Shu-Fen Wung

Interests

Research

My program of research is focused on the timely detection of health changes using technology to support “precision health monitoring” to achieve quality and safety of care. The context of my program of research is health technology across care settings and the subject is older adults with complex and acute care needs. My research line of inquiry is integrating technology to support “precision health monitoring” involving four primary areas: Area 1: Timely and Accurate Detection of Acute Myocardial Ischemia/Infarction and ArrhythmiasArea 2: Integrate Human Factors Principles to Improve the Human-Technology Interface and Safe Use of Precision Monitoring TechnologyArea 3. Sensor-Based Precision Health MonitoringArea 4: Leverage Genetic Technologies for Precision Health Monitoring

Teaching

(1) Cardiac ischemia and arrhythmia; (2) Advanced Cardiovascular Management; (3) Acute and multiple chronic illness management; (4) Advanced practice; (5) Clinical genetics/genomics;(6) Statistics

Courses

Scholarly Contributions

Chapters

• Wung, S. F. (2017). Extra Electrocardiographic Leads: Right Precordial and Left Posterior Leads. In AACN Procedure Manual for High Acuity, Progressive, and Critical Care(pp 494-500). St. Louis, Missouri: Elsevier.
• Wung, S. F. (2017). Twelve-Lead Electrocardiogram. In AACN Procedure Manual for High Acuity, Progressive, and Critical Care, 7e (Aacn Procedure Manual for Critical Care) 7th Edition. Elsevier.
• Schwertz, D., Aouizerat, B. E., & Wung, S. F. (2007). Gene-environmental interaction in cardiovascular disease. In Cardiac Nursing: A Companion to Braunwald's Heart Disease(pp 171-187). St. Louis: Saunders Elsevier.
• Wung, S. F. (2005). Electrocardiography in Heart Disease. In AACVPR Resource Manual in Cardiovascular Rehabilitation(pp 89-106).

Journals/Publications

• Fu, M. R., Kurnat-Thoma, E., Starkweather, A., Henderson, W. A., Cashion, A. K., Williams, J. K., Katapodi, M. C., Reuter-Rice, K., Hickey, K. T., Barcelona de Mendoza, V., Calzone, K., Conley, Y. P., Anderson, C. M., Lyon, D. E., Weaver, M. T., Shiao, P. K., Constantino, R. E., Wung, S. F., Hammer, M. J., , Voss, J. G., et al. (2020). Precision health: A nursing perspective. International journal of nursing sciences, 7(1), 5-12.
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  Precision health refers to personalized healthcare based on a person's unique genetic, genomic, or omic composition within the context of lifestyle, social, economic, cultural and environmental influences to help individuals achieve well-being and optimal health. Precision health utilizes big data sets that combine omics (i.e. genomic sequence, protein, metabolite, and microbiome information) with clinical information and health outcomes to optimize disease diagnosis, treatment and prevention specific to each patient. Successful implementation of precision health requires interprofessional collaboration, community outreach efforts, and coordination of care, a mission that nurses are well-positioned to lead. Despite the surge of interest and attention to precision health, most nurses are not well-versed in precision health or its implications for the nursing profession. Based on a critical analysis of literature and expert opinions, this paper provides an overview of precision health and the importance of engaging the nursing profession for its implementation. Other topics reviewed in this paper include big data and omics, information science, integration of family health history in precision health, and nursing omics research in symptom science. The paper concludes with recommendations for nurse leaders in research, education, clinical practice, nursing administration and policy settings for which to develop strategic plans to implement precision health.
• Ruppel, H., Funk, M., Kennedy, H. P., Bonafide, C., Wung, S. F., & Robin, W. (2019). Critical care nurses' clinical reasoning about physiologic monitor alarm customization: An interpretive descriptive study. Journal of clinical Nursing, 28(15-16), 3033-3041. doi:10.1111/jocn.14866
• Lin, P., Chou, P., & Wung, S. F. (2018). Geographic Diversity in Genotype Frequencies and Meta-Analysis of the Association between rs1801282 Polymorphisms and Gestational Diabetes Mellitus. Diabetes Research and Clinical Practice, 143, 15-23. doi:10.1016/j.diabres.2018.05.050
• Ruppel, H., Funk, M., Whittermore, R., Wung, S. F., Bonafide, C., & Kennedy, H. P. (2018). Challenges of Customizing Electrocardiography Alarms in Intensive Care Units: A Mixed Methods Study. Heart and Lungs, 47(5), 502-508. doi:10.1016/j.hrtlng.2018.06.010
• Wung, S. F. (2018). Human Factors and Technology in the ICU. Crit Care Nurs Clin North Am, 30(2), 179-190. doi:10.1016/j.cnc.2018.02.001
• Wung, S. F., & Schatz, M. R. (2018). Critical care nurses’ cognitive ergonomics related to medical device alarms.. Critical Care Nursing Clinics North America, 30(2), 191-202. doi:10.1016/j.cnc.2018.02.002
• Wung, S. F., Malone, D. C., & Szalacha, L. (2018). Sensory overload and technology in critical care. Critical Care Nursing Clinics North America, 30(2), 179-190. doi:10.1016/j.cnc.2018.02.001
• Lin, P. C., Lin, W. T., Yeh, Y. H., & Wung, S. F. (2016). Transcription Factor 7-Like 2 (TCF7L2) rs7903146 Polymorphism as a Risk Factor for Gestational Diabetes Mellitus: A Meta-Analysis. PloS One, 11(4), e0153044. doi:10.1371/journal.pone.0153044
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  There are racial and ethnic differences in the prevalence of gestational diabetes mellitus (GDM). Prior meta-analyses included small samples and very limited non-Caucasian populations. Studies to determine the relationship between transcription factor 7 like-2 (TCF7L2) rs7903146 polymorphism and risk of GDM in Hispanics/Latinos are recently available. The present meta-analysis was to estimate the impact of allele variants of TCF7L2 rs7903146 polymorphism on GDM susceptibility in overall population and racial/ethnic subgroups.
• Wung, S. F. (2016). Bradyarrhythmias: Clinical Presentation, Diagnosis, and Management. Critical Care Nursing Clinics of North America, 28(3), 297-308. doi:10.1016/j.cnc.2016.04.003
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  Bradyarrhythmias are common clinical findings consisting of physiologic and pathologic conditions (sinus node dysfunction and atrioventricular [AV] conduction disturbances). Bradyarrhythmias can be benign, requiring no treatment; however, acute unstable bradycardia can lead to cardiac arrest. In patients with confirmed or suspected bradycardia, a thorough history and physical examination should include possible causes of sinoatrial node dysfunction or AV block. Management of bradycardia is based on the severity of symptoms, the underlying causes, presence of potentially reversible causes, presence of adverse signs, and risk of progression to asystole. Pharmacologic therapy and/or pacing are used to manage unstable or symptomatic bradyarrhythmias.
