Agreement in electrocardiogram interpretation in patients with septic shock.

Objective: The reliability of electrocardiogram interpretation to diagnose myocardial ischemia in critically ill patients is unclear. In adults with septic shock, we assessed intra-and inter-rater agreement of electrocardiogram interpretation, and the effect of knowledge of troponin values on these interpretations. Design: Prospective substudy of a randomized trial of vasopressin vs. norepinephrine in septic shock. Setting: Nine Canadian intensive care units. Patients: Adults with septic shock requiring at least 5 mu g/min of norepinephrine for 6 hrs. Interventions: Twelve-lead electrocardiograms were recorded before study drug, and 6 hrs, 2 days, and 4 days after study drug initiation. Measurements: Two physician readers, blinded to patient data and group, independently interpreted electrocardiograms on three occasions (first two readings were blinded to patient data; third reading was unblinded to troponin). To calibrate and refine definitions, both readers initially reviewed 25 trial electrocardiograms representing normal to abnormal. Cohen's Kappa and the phi statistic were used to analyze intra-and inter-rater agreement. Results: One hundred twenty-one patients (62.2 +/- 16.5 yrs, Acute Physiology and Chronic Health Evaluation II 28.6 +/- 7.7) had 373 electrocardiograms. Blinded to troponin, readers 1 and 2 interpreted 46.4% and 30.0% of electrocardiograms as normal, and 15.3% and 12.3% as ischemic, respectively. Intrarater agreement was moderate for overall ischemia (kappa 0.54 and 0.58), moderate/good for "normal" (kappa 0.69 and 0.55), fair to good for specific signs of ischemia (ST elevation, T inversion, and Q waves, reader 1 kappa 0.40 to 0.69; reader 2 kappa 0.56 to 0.70); and good/very good for atrial arrhythmias (kappa 0.84 and 0.79) and bundle branch block (kappa 0.88 and 0.79). Inter-rater agreement was fair for ischemia (kappa 0.29), moderate for ST elevation (kappa 0.48), T inversion (kappa 0.52), and Q waves (kappa 0.44), good for bundle branch block (kappa 0.78), and very good for atrial arrhythmias (kappa 0.83). Inter-rater agreement for ischemia improved from fair to moderate (kappa 0.52, p = .028) when unblinded to troponin. Conclusions: In patients with septic shock, inter-rater agreement of electrocardiogram interpretation for myocardial ischemia was fair, and improved with troponin knowledge. (Crit Care Med 2011; 39: 2080-2086)