PRIME ECG Mapping: The Science and the Practice

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PRIME ECG MappingThe Science and the Practice

• Brian ONeil MD, FACEP
• Professor,
• Emergency Medicine,
• Wayne State University,
• Research Director,
• William Beaumont Hospital

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When You are Trying to Get a Clear Idea of
Something
Be Sure to Get the Full View
3
Its All About Resolution
VS
PONG
KONG
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15 is better than 12

• Comparison of 12- and 15-lead ECGS in ED
• Brady WJ et al. Am J Emerg Med. 200018239-43
• 600 pts in each group
• each group 30 had AE
• USA/MI 101
• The 15 ECG provided a more complete description
  of myocardial injury
• without changing
• -ED diagnosis,
• -ED-based therapy
• -hospital disposition

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18 is better than 15

• Zalenski RJ, J Electrocardiol. 199831164-71
• prospective trial of seven EDs
• gt 35 yo and CCU admission
• ECG leads were test positive if ST ? was gt 0.1
  mV.
• Outcome was inpatient
• VF, VT, high grade block, shock, arrest, or death

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18 is better than 15 Zalenski RJ, J
Electrocardiol. 199831164-71

• 533 patients,
• 64.7 AMI
• 15.8 had events.
• 18 v 15 lead for events
• Sens increased by 5.8
• specificity decreased by 8.2
• Independent predictors of events
• V1 (odds 3.2)
• V6R (odds 3.1)

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80 Lead Body Mapping and AMI

• Kornreich F. Body surface potential mapping of ST
  segment changes in acute myocardial infarction.
  Implications for ECG enrollment criteria for
  thrombolytic therapy. Circ 1993 87773-82

/- ST ??, circled leads were best
discriminators for A anterior, I
inferior, and P posterior MIs
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Comparison of the 80-lead body surface map to
physician and to 12-lead electrocardiogram in
detection of acute myocardial infarction.

• McClelland AJJ et al. Am J Cardiol 200392252-7
• AMI-prevalence (53/103)

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80 Body Mapping in the ED

• 80-lead body surface mapping detects acute STEMI
  missed by standard 12-lead ECG
• Ornato JP, et al. JACC, 2002332A
• 481 ED CP pts with 107 AMIs
• pretest probability to 0.22

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80-Lead ECG increases sensitivity and maintains
specificity when compared to 12-lead ECG
Conclusion The 80-Lead ECG is more sensitive for
detecting STEMI than the 12-Lead ECG, but has
comparable specificity.
J Am Coll Cardiol 2002 39(5) p. 332A.
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80-Lead ECG is associated with greater
sensitivity compared to 12-lead in detection of MI

• In 3 head-to-head, blinded studies, the 80-lead
  ECG identified more MIs than 12-lead upon
  presentation

Sensitivity ()
n481
n103
n294
Ornato JP, et al 80-lead Body Map Detects Acute
ST-elevation Myocardial Infarction Missed by
Standard 12-lead Electrocardiography, Journal of
the American College of Cardiology, 2002 39(5)
332A McClelland, et al Comparison of 80-lead
Body Surface Mapping Algorithm to Physician and
to 12-Lead Electrocardiogram in Detection of
Acute Myocardial Infarction, American Journal of
Cardiology, 2003 92 252-257 Owens CG, et
al Pre-hospital 80-lead mapping Does it add
significantly to the diagnosis of acute coronary
syndromes?, Journal of Electrocardiology, 2004
37 223-232
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PRIME ECG has consistently demonstrated superior
performance vs. 12-lead ECG

• In 3 studies of 878 patients compared to 12-lead
  ECG, PRIME on average
• identified 40 more MIs
• 18 increase in sensitivity
• more true MIs, True
• Maintains specificity
• similar False MIs, False

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Comparison of a cardiac mapping device with
standard 12-Lead ECG in the diagnosis of acute
coronary syndrome

• 90 ED CP pts eval for ACS
• Physicians given 12 and 80 lead
• estimate the prob of AMI on Likert scale
• Asked if adds information or assist with
  treatment
• Outcome 30 day ACS

Fermann G et al. Annals of EM, 200444s73
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Comparison of a cardiac mapping device with
standard 12-Lead ECG in the diagnosis of acute
coronary syndromeFermann G et al. Annals of EM,
200444s73

• 21 ACS, 19 with adverse event

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PRIME ECG Improves ED Diagnosis and Management of
Moderate- to High-Risk Unstable Angina/Non-ST
Elevation Myocardial Infarction Patients.

