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Background: 12-lead ECG is a critical component of initial evaluation of cardiac ischemia, but has traditionally been limited to large, dedicated equipment in medical care environments. Smartphones provide a potential alternative platform for the extension of ECG to new care settings and to improve timeliness of care. Objective: To gain experience with smartphone electrocardiography prior to designing a larger multicenter study evaluating standard 12-lead ECG compared to smartphone ECG. Methods: 6 patients for whom the hospital STEMI protocol was activated were evaluated with traditional 12-lead ECG followed immediately by a smartphone ECG using right (VnR) and left (VnL) limb leads for precordial grounding. The AliveCor TM Heart Monitor was utilized for this study. All tracings were taken prior to catheterization or immediately after revascularization while still in the catheterization laboratory. Results: The smartphone ECG had excellent correlation with the gold standard 12-lead ECG in all patients. Four out of six tracings were judged to meet STEMI criteria on both modalities as determined by three experienced cardiologists, and in the remaining two, consensus indicated a non-STEMI ECG diagnosis. No significant difference was noted between VnR and VnL. Conclusions: Smartphone based electrocardiography is a promising, developing technology intended to increase availability and speed of electrocardiographic evaluation. This study confirmed the potential of a smartphone ECG for evaluation of acute ischemia and the feasibility of studying this technology further to define the diagnostic accuracy, limitations and appropriate use of this new technology. The contents of this paper constitute original research performed wholly by the named authors and at the named institutions. The authors have each approved its publication. This original research has not previously been published and is not currently submitted for publication elsewhere. Additionally, it is acknowledged that if accepted for publication, it will not be published elsewhere, including electronically, in the same form, in English or in any other language, without the written consent of the copyright-holder.

Background While the process of informed consent is designed to transfer knowledge of the risks and benefits of treatment and to engage patients in shared medical decision-making, this is poorly done in routine clinical care. We assessed the impact of a novel informed consent form for percutaneous coronary intervention (PCI) that is more simply written, includes images of the procedure and embeds individualized estimates of outcomes on multiple domains of successful informed consent and shared decision-making. Methods We interviewed 590 PCI patients receiving traditional consent documents and 527 patients receiving novel ePRISM consents at 9 US centers and compared patients' perceptions, knowledge transfer and engagement in medical decision-making. Heterogeneity across sites was assessed and adjusted for using hierarchical models. Results Site-adjusted analyses revealed more frequent review (72% for ePRISM vs. 45% for original consents) and better understanding of the ePRISM consents (odds ratios (ORs)=1.8–3.0, depending upon the outcome) with marked heterogeneity across sites (median relative difference (MRD) in the ORs of ePRISM's effect = 2–3.2). Patients receiving ePRISM consents better understood the purposes and risks of the procedure (ORs=1.9–3.9, MRDs=1.1–6.2), engaged more in shared decision-making (proportional OR=2.1 [95%CI=1.02–4.4], MRD=2.2) and discussed stent options with their physicians (58% vs. 31%; site-adjusted odds ratio=2.7 [95% CI=1.2, 6.3], MRD=2.6) more often. Conclusions A personalized consent document improved the process of informed consent and shared decision-making. Marked heterogeneity across hospitals highlights that consent documents are but one aspect of engaging patients in understanding and participating in treatment.

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Background Appropriate Use Criteria (AUC) for coronary revascularization have been developed by selected experts. Objective To compare the consistency in AUC ratings among a broader range of practicing cardiologists and the AUC Technical Panel. Methods Prior to AUC publication, 85 cardiologists from 10 U.S. institutions assessed the appropriateness of coronary revascularization for 68 indications that had been evaluated by the Technical Panel. Each indication was classified as appropriate, uncertain, or inappropriate, based on the physician group’s median rating. Rates of concordance between the physician group and the AUC Technical Panel (i.e., same appropriateness category assignment) and rates of non-agreement within the physician group (≥25% of panelists’ ratings outside the group’s appropriateness category assessment) were determined. Results Overall concordance between the 2 groups was 84%. Among indications classified as appropriate by the Technical Panel, concordance between the 2 groups was excellent (94% [34/36]); however, non-agreement within the physician group was 44% (16/36). Among indications classified as uncertain, there was 73% (16/22) concordance between the 2 groups. Among inappropriate indications, concordance was moderate (70% [7/10]), but non-agreement occurred frequently (70% [7/10]). Moreover, there was substantial variation in appropriateness ratings between individual physicians and the Technical Panel (weighted kappa range: 0.05–0.76). Conclusions While there was good concordance in assessments of appropriateness for coronary revascularization between physicians and the AUC Technical Panel, non-agreement within the physician group was common and there was marked variation in ratings between individual physicians and the Technical Panel.

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