing multiple medications; this score does not include pharmacokinetic drug interactions.
  • This score also does not consider dosing adjustments for renally-eliminated drugs.
  • Clinicians should always try to avoid QT-prolonging medications when possible.
  • Maintaining normal electrolyte levels can help reduce the risk of QT prolongation as well.
  • Patients with very poor ejection fractions (<20%) are particularly high risk for QT prolongation.

Tisdale Risk Score for QT Prolongation. Addition of the selected points*:

Risk factorPoints
Age ≥68 years1
Gender: Female1
The use of loop diuretics1
Potassium in blood plasma ≤3.5 mmol / l2
Admission QTc** ≥450 msec2
Acute myocardial infarction**2
Heart failure with low PV3
1 drug that prolongs the QTc interval ***3
≥2 drugs that prolong the QTc interval **3
Sepsis**3
Maximum score21

* Risk categories: low risk = <7; moderate risk = 7-10; high risk = ≥11.
** During an acute event / illness; as a rule, the QTc interval returns to normal after the condition is cured. *** Three points for taking 1 drug that prolongs the QTc interval; 3 additional points for taking ≥2 drugs that prolong the QTc interval (a total of 6 points).

Interpretation:

Tisdale Risk ScoreRisk for QT prolongationRecommendation
≤6LowAlways consider that higher risk may develop depending on clinical course and drug interactions and pharmacokinetics.
7-10ModerateConsider consultation with pharmacist, adjusting risk factors as much as possible. EKG should be repeated after 5 half-lives of QT-prolonging drugs given to evaluate QTc. 
≥11HighConsider consultation with pharmacist, adjusting risk factors as much as possible, and using alternative medications if possible. EKG should be repeated after 5 half-lives of QT-prolonging drugs given to evaluate QTc. 

ECG should be repeated 8-12 hours after starting QT-prolonging drug to look for signs of QT prolongation, with closer monitoring if it is observed.

Correct electrolyte abnormalities and maintain serum potassium >4.0 mEq/L and serum magnesium >2.0 mg/dL.

This scale was launched during COVID-19 crisis. 

This score was derived and internally validated for hospitalized patients, and may not predict outpatient risk of QT prolongation as accurately (but has not been studied in this population).

LITERATURE:
Tisdale JE, Jaynes HA, Kingery JR, et al. Development and validation of a risk score to predict QT interval prolongation in hospitalized patients. Circ Cardiovasc Qual Outcomes. 2013;6(4):479-87. https://pubmed.ncbi.nlm.nih.gov/23716032/
Tisdale JE, Jaynes HA, Kingery JR, et al. Effectiveness of a clinical decision support system for reducing the risk of QT interval prolongation in hospitalized patients [published correction appears in Circ Cardiovasc Qual Outcomes. 2014 Nov;7(6):981]. Circ Cardiovasc Qual Outcomes. 2014;7(3):381-390. doi:10.1161/CIRCOUTCOMES.113.000651  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696749/
Tisdale JE. Drug-induced QT interval prolongation and torsades de pointes: Role of the pharmacist in risk assessment, prevention and management. Can Pharm J (Ott). 2016;149(3):139-152. doi:10.1177/1715163516641136 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860751/

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