Abstract
Purpose
To review the application of intraoperative computerized ST analysis and its potential impact on postoperative outcomes.
Source
Existing anaesthesia and cardiology literature.
Principal findings
Computerized ST analysis was introduced into the operating room using exercise electrocardiographic (ECG) systems. In spite of sophisticated algorithms, errors do occur. Downsloping or horizontal ST depression are the classical criteria for ischaemia. Although algorithms have been developed and evaluated in exercise stress testing, only limited evaluation has been carried out in the operating room. This may be a concern since circumstances in the operating room may frequently lead to false positives. Similarly, studies suggest that all myocardial ischaemia may not exhibit ST changes. The diagnostic accuracy of ST depression in exercise stress testing also cannot be assumed in the operating room. Finally, if ST analysis is applied widely, without considering the population or disease prevalence, misdiagnosis may occur.
Conclusion
Given the number of anaesthetic tasks at-hand, on-line computerized ST analysis in the operating room can be a useful asset. The technology has its problems and should be applied with an understanding of its limitations and potential for errors. It should be applied in the operating room within the context of the population and disease prevalence.
Résumé
Objectif
Revoir l’utilisation peropératoire de l’analyse du segment ST informatisée et son impact potentiel sur le pronostic postopératoire.
Source
La littérature anesthésique et cardiologique actuelle.
Données principales
L’analyse informatisée du segment ST a fait son apparition en salle d’opération après les épreuves électrocardiographiques d’effort. Malgré la perfectionnement des algorithmes, des erreurs surviennent. Les sous-décalages en pente descendante et horizontaux représentent les critères classiques de l’ischémie. Bien que des algorithmes aient été développés et évalués en ce qui concerne l’épreuve d’effort, l’évaluation demeure incomplète pour la salle d’opération. Dans certaines conditions propres à la salle d’opération, l’incidence des faux positifs est alarmante. Des études suggèrent en outre que l’ischémie myocardique peut exister sans que des changements se manifestent au niveau du segment ST. Contrairement à l’épreuve d’effort, on ne peut présumer de la précision de la dépression du segment ST en salle d’opération. Finalement, des erreurs de diagnostic peuvent survenir si l’analyse du segment ST est généralisée sans qu ’on tienne compte du type de population et de la nature de la maladie.
Conclusion
En anesthésie, considérant le nombre de tâches à accomplir, l’analyse du segment ST informatisée et «en ligne» en salle d’opération peut être utilisée avec avantage. Cette technologie pose des problèmes et doit être pratiquée en respectant ses limites et de son potentiel d’erreurs. Son utilisation en salle d’opération doit tenir compte du type de population et de la nature de la maladie.
Article PDF
Similar content being viewed by others
References
Vincent GM, Abildskov JA, Burgess MJ. Mechanisms of ischemic ST-segment displacement. Evaluation by direct current recordings. Circulation 1977; 56: 559–66.
Bousfield G. Angina pectoris: changes in electrocardiogram during paroxysm. Lancet 1918; 2: 457–8.
Feil H, Siegel ML. Electrocardiographic changes during attacks of angina pectoris. Am J Med Sci 1928; 175: 255–60.
Wood FC, Wolferth CC. Angina pectoris. The clinical and electrocardiographic phenomena of the attack and their comparison with the effects of experimental temporary coronary occlusion. Arch Int Med 1931; 47: 337–65.
Katz LN, Landt H. The effect of standardized exercise on the four-lead electrocardiogram. Its value in the study of coronary disease. Am J Med Sci 1935; 189: 346–51.
Master AM, Jaffe HL The electrocardiographic changes after exercise in angina pectoris. J Mt Sinai Hosp NY 1941; 7: 629–32.
Blackburn H, Katigbak R. What electrocardiographic leads to take after exercise? Am Heart J 1964; 67: 184–5.
Sketch MH, Nair CK, Esterbrooks DJ, Mohiuddin SM. Reliability of single-lead and multiple-lead electrocardiography during and after exercise. Chest 1978; 74: 394–401.
