European Heart Journal Advance Access originally published online on November 6, 2007
European Heart Journal 2008 29(1):31-37; doi:10.1093/eurheartj/ehm503
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Local hospital vs. core-laboratory interpretation of the admission electrocardiogram in acute coronary syndromes: increased mortality in patients with unrecognized ST-elevation myocardial infarction
1 Sunnybrook Health Sciences Centre, Toronto, ON, Canada
2 Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael’s Hospital, University of Toronto, 30 Bond St, Rm 6-034Q, Toronto, ON, Canada, M5B 1W8
3 The Canadian Heart Research Centre, Toronto, ON, Canada
Received 13 April 2007; revised 2 October 2007; accepted 4 October 2007; online publish-ahead-of-print 6 November 2007.
* Corresponding author. Tel: +1 416 864 5722, Fax: +1 416 864 5407, Email: goodmans{at}smh.toronto.on.ca
See page 1 for the editorial comment on this article (doi:10.1093/eurheartj/ehm573)
Aims: Previous analyses suggest only modest agreement between local site and core-laboratory (core-lab) electrocardiogram (ECG) interpretation in patients with acute coronary syndromes (ACSs); however, this has not been well examined outside of clinical trial populations.
Methods and results: Patients (n = 5277 from 51 hospitals; 4916 with 1 year vital status) participating in the Canadian ACS Registry who were hospitalized with an ACS and had an interpretable initial ECG were included in this study. Core-lab ECG interpretation was blinded to site interpretation and outcomes. There was moderate agreement between site and core-lab regarding the predominant ECG findings (
= 0.49). Patients with core-lab-defined ST-elevation and cardiac marker elevation (n = 1202) not classified as ST-elevation by the site were less likely to receive acetylsalicylic acid (ASA) (90 vs. 96%, P < 0.0001), heparin (91 vs. 95%, P = 0.04), and reperfusion therapy (14 vs. 76%, P < 0.0001) than patients for whom there was agreement that ST-elevation was present. After adjusting for other validated prognostic factors, site-unrecognized ST-elevation was independently associated with higher mortality (odds ratio = 2.21; 95% CI, 1.46–3.36; P < 0.001).
Conclusions: In patients with ACS, there was only moderate agreement between core-lab and site interpretation of the initial ECG. Site-unrecognized ST-elevation myocardial infarction was associated with underutilization of evidence-based therapies and increased 1-year mortality.
Key Words: Electrocardiogram • Acute coronary syndromes • Prognosis
A list of participating Canadian ACS Registry Investigators and Coordinators may be found in the Arch Intern Med 2007;167:1009–1016.
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