MAXIMIZING THE UTILITY OF THE PRIME ECG

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MAXIMIZING THE UTILITY OF THE PRIME ECG

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

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SO HOW DO YOU READ THIS DAMN THING ANYWAY??

• Patient Selection
• Evaluating the PRIME ECG results

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PRIME 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

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PRIME ECG Patient Selection

• 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

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PRIME ECG Patient Selection

• 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

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Reading 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

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Reading the PRIME ECG

• Regimented Reading Approach
• Low Quality Screen
• Assisted Beat Markings
• 80 Lead Screen
• 4 MAP View
• STO Filter View
• Computerized Reading

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PRIME ECG Case Study54 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

•  

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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

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54 year old Male with Chest Pain (ECG)

• Normal Sinus Rhythm at 72 bpm
• ST depression anteriorly
• Tall R waves anteriorly

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54 year old Male with CP (Ancillary)

• Chest Xray Normal
• Initial Cardiac Markers
• CK 37, MB ,1.0
• TnI lt 0.05
• Renal Function Normal
• Hb 14
• TIMI 5

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PRIME ECG Applied

• 628

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54 year old Male with CP (PRIME)
Low Qual

• STEP 1 LOW QUALITY REVIEW

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54 year old Male with CP (PRIME)
Rate, Axis, Intervals
80 Lead Toggle
Low Quality Lead

• STEP 1 LOW QUALITY REVIEW

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54 year old Male with CP (PRIME)
Hit Analyze Button
If OK, Accept

• STEP 2 ACCEPT BEAT MARKINGS

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54 year old Male with CP (PRIME)
STO Takeoff
End of T
Start of QRS

• STEP 2 ACCEPT BEAT MARKINGS

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54 year old Male with CP (PRIME)
80 Lead View Button

• Step 3 Scroll Through the 80 Leads

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54 year old Male with CP (PRIME)
4 View
Torso View
Isolate PQRST
Max ST Deviation

• Step 4 MAP 4 View (Torso)

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54 year old Male with CP (PRIME)
STO

• Step 5 ST0 Filter

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54 year old Male with CP (PRIME)
Rotate

• Step 5 Rotate Filter

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54 year old Male with CP (PRIME)

• Step 6 Read the Analysis Post MI

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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)

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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

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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

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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

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PRIME ECG Case Study53 yo Male with Chest Pain

•  

• 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

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53 year old Male with CP (PMH)

• 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
• FH Noncontributory
• Meds ASA, Lipitor, Lisinopril, Lamictal,
  Albuterol, Lopressor, Neurontin

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53 year old Male with Chest Pain (ECG)

• Normal Sinus Rhythm at 79 bpm
• Diffuse nonspecific ST/T wave changes
  anteriorly
• Early R wave progression anteriorly

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53 year old Male with CP (Ancillary)

• Chest Xray Mild cardiomegaly, no CHF
• Initial Cardiac Markers
• CK 221, MB 5.3
• TnI lt 0.05
• Renal Function Normal
• Hb 14

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Pain ReturnsPRIME Obtained

• 332

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53 year old Male with CP (ED Course)

• Cardiology consulted for acute anterior MI
• Cath Lab Activated
• Cardiologist at Bedside, agrees with PRIME
  interpretation
• Angiogram performed

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53 year old Male with CP (Cath Results)

• 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

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53 year old Male with CP (Course)

• 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
• Discharged home on hospital day 5
• Diagnosis Unstable Angina

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PRIME ECG Case Study62 yo Male with Chest Pain

•  

• 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

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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 Chest Pain (ECG)

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

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PRIME Obtained

• 290

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62 year old Male with CP (ED Course)

• Cardiology consulted for possible acute posterior
  MI
• 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

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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 (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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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

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OCCULT MI Trial Sites
Bay State Medical Center
Occult-MI study 1400 patients 10 sites
Columbia-Presbyterian
William Beaumont
Thomas Jefferson
Cleveland Clinic
Wake-Forest
UC-Davis
University of Cincinnati
Duke
Medical University of South Carolina
Tallahassee Heart Vascular Institute
Tampa General
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Inclusion Criteria

• Able to consent
• gt39 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).

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Exclusion Criteria

• Symptoms gt 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.

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Methods 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

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Primary 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.

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Secondary 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

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PRIME ECG Case OCCULT MI

• 6/10 Pain
• ECG with ST depression only in anterior and
  lateral leads
• Posterior leads OK
• PRIME ECG applied

001-046
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PRIME ECG Case Resolution

• Door to cath time 486 minutes
• TnI 186X ULN
• Final Dx NSTEMI

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PRIME ECG Case OCCULT MI

• ECG with nonspecific findings
• TIMI 2
• Pain 2/10 on arrival, PRIME Applied

003-0148
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PRIME ECG Case Resolution

• PRIME reading lateral ischemia
• No cath
• Troponin 210X ULN
• Final Dx NSTEMI

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PRIME ECG Case OCCULT MI

• Pain 2/10 on arrival
• ECG shows lateral ST depression
• PRIME Applied
• Serial Studies done 30 minutes apart as pain
  continued

004-0124 (2)
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PRIME ECG Case Resolution

• Rx as Unstable Angina
• Cath at 6022 min
• TnI 11X ULN
• Dx NSTEMI

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QUESTIONS??