Background: The modified Sgarbossa criteria have greater than 90% specificity for the diagnosis of acute coronary occlusion myocardial infarction (OMI) in patients presenting to the emergency department (ED) with ventricular paced rhythm (VPR) and symptoms concerning for coronary ischemia (e.g. chest pain or shortness of breath). The utility of these criteria has been questioned due to the low prevalence of OMI in such patients. However, the prevalence of OMI in patients with VPR and ischemic symptoms is not known. We assessed the hypothesis that the prevalence of OMI in ED patients with ischemic symptoms is similar among subjects with VPR versus without VPR.
Methods: This is a secondary analysis of two studies of patients who presented to the same urban, academic ED with ischemic symptoms; VPR patients from the PERFECT study (1/2014 – 12/2016, NCT02765477) versus non-VPR patients from UTROPIA (3/2014 – 5/2014, NCT02060760). Trained physicians, blinded to patient outcomes, adjudicated acute myocardial infarction (AMI) and myocardial injury by the Third Universal Definition of Myocardial Infarction. Statistics are by Chi-square and Fisher’s exact tests.
Results: The VPR and no-VPR groups consisted of 243 and 1031 patients, respectively. Patients with VPR were older (67 [SD 13] vs. 55 [SD 13] years-old), and had higher rates of known CAD (154 [63%] vs. 167 [16%], 30-day cardiac readmission (66 [27%] vs. 23 [2.5%]), in-hospital death (8 [3.3%] vs. 7 [0.68%]), and 6-month mortality (22 [7.8%] vs. 28 [2.7%]) (p < 0.001 for all). Initial troponin-I (0.088 [SD 0.24] vs. 0.11 [SD 1.5]) and peak troponin-I (0.40 [SD 2.8] vs. 0.60 [SD 4.5]) levels were not different between VPR and no VPR groups
There was no difference in the rate of OMI (3 [1.23%] vs. 11 [1.07%]; p = 0.8), or any AMI (43 [17.7%] vs. 156 [15.1%]; p = 0.3) between VPR and no-VPR. Myocardial injury not due to AMI was more prevalent in VPR (86/200 [43%]) vs. no-VPR (128/903 [14.6%]; p < 0.0001).
Conclusion: In patients presenting to the ED with symptoms concerning for coronary ischemia, those with VPR had a similar prevalence of OMI when compared to patients without VPR. The overall prevalence of OMI was low. The low prevalence of OMI in ED patients with ischemic symptoms should not dissuade physicians from applying the most accurate diagnostic criteria available.