Mason RE, Likar I. A new system of multiple-lead exercise electrocardiography. Am Heart J 1966; 71: 196–205.
Mason RE, Likar I, Biern RO, Ross RS. Multiple-lead exercise electrocardiography. Experience in 107 normal subjects and 67 patients with angina pectoris, and comparison with coronary cinearteriography in 84 patients. Circulation 1967; 36: 517–25.
Blomqvist G. The Frank lead exercise electrocardiogram. A quantitative study based on averaging technic and digital computer analysis. Acta Med Scand 1965; 178 (Suppl 440): 7–93.
Bruce RA, Mazzarella JA, Jordan JW Jr, Green E. Quantitation of QRS and ST segment responses to exercise. Am Heart J 1966; 71: 455–66.
Oliver G, Schäfer EA. The physiological effects of extracts of the suprarenal capsules. J Physiol 1895; 18: 230–76.
Levy AG, Lewis T. Heart irregularities, resulting from the inhalation of low percentages of chloroform vapour, and their relationship to ventricular fibrillation. Heart 1911; 3: 99–112.
Cannard TH, Dripps RD, Helwig J Jr, Zinsser HF. The electrocardiogram during anesthesia and surgery. Anesthesiology 1960; 21: 194–202.
Kaplan JA, King SB. The precordial electrocardiographic lead (V5) in patients who have coronary-artery disease. Anesthesiology1976; 45: 570–4.
Roy WL, Edelist G, Gilbert B. Myocardial ischemia during non-cardiac surgical procedures in patients with coronary-artery disease. Anesthesiology 1979; 51: 393–7.
Kotrly KJ, Kotter GS, Mortara D, Kampine JP. Intraoperative detection of myocardial ischemia with an ST segment trend monitoring system. Anesth Analg 1984; 63: 343–5.
Mirvis DM, Berson AS, Goldberger AL, et al. Instrumentation and practice standards for electrocardiographic monitoring in special care units. Circulation 1989; 79: 464–71.
Berson AS, Pipberger HV. The low-frequency response of electrocardiographs, a frequent source of recording errors. Am Heart J 1966; 71: 779–89.
Burns MP, Downs WG. Clinical evaluation of a bedside ST-segment monitor. Computers in Cardiology Proceedings. Washington, DC. IEEE Computer Society Press. 1989; 97–100.
Jamal SM, Mitra-Duncan L, Kelly DT, Freedman SB. Validation of a real-time electrocardiographic monitor for detection of myocardial ischemia secondary to coronary artery disease. Am J Cardiol 1987; 60: 525–7.
Slogoff S, Keats AS, David Y, Igo SR. Incidence of perioperative myocardial ischemia detected by different electrocardiographic systems. Anesthesiology 1990; 73: 1074–81.
Stuart RJ Jr, Ellestad MH. Upsloping S-T segments in exercise stress testing. Six year follow-up study of 438 patients and correlation with 248 angiograms. Am J Cardiol 1976; 37: 19–22.
Morise AP, Duval RD. Accuracy of ST/heart rate index in the diagnosis of coronary artery disease. Am J Cardiol 1992; 69: 603–6.
Goldschlager N, Selzer A, Cohn K. Treadmill stress tests as indicators of presence and severity of coronary artery disease. Ann Int Med 1976; 85: 277–86.
McHenry PL, Stowe DE, Lancaster MC. Computer quantitation of the ST-segment response during maximal treadmill exercise. Clinical correlation. Circulation 1968; 38: 691–701.
Sheffield LT, Holt JH, Lester FM, Conroy DV, Reeves TJ. On-line analysis of the exercise electrocardiogram. Circulation 1969; 40: 935–44.
Okin PM, Bergman G, Kligfield P. Effect of ST segment measurement point on performance of standard and heart rate-adjusted ST segment criteria for the identification of coronary artery disease. Circulation 1991; 84: 57–66.
