title: Differentiating ST-elevation myocardial infarction from nonischemic ST-elevation in patients with chest pain.
abstract: Current guidelines state that patients with compatible symptoms and ST-segment elevation (STE) in ≥2 contiguous electrocardiographic leads should undergo immediate reperfusion therapy. Aggressive attempts at decreasing door-to-balloon times have led to more frequent activation of primary percutaneous coronary intervention (pPCI) protocols. However, it remains crucial to correctly differentiate STE myocardial infarction (STEMI) from nonischemic STE (NISTE). We assessed the ability of experienced interventional cardiologists in determining whether STE represents acute STEMI or NISTE. Seven readers studied electrocardiograms of consecutive patients showing STE. Patients with left bundle branch block or ventricular rhythms were excluded. Readers decided if, based on electrocardiographic results, they would have activated the pPCI protocol. If NISTE was chosen, readers selected from 12 possible explanations as to why STE was present. Of 84 patients, 40 (48%) had adjudicated STEMI. The percentage for which readers recommended pPCI varied (33% to 75%). Readers' sensitivity and specificity ranged from 55% to 83% (average 71%) and 32% to 86% (average 63%), respectively. Positive and negative predictive values ranged from 52% to 79% (average 66%) and 67% to 79% (average 71%), respectively. Broad inconsistencies existed among readers as to the chosen reasons for NISTE classification. In conclusion, we found wide variations in experienced interventional cardiologists in differentiating STEMI with a need for pPCI from NISTE.
authors.affiliation: Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Viet
authors.initials: V
authors.lastname: Tran
authors.forename: Henry D
authors.initials: HD
authors.lastname: Huang
authors.forename: Jose G
authors.initials: JG
authors.lastname: Diez
authors.forename: Gerardo
authors.initials: G
authors.lastname: Kalife
authors.forename: Rajiv
authors.initials: R
authors.lastname: Goswami
authors.forename: David
authors.initials: D
authors.lastname: Paniagua
authors.forename: Hani
authors.initials: H
authors.lastname: Jneid
authors.forename: James M
authors.initials: JM
authors.lastname: Wilson
authors.forename: Scott R
authors.initials: SR
authors.lastname: Sherron
authors.forename: Yochai
authors.initials: Y
authors.lastname: Birnbaum
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D003329:Coronary Vasospasm / Q000150:complications / Q000175:diagnosis*; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity