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Transcript of Presentación ITMS
TELEMEDICINE AND TELEELECTROCARDIOGRAPHY
IN CHILEEDGARDO ESCOBAR MD, FACC, FAHA
PROFESSOR OF MEDICINEMEDICAL DIRECTOR ITMS-TELEMEDICINE
CHILE
Chilean Demography
POPULATION: 17.000.000 NUMBER OF
PHYSICIANS: 1/559 UNEVEN DISTRIBUTION
OF PHYSICIANS LIMITED NUMBER OF
SPECIALISTS EXTENSIVE RURALITY
TELEELECTROCARDIOGRAPHY IN CHILE
55% OF POPULATION HAS A HIGH OR VERY HIGH RISK OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
CARDIOVASCULAR DISEASES ARE THE FIRST CAUSE OF MORTALITY : 29% OF TOTAL MORTALITY
CORONARY HEART DISEASE RESPONDS FOR 31% OF CARDIOVASCULAR DEATHS
32% OF CARDIOVASCULAR DEATHS ARE DUE TO CEREBROVASCULAR DISEASES
TELEELECTROCARDIOGRAPHY IN CHILE
NOT ENOUGH NUMBER OF SPECIALISTS NOT ENOUGH MEANS OF TRANSPORTATION IN RURAL PLACES
(Primary care). IT IS IMPORTANT TO AVOID UNNECESSARY TRANSPORTATION OF PATIENTS TO A PLACE OF HIGHER COMPLEXITY
ON THE OTHER HAND: THERE IS A VERY GOOD TECHNOLOGY SUPPORT AND A GOOD
LEVEL OF COMMUNICATIONS (TELEPHONE, FAX, AND IN MANY CASES INTERNET)
TRILOGY OF TELEMEDICINE SERVICE
1.PHYSICIANS
2.- TELECOMUNICATION SYSTEMS
3.- TECHNOLOGY SUPPORT
(INFORMATIC)
TELE-ELECTROCARDIOGRAPHY IN CHILE
EQUIPMENTS ARE DISTRIBUTED: IN 493 PLACES (381 DEPENDING OF THE MINISTRY OF HEALTH) SOME OF
THEM VERY REMOTE, INCLUDING EASTERN ISLAND, and IN 75 DISTRICTS (MUNICIPALIDADES)
EKGS ARE CAPTURED WITH VERY SMALL EQUIPMENTS EITHER AEROTEL OR CARDIETTE
EKG IS SENT EITHER BY PHONE, MOBILE PHONE OR INTERNET AND RECEIVED IN THE CALL CENTER IN A COMPUTER
WHATEVER THE ORIGINAL SIGNAL IS , IT ENTERS THRU AN INTEGRATED SYSTEM: Integrated platform of Telemedicine (IPT-PIT )
MEASUREMENTS OF AMPLITUDES AND INTERVALS ARE MADE WITH AN ELECTRONIC CURSOR AT 25, 50 OR 100mm/sec.
HOW DOES Tele-EKG WORK ?
EKG REGISTERED AND SENT
TELEPHONE
CALL CENTER RECEIVES EKG, PARAMEDIC GIVES THE APPROVAL PARAMEDIC GIVES THE APPROVAL AND COLLECTS INFORMATION OF A LIST AND COLLECTS INFORMATION OF A LIST OF SYMPTOMS AND DEMOGRAPHICOF SYMPTOMS AND DEMOGRAPHIC DATADATA
GENERAL PRACTITIONER RECEIVES THE REPORT AND EVENTUALLY CALL BACK FOR QUESTIONS
EKG IS SENT BACK BY MAIL OR FAX
OPERATOR PRINTS EKG
AND SAVES THE
INFORMATION TO A CENTRAL
DATABASE
CARDIOLOGISTS MAKES THE REPORT
TELE-ELECTROCARDIOGRAPHY IN CHILE
TELE-EKG
TELEELECTROCARDIOPRAHY IN CHILE
THE REPORT IS MADE ACCORDING TO THE EKG GUIDE USED BY THE AMERICAN BOARD OF INTERNAL MEDICINE AND
AMERICAN COLLEGE OF CARDIOLOGY.
REPORT IS MADE BY THE CARDIOLOGIST AND SENT BACK BY FAX OR e-MAIL.