• Wung, S. F., Hepworth, J. T., Sparenga, D., & Merkle, C. J. (2015). Cardiovascular Disease Risk and Breast Cancer Outcomes: A Pilot Study. Oncology Nursing Forum, 42(5), E330-8. doi:10.1188/15.ONF.E330-E338
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  To assess feasibility of using electronic health records for profiling multiple cardiovascular disease (CVD) risk factors in women with breast cancer at diagnosis and five years post-treatment, and to explore relationships among CVD risk factors and breast cancer outcomes.
• Stoodley, L., & Wung, S. (2014). Hyperglycemia after cardiac surgery: improving a quality measure. AACN advanced critical care, 25(3), 221-7.
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  The Surgical Care Improvement Project #4 (SCIP#4) performance measure is used to evaluate achievement of target blood glucose control after cardiac surgery.
• Wung, S. F. (2014). Atrial fibrillation in the elderly: management strategies to achieve performance measures. AACN advanced critical care, 25(3), 205-12.
• Merkle, C. J., Hom, S., & Wung, S. (2013). Flipping the Classroom: A Model to Improve Understanding and Applications of Concepts in Cell Biology and Physiology. MOLECULAR BIOLOGY OF THE CELL, 24.
• Wung, S., Hickey, K. T., Taylor, J. Y., & Gallek, M. J. (2013). Cardiovascular Genomics. JOURNAL OF NURSING SCHOLARSHIP, 45(1), 60-68.
• Goodson, B. L., Wung, S. F., & Archbold, K. H. (2012). Obstructive sleep apnea hypopnea syndrome and metabolic syndrome: a synergistic cardiovascular risk factor. Journal of the American Academy of Nurse Practitioners, 24(12), 695-703.
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  Cardiovascular disease (CVD) is the leading cause of morbidity and mortality for adults in the United States. One risk factor for CVD is metabolic syndrome, which encompasses obesity, hypertension, insulin resistance, proinflammatory state, and prothrombotic state. A lesser-understood risk factor is obstructive sleep apnea hypopnea syndrome (OSAHS). This article explores the physiological consequences of the interaction between OSAHS and metabolic syndrome on the cardiovascular system.
• Kozik, T. M., & Wung, S. (2012). Acquired long QT syndrome: Frequency, onset, and risk factors in intensive care patients. Critical Care Nurse, 32(5), 32-41.
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  PMID: 23027789;Abstract: Background: Acquired long QT syndrome is a reversible condition that can lead to torsades de pointes and sudden cardiac death. Objective: To determine the frequency, onset, frequency of medications, and risk factors for the syndrome in intensive care patients. Methods: In a retrospective chart review of 88 subjects, hourly corrected QT intervals calculated by using the Bazett formula were collected. Acquired long QT syndrome was defined as a corrected QT of 500 milliseconds or longer or an increase in corrected QT of 60 milliseconds or greater from baseline level. Risk factors and medications administered were collected from patients' medical records. Results: The syndrome occurred in 46 patients (52%); mean time of onset was 7.4 hours (SD, 9.4) from time of admission. Among the 88 patients, 52 (59%) received a known QTc-prolonging medication. Among the 46 with the syndrome, 23 (50%) received a known QT-prolonging medication. No other risk factor studied was significantly predictive of the syndrome. Conclusions: Acquired long QT syndrome occurs in patients not treated with a known QT-prolonging medication, indicating the importance of frequent QT monitoring of all intensive care patients. © 2012 American Association of Critical-Care Nurses.
• Wung, S., & Lin, P. (2011). Shared genomics of type 2 and gestational diabetes mellitus.. Annual review of nursing research, 29, 227-260.
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  PMID: 22891507;Abstract: Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and the prevalence of GDM is increasing worldwide. Short- and long-term complications of GDM on mothers and fetuses are well-recognized. These include more than seven-fold higher risk for type 2 diabetes mellitus (T2DM) later in life in women with GDM than those without. Evidence supports that GDM shares several risk factors with T2DM, including genetic risks. This chapter reviewed studies on candidate genes shared by T2DM and GDM published from 1990 to 2011. At least 20 susceptible genes of T2DM have been studied in women with GDM in various races. Results from current association studies on T2DM susceptible genes in GDM have shown significant heterogeneity There may be primary evidence that polymorphisms of susceptible genes of T2DM such as transcription factor 7-like 2 (TCF7L2) gene, potassium channel voltage-gate KQT-like subfamily member 1 (KCNQ1) gene, and cyclin-dependent kinase 5 regulatory subunit-associated protein 1-like 1 (CDKAL1) gene, may increase risk of GDM. Associations between GDM and many genetic variants have led to different findings across populations. Many genetic polymorphisms related to GDM were investigated in a single study or a single population. Replication studies to verify contributions of both common and rare genetic variants for GDM and T2DM in specific racial/ethnic groups are needed.
• Calzone, K. A., Cashion, A., Feetham, S., Jenkins, J., Prows, C. A., Williams, J. K., & Wung, S. (2010). Nurses transforming health care using genetics and genomics. Nursing outlook, 58(1), 26-35.
• Edmonds, C. R., Wung, S. F., Pemberton, B., & Surrett, S. (2009). Comparison of anterior chamber depth of normal and keratoconus eyes using Scheimpflug photography. Eye & contact lens, 35(3), 120-2.
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  To compare the corneal anterior chamber depth (ACD) adjusted by age and sex in normal and keratoconus eyes.
• Frazier, L., Wung, S., Sparks, E., & Eastwood, C. (2009). Cardiovascular nursing on human genomics: What do cardiovascular nurses need to know about congestive heart failure?. Progress in Cardiovascular Nursing, 24(3), 80-85.
