EASI ECG Monitoring - Final

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Centre for Clinical Nursing Research

Deakin University Epworth Hospital

EASI ECG Monitoring _Final
Author: Bernice Redley
2
Table of Contents

What is EASI ECG Monitoring? ................................................................................3
Advantages of the EASI ECG monitoring system ...................................................4
Disadvantages of the EASI ECG monitoring System ..............................................4
Comparisons between the EASI and Mason-Likar 12 lead ECG systems ................5
Summary of the Research ...........................................................................................6
Methods..............................................................................................................6
Detection of acute ischaemia and Myocardial Infarction (MI) .............................6
Lead amplitudes .................................................................................................7
Conduction and rhythm disturbances ..................................................................7
Misdiagnosis ......................................................................................................7
Limitations .............................................................................................................8
Summary ................................................................................................................8
APPENDIX 1. Summary Table by Author ..............................................................9
APPENDIX 2. Summary Table by Parameter ....................................................... 13
References ............................................................................................................ 19

Centre for Clinical Nursing Research
Deakin University Epworth Hospital

3
What is EASI ECG Monitoring?
EASI is a method of continuous electrocardiogram (ECG) monitoring that is an
alternative to both the commonly used 5-electrode lead bedside monitoring system
and the traditional 10-electrode Mason-Likar 12lead ECG system. The EASI lead
configuration enables continuous 12 lead ECG ambulatory monitoring using only 5
electrodes. The EASI 12 lead ECG is derived from this reduced lead set using a
method described by Dower et al. [1-3].
The EASI 12-lead ECG is derived from a set of 5 leads; 4 recording electrodes and
one grounding electrode. The placement of these leads is as follows [4].
E: Lower extreme of the sternum
A: Left mid-axillary line, same transverse line as E
S: Sternal manubrium
I: Right mid-axillary line, same transverse line as E
G: Fifth electrode is the ground and can be placed anywhere on the torso
Diagram of EASI electrode placement

[4 p. 180]

4
Advantages of the EASI ECG monitoring system
Easy to apply. The EASI is a 5 electrode system that provides a 12-lead ECG,
making it easier to rapidly and accurately apply the leads in stressful situations [4].
Time saving for staff. As a continuous 12-lead ECG is produced, there is no need
to perform traditional intermittent 12-lead ECGs.
Continuous 12-lead ECG. The reduced set of leads provides continuous 12-lead
ECG monitoring as opposed to a snapshot 10-15 second view ECG with the
traditional ECG [5].
Better patient comfort. The reduced set of EASI leads is less bulky than a 10-
electrode Mason-Likar system, improving patient comfort, simplifying application
and maintenance for continuous monitoring [5].
Less waveform interference. With less leads, the EASI system is less susceptible
patient movement, signal interference or myeloelectric noise making it more
suitable and sensitive (than the 10 electrode system) for continuous ambulatory
ECG monitoring [6-8].
Better serial comparisons. EASI derived ECGs have better reproducibility for serial
comparisons [6, 8, 9].
More leads viewed continuously. EASI provides a continuous 12-lead ECG
allowing detection of transient myocardial ischaemia across multiple leads, while
the more common 5-lead ambulatory monitoring system does not allow monitoring
of all the precordial leads at the same time (usually lead II and V1 only)[5, 10-12].

Disadvantages of the EASI ECG monitoring System
Unfamiliar to staff. The EASI system is unfamiliar to clinicians so training in this
system may be required [13]
Differs to traditional method. Some leads from the EASI derived ECG have been
found to differ slightly to the standard ECG, requiring consideration during
interpretation. These differences are outlined below.
Placement error. Lead placement error may lead to discrepancies [4].
Less sensitive in detecting some conditions. Due to lower amplitudes in some leads,
it is difficult to detect chamber enlargement (atrial and ventricular hypertrophy )
with EASI ECG [7, 12], though similar problems also exist with the standard ECG.

5
Comparisons between the EASI and Mason-Likar 12 lead ECG
systems
Duration and amplitude of P, QRS, ST and T waves may differ between the EASI
derived and standard ECG systems [5, 7, 9, 14], with the EASI system
demonstrating less amplitude. It is important that this is considered during analysis
and serial comparisons are made using the same system.
Frontal plane transition zone at V2-V3 in EASI and V3-V4 in traditional [7].
The correlation between EASI ECG and the standard ECG complex interpretations
reached less than 90% agreement in some leads (particularly III, aVL, aVF, V4 and
V5) [9].
High levels of correlation have been found between the EASI and the standard
ECG complexes in leads I, aVR, V1, V2, V3, and V6 [9].
Greater than 90% agreement for detection of small (100 V) ST segment changes
indicating acute ischaemia [12, 13]
Greater than 90% agreement for detection of prior myocardial infarction (Q wave,
isolated ST-T) [9, 12, 13].
Similar rates of false diagnosis or misinterpretation of ECGs by clinicians with both
systems [12, 13]
100% agreement for rhythm identification [7, 12].
95-100% agreement for conduction problems (Bundle branch blocks, fascicular
blocks) [7, 12].
Differences in axis of up to 30 degrees between the two systems [7, 12].

