Prehospital 80-LAD mapping: Does it add significantly to the diagnosis of acute coronary syndromes?

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Abstract

Early detection of acute myocardial infarction (MI) is vital in the management of acute coronary syndromes (ACS). Hence we compared the diagnostic capability of the standard 12-lead electrocardiogram (ECG) with the 80-lead ECG body surface map (BSM) prehospital. Methods: Consecutive patients (n = 294) presenting prehospital with ischemic type chest pain were included. All had an ECG and BSM pretreatment and a baseline and 12-hour cardiac troponin-T or I (cTnT or cTnI). Acute MI was defined as cTnT > 0.09 or cTnI > 0.1 ng/mL. Acute MI on the BSM was defined as ST elevation measured at the J-point, ≥1mm inferior/right ventricular/high right anterior/lateral regions, ≥2 mm anterior region, ≥0.5 mm posterior region. Results: Acute MI occurred in 182/294 (62%) based on cTnT or I. ST elevation on the standard ECG predicted acute MI in 103 (sensitivity 57%, specificity 94%; c-statistic 0.73). The optimal model for the standard ECG included ST elevation, summed ST depression and past history of MI (c-statistic 0.82; Chi-square (Wald) 120.7, 3df). The BSM predicted acute MI in 146 (sensitivity 80%, specificity 92%; c-statistic 0.86). The optimal model for the BSM included BSM criteria for acute MI and past history of MI (c-statistic 0.91; Chi-square (Wald) 180.3, 2df). Conclusion: The 80-lead BSM is superior to the standard 12-lead ECG in predicting acute MI prehospital.

Section snippets

Patient recruitment

Patients were recruited consecutively between January 2002 and January 2004 as they presented to the physician-manned mobile coronary care unit. Patients were enrolled over 24 hours if they presented with ischemic type chest pain of <12 hours duration regardless of the initial 12-lead ECG. All patients had a 12-lead ECG and BSM performed at presentation outside the hospital together with initial and 12-hour cardiac Troponin-I (cTnI) (January 2002-August 2003) or cardiac Troponin-T (cTnT)

Results

Between January 2002 and 2004, 294 patients were recruited. The mean age of the patients was 64 ± 12 years and 209 were male (71%). A past history of hypertension was present in 122 (42%), hypercholesterolemia (defined as total cholesterol >193 mg/dL) in 120 (41%), smokers in 97 (33%) and diabetes mellitus in 44 (15%). Acute MI occurred in 182/294 (62%) based on cTnT or cTnI.

Discussion

In the immediate triage and infarct recognition of ACS patients, ECG technology, which is still core to the diagnosis, has lagged behind relative to other diagnostic methods. Echocardiography, radionuclide imaging and even MRI have all added value in ACS patients particularly those with non-diagnostic ECG’s 1, 24, 25 but these tests are not available routinely in all emergency departments and not in the pre-hospital setting. Current markers of myocardial necrosis, though highly sensitive and

Conclusion

Despite addition of QRST variables to the 12-lead ECG (ST-elevation), the BSM is superior in predicting acute MI prehospital and thus adds significantly to the diagnosis and management of ACS. Because rapid diagnosis and treatment is the cornerstone for patients both with STEMI and NSTEMI, electrocardiographic methods such as body surface mapping which detect myocardial injury early are more useful for guiding the appropriate early use of treatment at first presentation at a time when the

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This study was supported by research fellowships from the Research and Development of the Northern Ireland Health and Social services Agency and the Frances and Augustus Newman Foundation.

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