1. PRIME ECG Mapping: The Science and the Practice Brian O’Neil MD, FACEP Professor, Emergency Medicine, Wayne State University, Research Director, William Beaumont Hospital

2. When You are Trying to Get a Clear Idea of Something Be Sure to Get the Full View

3. It’s All About Resolution VS PONGKONG

4. 15 is better than 12 Comparison 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

5. 18 is better than 15 Zalenski 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

6. 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)

7. 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

8. 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 algorithmPhysician & 12 lead80-lead algorithm Sens0.32 (17/53)0.45 (24/53)0.64 (34/53) Spec0.98 (49/50)0.94 (47/50) PPV0.94 (17/18)0.89 (24/27)0.92 (34/37) NPV0.57 (49/85)0.62 (47/76)0.71 (47/66)

9. 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, 2002;332A 481 ED CP pts with 107 AMIs –pretest probability to 0.22 Standard12-lead80-lead BSM Sensitivity0.252 (27/107)0.336 (36/107) Specificity0.976 (365/374)0.965 (361/374) PPV0.750 (27/36)0.735 (36/49) NPV0.820 (365/445)0.836 (361/432)

10. 80-Lead ECG increases sensitivity and maintains specificity when compared to 12-lead ECG The 80-Lead ECG is more sensitive for detecting STEMI than the 12-Lead ECG, but has comparable specificity. Conclusion: The 80-Lead ECG is more sensitive for detecting STEMI than the 12-Lead ECG, but has comparable specificity. N12-LeadSensitivity 80-Lead Sensitivity p 12-Lead Specificity 80-Lead Specificity p CKMB-MI22/36572.7%100%0.0297.1%96.5%ns TROP-MI28/22557.1%92.9%0.00896.5%94.9%ns CLIN-MI41/64775.6%90.2%0.0998.0%96.7%ns J Am Coll Cardiol 2002; 39(5); p. 332A.

11. 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 *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 Sensitivity (%) n=481n=103n=294

12. 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 +

13. 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

14. Comparison of a cardiac mapping device with standard 12-Lead ECG in the diagnosis of acute coronary syndrome Fermann G et al. Annals of EM, 2004;44:s73 21% ACS, 19% with adverse event 12 lead80 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%

15. 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 DeathAMIStenosis > 50% PCIStentCABG # / 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

16. 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  PRIME supplied additional information in 59%  PRIME changed disposition in 1/5 to 1/3

17. Advantages of 80-Lead ECG in Diagnostic Dilemmas: 1. Posterior MI 2. RV infarct 3. Left Bundle Branch Block

18. 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

19. 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.]

20. 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

21. 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% 8% 10% 36% 80-Lead Posterior Augmented 12-Leads

22. Right Ventricular MI Torso map localizes & demonstrates injury extent

23. 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 Right V4 Right V2 & V4 16% 42%42% 58% 80-Lead RV Map Augmented 12-Leads

24. Inferior MI Torso map localizes & demonstrates injury extent

25. Advantages of 80-Lead ECG in Diagnostic Dilemmas: Left Bundle Branch Block

26. STEMI and Left Bundle Branch Block: the 12-lead picture V leads are swamped by deep, wide QRS of LBBB

27. 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)

28. 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)

29. 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

30. 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 Sens0.33 (6/18)0.17 (3/18)0.67 (12/18) Spec0.97 (37/38)0.87 (33/38)0.71 (27/38) PPV0.86 (6/7)0.38 (3/8)0.52 (12/23) NPV0.76 (37/49)0.69 (33/48)0.82 (27/33)