• Objective Does bedside evaluation with PRIME
• Diagnosis
• Disposition
• Therapy
• Higher risk pts TIMI gt 3
• 68 had MACE

Batton AL, ONeil B, et al Annals of Emerg Med,
2004 (320)S99
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PRIME ECG Improves Emergency Department Diagnosis
and Management of Moderate- to High-Risk Unstable
Angina/Non-ST Elevation Myocardial Infarction
PatientsBatton AL, ONeil B, et al Annals of
Emerg Med, 2004 (320)S99

• PRIME supplied additional information in 59
• PRIME changed disposition in 1/5 to 1/3

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Advantages of 80-Lead ECG in Diagnostic
Dilemmas 1. Posterior MI 2. RV infarct 3.
Left Bundle Branch Block
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Example of potential misdiagnosis with a 12-lead
ECG
Shown here is the 12-Lead ECG of a patient that
presented with substantial chest pain. Note that
there is no evidence of ST segment elevation.
www.wikidoc.org
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Leads 68, 69 72 meet criteria for STEMI
Posterior
Anterior
3 contiguous leads gt.5mm ST elevation, with
reciprocal depression (seen in V3/V4 area)
80-lead Single-Beat Display with pop-up window.

• In this example, a series of sequential beats
  can be observed by placing a cursor over any beat
  (shows instantly in the pop-up window).

Actual screen shot for same patient.
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Example of potential misdiagnosis with a 12-Lead
ECG (cont.)
Shown here is the color representation of the
same patients 80-Lead ECG. The area of injury is
shown in red on the patient's back, corresponding
to the inferior-posterior location of the MI.
www.wikidoc.org
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80-Lead ECG more often detects posterior ST
elevation gt 0.5 mm than augmented anterior
12-lead
36
10
8
6
Posterior V7
Posterior V9
Posterior V7 V9
80-Lead Posterior
Augmented 12-Leads
Menown et al, Am J Cardiol 200085934-8
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Torso map localizes demonstrates injury extent

• Right Ventricular MI

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80-Lead ECG more often detects right ventricular
ST elevation gt 1.0 mm than augmented 12-lead
58
42
42
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Right V2
Right V4
Right V2 V4
80-Lead RV Map
Augmented 12-Leads
Menown et al, Am J Cardiol 200085934-8
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Torso map localizes demonstrates injury extent

• Inferior MI

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Advantages of 80-Lead ECG in Diagnostic
Dilemmas Left Bundle Branch Block
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STEMI and Left Bundle Branch Block the 12-lead
picture
V leads are swamped by deep, wide QRS of LBBB
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STEMI and Left Bundle Branch Block the 80-lead
view
12 lead area swamped by LBBB complexes, unable to
tell position of ST0 (J point)
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STEMI and Left Bundle Branch Block the 80-lead
view
ECG from unaffected area sets ST0 (J point), the
middle marker
12 lead area swamped by LBBB complexes, unable to
tell position of ST0 (J point)
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STEMI and Left Bundle Branch Block the 80-lead
view
ECG from unaffected area sets ST0 (J point), the
middle marker
12 lead area swamped by LBBB complexes, unable to
tell position of ST0 (J point)
Now see true ST0 elevation Inferior MI
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80 Lead Mapping and LBBB

• Maynard SJ et al. Body surface mapping improves
  early diagnosis of acute myocardial infarction
  with LBBB Heart 200389998-1002
• 56 CP pts and LBBB,
• 32 AMI