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A Comparison of Methods for the Detection of Myocardial Ischemia During Noncardiac Surgery

Automated ST-Segment Analysis Systems, Electrocardiography, and Transesophageal Echocardiography

Department of Anesthesia and Critical Care and Department of Internal Medicine, The University of Chicago, Chicago, Illinois

Abstract

Clinicians often fail to detect intraoperative ischemic electrocardiographic (ECG) changes when viewing oscilloscopes. Automated ST-segment monitors promise to increase the detection of such ECG changes. We investigated the capacity of two commercially available ST-segment monitors to detect intraoperative myocardial ischemia in patients at high risk for developing intraoperative myocardial ischemia during vascular and other noncardiac procedures. The ST-segment monitors were compared with two reference monitors: (a) printed eight-lead ECGs, as interpreted by a cardiologist, and (b) the presence of segmental wall motion abnormalities and thickening abnormalities detected by transesophageal echocardiography (TEE). We also examined the capacity of the printed ECG to diagnose myocardial ischemia when compared with TEE. We studied 44 patients who underwent TEE, printed multilead ECG, oscilloscope monitoring of leads V₅ and II, and measurement or ST-segment deviation from the baseline using an automated Hewlett Packard ST-segment device. The sensitivities for the Hewlett Packard system were 40% for TEE-diagnosed myocardial ischemia and 75% for ECG-diagnosed ischemia. Comparison of the printed ECG with TEE revealed that ST-segment changes in the printed ECG, as analyzed by a cardiologist, were 25% sensitive and 62% specific for the detection of TEE-diagnosed myocardial ischemia. When T-wave inversions were added to ST-segment depression as a criterion for the diagnosis of myocardial ischemia by the printed ECG, the sensitivity of ECG for the detection of intraoperative myocardial ischemia, as determined by TEE, was 40% and specificity was 58%. Twenty-three of the 44 patients were simultaneously monitored in leads I, II, and V₅ with an automated Marquette ST-segment monitor. In the 23 patients monitored with both Hewlett Packard and Marquette systems, the sensitivities (80% vs 100%, respectively) and specificities (67% vs 50%, respectively) were similar for ECG-diagnosed myocardial ischemia. Monitors of intraoperative myocardial ischemia often do not agree with each other; however, automated ST-segment monitors predict most ischemic changes seen on the printed ECG and can be used as an alarm to alert the clinician to examine the ECG.

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