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  PMID: 19737164;PMCID: PMC2749227;Abstract: This paper presents the main causes of heart failure (HF) and an update on the genetics studies on each cause. The review includes a delineation of the etiology and fundamental pathophysiology of HF and provides rational for treatment for the patient and family. Various cardiomyopathies are discussed, including primary cardiomyopathies, mixed cardiomyopathies, cardiomyopathies that involve altered cardiac muscle along with generalized multiorgan disorders, and various cardiovascular conditions, such as coronary artery disease (ischemic cardiomyopathy) and hypertension (hypertensive cardiomyopathy). A brief review of pharmacogenetics and HF is presented. The application of the genetic components of cardiomyopathy and pharmacogenetics is included to enhance cardiovascular nursing care. © 2009 Wiley Periodicals, Inc.
• Kozik, T. M., & Wung, S. (2009). Cardiac arrest from acquired long QT syndrome: A case report. Heart and Lung: Journal of Acute and Critical Care, 38(3), 238-242.
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  PMID: 19486793;Abstract: Background: Many classes of medications initiated by clinicians can cause adverse events, such as cardiac disturbances. One such adverse outcome is that of acquired long QT syndrome, which can lead to arrhythmias and sudden death. When health care practitioners were surveyed about their knowledge of this condition, 20% indicated they knew very little about long QT syndromes and more than 30% failed to check on current therapy before prescribing QT-prolonging medications. Methods: A case will be presented to illustrate the importance of understanding this syndrome. Results: The causes and pathophysiology of acquired long QT syndrome are discussed, and the resources for clinicians to obtain more information and growing number of offending medications leading to acquired long QT syndrome are provided. Conclusions: On-going education is needed to heighten awareness in the health care community to prevent the deleterious outcomes associated with medication induced acquired long QT syndrome. © 2009 Mosby, Inc. All rights reserved.
• Chang, S., Wung, S., & Crogan, N. L. (2008). Improving activities of daily living for nursing home elder persons in Taiwan. Nursing Research, 57(3), 191-198.
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  PMID: 18496105;Abstract: Background: Excess disability among nursing home elder persons can be prevented or remediated. Because of self-selected disuse and caregiver support of dependency, nursing home residents are likely to develop excess disability. No study was found to test a theory-based program aimed at improving elder persons' self-care abilities for Taiwanese nursing home elder persons who are at risk for developing excess disability. Objectives: The purpose of this study was to test the effectiveness of a theory-based intervention program on self-care, specifically on activities of daily living (ADLs) performance among nursing home elder persons in Taiwan. A secondary aim was to determine the correlation between ADLs performance and three bliss concepts: life satisfaction, self-esteem, and motivation in health behavior. Methods: This study used a quasi-experimental, two-group, pretest-posttest design. Forty-two qualified participants were recruited from two nursing homes located in southern Taiwan and assigned to either the experimental group (n = 21) or the comparison group (n = 21). Participants in the experimental group received the Self-Care Self-Efficacy Enhancement Program (SCSEEP), and those in the comparison group received biweekly social visits for 6 weeks. Levels of ADLs performance were measured by Tappen's Refined ADL Assessment Scale. Life satisfaction was measured by Adams' Life Satisfaction Index A. Self-esteem was measured by Rosenberg's Self-Esteem Scale. Motivation in health behavior was measured by Cox's Health Self-Determinism Index. Results: Elder persons receiving the SCSEEP had significant improvement in feeding, dressing, grooming, and washing activities. Self-esteem (p = .011) and life satisfaction (p = .033) but not motivation in health behavior (p = .282) were positively correlated with levels of ADLs performance. Discussion: The SCSEEP provides a theory-based intervention model for Taiwanese nursing home elder persons aimed at improving ADLs performance. Further research with a larger sample size is needed to determine the longterm maintenance and effectiveness of this theory-driven SCSEEP in specific culture groups. Copyright © 2008 Lippincott Williams & Wilkins.
• Wung, S., & Aouizerat, B. E. (2008). Candidate genes of the 5-lipoxygenase pathway in acute coronary syndrome: A pilot study. Biological Research for Nursing, 9(4), 280-292.
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  PMID: 18398223;Abstract: Purpose. The purpose of this pilot study was to examine arachidonate 5-lipoxygenase (ALOX5) and ALOX5-activating protein (ALOX5AP) gene variations in patients with and without acute coronary syndrome (ACS). Methodology. Four and six single nucleotide polymorphisms spanning the ALOX5 and ALOX5AP genes, respectively, were genotyped in 19 non-Hispanic Caucasian patients with ACS and 27 controls. Results. Presence of the common allele of rs9508835 (ALOX5AP) and the minor allele of rs2029253 (ALOX5) were associated with ACS. After adjustment for age, being a carrier of the rs9508835 common allele was associated with an increased risk of ACS (odds ratio = 2.86). Relevance for nursing practice. Through the inhibition of the ALOX5AP gene by downregulation of the leukotriene pathway, the risk of ACS may be decreased in individuals that carry susceptibility allele(s). Knowledge of the genetic basis of treatments that downregulate the leukotriene pathway may prove essential to the care of individuals with ACS. © 2008 Sage Publications.
• Wung, S., & Kozik, T. (2008). Electrocardiographic evaluation of cardiovascular status.. The Journal of cardiovascular nursing, 23(2), 169-174.
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  PMID: 18382260;Abstract: The electrocardiogram (ECG) is indispensable for the diagnosis and management of patients with a wide variety of cardiac and noncardiac diseases. The purpose of this paper is focused on recent research that used ECG, specifically the long-QT interval and microvolt T wave alternans, for the evaluation of life-threatening ventricular arrhythmias. Although remaining to be validated, QT prolongation along with other emerging electrocardiographic indices such as T wave morphology, T peak-to-T end time, or beat-to-beat QT variability may be sensitive indicators of malignant polymorphic ventricular tachyarrhythmia, torsade de pointes. Microvolt T wave alternans may provide important information in identifying a low-risk group with left ventricular dysfunction who is unlikely to benefit from unnecessary prophylactic implantable cardioverter defibrillator therapy. These ECG markers have the potential to aid in the safe administration of individualized medications, avoidance of sudden cardiac death, and provision of a noninvasive strategy to identify patients who are most and least likely to benefit from expensive prophylactic implantable cardioverter defibrillator placement.
• Chang, S., Crogan, N. L., & Wung, S. (2007). The self-care self-efficacy enhancement program for chinese nursing home elders. Geriatric Nursing, 28(1), 31-36.