6
Summary of the Research
Several studies have compared derived EASI 12-lead ECGs with the standard Mason-
Likar 12 lead ECG. Overall the two systems are similar for many of the parameters
examined, but some differences also exist. A summary of these studies is provided
below.
Methods
The strongest study design simultaneously collected the EASI derived and standard 12
lead ECGs continuously across a large population of subjects (540 patients) from
acute clinical areas (Emergency and cardiac catheter), then used a computer analysis
program to compare the recordings [12]. The authors then used a clinical expert to
examine the accuracy of the ECG interpretations in collaboration with clinical data
such as cardiac enzymes, echocardiography, patient history and clinical examination.
Use of computer analysis and simultaneous data collection were strengths as slightly
greater variations within and between EASI and standard ECG recordings have been
associated with human interpretations [7]; or ECGs that were not collected
simultaneously [4, 14]. Variations have also been noted between studies that used data
from healthy subjects in laboratory settings [4, 6] and those conducted in real clinical
circumstances with patients with variable diagnoses requiring cardiac monitoring [7,
9, 12-14]. Studies using patient population provide more useful clinically relevant
information. Few studies incorporated clinical findings to confirm the diagnosis
derived from the ECG [12, 14].
Detection of acute ischaemia and Myocardial Infarction (MI)
The rate of agreement between EASI ECG and the standard 12-lead ECG for the
detection of acute ischaemia was high in the majority of reviewed studies [9, 11-16].
Some ECG differences were detected between different types of ischemia. Both
inflation induced ischaemia during cardiac catheterisation and spontaneous ischaemic
events have been examined.
Rautaharju et al. [14] reported 85% agreement between EASI and standard ECGs in
the detection of inflation induced ischaemia during cardiac catheterisation. These
authors used 100 V (which is less than usually considered clinically significant) as
the ST segment threshold. The use of independent electro-cardiographers reading the
ECGs may have contributed to the lower agreement for ischaemic changes in this
study. Studies that used computer program analysis reported much higher agreement
(>99%) between EASI derived and standard ECGs for the detection of ischaemia [12,
13] than studies that used clinical experts with or without computer assistance [7, 14].
Drew et al. [12] reported the EASI system accurately detected 93% of acute transient
myocardial ischaemic events, while the leads routinely used for bedside monitoring
(Leads II and V1) detected only 42%. In this study, discrepancies between the EASI
and standards ECG were found in 17 of 238 ST events. Review by an expert clinician
revealed the EASI system was less sensitive in detecting low voltage ST segment
changes. None of these 17 discrepancy events were associated with chest pain, none
involved large changes (>200 V) and none involved the need for clinical
intervention. These findings suggest that these differences were not clinically
significant.

