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      New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block

      research-article
      , MD 1 , , , MD 1 , , MD, PhD 2 , , MD, PhD 3 , , MD 4 , , MD, PhD 1 , , MD 1 , , MD, PhD 2 , , MD 4 , , MD 3 , , MD 3 , , MD 2 , , MD 4 , , MD, PhD 1 , , MD, PhD 1 , , MD, PhD 1
      Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
      John Wiley and Sons Inc.
      acute myocardial infarction, electrocardiography, left bundle branch block, primary percutaneous coronary intervention, Electrocardiology (ECG), Acute Coronary Syndromes

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          Abstract

          Background

          Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction ( AMI) in the presence of left bundle branch block.

          Methods and Results

          A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre‐2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm ( BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%–95%), negative predictive value (96%–97%), efficiency (91%–94%) and area under the receiver operating characteristic curve (0.92–0.93), significantly higher than previous electrocardiographic rules ( P<0.01); the specificity was good in both groups (89%–94%) as well as the control group (90%).

          Conclusions

          In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.

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          Most cited references27

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          2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

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            Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.

            Identification of key factors associated with the risk of developing cardiovascular disease and quantification of this risk using multivariable prediction algorithms are among the major advances made in preventive cardiology and cardiovascular epidemiology in the 20th century. The ongoing discovery of new risk markers by scientists presents opportunities and challenges for statisticians and clinicians to evaluate these biomarkers and to develop new risk formulations that incorporate them. One of the key questions is how best to assess and quantify the improvement in risk prediction offered by these new models. Demonstration of a statistically significant association of a new biomarker with cardiovascular risk is not enough. Some researchers have advanced that the improvement in the area under the receiver-operating-characteristic curve (AUC) should be the main criterion, whereas others argue that better measures of performance of prediction models are needed. In this paper, we address this question by introducing two new measures, one based on integrated sensitivity and specificity and the other on reclassification tables. These new measures offer incremental information over the AUC. We discuss the properties of these new measures and contrast them with the AUC. We also develop simple asymptotic tests of significance. We illustrate the use of these measures with an example from the Framingham Heart Study. We propose that scientists consider these types of measures in addition to the AUC when assessing the performance of newer biomarkers.
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              Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.

              Methods of evaluating and comparing the performance of diagnostic tests are of increasing importance as new tests are developed and marketed. When a test is based on an observed variable that lies on a continuous or graded scale, an assessment of the overall value of the test can be made through the use of a receiver operating characteristic (ROC) curve. The curve is constructed by varying the cutpoint used to determine which values of the observed variable will be considered abnormal and then plotting the resulting sensitivities against the corresponding false positive rates. When two or more empirical curves are constructed based on tests performed on the same individuals, statistical analysis on differences between curves must take into account the correlated nature of the data. This paper presents a nonparametric approach to the analysis of areas under correlated ROC curves, by using the theory on generalized U-statistics to generate an estimated covariance matrix.
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                Author and article information

                Contributors
                ayfanciu@hotmail.com
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                04 July 2020
                21 July 2020
                : 9
                : 14 ( doiID: 10.1002/jah3.v9.14 )
                : e015573
                Affiliations
                [ 1 ] Heart Disease Institute Bellvitge University Hospital Barcelona Spain
                [ 2 ] Cardiology Department Hospital de la Santa Creu I Sant Pau IIB‐Santpau CIBERCV Universitat Autonoma de Barcelona Spain
                [ 3 ] Cardiology Department Germans Trias i Pujol University Hospital CIBERCV Badalona Spain
                [ 4 ] Cardiology Department Hospital Clinic CIBERCV Barcelona Spain
                Author notes
                [*] [* ]Correspondence to: Andrea Di Marco, MD, Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Calle feixa llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain. E‐mail: ayfanciu@ 123456hotmail.com
                [†]

                Dr Di Marco and Dr Rodriguez contributed equally to this work.

                Article
                JAH35133
                10.1161/JAHA.119.015573
                7660719
                32627643
                bb855d67-e225-4b1c-9e09-230437437348
                © 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Page count
                Figures: 6, Tables: 7, Pages: 15, Words: 8703
                Categories
                Original Research
                Original Research
                Coronary Heart Disease
                Custom metadata
                2.0
                21 July 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.8 mode:remove_FC converted:29.08.2020

                Cardiovascular Medicine
                acute myocardial infarction,electrocardiography,left bundle branch block,primary percutaneous coronary intervention,electrocardiology (ecg),acute coronary syndromes

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