MAXIMIZING THE UTILITY OF THE PRIME ECG James Hoekstra, MD Professor and Chairman Department of...

MAXIMIZING THE UTILITY OF THE PRIME ECG

MAXIMIZING THE UTILITY OF THE PRIME ECG

James Hoekstra, MD

Professor and Chairman

Department of Emergency Medicine

Wake Forest University

James Hoekstra, MD

Professor and Chairman

Department of Emergency Medicine

Wake Forest University

SO HOW DO YOU READ THIS DAMN THING ANYWAY??

SO HOW DO YOU READ THIS DAMN THING ANYWAY??

• Patient Selection

• Evaluating the PRIME ECG results

• Patient Selection

• Evaluating the PRIME ECG results

PRIME ECG Patient SelectionPRIME ECG Patient Selection

• The PRIME ECG does not replace the screening ECG

– Too time intensive

– Too expensive

• PRIME sensitivity and specificity was determined from high risk subsets of patients

• Low risk chest pain patients will result in high false positive rates, just like the 12 lead ECG

• The PRIME ECG does not replace the screening ECG

– Too time intensive

– Too expensive

• PRIME sensitivity and specificity was determined from high risk subsets of patients

• Low risk chest pain patients will result in high false positive rates, just like the 12 lead ECG


• High Risk Patients

• High index of suspicion for evolving STEMI: Serial PRIME

• ST Depression

• Abnormal but nonspecific ECG, BBB, LVH

• Troponin Positive (after TnI or TnT comes back)

• TIMI 2+

• High Risk Patients

• High index of suspicion for evolving STEMI: Serial PRIME

• ST Depression

• Abnormal but nonspecific ECG, BBB, LVH

• Troponin Positive (after TnI or TnT comes back)

• TIMI 2+


• Should not be used to screen for “safe to go home” screening scenarios

• Should not be used in “observation unit” patients (TIMI 0-1)

• Should be used in “admissions,” in serial fashion, especially if high risk

• Should not be used to screen for “safe to go home” screening scenarios

• Should not be used in “observation unit” patients (TIMI 0-1)

• Should be used in “admissions,” in serial fashion, especially if high risk

Reading the PRIME ECGReading the PRIME ECG

• Regimented Reading

– Assure a quality recording

– Stepwise approach to reading

• Match the ECG to the Patient

– Like the 12 Lead ECG, when in doubt, go back to the clinical scenario

• Regimented Reading

– Assure a quality recording

– Stepwise approach to reading

• Match the ECG to the Patient

– Like the 12 Lead ECG, when in doubt, go back to the clinical scenario

Reading the PRIME ECGReading the PRIME ECG

• Regimented Reading Approach

– Low Quality Screen

– Assisted Beat Markings

– 80 Lead Screen

– 4 MAP View

– STO Filter View

– Computerized Reading

• Regimented Reading Approach

– Low Quality Screen

– Assisted Beat Markings

– 80 Lead Screen

– 4 MAP View

– STO Filter View

– Computerized Reading

PRIME ECG Case Study:54 yo Male with Chest PainPRIME ECG Case Study:

54 yo Male with Chest Pain

• Arrives in the ED with chest pain that had been constant since 11 AM.

• Pain is described as intense, midline substernal, radiating to the left arm, associated with shortness of breath and nausea. It began with light walking. It feels like his prior MI pain

• Pain 8/10 on arrival, in mild distress

• Arrives in the ED with chest pain that had been constant since 11 AM.

• Pain is described as intense, midline substernal, radiating to the left arm, associated with shortness of breath and nausea. It began with light walking. It feels like his prior MI pain

• Pain 8/10 on arrival, in mild distress

54 year old Male with CP (PMH)54 year old Male with CP (PMH)

• PMH: CAD, MI

• Prior stent placed for MI

• SH: Smoker

• FH: Noncontributory

• Meds: ASA. Noncompliant with other medications

• PMH: CAD, MI

• Prior stent placed for MI

• SH: Smoker


• Meds: ASA. Noncompliant with other medications

54 year old Male with Chest Pain (ECG)

• Normal Sinus Rhythm at 72 bpm

• ST depression anteriorly

• Tall R waves anteriorly

54 year old Male with CP (Ancillary)54 year old Male with CP (Ancillary)

• Chest Xray: Normal

• Initial Cardiac Markers:

– CK 37, MB ,1.0

– TnI < 0.05

– Renal Function Normal

– Hb 14

– TIMI 5

• Chest Xray: Normal


– CK 37, MB ,1.0

– TnI < 0.05


– Hb 14

– TIMI 5

PRIME ECG AppliedPRIME ECG Applied

628628

54 year old Male with CP (PRIME)54 year old Male with CP (PRIME)

