15-Lead ECG
Nicole Gamblin, Alissa Graft, Holly Krause,
Faith Metzinger, Sam Parmenter, Jenna
Quill, Molly Reasner, Brittany Rowe, Allison
Silver, Jessie Tucek
Objectives8
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To determine the effect of utilizing additional leads
with the conventional 12 lead ECG in patients
presenting with suspected Posterior Myocardial
Infarction (PMI)
To determine the utility of 15-lead ECG in the early
diagnosis of acute posterior myocardial infarction
Background7
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Acute posterior myocardial infarctions (PMI) and right
ventricular myocardial infarctions are likely to be
underdiagnosed; the standard 12-lead ECG does not
assess these areas directly
Consequently, this underdiagnosis often leads to delay
of early intervention and undertreatment
Leads V7, V8, and V9 view the posterior wall of the left
ventricle, while leads V3R, V4R, and V5R reflect the
status of the right ventricle and the posterior left
ventricle
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Background 6, 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.
PICO
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?
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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
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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 Review3, 8
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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
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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
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Strengths
o Mix of qualitative and
quantitative studies
o Comparison of
results from many
studies
o Not limited to specific
geographics, type of
patient, unit,
protocols, and
treatments.
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Weaknesses
o Lack of randomized
control trials
o Small sample sizes
o Research conducted
within one hospital
Research conducted
outside of the U.S.
Some research
found that 15 lead,
as compared to 12
lead, did not alter
diagnosis, therapy,
o
o
AACN Levels of Evidence
Level
Description
A
Meta-analysis of multiple controlled studies or metasynthesis of qualitative
studies with results that consistently support a specific action, intervention,
or treatment
B
Well-designed controlled studies, both randomized and nonrandomized, with results that
consistently support a specific action, intervention, or treatment
C
Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or
randomized controlled trials with inconsistent results
D
Peer-reviewed professional organizational standards, with clinical studies to support
recommendations
E
Theory-based evidence from expert opinion or multiple case reports
M
Manufacturer’s recommendation only
Levels of Evidence
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1.
•
1.
Level A
Somers, M., Brady, W., Bateman, D.,
Mattu, A., & Perron, A. (2003). A
Level D
Krishnaswamy, A., Lincoff, M., & Menon,
V. (2009)
•
Level B
1.
Aqel, R. A., Hage, F. G., Ellipeddi, P.,
Blackmon, L., McElderry, H. T., Neal Kay,
G., & Plumb, V. (2009).
2.
McElderry, H. T., Neal Kay, G., & Plumb,
V. (2009).
3.
Katoh, T., Veno, A., Tanaka, K., Suto, J.,
& Wei, D. (2011).
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.
Implementation
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Hospital wide statement to increase awareness of
change in protocol and its significance
Education on placement and positioning of additional
leads
Education on reading and interpreting the additional
views from 15-Lead ECG
Considering updating and replacing current equipment if
indicated
Purchase of additional leads
Barriers to Implementation
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Additional time for placement of additional leads
Time to educate personnel on 15 lead ECG placement
Cost for new equipment for 15 lead ECG
Questions?
References
1.
Aqel, R. A., Hage, F. G., Ellipeddi, P., Blackmon, L., McElderry, H. T., Neal Kay, G., & Plumb, V. (2009).
Usefulness of three posterior chest leads for the detection of posterior wall acute myocardial infarction. The
American Journal of Cardiology, 160-163. doi:10.1016/j.amjcard.2008.09.008
2.
Katoh, T., Veno, A., Tanaka, K., Suto, J., & Wei, D. (2011). Clinical Significance of Synthesized Posterior/Right
Sided Chest Lead Electrocardiograms in Patients with Acute Chest Pain. Journal of Nippon Medical School
78(1), 22-29.
3.
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).
4.
Krishnaswamy, A., Lincoff, M., & Menon, V. (2009). Magnitude and consequences of missing the acute infarctrelated circumflex artery. American Heart Journal, 158(5), 706-712. doi: 10.1016/j.ahj.2009.08.024
5.
Rosengarten, P., Kelly, A., & Dixon, D. (2001). Does routine use of the 15-lead ecg improve the diagnosis of
acute myocardial infarction in patients with chest pain?. PubMed, 13(2), 190-193.
6.
Somers, M., Brady, W., Bateman, D., Mattu, A., & Perron, A. (2003). Additional electrocardiographic leads in the
ED chest pain patient: right ventricular and posterior leads. American Journal of Emergency Medicine, 21(7),
563-573.
7.
Wahab, S., Islam, A., Haque, M., Hossain, S., Kamal, M., Ali, S., & Mahabub, S. (2012). Comparative study
between 12 and 15 lead electrocardiograms for evaluation of acute posterior myocardial infarction.
Cardiovascular Journal, 4(2), 154-163. Retrieved October 16, 2012
8.
Wung, Shu-Fen. (2007). Discriminating Between Right Coronary Artery and Circumflex Artery Occlusion by Using a
Noninvasive 18-Lead Electrocardiogram. American Journal of Critical Care, 16(1), 63-71.