7
Similar findings were experienced in the detection of ECG changes suggesting old
MI. Comparisons of EASI derived and standard ECGs revealed 95% agreement for
anterior and 92% agreement for inferior Q-wave MI in a large study sample [12]. The
EASI system had greater sensitivity than the standard system in detecting these
changes (59% vs 55%) but slightly less specificity (95% vs 99%).
Lead amplitudes
Differences in the amplitudes of several leads have been consistent findings in studies
comparing the EASI derived ECG with the standard 12-lead. Most commonly
discrepancies were detected in V3-V4 [4, 7, 9, 13] or isolated ST-T segment changes
of low amplitude [12, 14]. Only minor differences of 14-30 degrees in frontal plane
axis were detected [7, 12]. These small differences are not usually clinically
significant.
Low amplitudes were also associated with low sensitivity in detecting chamber
enlargements using the both methods of ECG acquisition. These difficulties were
similar with both the EASI derived and standard ECG, except in the cases of left
ventricular hypertrophy where the EASI derived ECG had higher specificity than the
standard ECG [12].
EASI derived ECG have shown lower amplitude Q waves in V6, smaller amplitude R
wave in V1, V2 and V4, and less ST amplitude in V4 and V5 [14]. Horacek [9]
compared ECGs collected from clinical settings revealing less than a 90% correlation
between EASI derived and standard ECG in leads III, aVL for normal and post MI
ECGs, with Q waves, non-Q waves and history of VT.
Conduction and rhythm disturbances
Comparisons between the EASI derived and standard ECGs consistently demonstrate
high levels of agreement (95%-100%) in the detection of conduction problems such as
pre-excitation patterns, bundle branch blocks, fascicular blocks [7, 12, 16] and rhythm
disturbances such as VT and SVT [9, 12, 16]. Minor deviations of 0-2ms in the
cardiac intervals for the PR, QRS, QT and QT
C
have been detected. While the
observed difference of 1ms in QRS was statistically significant it was not clinically
significant [12]. Again the clinical significance of these findings must be questioned.
Misdiagnosis
Similar rates of misdiagnosis have been reported for the two types of ECGs with the
majority related to old MI changes. Drew et al. [7] reported two false positives and
four false negative in EASI derived ECGs from patients with prior myocardial
ischaemia, while six false negatives were reported from the standard ECGs from
patients with a prior MI. Similarly Rautaharju [14] reported 10% of ECGs had
significant differences between the EASI derived and standard method with 3.4%
involving Q-wave MI or ST changes in lead II. However, in this study none of the
new changes were identified as old, and none of the Q-wave MIs were missed using
the EASI derived ECG for interpretation. Drew [13] found only one false negative
from 207 derived ECGs and in her 1999 study, two ECGs were misdiagnosed using
both the EASI derived and standard ECG methods.

8
Limitations
There are several variables to consider that pose limitations to these study findings.
The clinical significance of these limitations must be considered when deciding about
the appropriateness of the EASI methods for continuous ECG monitoring.
Various computer programs (Phillips, Marquette, Montana) and equipment were used
to collect ECG data across the studies. The types of electrode, the method used for
placement of ECG electrodes, the expertise of the person applying the electrodes and
the timing of data collected are all independent variables not addressed in many
studies. It has been established that slight variations in the placement of the
electrodes may increase error when making ECG comparisons [8]. The influence of
these factors on the quality of the recordings and subsequent comparisons is unknown.
The clinical conditions under which data were collected also varied. Laboratory
conditions and healthy subjects differed to clinical conditions and ill patients. Finally,
few studies confirmed the ECG diagnosis using other clinical diagnostic criteria,
suggesting that the error in patient diagnosis may have been higher with both methods
of ECG data acquisition.
Summary
EASI derived ECGs are comparable to the standard ECG for the diagnosis of wide
complex tachycardias [9, 12, 16] and myocardial ischaemia [9, 11-16]. The
reproducibility of the EASI derived ECG makes it more useful in serial comparisons
over time. The EASI derived system for continuous ambulatory monitoring has
advantages over the standard 5-lead monitoring systems and continuous 12 lead
monitoring systems with the benefits of both. The EASI system allows continuous 12
lead monitoring instead of the limited II and V1 capability of the traditional 5-
electrode method. The EASI system is less susceptible to noise and interference than
the bulky 10-electrode 12-lead system. These benefits enable significant
improvements in the detection of spontaneous ischemia during continuous ambulatory
monitoring.
While there are differences between ECG data collected using the EASI derived and
standard 12-lead ECG methods, the clinical significance of these changes is
questionable. The lower amplitude of some leads in the EASI derived ECG may be
overcome by adjusting the thresholds used to determine clinical significance and
training staff in interpretation. Similar limitations in terms of clinical diagnosis and
variation in interpretation by clinicians affect both methods of 12-lead ECG
collection.

9
APPENDIX 1. Summary Table by Author
AUTHOR TITLE STUDY DESIGN Number of
Comparisons
FINDINGS
Drew [12] Accuracy of the
EASI 12 lead ECG
compared to the
standard 12 lead
ECG for
diagnosing cardiac
abnormalities
Two methods of
continuous ECG
monitoring
simultaneously from
ED admission or from
catheter based
intervention. Computer
analysis program used
to compare ECGs.
Disagreements
examined and diagnosis
made by specialist and
clinical and echo
criteria.
All ED patients over 2
year period. 540
patients enrolled, 426
with acute coronary
syndromes. Some not
diagnosed with acute
ischaemia and ruled
out.
EASI and standard ECG compared for cardiac
rhythm, cardiac intervals, QRS axis, chamber
enlargement-hypertrophy, BBB and fascicular
blocks and prior MI. 100% agreement on
rhythm identification 84-89% agreement on
chamber enlargement, 997% agreement on R &
L BBB, 97-98% agreement on fascicular
blocks, and 92-95% agreement on prior MI.
Drew [13] Comparison of
standard and
derived 12 lead
ECG for diagnosis
of coronary
angioplasty
induced myocardial
ischaemia
Compared standard and
derived continuous
ECG
Threshold of >1 lead of
>100 V, 80 ms post j
point used to define
ischaemia
207 patients with timed
measurements (derived
analysed every 20 secs,
standard continuously),
151 during procedure
Agreement regarding ischaemia in 150 of 151
patients with both methods.
Different time ratio for measurement may have
led to error in one care but may also have led to
agreement in others.