Ribisl PM, Liu J, Mousa I, et al. Comparison of computer ST criteria for diagnosis of severe coronary artery disease. Am J Cardiol 1993; 71: 546–51.
Kleiner JP, Nelson WP, Boland MJ. The 12-lead electrocardiogram in exercise testing. A misleading baseline? Arch Intern Med 1978; 138: 1572–3.
Froelicher VF Jr, Wolthius R, Reiser N, et al. A comparison of two bipolar exercise electrocardiographic leads to lead V5. Chest 1976; 70: 611–6.
Chaitman BR, Bourassa MG, Wagniart P, Corbara F, Ferguson RJ. Improved efficiency of treadmill exercise testing using a multiple lead ECG system and basic hemodynamic exercise response. Circulation 1978; 57: 71–9.
Bazaral MG, Norfleet EA. Comparison of CB5 and V5 leads for intraoperative electrocardiographic monitoring. Anesth Analg 1981; 60: 849–53.
Griffin RM, Kaplan JA. Comparison of ECG leads V5, CS5, CB5, and II by computerized ST segment analysis. Anesth Analg 1986; 65: S65.
Fuchs RM, Achuff SC, Grunwald L, Yin FCP, Griffith LSC. Electrocardiographic localization of coronary artery narrowings: studies during myocardial ischemia and infarction in patients with one-vessel disease. Circulation 1982; 66: 1168–76.
Berry C, Zalewski A, Kovach R, Savage M, Goldberg S. Surface electrocardiogram in the detection of transmural myocardial ischemia during coronary artery occlusion. Am J Cardiol 1989; 63: 21–6.
Hall RI, O’Regan N, Gardner M. Detection of intraoperative myocardial ischæmia —a comparison among electrocardiographic, myocardial metabolic, and hæmodynamic measurements in patients with reduced ventricular function. Can J Anaesth 1995; 42: 487–94.
Eisenach JC, Tuttle R, Stein A. Is ST segment depression of the electrocardiogram during cesarean section merely due to cardiac sympathetic block? Anesth Analg 1994; 78: 287–92.
Lary D, Goldschlager N. Electrocardiographic changes during hyperventilation resembling myocardial ischemia in patients with normal coronary arteriograms. Am Heart J 1974; 87: 383–90.
Tanaka T, Friedman MJ, Okada RD, Buckels LJ, Marcus FI. Diagnostic value of exercise-induced S-T segment depression in patients with right bundle branch block. Am J Cardiol 1978; 41: 670–3.
Yen RS, Miranda C, Froelicher VF. Diagnostic and prognostic accuracy of the exercise electrocardiogram in patients with preexisting right bundle branch block. Am Heart J 1994; 127: 1521–5.
Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978; 299: 926–30.
Sackett DL, Haynes RB, Tugwell P. The selection of diagnostic tests. In: Clinical Epidemiology, 1st ed. Boston/ Toronto: Little, Brown and Company, 1985: 47–57.
Dupuis J-Y, Nathan HJ, Wynands JE. Clinical application of cardiac risk indices: how to avoid misleading numbers. Can J Anaesth 1991; 38: 1055–64.
Goldman L. Cardiac risk in noncardiac surgery: an update. Anesth Analg 1995; 80: 810–20.
Sackett DL, Haynes RB, Tugwell P. The interpretation of diagnostic data. In: Clinical Epidemiology, 1st ed. Boston/Toronto: Litle, Brown and Company, 1985: 59–138.
Froelicher VF Jr, Yanowitz FG, Thompson AJ. The correlation of coronary angiography and the electrocardiographic response to maximal treadmill testing in 76 asymptomatic men. Circulation 1973; 48: 597–604.
Pedersen F, Sandøe E, Lœrkeborg A. Prevalence and significance of an abnormal exercise ECG in asymptomatic males. Outcome of Thallium myocardial scintigraphy. Eur Heart J 1991; 12:766–9.
Goldman S, Tselos S, Cohn K. Marked depth of ST-segment depression during treadmill exercise testing. Chest 1976; 69: 729–33.
