title: Clinical Utility of Ventricular Repolarization Dispersion for Real-Time Detection of Non-ST Elevation Myocardial Infarction in Emergency Departments.
abstract: BACKGROUND
  A specific electrocardiographic (ECG) marker of ischemia would greatly improve the speed and accuracy of detecting and treating non-ST elevation myocardial infarction (NSTEMI). We hypothesize that ischemia induces ventricular repolarization dispersion (VRD), altering the T-wave before any ST segment deviation. We sought to evaluate the clinical utility of VRD to (1) detect NSTEMI cases in the emergency department (ED) and (2) identify NSTEMI cases at high risk for in-hospital major adverse cardiac events (MACEs).
  
  
  RESULTS
  We continuously recorded 12-lead Holter ECGs from chest pain patients upon their arrival to the ED. VRD was quantified using principal component analysis of the 12-lead ECG to compute a T-wave complexity ratio (ie, ratio of second to first eigenvectors of repolarization). Clinical outcomes were obtained from hospital records. The sample was composed mainly of older males (n=369; ages 63±12 years; 63% males), and 92 (25%) had NSTEMI and 26 (7%) had MACEs. Baseline T-wave complexity ratio modestly correlated with peak troponin levels (r=0.41; P<0.001) and was a good classifier of NSTEMI events (area under the curve=0.70). An increased T-wave complexity ratio on the presenting ECG was strongly associated with NSTEMI (odds ratio [OR]=3.8 [2.1 to 5.8]) and in-hospital MACE (OR=8.2 [3.1 to 21.5]).
  
  
  CONCLUSIONS
  A simple measure of global VRD on the presenting 12-lead ECG correlates with ischemic myocardial injury and can discriminate NSTEMI cases very early during evaluation. Prospective studies should validate these findings and test whether VRD can guide therapy.
authors.affiliation: School of Nursing, University of Pittsburgh, PA (S.S.A.Z.).
authors.forename: Salah S
authors.initials: SS
authors.lastname: Al-Zaiti
authors.affiliation: Emergency Medicine, University of Pittsburgh, PA (C.W.C.).
authors.forename: Clifton W
authors.initials: CW
authors.lastname: Callaway
authors.affiliation: Clinical Research, Dignity Health, St. Joseph Medical Center, Stockton, CA (T.M.K.).
authors.forename: Teri M
authors.initials: TM
authors.lastname: Kozik
authors.affiliation: Clinical Nursing Research Center, University of Rochester Medical Center, Rochester, NY (M.G.C.).
authors.forename: Mary G
authors.initials: MG
authors.lastname: Carey
authors.affiliation: School of Nursing, University of California San Francisco (UCSF), San Francisco, CA (M.M.P.).
authors.forename: Michele M
authors.initials: MM
authors.lastname: Pelter
mesh_terms: D000200:Action Potentials; D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D000368:Aged; D000789:Angina, Unstable / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D002140:California; D016507:Cardiology Service, Hospital; D016009:Chi-Square Distribution; D003937:Diagnosis, Differential; D015716:Electrocardiography, Ambulatory; D004636:Emergency Service, Hospital; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology*; D006352:Heart Ventricles / Q000503:physiopathology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D009505:Nevada; D016017:Odds Ratio; D011237:Predictive Value of Tests; D025341:Principal Component Analysis; D011379:Prognosis; D012720:Severity of Illness Index; D012815:Signal Processing, Computer-Assisted; D013997:Time Factors
keywords: ECG; complications; ischemia; myocardial infarction; repolarization