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


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-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


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


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.


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.


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


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


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


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


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

•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.


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


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

presentación itms

Technology

ekg tracings

traditional ekg

ekg diagnosis

ekg guide

tele ekg

cardiette ekg

teleekg work

chile equipments