• STEP 1: LOW QUALITY REVIEW• STEP 1: LOW QUALITY REVIEW

LowQualLowQual


• STEP 1: LOW QUALITY REVIEW• STEP 1: LOW QUALITY REVIEW

Rate,Axis,Intervals

Rate,Axis,Intervals

Low QualityLead

Low QualityLead

80 Lead Toggle80 Lead Toggle


• STEP 2: ACCEPT BEAT MARKINGS• STEP 2: ACCEPT BEAT MARKINGS

Hit AnalyzeButtonHit AnalyzeButton

If OK, AcceptIf OK, Accept


• STEP 2: ACCEPT BEAT MARKINGS • STEP 2: ACCEPT BEAT MARKINGS

End of TEnd of T

Start of QRSStart of QRS

STO TakeoffSTO Takeoff


Step 3: Scroll Through the 80 LeadsStep 3: Scroll Through the 80 Leads

80 LeadViewButton

80 LeadViewButton


• Step 4: MAP 4 View (Torso)• Step 4: MAP 4 View (Torso)

Max STDeviationMax STDeviation

IsolatePQRSTIsolatePQRST

TorsoViewTorsoView

4 View4 View


• Step 5: ST0 Filter• Step 5: ST0 Filter

STOSTO


• Step 5: Rotate Filter• Step 5: Rotate Filter

RotateRotate


• Step 6: Read the Analysis: Post MI• Step 6: Read the Analysis: Post MI

54 year old Male with CP (ED Course)54 year old Male with CP (ED Course)

• Cardiology consulted for possible acute posterior MI

• Cardiologist saw pt in the ER

• Pain reduced, workup complete, decision is made to admit to CCU for medical management pre-cath (treat as NSTE ACS)


• Cardiologist saw pt in the ER

• Pain reduced, workup complete, decision is made to admit to CCU for medical management pre-cath (treat as NSTE ACS)

54 year old Male with CP (CCU Course)54 year old Male with CP (CCU Course)

• Second set of markers elevated with CKMB 37, TnI 6.6

• Pain continues, 2-3/10, despite maximal medical management

• Patient taken to cath lab for urgent PCI

• Second set of markers elevated with CKMB 37, TnI 6.6

• Pain continues, 2-3/10, despite maximal medical management

• Patient taken to cath lab for urgent PCI

54 year old Male with CP (Cath Results)54 year old Male with CP (Cath Results)

• 99% thrombotic lesion of the proximal first obtuse marginal off the circumflex

• Remainder of circumflex without stenoses

• LAD and RCA with mild lumenal irregularities, none more than 20% obstructive

• LVEF 50%

• 99% thrombotic lesion of the proximal first obtuse marginal off the circumflex

• Remainder of circumflex without stenoses

• LAD and RCA with mild lumenal irregularities, none more than 20% obstructive

• LVEF 50%

54 year old Male with CP (Course)54 year old Male with CP (Course)

• Patient underwent PCI with taxus stent of the proximal obtuse marginal 99% lesion with good result.

• Discharged home on hospital day 5

• Final diagnosis: Acute Posterior MI

• Patient underwent PCI with taxus stent of the proximal obtuse marginal 99% lesion with good result.





• Arrives in the ED with chest pain that had been stuttering for the past 12 hours

• Pain is described as dull, substernal, associated with shortness of breath and nausea

• Pain 2/10 on arrival, in no distress

• Arrives in the ED with chest pain that had been stuttering for the past 12 hours

• Pain is described as dull, substernal, associated with shortness of breath and nausea

• Pain 2/10 on arrival, in no distress


• PMH: HTN, CVA, Seizures, CAD, Ashma

• EF 40% secondary to past MIs (anatomy unclear due to cath at outside hospital)

• SH: Smoker 1 ppd X 30 years


• Meds: ASA, Lipitor, Lisinopril, Lamictal, Albuterol, Lopressor, Neurontin

• PMH: HTN, CVA, Seizures, CAD, Ashma

• EF 40% secondary to past MIs (anatomy unclear due to cath at outside hospital)

• SH: Smoker 1 ppd X 30 years


• Meds: ASA, Lipitor, Lisinopril, Lamictal, Albuterol, Lopressor, Neurontin



• Diffuse nonspecific ST/T wave changes anteriorly

• Early R wave progression anteriorly

53 year old Male with CP (Ancillary)53 year old Male with CP (Ancillary)