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  PMID: 17340774;Abstract: The purpose of this article is to introduce a theory-based intervention program, the Self-Care Self-Efficacy Enhancement Program (SCSEEP), which was derived from Bandura's Social Cognitive Theory (SCT). The SCSEEP, based on the concept of "perceived self-efficacy" within the SCT, was designed to improve self-care ability in Chinese nursing home elders. The theory-based SCSEEP was tested during a pilot study involving 42 elders from 2 nursing homes in Taiwan. Following the study, basic activities of daily living performance improved significantly in treatment group residents. Many Chinese elders are placed in nursing homes in the United States; thus, the SCSEEP may also be used as a theory-based caring model to improve self-care performance in Chinese Americans. © 2007 Mosby, Inc.
• Wung, S., & Wung, S. -. (2007). Discriminating between right coronary artery and circumflex artery occlusion by using a noninvasive 18-lead electrocardiogram. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 16(1).
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  Differentiating occlusion of the circumflex branch of the left coronary artery (also called the circumflex artery) from occlusion of the right coronary artery is often difficult because either may be associated with a pattern of acute inferior myocardial infarction on the electrocardiogram.
• Wung, S., & Kahn, D. Y. (2006). A quantitative evaluation of ST-segment changes on the 18-lead electrocardiogram during acute coronary occlusions. Journal of Electrocardiology, 39(3), 275-281.
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  PMID: 16777513;Abstract: This study determined quantitative ST segment changes on the 18-lead electrocardiogram (ECG) during occlusions in each of the coronary arteries. Methods: Continuous 18-lead ECGs, including standard 12 leads, posterior (V7-9), and right ventricular (RV) leads (V3-5R) were recorded for 155 subjects undergoing percutaneous coronary occlusions, the maximum intervention. Results: During 58 left anterior descending (LAD) coronary occlusions, the maximum ST elevation and depression were in V3 (4.2mm) and III (-0.9mm), respectively. During 44 right coronary artery (RCA) occlusions, the maximum ST elevation and depression were in III (2.2mm) and aVL (-1.4mm), respectively. During 53 left circumflex (LCX) occlusions, the maximum ST elevation and depression were in V7 (0.8mm) and V2 (-1.6mm), respectively. Conclusions: ST elevation often occurred in the anteroapical (V1-V6), lateral (I, aVL), and RV lead V3R during LAD occlusions; in the inferior, RV, and posterior leads during RCA occlusions; and in the posterior, inferior, and apical leads (V5-V6) during LCX occlusions. © 2006 Elsevier Inc. All rights reserved.
• Wung, S., Kulkarni, M. V., Pullinger, C. R., Malloy, M. J., Kane, J. P., & Aouizerat, B. E. (2006). The lipoprotein lipase gene in combined hyperlipidemia: Evidence of a protective allele depletion. Lipids in Health and Disease, 5.
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  PMID: 16822320;PMCID: PMC1538992;Abstract: Background: Lipoprotein Lipase (LPL), a key enzyme in lipid metabolism, catalyzes the hydrolysis of triglycerides (TG) from TG-rich lipoproteins, and serves a bridging function that enhances the cellular uptake of lipoproteins. Abnormalities in LPL function are associated with pathophysiological conditions, including familial combined hyperlipidemia (FCH). Whereas two LPL susceptibility alleles were found to co-segregate in a few FCH kindred, a role for common, protective alleles remains unexplored. The LPL Ser447Stop (S447X) allele is associated with anti-atherogenic lipid profiles and a modest reduction in risk for coronary disease. We hypothesize that significant depletion of the 447X allele exists in combined hyperlipidemia cases versus controls. A case-control design was employed. The polymorphism was assessed by restriction assay in 212 cases and 161 controls. Genotypic, allelic, and phenotypic associations were examined. Results: We found evidence of significant allelic (447Xcontrol: 0.130 vs. 447Xcase: 0.031, χ2 = 29.085; 1df; p < 0.001) and genotypic association (SS: 0.745 vs. 0.939, and SX+XX: 0.255 vs. 0.061) in controls and cases, respectively (χ2 = 26.09; 1df; p < 0.001). In cases, depletion of the 447X allele is associated with a significant elevation in very-low-density lipoprotein cholesterol (VLDL-C, p = 0.045). Consonant with previous studies of this polymorphism, regression models predict that carriers of the 447X allele displayed significantly lower TG, low-density lipoprotein cholesterol (LDL-C) and TG/high-density lipoprotein cholesterol (HDL-C) ratio. Conclusion: These findings suggest a role for the S447X polymorphism in combined hyperlipidemia and demonstrate the importance of evaluating both susceptibility and protective genetic risk factors. © 2006 Wung et al; licensee BioMed Central Ltd.
• Brunsvold, A. N., Wung, S. F., & Merkle, C. J. (2005). BRCA1 genetic mutation and its link to ovarian cancer: implications for advanced practice nurses. Journal of the American Academy of Nurse Practitioners, 17(12), 518-26.
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  The purpose of this paper is to review (a) the linkage between the BRCA1 gene and ovarian cancer and (b) BRCA1 testing and its related issues. This review is aimed for nurse practitioners (NPs), who may be in positions to identify those at risk for BRCA1-associated ovarian cancer and to assist patients with related issues.
• Edmonds, C. R., Wung, S., Husz, M. J., & Pemberton, B. (2004). Corneal endothelial cell count in keratoconus patients after contact lens wear. Eye and Contact Lens, 30(1), 54-58.
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  PMID: 14722472;Abstract: Purpose. The influence of contact lenses on healthy corneal endothelium has been well documented, but little is known about the effect of contact lens wear on the corneal endothelial cells of patients with keratoconus. This cross-sectional comparative study was conducted to determine quantitative characteristics of corneal endothelial cells of 100 patients with keratoconus with or without contact lenses. Methods. A Humphrey Atlas corneal topographer was used to map the keratoconic cornea. The corneal apex of the cone was located by using the axial topography map. The Konan SP-9000 Noncon Robo Pachy specular microscope and the Konan SP-400 specular microscopes were used to photograph the endothelium at the apex of the cone, and the average endothelial cell count was obtained. Patients were categorized into four groups based on the types of contact lenses worn: no contact lenses, SofLens 66 toric contact lenses, SoftPerm contact lenses, and FluoroPerm 30 aspheric rigid gas-permeable (RGP) contact lenses. Analysis of variance was used to determine differences in endothelial cell counts among groups. Results. After controlling for age and severity of keratoconus, patients who wore SoftPerm contact lenses had 18% lower endothelial cell counts (2,157 ± 442) than did patients without contact lenses (2,538 ± 398). These patients also had 15% lower endothelial cell counts than did patients who wore soft toric disposable contact lenses (2,483 ± 292). There was a 7% lower endothelial cell count in the group wearing aspheric RGP contact lenses than in the group that did not wear contact lenses, and a 5% lower endothelial cell count in the group wearing aspheric RGP contact lenses than in the group that wore soft toric contact lenses, but these differences were not statistically significant. Conclusions. Patients with keratoconus who wear SoftPerm contact lenses have a significantly lower endothelial cell count than those patients with keratoconus who do not wear lenses, or who wear soft toric disposable contact lenses or RGP contact lenses. © 2004 Contact Lens Association of Ophthalmologists, Inc.