ADVISE IS GIVEN BY PHONE UPON REQUEST AND ALWAYS IF THERE IS SUBEPICARDIAL LESION
TELE-ELECTROCARDIOGRAPHY IN CHILE
ALL EKG DIAGNOSIS ARE CODIFIED AND MOVED TO THE FINAL REPORT JUST MAKING A CLICK ON IT. THIS MAKES THE PROCEDURE VERY FAST
(No more than 10 minutes)
DIAGNOSIS ARE SAVED IN A DATABASE FROM WHERE THEY MAY BE RECOVERED AT ANYTIME. STATISTICAL STUDIES ARE EASY TO PERFORM
Comparison of some leads between traditional EKG and TeleEKG
ECG Hospital del Salvador
ALTMAN BLAND METHOD: Comparison of V4
amplitude in traditional EKG and TeleEKG
V4: Data after Logarithmic Transformation
-0,40
-0,30
-0,20
-0,10
0,00
0,10
0,20
0,30
0,40
0,50
0,00 0,20 0,40 0,60 0,80 1,00 1,20 1,40 1,60
Average Log ITMS-Traditional Method
Dif
fere
nce
in L
og
ITM
S-T
rad
itio
nal
Met
ho
d
Mean + 2 s
Mean - 2 s
Mean
Altman and Bland: Logaritmic comparison of V4 amplitude between traditional EKG and Tele EKG
Teleelectrocardiography in ChileTeleelectrocardiography in Chile
1300 to 1600 ECGs are received daily Monday 1300 to 1600 ECGs are received daily Monday thru Friday and 600 to 800 during the thru Friday and 600 to 800 during the weekends weekends
There are about 1500 000 electrocardiograms There are about 1500 000 electrocardiograms in our data basein our data base
TOTAL NUMBER OF TRACINGS: 1 459 297 (Sept 1, 2002 up to Oct 31 ,2010)
Normal 60%
ABNORMAL 40%
Normal Abnormal
ABNORMAL TRACINGS
18,8%
45,7%6,5%
7,0%
15,0%
5,0%
1,8%
0,2%Enlargement of cavities
BBB and IV conduction delays
Ventricular arrhytmias
Supraventricular arrhytmias
Subepicardial andsubendocardial lesions
Prolonged QT interval
AV conduction defects and AVjunction rhytms
Other
Nuestra Política de Confidencialidad de la Información
VIGESIMO PRIMERO: El soporte médico remoto y/o el apoyo al diagnóstico e informe de electrocardiograma proporcionado por los especialistas de ITMS, no sustituye, en ningún caso la responsabilidad directa que emana de la relación médico-paciente que regula la práctica de la profesión médica en Chile…
VIGESIMO: Con el objeto de monitorear la calidad de servicio … ITMS podrá grabar parte o la totalidad de la conversación… manteniendo tales registros en la más estricta reserva, siendo éstos accesibles sólo por el Director Médico de ITMS y el médico representante del Usuario
ASPECTOS DESTACADOS POR LOS USUARIOS DE ITMS
Rapidez de Interpretación y del Informe del Especialista (+/- 5 min.) Facilidad en manejo del dispositivo y de toma del examen Cobertura en cualquier lugar- Portabilidad del equipo Evaluación por cardiólogo- Segunda opinión inmediata Derivación oportuna en pacientes con ECG alterados Disponibilidad permanente Se evitan traslados innecesarios Sistema eficiente y eficaz – de gran utilidad en Salud Pública por
cobertura y bajo costo
TEACHING AND RESEARCH
MEETINGS TO DISCUSS DIFFICULT TRACINGS OR INTERESTING ONES
STUDIES OF PREVALENCE OF SOME ABNORMAL TRACINGS
Conclusions OUT OF THE 523 371 EKG TRACINGS 3656 SUBEPICARDIAL LESIONS WERE
DIAGNOSED.
GREATER INCIDENCE OF STEMI IN MEN (69 vs 31%) AND PRESENTATION IN AN OLDER AGE IN WOMEN ARE CONFIRMED.
GREATER NUMBER OF STEMI BETWEEN APRIL AND JULY AND BETWEEN 09 AM AND 11 PM WITH A PEAK BETWEEN 11 AM AND 1 PM,
SIMILARLY IN MEN AND WOMEN.
7th AND 9th REGIONS HAD THE GREATER INCIDENCE OF STEMI.
TELEMEDICINE IS A TOOL OF A GREAT VALUE FOR THE EARLY DIAGNOSIS OF AMI AND ITS TREATMENT, PARTICULARLY IN REMOTE AREAS.
TELEMEDICINE MADE POSSIBLE THE APPLICATION OF THE AUGE LAW
Copyright ©2008 American Heart Association
Ting, H. H. et al. Circulation 2008;118:1066-1079
Reperfusion time goals for patients with ST-segment-elevation myocardial infarction
CHALLENGES IN CHILE FEW CARDIOLOGISTS NOT ENOUGH NUMBER OF WELL EQUIPPED HOSPITALS NOT ENOUGH MEANS OF TRANSPORT AVAILABLE AT PRIMARY
CARE LEVEL
THEREFORE
PRECISE AND TIMELY DIAGNOSIS ARE IMPORTANT FOR EARLY TREATMENT AND TO AVOID UNNECESSARY TRANSPORT OF PATIENTS TO A HIGHER COMPLEXITY HEALTH CARE PLACE
AUGE LAW A PATIENT WITH CHEST PAIN
SUGGESTIVE OF ISCHEMIC ORIGIN MUST HAVE AN EKG TAKEN WITHIN 15 MINUTES OF CONSULTATION. RESPONSE TO THIS REQUIREMENT IN
MANY PLACES: TELEMEDICINE
THROMBOLYSIS WITH STREPTOKINASE SHOULD BE STARTED, OR PATIENT SHOULD BE REFERRED FOR PRIMARY ANGIOPLASTY, WHICH IS ONLY POSSIBLE IN FEW PLACES
TELEMEDICINE AND ITS ALLIANCE WITH THE MINISTRY OF HEALTH
SINCE MAY 1ST 2004 THE MINISTRY OF HEALTH IMPLEMENTED NATIONAL COVERAGE OF EKG IN PATIENTS CONSULTING WITH CHEST PAIN SUGGESTIVE OF ACE
TELEMEDICINE WAS RECOGNIZED AS THE DIAGNOSTIC SUPPORT TO PERFORM THROMBOLYSIS 24 HOURS A DAY, EVERY DAY OF THE YEAR, PARTICULARLY IN HOSPITALS OF LOWER COMPLEXITY
TELEMEDICINE IN THE CASE OF AN ACE
Primary Care or ER
Rescue
Coordination with Reference Hospital Center
Coordination withRescue and transfer
AUGE law and AMI
Ministry of Health implemented 180 places to perform Thrombolysis, even in rural areas
After the procedure is performed high risk patients are referred to a hospital of tertiary level, for further treatment
Impact of AUGE law in the treatment of AMI
GLOBAL MORTALITY DECREASED FROM 12 TO 8.6%; OR 0.64 ( adjusted by age, gender, risks factors, previous MI and Killip score at admission)
GREATER REDUCTION OF MORTALITY IN PATIENTS OF HIGHER RISK (WOMEN, OLDER THAN 75 YEARS)
IN PATIENTS TREATED WITH THROMBOLYSIS MORTALITY DECREASED FROM 10.6% TO 6.8%
(p< 0.005) , EVEN IN HOSPITALS OF LOW COMPLEXITY
SIGNIFICANT INCREASES IN THE PRESCRIPTION OF STATINS, BETABLOCKERS, ACEI, ASPIRIN
Innovative strategies in Chile for treatment of STEMI
1. Existence of a law which compels to have an early diagnosis and treatment of AMI
2. Guidelines for the treatment of Acute Myocardial Infarction are “official”, distributed by decision of the State through the public health system
3. The support of Telemedicine for early diagnosis4. Implementation to perform thrombolysis, even in rural
areas ( although only with streptokinase)
Servicios actuales de Telemedicina
Electrocardiografía Monitoreo ambulatorio de la presión arterial de 24
horas (MAPA) Monitoreo ambulatorio del electrocardiograma de
24 horas (Holter de arritmias) Espirometría Teleradiología
Telemedicina y atención médica
Los grandes beneficiados son:
Los pacientes: mejora la accesibilidad, la coberturta y la equidad de la atención
Los médicos de atención primaria, que pueden contar con elementos de diagnóstico que les permite resolver de inmediato muchos problemas que en otra forma habrían sido postergados. El médico se siente así apoyado en una atención médica de suyo difícil en nuestro país.
