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Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations

May 3, 2024

Written by Clark Strunk

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A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.

When the computer says the ECG is not bad, the patient could still need the cath lab…
This was a multicenter, retrospective cohort study from 2016 to 2022 evaluating the initial computer ECG interpretation of all 536 patients who went emergently to the cath lab from the emergency department as a Code STEMI. Out of the 536 patients, 394 patients were found to have culprit lesions, 16 (4.1%) of which had an initial ECG labeled as normal by the computer, 6 of which were identified in real time by the emergency physician. This leads the authors to conclude the importance of emergency provider triage ECG interpretation despite a normal interpretation by the computer. This study provides an alternate perspective regarding the necessity of reviewing ECGs that the computer has identified as normal, as multiple recent studies have advocated that this may not be necessary. However, many of these studies reviewed only normal ECGs in small patient populations who were relatively low risk, over a more abbreviated period of time, with suboptimal outcome measures1-3.

How will this change my practice?
The number of patients with an occlusion MI who would benefit from emergent coronary angiography who have an initial ECG interpreted by the computer as normal is relatively small but significant. Thus, I will continue to prioritize timely ECG interpretation, independent of the computer interpretation, despite the many distractions in the emergency department. Patients benefit from clinicians trained in advanced ECG interpretation to identify OMI, which can easily be missed by the conventional computer algorithm.

Emergency department Code STEMI patients with initial electrocardiogram labeled “normal” by computer interpretation: A 7-year retrospective review. Acad Emerg Med. 2024 Mar;31(3):296-300. doi: 10.1111/acem.14795. Epub 2023 Sep 17. PMID: 37620163.

Works Cited

  1. Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients. West J Emerg Med. 2024 Jan;25(1):3-8. doi: 10.5811/westjem.58464. PMID: 38205978; PMCID: PMC10777178.
  2. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. 2022 Jan;51:384-387. doi: 10.1016/j.ajem.2021.11.023. Epub 2021 Nov 17. PMID: 34823195.
  3. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Acad Emerg Med. 2017 Jan;24(1):120-124. doi: 10.1111/acem.13067. PMID: 27519772.

What are your thoughts?