title: Interobserver agreement in the electrocardiographic diagnosis of acute myocardial infarction in patients with left bundle branch block.
abstract: OBJECTIVE
  To determine the interobserver agreement between cardiologists and emergency physicians in the ECG diagnosis of acute myocardial infarction (AMI) in patients with left bundle branch block (LBBB) using the ECG algorithm previously described by Sgarbossa et al.
  
  
  METHODS
  Using the Sgarbossa ECG algorithm, 4 cardiologists and 4 emergency physicians independently interpreted a test set of 224 ECGs with LBBB, of which 100 ECGs were from patients with an evolving AMI. A subset of 25 ECGs was reinterpreted by each reader to test intraobserver agreement for AMI as well as interobserver agreement for the degree of ST-segment deviation. Agreement rates for AMI were estimated using the kappa statistic. In addition, the sensitivity and specificity for diagnosing AMI were determined for each reader, using the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) enzyme criteria for AMI as the gold standard. The study was conducted at 3 university-affiliated medical centers. The test set contained ECGs from 100 patients enrolled in the GUSTO I trial with LBBB on their initial ECG and an evolving AMI confirmed by serum cardiac enzyme changes, and 124 control patients from the Duke Databank for Cardiovascular Disease who had stable, angiographically documented coronary artery disease and LBBB.
  
  
  RESULTS
  There was excellent interobserver agreement (kappa=0.81, 95% confidence interval [CI] 0.80 to 0.83) between cardiologists and emergency physicians for diagnosing AMI. Intraobserver agreement kappa values for AMI diagnosis by cardiologists and emergency physicians were 0.81 (95% CI 0.67 to 0.94) and 0.71 (95% CI 0.54 to 0.89). The median sensitivity for diagnosing AMI by cardiologists and emergency physicians was 73% (range 66% to 80%) versus 67% (range 61% to 75%); median specificity was 98% (range 97% to 99%) versus 99% (range 98% to 99%). Spearman rank correlation coefficients for the degree of ST-segment deviation in all 12 leads was 0.86 (95% CI 0.85 to 0.87) among all readers.
  
  
  CONCLUSIONS
  There is excellent interobserver agreement between cardiologists and emergency physicians for diagnosing AMI when applying the Sgarbossa ECG algorithm to patients with LBBB. Emergency physicians should be able to reliably use this algorithm when evaluating patients.
authors.affiliation: Divisions of Emergency Medicine and Cardiology, University of California-Davis School of Medicine, Davis, CA, USA. pesokolove@ucdavis.edu
authors.forename: P E
authors.initials: PE
authors.lastname: Sokolove
authors.forename: E B
authors.initials: EB
authors.lastname: Sgarbossa
authors.forename: E A
authors.initials: EA
authors.lastname: Amsterdam
authors.forename: R
authors.initials: R
authors.lastname: Gelber
authors.forename: T C
authors.initials: TC
authors.lastname: Lee
authors.forename: C
authors.initials: C
authors.lastname: Maynard
authors.forename: J R
authors.initials: JR
authors.lastname: Richards
authors.forename: R
authors.initials: R
authors.lastname: Valente
authors.forename: G S
authors.initials: GS
authors.lastname: Wagner
mesh_terms: D000328:Adult; D000368:Aged; D002037:Bundle-Branch Block / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology*; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology*; D015588:Observer Variation; D012680:Sensitivity and Specificity