Los especialistas a quienes se refirarán pacientes que antes no hubieran tenido oportunidad de conocer
MUCHAS GRACIAS POR SU ATENCION
EKG in the diagnosis of an acute coronary event (ACE)
“TWELVE LEAD EKG IT IS IN THE CENTER OF THE DECISION TO EVALUATE AND TO TREAT PATIENTS WITH CHEST PAIN..........” (ACC/AHA)
ISCHEMIC CHANGES IN THE EKG ARE EVOLUTIVE. CONFOUNDERS ARE STATIC
SUFFICIENT EVIDENCE THAT PREHOSPITAL EKG SPEEDS STEMI PATIENTS’ ROUTE TO TREATMENT, DECREASING DOOR- TO-DRUG TIME AND DOOR TO BALLOON TIME .
“TIME IS MYOCARDIUM”
TELEMEDICINE ALLOWS THE DIAGNOSIS OF AMI IN THE FIELD, CAPTURING A DIAGNOSTIC QUALITY 12 LEAD ELECTROCARDIOGRAM
Subepicardial lesions in Chile (Acute Myocardial Infarction with
ST segment elevation)Experience with Telemedicine
Escobar E, Vèjar M, del Pino RRev. Chilena Cardiol 2009:28,73-80
METHOD
523 371 ELECTROCARDIOGRAMS WERE ANALYZED
SUBEPICARDIAL LESIONS WERE DEFINED AS ST ELEVATION OF AT LEAST 1mm IN 2 OR MORE CONSECUTIVE LEADS.
AMBIGUOUS LESIONS AS WELL AS NON EVOLUTIVE WERE DISCARDED.
Objectives of treatment of Myocardial Infarction
Improvement of symptoms Improvement of Survival Decrease of Myocardial damage (“Time is
myocardium”)
PATIENT WITH SYMPTOMSOFAMI
ECG
STE or LBBB ECG (+) for ISCHEMIANSTE T (-)
NORMAL or AMBIGUOUS
ADMISSION ADMISSION
ANTI ISCHEMICTHERAPY
ECG ENZYMESECHO
ANTI ISCHEMICTHERAPY
THROMBOLYSISorPCI
EVIDENCE of ISCHEMIA
NO
OTHER DIAGNOSIS
YES
Impact of AUGE law in the treatment of AMI
3547 patients with AMI were analyzed in 9 hospitals: 2623 pre AUGE and 924 after AUGE law
Time between initiation of symptoms and admission was 4 hours in both periods (only 25% before 3 hours)
Time between admission and thrombolysis was 31 min.
IMPACT OF AUGE LAW IT HAS PRODUCED A CHANGE OF
ATTITUDE IN PHYSICIANS, NURSES AND PARAMEDICAL PERSONNEL OF PRIMARY CARE FACING NEW CHALLENGES IN THE TREATMENT OF AMI
IT HAS POWERFULLY CONTRIBUTED TO THE EARLY TREATMENT OF AMI
PREVALENCE OF PREVALENCE OF EKG BRUGADA EKG BRUGADA
PATTERNPATTERNEXPERIENCE IN CHILE
E. ESCOBAR, MD; P.ADRIAZOLA, MD
F.BELLO, MD; M.ORELLANA, MD; P.TREJO, MD
ITMS, TELEMEDICINE, CHILE
METHOD
402 947 TRACINGS WERE RECEIVED IN OUR CENTER BETWEEN JAN 2004 AND SEPT 2007
TWO GROUPS, ONE FROM JAN 2004 TO MAY 2005 AND THE OTHER ONE FROM MARCH 2007 TO SEPT 2007, INCLUDING 1430 CHILDREN UNDER 15 YEARS OF AGE, WERE ANALYZED, MAKING A TOTAL OF
122 000 TRACINGS
CONCLUSIONS
IRBB IS PRESENT IN 5.9% OF CHILEAN POPULATION
BRUGADA PATTERN (1+2+3) :-IT HAS A PREVALENCE OF 37/10 000 -REPRESENT 6.4% OF IRBB-IT IS MORE FREQUENT IN MEN (2.3/1) AND BETWEEN THE 4TH AND 6TH DECADES
OF AGE
CONCLUSIONS THESE RESULTS ARE SIMILAR TO OTHER STUDIES
PREVALENCE OF TYPE 1 (BRUGADA SYNDROME) IS 4.6/10 000
PATIENTS WITH BRUGADA TYPE 1 AND THEIR FAMILIES SHOULD BE CLOSELY FOLLOWED UP
TELEMEDICINE PROVIDES AN EXCELLENT TOOL FOR THIS KIND OF STUDIES
Prevalence of prolonged QT interval in different electrocardiographic patterns
Study by Teleelectrocardigoraphy
Orellana M, Bello F ,Escobar E. Adriazola P,Trejo P, Gonzalez P
Rev.Chilena Cardiol 2009 28:349-356
Prolonged QTc interval Group 1: 8459 normal tracings Group 2: 2647 tracings with complete BBB : 532 with LBBB + 2115 with RBBB Group 3: 2503 tracings with left ventricular
enlargment: 377 by voltage criteria + 1083 by voltage and ST-T
changes + 1043 only by ST-T changes
RESULTS
0
10
20
30
40
50
60
70
80
90
Normal LBBB RBBB LVHvoltage
LVHVolt &repol
LVH xrep
Normal QTc Prolonged QTc
Prolonged QTc interval
QTc duration of 500 msec or more:
LVH by voltage criteria…………4.7%
LVH by voltage + ST-T changes..7,9%
LVH by ST-T changes only……...8,3%
Prolonged QTc interval:CONCLUSIONS 1.- HIGH PREVALENCE OF PROLONGED QTc EVEN IN NORMAL TRACINGS (16%),
but more so in COMPLETE LBBB (51,5%) COMPLET RBBB (25%) LVH by voltage + ST-T changes(42%) LVH by voltage criteria(28%) LVH by ST-T changes (29%)
2.-NO CORRELATION BETWEEN QRS DURATION AND QTc IN COMPLETE BBBs WAS OBSERVED
3.-PROGNOSTIC IMPACT OF PROLONGED QTc IN COMPLETE BBB NEEDS TO BE STUDIED
Francesca Bello, Edgardo Escobar, Denisse Lama, Gabriel Mezzano, Stefania Pavlov