• Chest Xray: Mild cardiomegaly, no CHF


– CK 221, MB 5.3

– TnI < 0.05


– Hb 14

• Chest Xray: Mild cardiomegaly, no CHF


– CK 221, MB 5.3

– TnI < 0.05


– Hb 14

Pain Returns

PRIME Obtained

Pain Returns

PRIME Obtained

332332


• Cardiology consulted for acute anterior MI

• Cath Lab Activated

• Cardiologist at Bedside, agrees with PRIME interpretation

• Angiogram performed

• Cardiology consulted for acute anterior MI

• Cath Lab Activated

• Cardiologist at Bedside, agrees with PRIME interpretation

• Angiogram performed

•LAD with 95% mid lesion•Critical stenosis of first diagonal branch •85% circumflex 2nd OM lesion•70% circumflex 3rd OM lesion•75% lesion of PDA off the RCA

•Apical hypokinesis and LVEF 40%

•LAD with 95% mid lesion•Critical stenosis of first diagonal branch •85% circumflex 2nd OM lesion•70% circumflex 3rd OM lesion•75% lesion of PDA off the RCA

•Apical hypokinesis and LVEF 40%



• Cardiothoracic Surgery consulted for CABG due to triple vessel disease

• Felt not to be surgical candidate due to prior CVA

• Day 2 underwent stenting of LAD 95% lesion, without complication

• Peak Troponin 0.10


• Diagnosis: Unstable Angina

• Cardiothoracic Surgery consulted for CABG due to triple vessel disease

• Felt not to be surgical candidate due to prior CVA

• Day 2 underwent stenting of LAD 95% lesion, without complication

• Peak Troponin 0.10


• Diagnosis: Unstable Angina



• Arrives in the ED by EMS 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

• Arrives in the ED by EMS 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


• PMH: CAD, MI, DM, HTN, CHF, Neuropathy

• PSH: CABG, Pacemaker

• SH: Nonsmoker

• FH: MI

• Meds: ASA, Clopidogrel, Glucophage, Lantis, Lopressor, Lisinipril, Lasix, Lipitor, Neurontin

• PMH: CAD, MI, DM, HTN, CHF, Neuropathy

• PSH: CABG, Pacemaker

• SH: Nonsmoker

• FH: MI

• Meds: ASA, Clopidogrel, Glucophage, Lantis, Lopressor, Lisinipril, Lasix, Lipitor, Neurontin



• Bifascicular Block RBBB and LAHB

• Diffuse ST depression over anterior leads

PRIME ObtainedPRIME Obtained

290290



• Cardiologist at bedside. Agrees with PRIME Reading

• Patient offered PCI, but initially not willing to undergo cath. Agreed later after second set of TnI elevated at 6.1


• Cardiologist at bedside. Agrees with PRIME Reading

• Patient offered PCI, but initially not willing to undergo cath. Agreed later after second set of TnI elevated at 6.1


• 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%

• 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%


• 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 >80, Peak TnI >30



• 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 >80, Peak TnI >30



OCCULT – MI TRIAL OCCULT – MI TRIAL

• Mitchell Krucoff, MD and James Hoekstra, MD - Co-chair

• Heartscape - Sponsor

• Steering Committee

• DCRI - Prime ECG Core Laboratory

• PERFUSE Angiographic Core Lab

• Cardiovascular Clinical Studies -CRO

• Mitchell Krucoff, MD and James Hoekstra, MD - Co-chair

• Heartscape - Sponsor

• Steering Committee

• DCRI - Prime ECG Core Laboratory

• PERFUSE Angiographic Core Lab

• Cardiovascular Clinical Studies -CRO

OCCULT – MI Trial SitesOCCULT – MI Trial Sites

UC-DavisDuke

Bay State Medical Center

Thomas Jefferson

Wake-ForestUniversity of Cincinnati

Cleveland Clinic

Columbia-Presbyterian

Occult-MI study1400 patients

10 + sitesWilliam Beaumont

Tampa General

Tallahassee Heart & Vascular Institute *

Medical University of South Carolina *

Inclusion CriteriaInclusion Criteria

• Able to consent

• >39 years old

• Has access to a working telephone and the ability to hear by phone

• Non-trauma associated ACS symptoms beginning 12 hours or less before presentation

• Chest pain and at least one of the following: (i) ECG abnormality; (ii) known CAD; (iii) at least 3 coronary risk factors for CAD (including: family history, current or treated hypertension, hypercholesterolemia or treatment for it, diabetes mellitus and/or subject is a current smoker).

• Able to consent

• >39 years old

• Has access to a working telephone and the ability to hear by phone

• Non-trauma associated ACS symptoms beginning 12 hours or less before presentation

• Chest pain and at least one of the following: (i) ECG abnormality; (ii) known CAD; (iii) at least 3 coronary risk factors for CAD (including: family history, current or treated hypertension, hypercholesterolemia or treatment for it, diabetes mellitus and/or subject is a current smoker).