• Wung, S., & Aouizerat, B. E. (2004). Newly mapped gene for thoracic aortic aneurysm and dissection.. The Journal of cardiovascular nursing, 19(6), 409-416.
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  PMID: 15529063;Abstract: Thoracic aortic aneurysm and dissection (TAAD) is associated with high mortality and medical expense. These poor outcomes are preventable by surgical repair; however, identifying at-risk individuals is difficult. Researchers are actively surveying the human genome (the repository of human genes) to characterize the genetic determinants of TAAD by identifying chromosomal regions likely to harbor such predisposing genes. In previous studies, investigators identified genetic markers shared by a subset of families who were ascertained to have the disease, which clustered into 2 chromosomal regions: 5q13-q15 (TAAD1) and 11q23.2-q24 (familial aortic aneurysm [FAA1]). In a subsequent study, a third chromosomal region at 3p24-25 (TAAD2) was found to contribute to TAAD in a 4-generation, 52-member family that displayed little evidence of sharing either the TAAD1 or FAA1 regions. Although additional regions of the genome may contribute to TAAD, investigators are focusing their efforts on identifying the actual genes and the specific mutations that participate in the disease process. The goal of these endeavors is to develop screening tests to identify individuals at risk for familial TAAD. This genetic discovery has significant clinical implications because high-risk individuals and families can be closely monitored and can benefit from preventative surgical repairs.
• Wung, S., & Aouizerat, B. E. (2003). Gender and ethnic differences in a case-control study of dyslipidemia: using the apolipoprotein A-V gene as an exemplar in cardiovascular genetics.. Research and theory for nursing practice, 17(4), 281-299; discussion 335.
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  PMID: 14959997;Abstract: Common, complex genetic disorders such as coronary heart disease (CHD) frequently show large population differences, contributing to health disparities. It is also well known that CHD risk factor profiles and the frequency of coronary events differ by gender. Study of premature CHD has revealed that apolipoproteins are important discriminating factors for distinguishing individuals with CHD. Recent findings indicated that apolipoprotein A-V (APOA-V) gene promoter polymorphisms are an important determinant of plasma triglycerides (TG) and lipoprotein cholesterol, and a risk factor for CHD. Variations in APOA-V may have varying impacts in different ethnic groups. The purpose of this interdisciplinary genetic research project was to determine (1) the association of the APOA-V polymorphisms with lipoprotein profiles, and (2) the gender and ethnic differences in the T-1131C promoter polymorphism of the APOA-V gene in individuals with dyslipidemia versus controls. Results indicate that the minor -1131C allele (CC homozygotes + CT heterozygotes) was associated with elevated plasma TG (p = 0.007), very low density lipoprotein (VLDL)-TG (p = 0.019), LDL-TG (p = 0.004), high-density-lipoprotein (HDL)-TG (p < 0.001), and VLDL-cholesterol (p = 0.008). We found a striking elevation in the frequency of the minor C allele in Asians (p < 0.001) compared to Europeans. We also found a significant difference in genotype frequency between men and women in Asians (p = 0.031) and Europeans (p < 0.01). Remarkably, Asian women with the C allele have a 36% increase in TG compared to Asian women homozygous for the T allele. In summary, we found significant ethnic-specific and gender-based differences in the frequency of the minor allele of the -1131 APOA-V gene promoter polymorphism. Identification of genetic variations among ethnic groups and between genders may have significant potential for a better understanding of the development of cardiovascular disease.
• Zerwic, J. J., Sherry, D. C., Simmons, B., & Wung, S. F. (2003). Noncompliance in heart transplantation: a role for the advanced practice nurse.. Progress in cardiovascular nursing, 18(3), 141-146.
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  PMID: 12893976;Abstract: Many organ transplant recipients experience organ rejection because they are noncompliant with the requirements of the health care regimen. The advanced practice nurse is in an ideal position to assess predictors of noncompliance as well as to implement interventions to enhance patient compliance. The purpose of this paper is to present a case study of a young female heart transplant recipient whose death due to organ rejection was related to noncompliance. The role of the advanced practice nurse in reducing noncompliance is identified and relevant nursing interventions are discussed. Copyright 2003 CHF, Inc.
• Wung, S., & Wung, S. -. (2002). Genetic advances in coronary artery disease. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses, 11(6).
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  Traditionally, many health care providers consider clinical genetics to be a field that only applies to specialists who provide services to individuals with rare single-gene or chromosomal disorders. But this concept is changing rapidly. In the year 2000, nine of the ten leading causes of mortality, including heart disease, have identified genetic components. As patient advocates and health care providers, nurses have a responsibility to become familiar with genetic advances and translate this knowledge into improved individualized care for patients.
• Wung, S. F. (2001). Computer-assisted continuous ST-segment analysis for clinical research: methodological issues.. Biological research for nursing, 3(2), 65-77.
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  PMID: 11931524;Abstract: Continuous ST-segment monitoring has been used to detect acute myocardial ischemia, determine the success of the reperfusion therapy, and predict outcomes in both research and a variety of clinical settings. However, analyzing the abundant electrocardiography (ECG) data recorded using continuous multilead ST-segment monitoring techniques is time consuming and requires expertise. Experienced data interpreters in dedicated ECG core laboratories handle many continuous ECG data records from large clinical trials. Little information on measurement issues for computer-assisted ST-segment analysis is available for individual investigators. Unsupervised or inexperienced computer analysis of ST-segment deviations can, under certain circumstances, yield invalid or unreliable summary indices. The goal of this article is to discuss basic ST-segment measurement principles in evaluating acute myocardial ischemia and methodological issues surrounding the use of computer-assisted ST-segment analysis for continuous ECG data. Variables affecting ST-segment measurements will be examined. Sources and examples of variability for these potential errors will be identified.
• Wung, S., & Drew, B. J. (2001). New electrocardiographic criteria for posterior wall acute myocardial ischemia validated by a percutaneous transluminal coronary angioplasty model of acute myocardial infarction. American Journal of Cardiology, 87(8), 970-974.