ITMS, Telemedicina de Chile
En el presente trabajo se describe la relación contemporánea observada entre el terremoto del 27 de febrero del 2010 y el diagnóstico de lesión subepicárdica, en electrocardiogramas recibidos en ITMS, Telemedicina de Chile
Método Se analizó un total de 280.592 electrocardiogramas
recibidos a través de telemedicina correspondientes a los meses de:
Enero, Febrero, Marzo del año 2009 y los mismos meses del año 2010
Junio, Julio, Agosto del año 2009 y los mismos meses del año 2010
Resultados
Hubo un aumento estadísticamente significativo de las lesiones subepicárdicas (p<0,05) entre el fin de semana del terremoto y todos los fines de semana de los meses analizados
Distribución por género Distribución general Distribución 48 horas post
terremoto
Porcentaje lesiones subepicárdicas fines de semana
MAPA (27/02): frecuencia cardíaca
MAPA (27/02):PA diastólica
MAPA (27/02): PA sistólica
Conclusiones Se confirma un aumento significativo de las lesiones
subepicárdicas en relación al “stress” producido por el terremoto del 27/02/2010
Se invierte la relación porcentual de infartos entre hombres y mujeres
Esto coincide con un aumento de frecuencia cardíaca y presión arterial, especialmente diastólica
Conclusiones Este aumento puede estar subestimado ya que a pese a
que el servicio de Telemedicina estuvo operativo en los primeros 20 min del evento hubo interrupción de comunicaciones desde las zonas más afectadas y la mayoría de los exámenes se recibieron desde la RM, V y VI regiones.
Este es el primer estudio realizado con Telemedicina en estas circunstancias
1ª 2ª 3ª 4ª 5ª 6ª 7ª 8ª 9ª
%
Decades
Men
Women
BRUGADA PATTERN
Brugada type 1
60,87%
39,13% MenWomen
BRUGADA BRUGADA MORPHOLOGY IN THE EKG IS
KNOWN SINCE THE FIFTIES BUT ONLY UNTIL 1992 IT WAS DESCRIBED AS A CLINICAL ENTITY
BRUGADA SYNDROME IS DEFINED AS AN EKG WITH A IRBB BUT WITH CHARACTERISTIC COVED-TYPE ST SEGMENT ELEVATION IN V1 and V2 (sometimes in V3) AND A HIGH INCIDENCE OF SUDDEN DEATH WITHOUT STRUCTURAL HEART DISEASE
BRUGADA BRUGADA SYNDROME HAS THE RISK
OF SUDDEN DEATH IN YOUNG ADULTS, AT A MEAN AGE OF 41 ± 15 YEARS
ALTHOUGH IS A POTENTIAL CAUSE OF SEVERE ARRYTHMIAS BRUGADA PATTERN IT IS NOT WELL KNOWN BY PHYSICIANS
BRUGADA Prevalence is estimated to be 5/10 000 people; in Japan
and Southeast Asia: 12 to 14/10 000 It is dynamic (Fever, large meal) It may umasked by moving V1 to an upper intercostal
space or by NA CHANNEL BLOCKERS: ajmaline, flecainide, procainamide
MUTATION OF ALFA SUBUNIT OF NA CHANNEL GENE SCN5A
PROGRAMMED VENTRICULAR STIMULATION
BRUGADA PREVALENCE OF THIS PATTERN HAS NOT BEEN
ENOUGH STUDIED WORLDWIDE AND THERE IS NO STUDIES OF THIS MAGNITUDE IN SOUTHAMERICA
TELEMEDICINE SYSTEM PROVIDES US WITH AN EXCELLENT TOOL TO HAVE INFORMATION EVEN FROM REMOTE AREAS
IN THE CASE OF CHILE THE SYSTEM SERVES ALL THE COUNTRY INCLUDING THE EASTERN ISLAND
BRUGADA CHILE IS 4500 Kms LONG and 200 Kms WIDE WITH VERY
DIFFERENT CLIMATES
ON THE OTHER HAND ALTHOUGH THE GREAT MAJORITY OF THE POPULATION IS OF EUROPEAN ANCESTRY WE HAVE SOME DIVERSITY: SMALL GROUPS OF PEOPLE OF INDIAN ORIGIN IN THE NORTH AND SOUTH AND POLYNESIANS IN EASTERN ISLAND
THEREFORE: IT IS A REPRESENTATIVE POPULATION TO STUDY THE
PREVALENCE OF DIFFERENT DISEASES
DEFINITIONS TYPE 1: COVED TYPE ELEVATION ≥ 2 mms
FOLLOWED BY NEGATIVE T WAVE (V1,V2)
TYPE 2: SADDLE BACK-TYPE ST ELEVATION ≥ 2mms, THROUGH DISPLAYING ≥ 1mm, AND (+) OR BIPHASIC T WAVE (V1,V2)
TYPE 3: THE SAME AS 2 BUT WITH ST
ELEVATION < 1mm
METHOD INCOMPLETE RIGHT BUNDLE BRANCH
BLOCK (IRBB) WAS DIAGNOSED WHEN r AND r’ WAVES WERE PRESENT IN V1 AND V2
ANALYSIS OF THESE TRACINGS WAS PERFORMED AT LEAST BY TWO OF THE AUTHORS AND TYPES 2 AND 3 WERE CONSIDERED AS A WHOLE
Brugada type 1
Brugada type 2
Brugada type 3
RESULTS
94,1%
5,9%
Other diagnosisIRBB
n= 122 000
RESULTS
99,63%
0,37%
OtherdiagnosisBrugada
n= 122 000
( 37 * 10 000 )
RESULTS
93,6%
6,4%
IRBB
Brugada
n= 7 155 ( IRBB )
RESULTS
12,4%
87,6%
Brugada type 1Brugada type 2+3
n= 458 ( Brugada )
RESULTS
99,954%