Weiner DA, McCabe CH, Ryan TJ. Identification of patients with left main and three vessel coronary disease with clinical and exercise test variables. Am J Card 1980; 46: 21–7.
Simoons ML, Hugenholtz PG. Estimation of the probability of exercise-induced ischemia by quantitative ECG analysis. Circulation 1977; 56: 552–9.
Sketch MH, Mohiuddin SM, Nair CK, Mooss AN, Runco V. Automated and nomographic analysis of exercise tests. JAMA 1980; 243: 1052–5.
Detrano R, Salcedo E, Leatherman J, Day K. Computerassisted versus unassisted analysis of the exercise electrocardiogram in patients without myocardial infarction. J Am Coll Cardiol 1987; 10: 794–9.
London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12lead electrocardiography. Anesthesiology 1988; 69: 232–41.
Ellis JE, Shah MN, Briller JE, Roizen MF, Aronson S, Feinstein SB. A comparison of methods for the detection of myocardial ischemia during noncardiac surgery: automated ST-segment analysis systems, electrocardiography, and transesophageal echocardiography. Anesth Analg 1992; 75: 764–72.
Eisenberg MJ, London MJ, Leung JM, et al. Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. JAMA 1992; 268: 210–6.
Ashton CM, Petersen NJ, Wray NP, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med 1993; 118: 504–10.
Partridge BL, Barash PG, London MJ, McCann HA. Automated ST-segment trending: what does it mean? J Clin Monit 1992; 8: 66–73.
Ouyang P, Gerstenblith G, Furman WR, Golueke PJ, Gottlieb SO. Frequency and significance of early postoperative silent myocardial ischemia in patients having peripheral vascular surgery. Am J Cardiol 1989; 64: 1113–6.
McCann RL, Clements FM. Silent myocardial ischemia in patients undergoing peripheral vascular surgery: incidence and association with perioperative cardiac morbidity and mortality. J Vasc Surg 1989; 9: 583–7.
Pasternack PF, Grossi EA, Baumann FG, et al. The value of silent myocardial ischemia monitoring in the prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. J Vasc Surg 1989; 10: 617–25.
Frank SM, Beattie C, Christopherson R, Rock P, Parker S, Gottlieb SO. Perioperative rate-related silent myocardial ischemia and postoperative death. J Clin Anesth 1990; 2: 326–31.
Raby KE, Barry J, Creager MA, Cook EF, Weisberg ML, Goldman L. Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery. JAMA 1992; 268: 222–7.
Slogoff S, Keats AS. Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anesthesiology 1985; 62: 107–14.
Pasternack PF, Grossi EA, Baumann FG, et al. Beta blockade to decrease silent myocardial ischemia during peripheral vascular surgery. Am J Surg 1989; 158: 113–6.
Mangano DT, Hollenberg M, Fegert G, et al. Perioperative myocardial ischemia in patients undergoing noncardiac surgery —I: Incidence and severity during the 4-day perioperative period. J Am Coll Cardiol 1991 ; 17: 843–50.
Coriat P, Daloz M, Bousseau D, Fusciardi J, Echter E, Viars P. Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous nitroglycerin. Anesthesiology 1984; 61: 193–6.
Gordon MA, Urban MK, O’Connor T, Barash PG. Is the pressure rate quotient a predictor or indicator of myocardial ischemia as measured by ST —segment changes in patients undergoing coronary artery bypass surgery? Anesthesiology 1991; 74: 848–53.
Urban MK, Gordon MA, Harris SN, O’Connor T, Barash PG. Intraoperative hemodynamic changes are not good indicators of myocardial ischemia. Anesth Analg 1993; 76: 942–9.
Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 1990; 323: 1781–8.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Yang, H. Intraoperative automated ST segment analysis: a reliable ‘Black Box’?. Can J Anaesth 43, 1041–1051 (1996). https://doi.org/10.1007/BF03011907
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03011907