James Hoekstra, MD Professor and Chairman Department of Emergency Medicine Wake Forest University

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James Hoekstra, MDProfessor and
ChairmanDepartment of Emergency MedicineWake
Forest University

• 62 Year Old Male with Chest Pain

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PRIME ECG Case Study62 yo Male with Chest Pain

• Arrives in the ED by EMS at 0154 AM with chest
  pain that has been intermittent for 2 days, and
  constant for the last 2 hours.
• Pain is described as substernal, radiating to the
  left arm, associated with shortness of breath and
  nausea. He has been taking NTG without relief.
• Pain 8/10 on arrival, in moderate distress

James Hoekstra, acting as a paid consultant to
Heartscape Technologies, Inc., authored this case
review based on actual data, physician notes and
images extracted from the medical record of a
specific patient. Images and physician findings
and conclusions were based on the abstracted
medical record provided to him by Heartscape
Technologies, Inc.
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62 year old Male with CP (PMH)

• PMH CAD, MI, DM, HTN, CHF, Neuropathy
• PSH CABG, Pacemaker
• SH Nonsmoker
• FH MI
• Meds ASA, Clopidogrel, Glucophage, Lantis,
  Lopressor, Lisinipril, Lasix, Lipitor, Neurontin

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62 year old Male with CP (PMH)

• Hospitalized two weeks earlier at VA Hospital for
  NSTEMI.
• Patient had a cath at that time which showed all
  three grafts open and patent. No
  revascularization was performed.
• Pain today is like his prior MI pain

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62 year old Male with CP (Physical)

• Physical Exam
• Vital Signs BP 162/87, P 91, R 20
• Temp 98.0, pulse ox 94
• Lungs with occasional rales in bases
• Heart Sounds normal, no S3 or S4
• No edema, no JVD

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62 year old Male with Chest Pain (ECG)

• Normal Sinus Rhythm at 72 bpm
• Bifascicular Block RBBB and LAHB
• Diffuse ST depression over anterior leads

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62 year old Male with CP (Initial Rx)

• 0200 MD at Bedside
• 0205 Initial ED Treatment
• ASA 325 mg PO
• Heparin Drip
• NTG drip initiated to titrate to pain
• 0210 PRIME ECG Applied

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The PRIME ECG Technology
Single-patient Disposable Vest

• Easily-applied, self-adhesive plastic strips
  containing 80 data collection points
• Strips allow analysis of the hearts electrical
  activity with 360 degrees of spatial resolution
• Data from the 80 leads are processed into 3-D
  color maps for easy visualization

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Placement of the 80 Leads Provides a
Comprehensive View of the Heart

• 64 anterior and 16 posterior leads
• Conventional, precordial leads V1-V6 are marked

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Color-coded, Anatomically-referenced View of
Ischemia
3-D Color-coded Torso Map
Easy, Rapid Diagnosis of Cardiac Events
Red Positive Deflection Positive values
above isoelectric (MAXIMA) Blue Negative
Deflection Negative values below isoelectric
(MINIMA) Green No Deflection Zero
values (isoelectric or near isoelectric)
Maps are built using data from a single beat
taken at each electrode The crosses shown each
represent one of the 80 electrodes on the vest
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62 year old Male with CP (PRIME)

• Quad MAP View RBBB, Acute Post MI

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62 year old Male with CP (PRIME)

• MAP ECG View STE in Lead 70

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62 year old Male with CP (PRIME)

• MAP ST0 Filter Post STE, Ant STD

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62 year old Male with CP (ED Course)

• 0215 Cardiology consulted for possible acute
  posterior MI
• 0245 Cardiologist at bedside. Agrees with
  PRIME ECG Reading
• 0300 Patient offered PCI, but initially not
  willing to undergo another cath.
• Medical management and workup continues

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62 year old Male with CP (Ancillary)

• 0230 Chest Xray Cardiomegaly, mild CHF
• 1330 Initial Laboratory Studies
• CK 206, MB , 3.5
• TnI 0.06
• Renal Function Normal
• Hb 14
• Glucose 253

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62 year old Male with CP (CCU Course)

• 0400 Patients pain continues despite medical
  management.
• Patient relents, agrees to cardiac
  catheterization.
• 0415 Patient taken to cath lab for urgent PCI

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62 year old Male with CP (Cath Results)

• LAD, RCA, and circumflex all occluded from the
  native circulation.
• LIMA graft to LAD patent, distal LAD 80 stenosis
• Saphenous graft to the RCA patent without
  stenoses
• Saphenous graft to the circumflex occluded at the
  distal anastomosis
• LVEF 30

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62 year old Male with CP
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62 year old Male with CP (Course)

• Patient underwent PCI with taxus stent of the
  distal saphenous graft to the circumflex, with
  good results.
• Patient admitted to the CCU post procedure
• Peak CKMB gt80, Peak TnI gt30
• Discharged home on hospital day 5
• Final diagnosis Acute Posterior MI

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Teaching Points 62 year old Male

• Early application of PRIME ECG in patients with
  chest pain and initially non-diagnostic 12-lead
  ECG can diagnose STEMI early, and facilitate
  early PCI
• PRIME ECG is especially useful for diagnosing
  STEMI in patients with bundle branch blocks. The
  sensitivity of the PRIME ECG is approximately
  67 for STEMI with BBB, while the 12 lead
  sensitivity is only 17-30.