0,046%
Otherdiagnosis
Brugada 1
n= 122 000
( 4,6 * 10 000 )
BRUGADA PATTERN
70%
30%Men
Women
STRENGHTS-IT IS THE FIRST STUDY OF THIS MAGNITUDE OF
PREVALENCE OF BRUGADA IN SOUTH AMERICA
-ANALYSIS WAS MADE IN A SIGNIFICANT NUMBER OF EKG TRACINGS (122 000) FROM ALL OVER THE COUNTRY
-IT IS A REPRESENTATIVE POPULATION-ALERTS PRIMARY CARE PHYSICIANS ABOUT THE
DIAGNOSIS
LIMITATIONS-LACK OF ENOUGH CLINICAL DATA -NO FAMILY HISTORY OR FOLLOW UP
PROLONGED QT INTERVAL
PROLONGED QT INTERVAL HAS BEEN PROPOSED AS A RISK FACTOR FOR VENTRICULAR ARRYTHMIAS AND DEATH IN POST AMI PATIENTS, DIABETICS AND EVEN IN APPARENTLY HEALTHY POPULATION.
Circulation 2003;108:1985-1989
Prolonged QT interval
In left ventricular enlargement by ECG and/or echocardiography prolonged QT has been documented.
J of Hypertension 2001;19:1883-1991
Am J Cardiol 2000;86:1117–1122
Circulation 2003;107:1764-1769
Prolonged QT interval Prolongation of QT interval in relation to QRS
duration in complete bundle branch blocks has been a matter of discussion.
Am J Cardiol. 1992;70:628–629J Electrocardiol. 1990;23:49–52Circulation 2003;108:1985-1989
Prolonged QTc interval
Tracings were analyzed with a computer system using Aerotel HRS 6.0 software which allows measurements of different intervals at 10mm/sec at100 mm/seg.
Prolonged QTc interval
QT interval was measured in 4 leads: D1, aVL, V5 and V6, agreed by two observers.
The system automatically corrects by the square root of heart rate (QTc).
Prolonged QTc was defined by a value of > 440 mseg, in all four leads.
The most prolonged value was chosen for further analysis.
Prolonged QTc interval
Chi square was used for statistical anaylisis
In cases with BBB correlation analysis was used to evaluate the relationship between QRS and QTc durations
Results
Statistical analysis:CLBB vs normal tracings p<0,001CRBB vs normal tracings p<0,001LVH by voltage criteria + negative T wave vs
normal tracings p<0,001
QRS and QTc in complete LBBB
400
450
500
550
600
650
100 150 200 250QRS (ms)
QT
c (
ms
)
Pearson 0,311 (0,28 – 0,35)
R2 0,0971
400
450
500
550
600
650
100 150 200 250QRS (ms)
QT
c (
ms
)
QRS and QTc in complete RBBB
Pearson 0,181
(0,15 – 0,21)
R2 0,0326
400
450
500
550
600
650
100 150 200 250QRS (ms)
QT
c (
ms
)
QRS and QTc at a fixed HR in complete LBBB
HR 82 / min
Pearson 0.32
R2 0.102
400
450
500
550
600
650
0 50 100 150 200 250
QRS (ms)
QT
c (
ms
)
Complete RBBB: QRS and QTc at a fixed HR
HR 77 / min
Pearson 0,129
R2 0,016400
450
500
550
600
650
0 50 100 150 200 250
QRS (ms)
QT
c (m
s)
Limitations and strenghts
We only have the ECG analysis We do not know associated diseases and the
possible use of medications We do not have a follow up
HOWEWER: The results are valid due to the high number of
tracings analyzed, far above other studies
SUBEPICARDIAL LESIONS
69%
31%
MEN WOMEN
NUMBER OF LESIONS BY AGE
0
50
100
150
200
250
300
350
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+
Age range
Nú
me
ro d
e L
esi
on
es
WOMEN MEN
HOURLY DISTRIBUTION BY GENDER
0
20
40
60
80
100
120
140
160
0 - 1
1 - 2
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
8 - 9
9 - 1
0
10 -
11
11 -
12
12 -
13
13 -
14
14 -
15
15 -
16
16 -
17
17 -
18
18 -
19
19 -
20
20 -
21
21 -
22
22 -
23
23 -
0
Rango de Hora
Nú
me
ro d
e L
es
ion
es
Women Men
AREA OF SUBEPICARDIAL LESIONS
L
0
100
200
300
400
500
600
700
Anterolateral Anteroseptal Anterior wall Inferior
Nú
me
ro d
e L
es
ion
es
Women Men
Percentage of lesions out of the total of EKGs by region
Total EKGs =523371
0,52%
1,20%
1,60%
1,07%
2,72%
1,65%
2,34%
0,44%0,43%
0,90%
1,21%
0,79%
0,11%
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
3,0%
1 2 3 4 5 6 7 8 9 10 11 12 13
Region
MONTHLY DISTRIBUTION
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12
Mes
Fre
cu
en
cia
women Men
Antecedentes La asociación de “stress” y eventos coronarios agudos
(ECA) ha sido extensamente estudiada.Se ha documentado la relación entre terremotos y ECA.Se ha establecido una relación entre la intensidad del
terremoto, la hora de ocurrencia, la época del año y el riesgo de un ECA.