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  PMID: 11305988;Abstract: The standard 12-lead electrocardiogram (ECG) fails to detect ST-segment elevation in patients with posterior wall acute myocardial ischemia. However, additional posterior leads V7-9 provide limited additional diagnostic information to the standard 12-lead ECG when an ischemic criterion of 1-mm ST elevation is used. No study is available to delineate the ischemic criteria in the posterior electrocardiographic leads. Continuous 15-lead ECGs (standard 12 lead + V7-9) were recorded in 53 subjects undergoing elective left circumflex coronary angioplasty (posterior ischemia model). ST amplitudes (J + 60 ms) at preangioplasty baseline were subtracted from maximal ST amplitudes during balloon occlusion to create a positive or negative change score (ΔST) for each of the 15 leads. During 53 left circumflex occlusions, 26 subjects (49%) had ΔST elevation of ≥1 mm and 24 subjects (45%) had ΔST elevation ranging from 0.5 to 0.95 mm in ≥1 posterior leads. Five subjects (9%) had ΔST elevation of ≥1 mm in the posterior leads without ΔST elevation anywhere in any of the 12 leads. The sensitivity in detecting myocardial ischemia using 15-lead ECGs (58%) was not statistically different from the standard 12-lead ECG (49%) (p = 0.06). Adjusting the ischemic criterion from 1 to 0.5 mm in V7-9 significantly improved the sensitivity from 49% in the 12-lead ECG to 94% in the 15-lead ECG (p = 0.000). In addition, 12 subjects (23%) had posterior ST-segment elevation without anterior ST-segment depression. Thus, posterior leads V7-9 contribute significant additional diagnostic information above and beyond the standard 12-lead ECG only when a new ischemic criterion of 0.5 mm instead of 1 mm ST elevation is applied to the posterior leads. © 2001 Excerpta Medica, Inc.
• Wung, S. -., Lux, R. L., & Drew, B. J. (2000). Thoracic location of the lead with maximal ST-segment deviation during posterior and right ventricular ischemia: Comparison of 18-lead ECG with 192 estimated body surface leads. Journal of Electrocardiology, 33(SUPPL.), 167-174.
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  PMID: 11265718;Abstract: By using our database of continuous 18-lead electrocardiographic (ECG) recordings (standard + V3-5R + V7-9) during coronary angioplasty, we selected 68 patients with left circumflex balloon occlusions (posterior ischemia model) or proximal right coronary artery balloon occlusions (right ventricular [RV] ischemia model). ST-segment amplitudes (J + 60 ms) at preangioplasty baseline were subtracted from maximal ST amplitudes during balloon inflation to create a positive or negative change score (ΔST) for each of the 18 leads. ΔST elevation was used to describe a change in the ST level in the positive direction from baseline, whether or not actual ST elevation from the isoelectric line was present. ΔST depression was used to describe a change in the ST level in the negative direction from baseline, whether or not actual ST depression from the isoelectric line was present. ST amplitudes from 8 of the 12 standard leads were then used to estimate ST amplitudes at 192 body surface sites spanning the entire anterior and posterior thorax using the transformation technique of Lux. Thoracic distributions of the ΔST values were displayed on a torso figure, including locations of the 18 lead locations and points of maximal ST elevation and depression. The 192 estimated body surface unipolar leads were compared with 18-lead ECGs (bipolar and unipolar). During 53 left circumflex occlusions, the maximal ΔST elevation was always located in the 18-lead ECG, with the most frequent locations at leads III, II (41%), V7-8 (34%), and V5-6 (25%). The maximal ΔST depression was located outside the 18-lead ECG (89%), with the most frequent locations above standard lead V2 (67%) and V3 (14%). During 16 proximal right coronary artery occlusions, the maximal ΔST elevation was always located in the 18-lead ECG, with the most frequent locations at leads III (81%) and V2-3R (13%). The maximal ΔST depression was located outside the 18-lead ECG (93%), with the most frequent locations above standard lead V2 (50%), V3 (14%), and V4 (14%). We conclude that maximal ΔST elevation is always located in the 18-lead ECG and maximal ΔST depression is frequently located outside of 18-lead ECG during left circumflex and proximal right coronary artery occlusions. Future studies are required to determine the bipolar leads for the 192 estimated body surface potential mapping leads.
• Adams, M. G., Pelter, M. M., Wung, S., Taylor, C. A., & Drew, B. J. (1999). Frequency of silent myocardial ischemia with 12-lead ST segment monitoring in the coronary care unit: Are there sex-related differences?. Heart and Lung: Journal of Acute and Critical Care, 28(2), 81-86.
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  PMID: 10076107;Abstract: BACKGROUND: Ischemia that occurs in the coronary care unit (CCU), whether symptomatic of silent, is associated with significant in-hospital and out-of-hospital complications. Studies have reported that more than 90% of ischemic episodes are silent in patients with unstable angina who are treated in the CCU with maximal medical therapy. Prior reports indicate that women complained more frequently of chest pain than men did. PURPOSE: The aim of this study was to compare the frequency of silent myocardial ischemia in men versus women with use of continuous 12-lead ST segment monitoring in the CCU. A secondary goal was to determine whether silent ischemia was associated with less ST segment deviation as compared with METHOD: Patients admitted for treatment of acute coronary syndrome in the CCU and who subsequently had 1 or more ischemic events during their monitoring period were selected for this analysis. All patients were continuously monitored (42.5 hours ± 37.6) in the CCU with the EASI (Zymed Medical Instruments, Camarillo, Calif) 12-lead electrocardiogram (ECG) system that derives 12 leads with use of 3 information channels and 5 electrodes. RESULTS: Of 491 patients, 128 (91 men and 37 women) had at least 1 episode of transient myocardial ischemia. Men and women did not differ in their proportion of chest pain during ischemia (men 27% and women 21%, NS). For both men and women, ST segment deviation was significantly greater during symptomatic ischemia compared with silent ischemia. CONCLUSION: There are no sex-related differences in ischemic events in the CCU in regards to the variables of chest pain and sT magnitude. Therefore, because chest pain is not a reliable indicator of myocardial ischemia in the CCU, regardless of sex, patients should be adequately monitored for ischemic events.
• Drew, B. J., Pelter, M. M., Wung, S., Adams, M. G., Taylor, C., Evans Jr., G. T., & Foster, E. (1999). Accuracy of the EASI 12-lead electrocardiogram compared to the standard 12-lead electrocardiogram for diagnosing multiple cardiac abnormalities. Journal of Electrocardiology, 32(SUPPL.), 38-47.
