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7, 8
The use of the additional leads might not only confirm
the presence of AMI, but also provide a more accurate
reflection of the true extent of myocardial damage.
May help clinicians identify the occluded vessel before
PCI, which can help in stratifying risk and planning the
procedure, and in identify reocclusion after coronary
interventions
The 15-lead ECG can routinely be used in patients with
ischemic-like chest pain.
PIC
O
For a patient with signs and symptoms of an Acute
Myocardial Infarction (AMI), will the use of additional
posterior chest leads as compared to a standard 12 lead
improve the efficacy of diagnosing posterior wall AMIs?
Problem: missing diagnoses, or delaying the diagnosis
of posterior wall AMIs
Intervention: use of posterior chest leads
Comparison: 12 lead EKG
Outcome: improving diagnosis of posterior wall acute
myocardial infarction
Significance of the Problem1, 3,
4
Posterior myocardial infarction is commonly missed
because it is not usually visible in the standard leads
ST depression is absent in anterior leads of some
patients who had ST elevation in posterior leads;
slowing diagnosis and implementation of thrombolytic
therapy
In the US alone, data shows that greater than 200,000
patients annually may have a coronary occlusion that is
missed by the standard 12-lead ECG
(Zalenski et al., 1997)
(Khaw, 1999).
Literature
Review 3, 8
ST segment elevation is not seen on the standard 12
lead ECG in up to 50% of patients with posterior or
circumflex-related infarction
One study found 24% of participants had posterior
injury that was not detected in the 12 lead. Adding 3
posterior leads found 17% more posterior injury
patterns than the 12-lead.
Literature Review
Cont. 8
In 345 patients with AMI, an additional 29 had ST
elevation on nonstandard leads with when the 12 lead
ECG was negative for ST elevation
Another study found that the sensitivity for the detection
of left circumflex artery occlusion improved by twofold
with the posterior leads. Additionally, 11% of patients
with ST elevation in the posterior lead had no elevation
or depression in any other lead.
Quality of the
Research
Strengths Weaknesses
o Mix of qualitative and o Lack of randomized
quantitative studies control trials
o Comparison of o Small sample sizes
results from many o Research conducted
studies within one hospital
o Not limited to specific o
Research conducted
geographics, type of outside of the U.S.
patient, unit, o
Some research
protocols, and found that 15 lead,
treatments. as compared to 12
lead, did not alter
diagnosis, therapy, or
AACN Levels of
Evidence
Level Description
B Well-designed controlled studies, both randomized and nonrandomized, with results that
consistently support a specific action, intervention, or treatment
1.
Level A
Somers, M., Brady, W., Bateman, D.,
1.
Level B
Aqel, R. A., Hage, F. G., Ellipeddi, P.,
Mattu, A., & Perron, A. (2003). A Blackmon, L., McElderry, H. T., Neal Kay,
G., & Plumb, V. (2009).
2. McElderry, H. T., Neal Kay, G., & Plumb, V.
1.
Level D
Krishnaswamy, A., Lincoff, M., & Menon,
3.
(2009).
Katoh, T., Veno, A., Tanaka, K., Suto, J., &
Wei, D. (2011).
V. (2009) 4. Khaw, K. Moreyra, A. Tannenbaum, A.
Holser, M. Brewer, J. Agarwal, B. (1999).
Improved detection of posterior myocardial
wall ischemia with the 15-lead
electrocardiogram. American Heart
Journal, 138(5).
5. Rosengarten, P., Kelly, A., & Dixon, D.
(2001)
6. Wung, Shu-Fen. (2007)
7. Wahab, S., Islam, A., Haque, M., Hossain,
S., Kamal, M., Ali, S., & Mahabub, S.
(2012).
Clinical Guideline
(Protocol)
Individuals presenting with chest pain and other signs and
symptoms of a suspected MI should have a 15-lead
ECG in place of the usual 12-lead ECG protocol.
Implementatio
n Hospital wide statement to increase awareness of