Kloner, Leor: Natural disaster plus wake-up time: a deadly combination of triggers. AmHeart J. 1999; 137: 779-781
Ogawa, K; Tsuji, I; Shiono, K; Hisamichi, S. Increased acute myocardial infarction mortality following the 1995 great Hanshin-Awaji earthquake in Japan. Int J Epidemiol. 2000; 29:449-455.
Ching-Hong, T; For-Wey, L; Shing-Yaw, W. The 1999 Ji-Ji (Taiwan) Earthquake as a Trigger for Acute Myocardial Infarction. Psychosomatics. 2004; 45:477-482
Antecedentes El IAM se incrementó 3 veces en población cercana al
epicentro del terremoto de Hanshin-Awaji, predominantemente en mujeres.
Se documentó la asociación de enfermedad cardiovascular a través de cambios hemodinámicos y factores trombogénicos.
Kario, K; Mc Ewen, B; Pickering, G. Disasters and the Heart: a Review of the Effects of Earthquake-Induced Stress on Cardiovascular Disease. Hypertens Res. 2003; 26: 355-367.
STRESS
Diferencias individuales (genes, experiencia)
Respuesta emocional (depresión, ansiedad, enojo, etc)Respuesta conductual (insomnio, OH, etc)
Respuesta fisiológica
Eje Hipotálamo-hipófisis
Factores de riesgo crónicos:HTA, DM, Dislipidemia
ATEEnfermedad cardiovascular silente
Sistema nervioso simpáticoSistema nervioso simpático
Factores de riesgo agudos:Incremento en PA, disfunción endotelial, incremento en viscosidad sanguínea, activación plaquetaria y hemostática
Variación periódca
Condición predisponente
Modificado de Kario et al: Earthquakeand Cardiovascular Disease , Hypertens Res. 20003. Vol. 26, No. 5
Método
El diagnóstico de lesión subepicárdica se basó en la elevación nueva del segmento ST igual o mayor de 1 mm en dos o más derivaciones contiguas. Trazados dudosos no fueron considerados
Método Se analizó el porcentaje diario de lesiones
subepicárdicas
Se comparó estadísticamente el porcentaje de lesiones subepicárdicas registradas en el periodo posterior al terremoto (sábado 27 y domingo 28 de febrero de 2010) y se compararon con los fines de semana de los meses descritos (años 2009 y 2010)
Resultados El diagnóstico de lesión subepicárdica se realizó en
1.795 trazados de las fechas descritas.
El promedio de edad de presentación fue de 62 años (mujeres 67,7 años; hombres 60 años).
48 horas post terremoto el promedio de edad fue de 67 años (mujeres 70,6 años; hombres 59,7 años).
Enero 2009
Febrero 2009
Marzo 2009
Junio 2009
Julio 2009
Agosto 2009
Junio 2010
Julio 2010
Agosto 2010
Enero 2010
Febrero 2010
Marzo 2010
Resultados
Un estado hiperadrenérgico se puede evidenciar indirectamente a través del aumento de la frecuencia cardiaca y de la presión arterial observada en otros pacientes en el mismo día a la hora de la catástrofe
FECHA ECG
Lesiones subepicárdic
asRIESGO
ABSOLUTO p27 y 28 febrero 352 12 3,41%
2 y 3 ene 2010 705 12 1,70% p<0.05
9 y 10 ene 2010 670 6 0,90% p<0.0516 y 17 ene
2010 694 8 1,15% p<0.0523 y 24 ene
2010 739 9 1,22% p<0.0530 y 31 ene
2010 598 9 1,51% p<0.05
6 y 7 feb 20100 590 8 1,36% p<0.05
13 y 14 feb 2010 717 5 0,70% p<0.05
20 y 21 feb 2010 749 7 0,93% p<0.05
6 y 7 mar 2010 605 8 1,32% p<0.0513 y 14 mar
2010 595 8 1,34% p<0.0520 y 21 mar
2010 633 11 1,74% p<0.0527 y 28 mar
2010 632 11 1,74% p<0.05
FECHA ECG
Lesiones subepicárdica
sRIESGO
ABSOLUTO p
27 y 28 febrero 352 12 3,41%
5 y 6 jun 2010 751 8 1,07% p<0.05
12 y 13 jun 2010 823 13 1,58% p<0.05
19 y 20 jun 2010 750 6 0,80% p<0.05
26 y 27 jun 2010 795 8 1,01% p<0.05
3 y 4 jul 2010 757 13 1,72% p<0.05
10 y 11 jul 2010 696 7 1,01% p<0.05
17 y 18 jul 2010 660 11 1,67% p<0.05
24 y 25 jul 2010 778 10 1,29% p<0.0531 jul/01 ago
2010 712 9 1,26% p<0.05
07 y 08 ago 2010 752 7 0,93% p<0.05
14 y 15 ago 2010 721 10 1,39% p<0.05
21 y 22 ago 2010 834 10 1,20% p<0.05
28 y 29 ago 2010 757 7 0,92% p<0.05
FECHA ECG
Lesiones subepicárdica
sRIESGO
ABSOLUTO p
27 y 28 febrero 352 12 3,41%
3 y 4 ene 2009 590 9 1,53% p<0.05
10 y 11 ene 2009 582 6 1,03% p<0.05
17 y 18 ene 2009 645 10 1,55% p<0.05
24 y 25 ene 2009 585 12 2,05% p<0.0531 ene/ 01 feb
2009 618 10 1,62% p<0.05
7 y 8 feb 2009 647 11 1,70% p<0.05
14 y 15 feb 2009 624 7 1,12% p<0.05
21 y 22 feb 2009 611 12 1,96% p<0.0528 feb / 01 mar
2009 671 7 1,04% p<0.05
7 y 8 mar 2009 670 11 1,64% p<0.05
14 y 15 mar 2009 638 11 1,72% p<0.0521 y 22 mar
2009 580 6 1,03% p<0.0528 y 29 mar
2009 596 5 0,84% p<0.05
FECHA ECG
Lesiones subepicárdica
sRIESGO
ABSOLUTO p
27 y 28 febrero 352 12 3,41%
6 y 7 junio 2009 663 8 1,21% p<0.05
13 y 14 junio 2009 610 9 1,48% p<0.05
20 y 21 junio 2009 535 9 1,68% p<0.05
27 y 28 junio 2009 602 9 1,50% p<0.05
4 y 5 julio 2009 701 12 1,71% p<0.05
11 y 12 julio 2009 695 9 1,29% p<0.05
18 y 19 julio 2009 638 8 1,25% p<0.05
25 y 26 julio 2009 667 7 1,05% p<0.05
1 y 2 ago 2009 754 8 1,06% p<0.05
8 y 9 ago 2009 735 12 1,63% p<0.05
15 y 16 ago 2009 656 9 1,37% p<0.05
22 y 23 ago 2009 832 13 1,56% p<0.05
29 y 30 ago 2009 807 14 1,73% p<0.05
Stress and the heart
There are extensive data concerning “stressors” contribution to:
Sudden death Myocardial infarction and myocardial ischemia Changes in sympathetic activity and hemostasis
Earthquakes are acute stressors and there are data about the increase in
the number of AMI and sudden deaths.