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  PMID: 10688301;Abstract: This study was performed to compare a derived 12-lead electrocardiogram (ECG) using a simple 5-electrode lead configuration (EASI 12-lead) with the standard ECG for multiple cardiac diagnoses. Accurate diagnosis of arrhythmias and ischemia often require analysis of multiple (ideally, 12) ECG leads; however, continuous 12-lead monitoring is impractical in hospital settings. EASI and standard ECGs were compared in 540 patients, 426 of whom also had continuous 12-lead ST segment monitoring with both lead methods. Independent standards relative to a correct diagnosis were used whenever possible, for example, echocardiographic data for chamber enlargement- hypertrophy, and troponin levels for acute infarction. Percent agreement between the 2 methods were: cardiac rhythm, 100%; chamber enlargement- hypertrophy, 84%-99%; right and left bundle branch block, 95% and 97%, respectively; left anterior and posterior fascicular block, 97% and 99%, respectively; prior anterior and inferior infarction, 95% and 92%, respectively. There was very little variation between the 2 lead methods in cardiac interval measurements; however, there was more variation in P, QRS, and T-wave axes. Of the 426 patients with ST monitoring, 138 patients had a total of 238 ST events (26, acute infarction; 62, angioplasty-induced ischemia; 150, spontaneous transient ischemia). There was 100% agreement between the 2 methods for acute infarction, 95% agreement for angioplasty- induced ischemia, and 89% agreement for transient ischemia. EASI and standard 12-lead ECGs are comparable for multiple cardiac diagnoses; however, serial ECG changes (eg, T-wave changes) should be assessed using one consistent 12- lead method.
• Lau, K. Y., Wung, S. F., Adams, M. G., Zellner, C., & Drew, B. J. (1999). Frequency of ischemia during intracoronary ultrasound in women with and without coronary artery disease.. Critical care nurse, 19(5), 48-56.
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  PMID: 10808812;Abstract: Myocardial ischemia is common during ICUS imaging in women with and without CAD. Although no long-term adverse effects occurred in our small sample, a larger sample of women is required to confirm our observations and to determine the precise mechanisms of ischemia. Such studies may determine whether the smaller diameter of coronary vessels in women makes the women more vulnerable than men to the occurrence of chest pain and ischemia during ICUS. Although ICUS is valuable in guiding coronary interventions, disposable catheters are costly. Studies are required to assess the cost-benefit ratio of incorporating ICUS with coronary interventional procedures. Until more is known, we recommend that nurses educate patients about ICUS, monitor them closely for ischemia and arrhythmias during the procedure, and consider obtaining 12-lead ECGs when patients undergo and ICUS procedure.
• Wung, S. F. (1999). Multi-Lead ST segment monitoring in patients with acute coronary syndromes suggested clinical practice guidelines for healthcare professionals. American Journal of Critical Care, 8(6), 372-386.
• Wung, S. F., & Drew, B. (1999). Comparison of 18-lead ECG and selected body surface potential mapping leads in determining maximally deviated ST lead and efficacy in detecting acute myocardial ischemia during coronary occlusion. Journal of electrocardiology, 32 Suppl, 30-7.
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  Kornreich identified 6 body surface potential mapping (BSPM) leads outside the standard 12-lead electrocardiographic (ECG) sites for optimal recognition of ST segment elevation (+) and depression (-) during acute ischemia in anterior, inferior, and posterior myocardial zones (A+, A-, I+, I-, P+, P-). No comparison has been made between the 6 selected BSPM leads and 18-lead ECG (12 + V3-5R + V7-9) in detecting acute myocardial ischemia during coronary occlusion. Continuous 18-lead ECG and 6 selected BSPM leads were recorded in 68 patients (77 vessels) undergoing coronary angioplasty during balloon occlusion. Ischemia was defined as ST segment deviation (deltaST) > or = 100 microV > or = 1 lead from the preinflation baseline. The 18-lead ECG was a more frequent source of the maximal deltaST lead during left anterior descending artery, right coronary artery, and left circumflex artery occlusion (71 [92%]) than the 6 selected BSPM leads (5 [7%]). The 18-lead ECG was more efficacious than the 6 selected BSPM leads for detecting acute myocardial ischemia in the group as whole. The 18-lead ECG was also more efficacious for detecting right ventricular ischemia associated with proximal right coronary artery occlusion and for detecting ST segment elevation during left circumflex artery occlusion. Our findings indicate that the 18-lead ECG is the most frequent source of maximally deviated lead and is more efficacious in detecting myocardial ischemia during balloon occlusion than the 6 selected BSPM leads. The 6 selected BSPM leads do not add information above and beyond the 12- or 18-lead ECG, and thus cannot be recommended as optimal sites for continuous ST segment monitoring of patients with acute coronary syndromes.
• Wung, S., & Drew, B. (1999). Comparison of 18-lead ECG and selected body surface potential mapping leads in determining maximally deviated ST lead and efficacy in detecting acute myocardial ischemia during coronary occlusion. Journal of Electrocardiology, 32(SUPPL.), 30-37.
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  PMID: 10688300;Abstract: Kornreich identified 6 body surface potential mapping (BSPM) leads outside the standard 12-lead electrocardiographic (ECG) sites for optimal recognition of ST segment elevation (+) and depression (-) during acute ischemia in anterior, inferior, and posterior myocardial zones (A+, A-, I+, I-, P+, P-). No comparison has been made between the 6 selected BSPM leads and 18-lead ECG (12 + V(3-5R) + V7-9) in detecting acute myocardial ischemia during coronary occlusion. Continuous 18-lead ECG and 6 selected BSPM leads were recorded in 68 patients (77 vessels) undergoing coronary angioplasty during balloon occlusion. Ischemia was defined as ST segment deviation (ΔST) ≥ 100 μV ≥ 1 lead from the preinflation baseline. The 18- lead ECG was a more frequent source of the maximal ΔST lead during left anterior descending artery, right coronary artery, and left circumflex artery occlusion (71 [92%]) than the 6 selected BSPM leads (5 [7%]). The 18-lead ECG was more efficacious than the 6 selected BSPM leads for detecting acute myocardial ischemia in the group as whole. The 18-lead ECG was also more efficacious for detecting right ventricular ischemia associated with proximal right coronary artery occlusion and for detecting ST segment elevation during left circumflex artery occlusion. Our findings indicate that the 18-lead ECG is the most frequent source of maximally deviated lead and is more efficacious in detecting myocardial ischemia during balloon occlusion than the 6 selected BSPM leads. The 6 selected BSPM leads do not add information above and beyond the 12- or 18-lead ECG, and thus cannot be recommended as optimal sites for continuous ST segment monitoring of patients with acute coronary syndromes.
