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PRIME ECG Mapping: The Science and the Practice Brian O’Neil MD, FACEP Professor, Emergency...
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Transcript of PRIME ECG Mapping: The Science and the Practice Brian O’Neil MD, FACEP Professor, Emergency...
PRIME ECG Mapping:The Science and the Practice
Brian O’Neil MD, FACEPProfessor,
Emergency Medicine, Wayne State University,
Research Director,William Beaumont Hospital
When You are Trying to Get a Clear Idea of Something
Be Sure to Get the Full View
It’s All About Resolution
VS
PONG KONG
15 is better than 12Comparison of 12- and 15-lead ECGS in ED
– Brady WJ et al. Am J Emerg Med. 2000;18:239-43• 600 pts in each group• each group 30% had AE
• USA/MI 10:1
The 15 ECG provided a more complete description of myocardial injury
without changing-ED diagnosis, -ED-based therapy-hospital disposition
18 is better than 15Zalenski RJ, J Electrocardiol. 1998;31:164-71
• prospective trial of seven EDs
– > 35 yo and CCU admission
• ECG leads were test positive if ST ↑ was > 0.1 mV.
• Outcome was inpatient
– VF, VT, high grade block, shock, arrest, or death
18 is better than 15 Zalenski RJ, J Electrocardiol. 1998;31:164-71
• 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)
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; 87:773-82
+/- = ST , circled leads were best discriminators for A anterior, I inferior, and P posterior MIs
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 2003;92:252-7
• AMI-prevalence (53/103)
12-lead algorithm Physician & 12 lead 80-lead algorithm
Sens 0.32 (17/53) 0.45 (24/53) 0.64 (34/53)
Spec 0.98 (49/50) 0.94 (47/50) 0.94 (47/50)
PPV 0.94 (17/18) 0.89 (24/27) 0.92 (34/37)
NPV 0.57 (49/85) 0.62 (47/76) 0.71 (47/66)
80 Body Mapping in the ED80-lead body surface mapping detects acute STEMI
missed by standard 12-lead ECG
Ornato JP, et al. JACC, 2002;332A• 481 ED CP pts with 107 AMIs
– pretest probability to 0.22
Standard12-lead 80-lead BSM
Sensitivity 0.252 (27/107) 0.336 (36/107)
Specificity 0.976 (365/374) 0.965 (361/374)
PPV 0.750 (27/36) 0.735 (36/49)
NPV 0.820 (365/445) 0.836 (361/432)
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 The 80-Lead ECG is more sensitive for detecting STEMI than the 12-Lead ECG, but has comparable specificity.than the 12-Lead ECG, but has comparable specificity.
NN12-Lead12-Lead
SensitivitySensitivity80-Lead 80-Lead
SensitivitySensitivity pp12-Lead 12-Lead
SpecificitySpecificity80-Lead 80-Lead
SpecificitySpecificity pp
CKMB-MICKMB-MI 22/36522/365 72.7%72.7% 100%100% 0.020.02 97.1%97.1% 96.5%96.5% nsns
TROP-MITROP-MI 28/22528/225 57.1%57.1% 92.9%92.9% 0.0080.008 96.5%96.5% 94.9%94.9% nsns
CLIN-MICLIN-MI 41/64741/647 75.6%75.6% 90.2%90.2% 0.090.09 98.0%98.0% 96.7%96.7% nsns
J Am Coll Cardiol 2002; 39(5); p. 332A.
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
25
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34
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80
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Ornato, et.al.* McClelland, et.al.** Owens, et.al.***
12-L
PRIME ECG
*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
Se
ns
itiv
ity
(%
)S
en
sit
ivit
y (
%)
n=481 n=103 n=294
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 +
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, 2004;44:s73
Comparison of a cardiac mapping device with standard 12-Lead ECG in the
diagnosis of acute coronary syndromeFermann G et al. Annals of EM, 2004;44:s73
• 21% ACS, 19% with adverse event
12 lead 80 lead
AUC (ECG) 0.69
(0.55-0.82)
0.74
(0.62-0.86)
SENS (TnI) 20% 40%
SPEC (TnI) 91.8% 92.9%
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 > 3
68% had MACE Death AMI Stenosis >
50%PCI Stent CABG
# / 35 (%) 0 (0) 13 (38%) 17 (50%) 15 (44) 10 (29) 5 (15)
Batton AL, O’Neil B, et al Annals of Emerg Med, 2004 (320)S99
PRIME ECG Improves Emergency Department Diagnosis and Management of Moderate- to High-Risk
Unstable Angina/Non-ST Elevation Myocardial Infarction Patients
Batton AL, O’Neil B, et al Annals of Emerg Med, 2004 (320)S99
Added Information to 12 lead ECG
Changed Therapy or Disposition
Number with MACE Number inappropriately
triaged Attending Physician
20/34 7/34 6/7 1/7
Resident 18/34 11/34 10/11 1/11
PRIME supplied additional information in 59%
PRIME changed disposition in 1/5 to 1/3
Advantages of 80-Lead ECG in Diagnostic Dilemmas:
1. Posterior MI
2. RV infarct
3. Left Bundle Branch Block
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.orgwww.wikidoc.org
Leads 68, 69 & 72 meet criteria for STEMI
[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).]
80-lead Single-Beat Display with pop-up window.
PosteriorAnterior
3+ contiguous leads; >.5mm ST elevation, with reciprocal depression (seen in V3/V4 area)
[Actual screen shot for same patient.]
Shown here is the color representation of the same patient’s 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.
Example of potential misdiagnosis with a 12-Lead ECG (cont.)
www.wikidoc.org
0
5
10
15
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30
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% P
atie
nts
(n=
62
)80-Lead ECG more often detects posterior ST elevation
> 0.5 mm than augmented anterior 12-lead
Menown et al, Am J Cardiol 2000;85:934-8
Posterior V7
Posterior V9
Posterior V7 & V9
6%6%8%8%
10%10%
36%36%
80-LeadPosterior
Augmented 12-Leads
Right Ventricular MI
Torso map localizes & demonstrates injury extent
0
10
20
30
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1
% P
atie
nts
(n
=6
2)
80-Lead ECG more often detects right ventricular ST elevation > 1.0 mm than augmented 12-lead
Menown et al, Am J Cardiol 2000;85:934-8
Right V2
RightV4
Right V2 & V4
16%16%
42%42% 42%42%
58%58%
80-LeadRV Map
Augmented 12-Leads
Inferior MI
Torso map localizes & demonstrates injury extent
Advantages of 80-Lead ECG in Diagnostic Dilemmas:
Left Bundle Branch Block
STEMI and Left Bundle Branch Block: the 12-lead picture
V leads are swamped by deep, wide QRS of LBBB
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)
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)
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
80 Lead Mapping and LBBB• Maynard SJ et al. Body surface mapping improves early diagnosis
of acute myocardial infarction with LBBB Heart 2003;89:998-1002 – 56 CP pts and LBBB,
• 32% AMI
12-lead (Sgarbossa criteria)
12-lead (Hands criteria)
80-lead lost reversal
Sens 0.33 (6/18) 0.17 (3/18) 0.67 (12/18)
Spec 0.97 (37/38) 0.87 (33/38) 0.71 (27/38)
PPV 0.86 (6/7) 0.38 (3/8) 0.52 (12/23)
NPV 0.76 (37/49) 0.69 (33/48) 0.82 (27/33)