James-Jules Linton1, Debra Eagles2,3, Martin S Green4, Steven Alchi1, Marie-Joe Nemnom5, Ian G Stiell6,7,8. 1. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. 2. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, ON, Canada. 3. Ottawa Hospital Research Institute, Ottawa, ON, Canada. 4. Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada. 5. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 6. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, ON, Canada. istiell@ohri.ca. 7. Ottawa Hospital Research Institute, Ottawa, ON, Canada. istiell@ohri.ca. 8. Clinical Epidemiology Unit, F657, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. istiell@ohri.ca.
Abstract
INTRODUCTION: While wide complex tachycardia (WCT) is potentially lethal, little is known about its incidence in the ED or about expertise of ED physicians in diagnosing and treating it. We sought to compare WCT ED cases that were primary arrhythmias versus those with rapid heart rate secondary to medical issues, as well as the accuracy of ED diagnosis and appropriateness of treatment. METHODS: We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive patients over 28 months (2018-2020) with WCT (heart rate ≥ 120 bpm and QRS ≥ 120 ms). Cases were adjudicated for the accuracy of ECG diagnosis versus the cardiology read and for correctness of treatment as per guidelines by two ED physicians and one cardiologist. RESULTS: We identified 306 eligible cases (0.2% of all ED visits): mean age 73.9 years, male 66.0%, admitted 53.3%, died in ED 2.3%. Primary arrhythmias and secondary tachycardias were each 50.0% (95% CI 44.4-55.6%). ED physicians correctly interpreted 81.2% of ECGs. The most common presenting arrythmias and % correct were: atrial fibrillation 42.7% (95.0%), atrial flutter 22.2% (63.5%), sinus tachycardia 12.0% (78.6%), and supraventricular tachycardia (SVT) 11.1% (68.0%). Treatments were judged optimal in 84.3% of primary WCT and 86.9% in secondary WCT. Treatments were suboptimal for: inappropriate drug (3.9% for primary versus 1.3% for secondary), failure to reduce heart rate < 100 prior to discharge home (9.1% for primary versus 34.4% for secondary), and not treating the underlying cause in 5.9% of secondary WCT. CONCLUSIONS: WCT cases were evenly split between primary arrhythmias and secondary cases. ED physicians interpreted the ECG correctly in 81% but over-called atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of WCT in the ED.
INTRODUCTION: While wide complex tachycardia (WCT) is potentially lethal, little is known about its incidence in the ED or about expertise of ED physicians in diagnosing and treating it. We sought to compare WCT ED cases that were primary arrhythmias versus those with rapid heart rate secondary to medical issues, as well as the accuracy of ED diagnosis and appropriateness of treatment. METHODS: We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive patients over 28 months (2018-2020) with WCT (heart rate ≥ 120 bpm and QRS ≥ 120 ms). Cases were adjudicated for the accuracy of ECG diagnosis versus the cardiology read and for correctness of treatment as per guidelines by two ED physicians and one cardiologist. RESULTS: We identified 306 eligible cases (0.2% of all ED visits): mean age 73.9 years, male 66.0%, admitted 53.3%, died in ED 2.3%. Primary arrhythmias and secondary tachycardias were each 50.0% (95% CI 44.4-55.6%). ED physicians correctly interpreted 81.2% of ECGs. The most common presenting arrythmias and % correct were: atrial fibrillation 42.7% (95.0%), atrial flutter 22.2% (63.5%), sinus tachycardia 12.0% (78.6%), and supraventricular tachycardia (SVT) 11.1% (68.0%). Treatments were judged optimal in 84.3% of primary WCT and 86.9% in secondary WCT. Treatments were suboptimal for: inappropriate drug (3.9% for primary versus 1.3% for secondary), failure to reduce heart rate < 100 prior to discharge home (9.1% for primary versus 34.4% for secondary), and not treating the underlying cause in 5.9% of secondary WCT. CONCLUSIONS: WCT cases were evenly split between primary arrhythmias and secondary cases. ED physicians interpreted the ECG correctly in 81% but over-called atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of WCT in the ED.
Authors: Ashish R Panchal; Jason A Bartos; José G Cabañas; Michael W Donnino; Ian R Drennan; Karen G Hirsch; Peter J Kudenchuk; Michael C Kurz; Eric J Lavonas; Peter T Morley; Brian J O'Neil; Mary Ann Peberdy; Jon C Rittenberger; Amber J Rodriguez; Kelly N Sawyer; Katherine M Berg Journal: Circulation Date: 2020-10-21 Impact factor: 29.690
Authors: Qiong Chen; Jinyi Xu; Carola Gianni; Chintan Trivedi; Domenico G Della Rocca; Mohamed Bassiouny; Ugur Canpolat; Alfredo Chauca Tapia; J David Burkhardt; Javier E Sanchez; Patrick Hranitzky; G Joseph Gallinghouse; Amin Al-Ahmad; Rodney Horton; Luigi Di Biase; Sanghamitra Mohanty; Andrea Natale Journal: Heart Rhythm Date: 2019-09-20 Impact factor: 6.343
Authors: Marc W Deyell; Amir AbdelWahab; Paul Angaran; Vidal Essebag; Ben Glover; Lorne J Gula; Clarence Khoo; Christopher Lane; Isabelle Nault; Pablo B Nery; Lena Rivard; Michael P Slawnych; Heather L Tulloch; John L Sapp Journal: Can J Cardiol Date: 2020-06 Impact factor: 5.223