TELEMEDICINE has allowed us to study the impact of an earthquake on
the number of AMI
Earthquake in Chile
February 27th at 3:34 AM Chile suffered the most devastating earthquake and tsunami of its history, 8,8 of Richter`s scale.
Great destruction from the 5th to the 9th regions (center of the country, including Santiago, the capital)
Preliminary data 194.376 EKG by TELEMEDICINE were
analyzed
Group 1: First trimester 2009
Group 2: Second trimester 2009
Group 3 : First trimester 2010 1323 subepicardial lesions were diagnosed Daily distribution of lesions of group 3 was
compared with groups 1 and 2
Impact of earthquake: daily diagnosis of AMI
Group 1 (1st trimester ,2009):
0,2 - 2.7%; asimmetry coefficient: 1.08 Group 2 (2nd trimester, 2009):
0,2 - 3.0%; asimmetry coefficient : 1,14 Group 3 (1st trimester 2010):
0 - 4.8%; asimmetry coefficient: 2,8
Daily incidence of AMI: first trimester 2009
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
3,0%
3,5%
4,0%
4,5%
5,0%
January February March
Daily incidence of AMI, first trimester 2010
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
3,0%
3,5%
4,0%
4,5%
5,0%
January February March
earthquake
Impact of earthquake
The number of AMI is underestimated since communications were interrupted, although Telemedicine system restarted within 20 min.
This is the first study performed using Telemedicine under this situation
TELE-ELECTROCARDIOGRAPHY IN CHILE. CONCLUSIONS
IT HAS POWERFULLY CONTRIBUTED TO THE EARLY TREATMENT OF AMI .
IT HAS FACILITADED TREATMENT OF OTHER CARDIAC EMERGENCIES
IT HAS ALLOWED THE STUDY OF PREVALENCE OF SOME EKG PATTERNS
TELEELECTROCARDIOGRAPHY IN CHILE
GREAT SUPPORT TO PRIMARY CARE PHYSICIANS BY SPECIALISTS
REFERRAL OF NEW AND/OR COMPLICATED PATIENTS TO CARDIOLOGISTS
INCREASES EFFICIENCY OF MEDICAL PRACTICE IT IS A TOOL FOR PREVENTION PROGRAMS
TELEELECTROCARDIOGRAPHY IN CHILE
QUICK RESPONSE ( REPORT IN 5 TO 10 MIN). EQUIPMENT EASY TO USE POSSIBILITY TO USE EVEN IN REMOTE PLACES SECOND OPINION BY THE SPECIALIST AT ANY TIME FACILITATES DECISION MAKING: AVOIDS UNNECESSARY
TRANSFER OF PATIENTS; ACCELERATES THE ONES NEEDED; ALLOWS TO INITIATE IMMEDIATE
TREATMENT EXTENSIVE COVERAGE AND LOW COST
FEEDBACK OF USERS:
TELECTROCARDIOGRAPHY IN CHILE
CONTRIBUTORS AT PRESENT:
PATRICIA ADRIAZOLA ARTURO ARRIBADA WALTER KUHNE FRANCESCA BELLO ROBERTO DEL PINO
MIRTA ORELLANA JOSE DE HORTA PATRICIO CASTRO GUILLERMO DE LA CUADRA MIGUEL BENEDIKT ENRIQUE ALMAGRO MARCELO LINDH LEONEL VARGAS ALVARO SEPÚLVEDA CARLOS PIEDRA HERNÁN NOGUERA JOSÉ LIPCHENKA ALBERTO COHEN
THANKS VERY MUCH FOR YOUR ATTENTION
ITMS puede contribuir al diagnóstico de SCA a través del informe del ECG y al tratamiento mediante el apoyo telefónico del especialista
Lesiones subepicárdicas:resumenLesiones subepicárdicas:resumen Se analizaron 523 371 ECG Se analizaron 523 371 ECG Se detectaron 3656 lesionesSe detectaron 3656 lesiones 69% hombres. 31% mujeres69% hombres. 31% mujeres Mujeres en edades más tardíasMujeres en edades más tardías Mayor frecuencia entre Abril y JulioMayor frecuencia entre Abril y Julio Mayor frecuencia entre las 9 y 18 horas con un Mayor frecuencia entre las 9 y 18 horas con un
máximo entre las 11 y 13 horasmáximo entre las 11 y 13 horas Mayor número entre la 7 y 9 regiones Mayor número entre la 7 y 9 regiones
(1) (1) Rev.Chilena de Cardiologìa 2009;28:73-80Rev.Chilena de Cardiologìa 2009;28:73-80
