Acute Detection of ST-Elevation Myocardial Infarction Missed on Standard 12-Lead ECG With a Novel 80-Lead Real-Time Digital Body Surface Map: Primary Results From the Multicenter OCCULT MI Trial

Received 3 April 2009; received in revised form 16 June 2009; accepted 24 June 2009. published online 22 September 2009.

Refers to article:

The 80-Lead ECG: More Expensive NSTEMI or Occult STEMI , 22 September 2009
Judd E. Hollander
Annals of Emergency Medicine
December 2009 (Vol. 54, Issue 6, Pages 789-790)
Full Text | Full-Text PDF (106 KB)

Study objective

Although 80-lead ECG body surface mapping is more sensitive for ST-elevation myocardial infarction (STEMI) than the 12-lead ECG, its clinical utility in chest pain in the emergency department (ED) has not been studied. We sought to determine the prevalence, clinical care patterns, and clinical outcomes of patients with STEMI identified on 80-lead but not on 12-lead (80-lead-only STEMI).

Methods

The Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction trial was a multicenter prospective observational study of moderate- to high-risk chest pain patients presenting to the ED. Patients received simultaneous 12-lead and 80-lead ECGs as part of their initial evaluation and were treated according to the standard of care, with clinicians blinded to the 80-lead results. The primary outcome of the trial was door-to-sheath time in patients with 80-lead-only STEMI versus patients with STEMI identified by 12-lead alone (12-lead STEMI). Secondary outcomes included angiographic and clinical outcomes at 30 days.

Results

One thousand eight hundred thirty patients were evaluated, 91 had a discharge diagnosis of 12-lead STEMI, and 25 patients met criteria for 80-lead-only STEMI. Eighty-four of the 91 12-lead STEMI patients underwent cardiac catheterization, with a median door-to-sheath time of 54 minutes, versus 14 of the 25 80-lead-only STEMI patients, with a door-to-sheath time of 1,002 minutes (estimated treatment difference in median=881; 95% confidence interval 181 to 1,079 minutes). Clinical outcomes and revascularization rates, however, were similar between 80-lead-only STEMI and 12-lead STEMI patients.

Conclusion

The 80-lead ECG provides an incremental 27.5% increase in STEMI detection versus the 12-lead. Patients with 80-lead-only STEMI have adverse outcomes similar to those of 12-lead STEMI patients but are treated with delayed or conservative invasive strategies.

a Wake Forest University, Winston-Salem, NC

b Wayne State University, Detroit, MI

c Beth Israel Deaconess Medical Center, Boston, MA

d University of California Davis, Sacramento, CA

e Cleveland Clinic Foundation, Cleveland, OH

f University of Cincinnati, Cincinnati, OH

g New York Presbyterian Hospital, New York, NY

h Duke University Medical Center, Durham, NC

i University of North Carolina, Chapel Hill, NC

j Tufts University Medical Center, Boston, MA

k Boston University, Boston, MA

Address for correspondence: James Hoekstra, MD, Department of Emergency Medicine, Wake Forest University Health Sciences, Medical Center Blvd, Winston-Salem, NC 27023; 336-716-4626, fax 336-716-5438

Provide feedback on this article at the journal's Web site, www.annemergmed.com.

Supervising editor: Judd E. Hollander, MD

Author contributions: JWH and MK were the co–principal investigators. JWH was responsible for primary article preparation. JWH, JG, MAK, and MK were responsible for study design. BJO, CL, DD, GJF, and AC were the site principal investigators. BJO, CL, DD, and JG enrolled patients. BJO, JG, and MAK were members of the steering committee. BJO, YP, CD, DD, WFP, GJF, CMG, DP, MAK, and MK were responsible for article editorial assistance. YP, CMG, and DP conducted angiographic analysis. CL, AC, CBC, and MK conducted ECG core laboratory analysis. JWH, JM, and MK conducted data analysis. JM conducted statistical analysis. JWH takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflicts of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The trial was funded by Heartscape, Inc., the makers of the 80-lead technology. The data were collated and analyzed by an independent contract research organization (CCT, Inc.). The steering committee had full control of the study design, and CCT had complete control of the data, without sponsor influence. The authors do not hold stock in the company, although a few have served as consultants to the company in trial design and product development. The authors have had complete access to and control of the data and complete freedom with data analysis and results presentation in this article, without influence from Heartscape.

Reprints not available from the authors.

Publication date: Available online September 19, 2009.

PII: S0196-0644(09)01223-2

doi:10.1016/j.annemergmed.2009.06.525

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