Exclusion CriteriaExclusion Criteria

• Symptoms > 12 hours

• Prior 12-lead STEMI within the past 48 hours

• Hemodynamic instability

• Cardiogenic shock

• Pulmonary edema (Killips class 3: overt failure with 1/3 of lung fields)

• Recent trauma.

• Symptoms > 12 hours

• Prior 12-lead STEMI within the past 48 hours

• Hemodynamic instability

• Cardiogenic shock

• Pulmonary edema (Killips class 3: overt failure with 1/3 of lung fields)

• Recent trauma.

Methods: Data CaptureMethods: Data Capture

• Prospective, cohort study of PRIME ECG

• Participants blinded to PRIME result

• Brief medical history (vital signs, height, weight, cardiopulmonary exam, concomitant medications)

• 12-L and PRIME SERIAL recordings – near simultaneous at enrollment, simultaneous at change of symptoms or at least one additional recording within 3 hours; with pain assessment at time of each recording

• Clinical labs including cardiac markers – must include troponin [ I or T ]

• TIMI risk assessment

• Interventional therapies

• Angiographic films

• Results of: stress MPI, echocardiography, and SPECT scan during index ED visit / hospitalization

• 30 day f/u for MACE

• Prospective, cohort study of PRIME ECG

• Participants blinded to PRIME result

• Brief medical history (vital signs, height, weight, cardiopulmonary exam, concomitant medications)

• 12-L and PRIME SERIAL recordings – near simultaneous at enrollment, simultaneous at change of symptoms or at least one additional recording within 3 hours; with pain assessment at time of each recording

• Clinical labs including cardiac markers – must include troponin [ I or T ]

• TIMI risk assessment

• Interventional therapies

• Angiographic films

• Results of: stress MPI, echocardiography, and SPECT scan during index ED visit / hospitalization

• 30 day f/u for MACE

Primary EndpointPrimary Endpoint

DTST for Prime-only STEMI subjects vs. STEMI subjects.

DTST will be measured in minutes, from the time stamped on the ED intake sheet to the time of sheath insertion in the cardiac catheterization laboratory.

DTST for Prime-only STEMI subjects vs. STEMI subjects.

DTST will be measured in minutes, from the time stamped on the ED intake sheet to the time of sheath insertion in the cardiac catheterization laboratory.

Secondary EndpointsSecondary Endpoints

• 10+ endpoints of clinical and economic factors

• Sub-group analyses between Prime-only STEMI, STEMI, non-STEMI

• Clinical factors analyzed will include: 30-day MACE rates, AMI detection, ACS detection, angiographic determination of arterial stenosis/occlusion, revascularization rates, medical therapy regimens

• 10+ endpoints of clinical and economic factors

• Sub-group analyses between Prime-only STEMI, STEMI, non-STEMI

• Clinical factors analyzed will include: 30-day MACE rates, AMI detection, ACS detection, angiographic determination of arterial stenosis/occlusion, revascularization rates, medical therapy regimens

PRIME ECG Case: OCCULT MIPRIME ECG Case: OCCULT MI

• 6/10 Pain

• ECG with ST depression only in anterior and lateral leads

• Posterior leads OK

• PRIME ECG applied

• 6/10 Pain

• ECG with ST depression only in anterior and lateral leads

• Posterior leads OK

• PRIME ECG applied

001-046001-046

PRIME ECG Case ResolutionPRIME ECG Case Resolution

• Door to cath time 486 minutes

• TnI 186X ULN

• Final Dx NSTEMI

• Door to cath time 486 minutes

• TnI 186X ULN

• Final Dx NSTEMI


ECG with nonspecific findings

TIMI 2

Pain 2/10 on arrival, PRIME Applied

ECG with nonspecific findings

TIMI 2

Pain 2/10 on arrival, PRIME Applied

003-0148003-0148


• PRIME reading lateral ischemia

• No cath

• Troponin 210X ULN

• Final Dx NSTEMI

• PRIME reading lateral ischemia

• No cath

• Troponin 210X ULN

• Final Dx NSTEMI


• Pain 2/10 on arrival

• ECG shows lateral ST depression

• PRIME Applied

• Serial Studies done 30 minutes apart as pain continued

• Pain 2/10 on arrival

• ECG shows lateral ST depression

• PRIME Applied

• Serial Studies done 30 minutes apart as pain continued

004-0124 (2)004-0124 (2)


• Rx as Unstable Angina

• Cath at 6022 min

• TnI 11X ULN

• Dx: NSTEMI

• Rx as Unstable Angina

• Cath at 6022 min

• TnI 11X ULN

• Dx: NSTEMI

QUESTIONS??QUESTIONS??

Date post:	11-Jan-2016
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MAXIMIZING THE UTILITY OF THE PRIME ECG James Hoekstra, MD Professor and Chairman Department of...

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