IMPACT OF AUGE IN THE TREATMENT OF PATIENTS WITH AMI
0
10
20
30
40
50
60
70
%
1 2 3 4 5
pre AUGE
AUGE
1. Thrombolysis
2. Primary PTCA
3. Coronariography
4. Rescue PTCA
5. Delayed PTCA
P. CAMPOS ET AL. REV CHIL CARDIOL. VOL 26 2007.
Servicio de Tele-ECG en apoyo a Eventos Coronarios Agudos
SAPU
SAMU
Hospital de Referencia
SAPU o Traslado
ECG
•Tiempo es Miocardio
•Tiempo “Puerta-a-Tratamiento”
•Tiempo “Llamada-a-Tratamiento”
•Infarto pequeño significa menor número de complicaciones
AMI / CHEST PAIN
ECG94,7%
AMI5,3%
A
TOTAL NUMBER OF DIAGNOSIS: 1 522 546TOTAL NUMBER OF TRACINGS: 838 077 (Sept 1, 2002
up to May 13, 2009)
Telemedicina de Chile
Al 11 de Julio del 2006 existen en nuestra base de datos 262 776 electrocardiogramas.
212 542 en plataforma HRS y 50 234 en plataforma Rems.
TELE-ELECTROCARDIOGRAPHY IN CHILE
BETWEEN SEPT.1, 2002 and MAY 13, 2009
WE HAVE READ:838 707 TRACINGS
REPRESENTING 1 522 546 DIAGNOSIS
TOTAL NUMBER OF DIAGNOSIS: 890 522TOTAL NUMBER OF TRACINGS: 568 775 (Sept 1, 2002 up to March 11,2008)
Normal; 581.052; 65%
ABNORMAL: 309.470; 35%
Normal Abnormal
Resumen Investigación Dr. Ricardo VillarroelDirector Médico H. La Ligua
Estudio en Eventos Coronarios Agudos en Hospital La Ligua. (Oct. 2003 – Mayo 2004 basado en informes de telemedicina)
Sensibilidad 98%Especificidad 100%
Resultado Test Enfermedad Presente
Enfermedad Ausente
POSITIVO 67 0
NEGATIVO 1 582
Relación Costo Efectividad(Costo Unitario de Traslado)
Móvil (240 Km) $25.000
Personal ( sin hrs. Médicas ) $ 8.000
Insumos $ 4.000
Otros (mantención equipos, etc) $ 1.000
Total $38.000
Resumen Investigación Dr. Ricardo VillarroelDirector Médico H. La Ligua
TELE-ELECTROCARDIOGRAPHY IN CHILE
COWORKERS.
PHYSICIANS: PATRICIA ADRIAZOLA ARTURO ARRIBADA RAFAEL MENDEZ MARGARITA VEJAR WALTER KUHNE JORGE LARROSA FRANCESCA BELLO ROBERTO DEL PINO MIRTA ORELLANA JOSE DE HORTA PAMELA TREJO VICTOR ROSSEL LEONOR VILLALBA PATRICIO CASTRO BARBARA CLERICUS ROBERTO CONCEPCION MARIANELA SEGUEL GUILLERMO DE LA CUADRA SOLANGE DONOSO MIGUEL BENEDIKT MARCELO LINDH ENRIQUE ALMAGRO
ENGINEERS: FRANCISCO FERNANDEZ HUGO LEON JORGE ARAVENA FERNANDO FIGUEROA
Intervalo QT prolongado En el crecimiento VI por criterio
electrocardiográfico y/o ecocardiográfico se ha documentado una asociación con intervalo QT prolongado.
J of Hypertension 2001;19:1883-1991 Am J Cardiol 2000;86:1117–1122 Circulation 2003;107:1764-1769
Intervalo QT prolongado La prolongación del intervalo QT en relación a la
duración del QRS en los bloqueos completos de rama ha sido motivo de discusión.
Am J Cardiol. 1992;70:628–629J Electrocardiol. 1990;23:49–52Circulation 2003;108:1985-1989
Intervalo QTc prolongado Los trazados fueron analizados con un sistema
computacional, utilizando el software Aerotel HRS 6.0, que permite efectuar mediciones de los diferentes intervalos a una velocidad de 100 mm/seg.
Intervalo QTc prolongado
Se consideró prolongado un valor de QTc ≥ 440 mseg., en las tres derivaciones.
Se eligió para el análisis posterior el valor más prolongado.
Intervalo QTc prolongado
Para el análisis estadístico se utilizó la prueba de chi-cuadrado
En los bloqueos de rama se utilizó análisis de correlación para evaluar la relación entre la duración del QRS y el QTc
Resultados El análisis del intervalo QTc mostró diferencias
estadísticamente significativas:
BCRI vs trazados normales p<0,001
BCRD vs trazados normales p<0,001
CVI por criterio de voltaje vs trazados normales p<0,001
QRS y QTc en BCRD
Pearson 0,181
(0,15 – 0,21)
R2 0,0326
400
450
500
550
600
650
100 150 200 250QRS (ms)
QT
c (
ms
)
QRS y QTc para frecuencia fija en BCRI
FC 82 / min
Pearson 0.32
R2 0.102
400
450
500
550
600
650
0 50 100 150 200 250
QRS (ms)
QT
c (
ms
)
QRS y QTc para frecuencia fija en BCRD
FC 77 / min
Pearson 0,129
R2 0,016400
450
500
550
600
650
0 50 100 150 200 250
QRS (ms)
QT
c (m
s)
Limitaciones
Sólo tenemos el análisis del trazado electrocardiográfico
Desconocemos las patologías asociadas de estos pacientes y el uso eventual de medicamentos
No conocemos la evolución clínica posterior
Sin embargo, estos resultados adquieren validez por el alto número de trazados analizados, muy superior a lo descrito en la literatura.
Results
0
10
20
30
40
50
60
70
80
90
Normales BCRI BCRD CVIvoltaje
CVI Volty repol
QTc normalQTc prolongado
Results
0
10
20
30
40
50
60
70
80
90
Normales BCRI BCRD CVI voltaje
TELE-ELECTROCARDIOGRAPHY IN CHILE