• Drew, B. J., Pelter, M. M., Adams, M. G., Wung, S. F., Chou, T. M., & Wolfe, C. L. (1998). 12-lead ST-segment monitoring vs single-lead maximum ST-segment monitoring for detecting ongoing ischemia in patients with unstable coronary syndromes. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 7(5), 355-63.
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  12-lead ECG monitoring of the ST segment is more sensitive than patients' symptoms for detecting ischemia after thrombolytic therapy or catheter-based interventions, but it is unclear whether monitoring of the single lead showing maximum ST deviation would be as efficacious.
• Drew, B. J., Wung, S. -., Adams, M. G., & Pelter, M. M. (1998). Bedside diagnosis of myocardial ischemia with ST-segment monitoring technology: Measurement issues for real-time clinical decision making and trial designs. Journal of Electrocardiology, 30(SUPPL.), 157-165.
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  PMID: 9535494;Abstract: Monitoring of the ST segment is a valuable tool for guiding clinical derision making and evaluating anti-ischemia interventions in clinical trials; however, measurement issues hamper its diagnostic accuracy. This study reports the frequency and type of false positives and other measurement issues we have encountered during 12-lead ST-segment monitoring of patients in a cardiac care unit. Of 292 patients, 117 (40%) had one or more false positive events during an average of 41 hours of ST-segment monitoring, for a total of 506 false positive events. The 506 false positive events included 167 (36%) due to body positional change; 132 (26%) due to sudden increase in QRS complex/ST-segment voltage; 96 (19%) due to transient arrhythmia or pacing; 80 (16%) due to heart rate change in steeply sloped ST-segment contours; 26 (5%) due to a noisy signal; and 5 (1%) due to lead misplacement. It is concluded that many conditions in addition to myocardial ischemia can cause transient ST-segment deviation in patients with unstable coronary syndromes. Accurate ST-segment monitoring requires expertise in electrocardiogram interpretation, an understanding of the patient's clinical situation, and knowledge of the functions and limitations of the ST-segment monitoring system.
• Pelter, M. M., Adams, M. G., Wung, S. F., Paul, S. M., & Drew, B. J. (1998). Peak time of occurrence of myocardial ischemia in the coronary care unit. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 7(6), 411-7.
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  The onset of acute myocardial infarction and sudden cardiac death has a circadian variation, with the peak occurrence between 6 AM and 12 noon.
• Drew, B. J., Adams, M. G., McEldowney, D. K., Lau, K. Y., Wung, S. F., Wolfe, C. L., Ports, T. A., & Chou, T. M. (1997). Frequency, duration, magnitude, and consequences of myocardial ischemia during intracoronary ultrasonography. American heart journal, 134(3), 474-8.
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  To determine the frequency, duration, magnitude, and possible adverse effects of ischemia during intracoronary ultrasonography, real-time standard 12-lead electrocardiograms were recorded before, during, and after ultrasonography. Ischemia was defined as new-onset ST segment deviation of > or = 1 mm in one or more leads, measured at J + 80 msec. The magnitude of ischemia was expressed as the sum of absolute ST segment deviations across 12 leads. Eighteen (67%) of 27 patients had ischemia during intracoronary ultrasonography. The electrocardiogram resembled the characteristic pattern observed with occlusion of the vessel under study, involving ST segment elevation in contiguous leads in 89% of patients. A higher proportion of women (88%) had ischemia than men (58%), and women had smaller arterial lumenal areas compared with men (6.3 vs 9.1 mm2; p < 0.05). Individuals with ischemia were smaller than those without ischemia (body surface area = 1.99 vs 1.79 m2; p = 0.01). The mean duration of ischemia was 4 minutes and the mean 12-lead ST segment deviation score was 8.5 mm (maximum 20.5 mm). No patient with ischemia during ultrasonography had complications. Ischemia is common during intracoronary ultrasonography, particularly in women and individuals with smaller vessels; however, no adverse outcomes occur as a result.
• Drew, B. J., Adams, M. G., Pelter, M. M., Wung, S., & Caldwell, M. A. (1997). Comparison of standard and derived 12-lead electrocardiograms for diagnosis of coronary angioplasty-induced myocardial ischemia. American Journal of Cardiology, 79(5), 639-644.
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  PMID: 9068524;Abstract: To determine whether a derived 12-lead electrocardiogram (ECG) would demonstrate typical ST-segment changes of ischemia during percutaneous transluminal coronary angioplasty (PTCA), 207 patients were monitored with continuous 12-lead ST-segment monitoring during angioplasty. Additionally, to compare the derived and standard ECGs during known periods of ischemia with PTCA balloon inflation, 151 patients were recorded with both electrocardiographic methods during the procedure. Of the 207 patients recorded with the derived ECG, 171 (83%) had typical ischemic ST-segment changes during PTCA balloon inflation. The amplitudes of these ST deviations were similar to those observed during transient myocardial ischemia observed in clinical settings (median peak ST deviation, 225 μV). There was agreement regarding presence or absence of ischemia in 150 of the 151 patients recorded with bath derived and standard electrocardiographic methods (>99% agreement). With use of the standard ECG as the 'gold standard' for ischemia diagnosis, there were no false-positive results and only 1 false-negative result with the derived ECG. Furthermore, there was nearly perfect agreement between the two 12-lead methods in terms of anterior versus inferior wall patterns of ischemia. Future studies are required to determine whether continuous monitoring with a derived ECG would improve diagnosis and lead to batter patient outcomes.
• Drew, B. J., Adams, M. G., Pelter, M. M., & Wung, S. F. (1996). ST segment monitoring with a derived 12-lead electrocardiogram is superior to routine cardiac care unit monitoring. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 5(3), 198-206.
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  Prior studies have shown that a derived 12-lead electrocardiogram with a simple electrode configuration is comparable with the standard electrocardiogram for arrhythmia analysis.
• Drew, B. J., Adams, M. G., Wung, S. F., & Dower, G. E. (1995). Value of a derived 12-lead ECG for detecting transient myocardial ischemia. Journal of electrocardiology, 28 Suppl, 211.