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Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the Myocardial Infarction Triage and Intervention (MITI) project

Peter J. Kudenchuk, MD, FACC^a*, Charles Maynard, PhD^a*, Leonard A. Cobb, MD, FACC^a*, Mark Wirkus^a*, Jenny S. Martin, RN^a*, J. Ward Kennedy, MD, FACC^a*, W. Douglas Weaver, MD, FACC^a* for the MITI Investigators

^a Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
^* Henry Ford Hospital, Detroit, Michigan, USA

View larger version (63K): [in a new window]   Figure 1 Serial changes are depicted between the prehospital (left) and initial hospital (right) ECG in a patient with chest pain. The prehospital ECG depicts acute ST segment elevation in leads I, aVL and V4 to V6. On the initial hospital ECG, obtained 35 min after the prehospital tracing, ST segment elevation is more difficult to appreciate in leads I and aVL and deceptively masquerades as an apparent widening of the QRS complex in leads V4 to V6.

View larger version (35K): [in a new window]   Figure 2 Serial changes are depicted between the prehospital (left) and initial hospital (right) ECG in a patient with chest pain. The prehospital ECG shows ST segment elevation in leads V1 to V4, with ST segment sagging and T wave inversion in leads II, III and aVF. On the initial hospital ECG, obtained 23 min after the prehospital tracing, ST segment elevation has resolved and ST-T wave abnormalities are less pronounced in the inferior leads, whereas ST segment sagging is now evident in leads V4 and V5.

View larger version (49K): [in a new window]   Figure 3 Serial changes are depicted between the prehospital (left) and initial hospital (right) ECG in a patient with chest pain. The prehospital ECG shows subtle ST-T wave abnormalities that are nondiagnostic of myocardial ischemia. On the initial hospital ECG, obtained 36 min after the prehospital tracing, ST segment elevation is now evident in leads I, aVL and V2, with ST segment depression and T wave inversion in the inferior leads (II, III and aVF).

View larger version (29K): [in a new window]   Figure 4 The sensitivity, specificity and positive predictive value (PPV) of ST segment elevation or any ST segment T or Q wave or LBBB abnormality for acute myocardial ischemia or infarction are compared between the initial hospital ECG (open bars) and the initial ECG plus serial (prehospital and initial hospital) changes (solid bars). As compared with the initial hospital ECG alone, added consideration of serial changes between the prehospital and initial hospital ECG in these variables significantly improved the sensitivity for acute myocardial ischemia or infarction, at the expense of a reduction in specificity and positive predictive value. Data are shown for 1,254 patients with and 1,411 patients without acute myocardial ischemia or infarction.