10

Comparisons
FINDINGS
Drew [16] Comparison of a
new reduced lead
set ECG with
standard ECG for
diagnosing cardiac
arrhythmias and
myocardial
ischaemia
Compared EASI with
Interpolated standard
limb leads and V1 and
V5
649 patients (CP in ED
= 509 and Tachycardia
in EP Lab = 140).
Identical for BBB, LAH, RVH, prior MI. 99.2%
agreement of ischaemia in the ED. Appears to
have higher agreement than EASI model.
Applied to patients by expert.
Drew [7] Comparison of a
vectorcardiography
derived 12-lead
ECG with the
conventional ECG
during wide QRS
complex
tachycardia, and its
potential
application for
continuous bedside
monitoring.
Compare during EP
studies. Simultaneous
recordings and two
expert investigators
independently
compared using
standard criteria
including QRS pattern,
sequence, width,
morphology and
voltages.
64 episodes of wide
QRS complex
tachycardia in 49
patients
9 pts had LVH, only 6 with evidence on derived
ECG. 6 pts with WPW identical delta wave
morphology, 45 pts with prior MI 92%
agreement Lower voltages present in V3 and
V4 of derived ECG. QRS morphology
dissimilar in 35% of pts in V3 and 51% in V4.
(early transition of the RV rS to the LV qR in
derived). Transitional zone generally appeared
in V3 or V4 or the ECG appeared in V2-V3 of
the derived ECG. QRS voltage less in the
precordial leads of the derived ECG affecting
Dx of LVH. Derived ECG had false positive in
2 cases prior MI in young person with no
history, 2 false negative of inferior MI.

11

Comparisons
FINDINGS
Horacek [9] Diagnostic
accuracy of derived
compared to
standard 12-lead
ECG
290 normal subjects
and 497 with prior MI
(36 with non Q, 282 Q-
wave, 179 with history
of VT)
V6 best derived lead with highest agreement
closely followed by V1 and V2. V3-V5 not
reproduced well in the MI subgroups as they are
in normal subjects. Worse as the structural
damage to the myocardium increases the
diagnostic performance markedly increases.
Rautaharju [14] Comparability of
12-lead ECGs
derived from EASI
leads with standard
12-lead ECG in
classification of
AMI and old MI
Read by two
independent expert
ECG readers and
analysis program.
ECGs printed side by
side in random order.
Readers blinded.
Coding forms used to
classify the ECGs
40 patients recorded
prior to and at peak
inflation during PCTA,
382 with old MI ECGs
472 with non MI.
No significant differences between ECG
readers in acute ischaemia. Suggest need for
modified prior MI criteria and ST thresholds for
AMI specific for EASI. Significant differences
within readers and the program
10% with clinically significant differences,
3.4% classed as q-MI and 11 as isolated ST-T
evolution
Sejersten [4] The relative
accuracies of ECG
precordial lead
waveforms derived
from EASI leads
and those acquired
from paramedic
applied standard
leads
Compared waveforms
from Gold Standard
ECG with paramedic
applied and EASI
derived ECGs. First
acquired from
paramedic the two
simultaneously by
technician. Difference
threshold of 10 V.
20 paramedics
collected data on each
other. Paired to act as
experimental technician
and study participant. 3
ECGs on each. 720
comparisons of
precordial leads.
EASI and paramedic waveforms were equally
accurate in 47%, paramedic more accurate in
31% and EASI in 22% when compared to Gold
Standard. Significant difference in paramedic
placement of leads mean 30mm misplacement.
Review of discrepancies revealed that EASI
more accurate for ST changes in V4 & V5. and
T in V6. Paramedic more accurate Q amplitude
in V6, R amplitude in V1, V2, V4 and ST
deviation in V1

12

Comparisons
FINDINGS
Welinder [6] Comparison of
signal quality
between EASI and
Mason-Likar 12-
Lead ECG during
physical activity
Compared baseline
wander and myoelectric
noise amplitudes of
EASI and traditional.
Simultaneous
recordings. Inter-rater
not addressed. Range
thresholds (?valid)
established for noise.
20 healthy volunteers
with simultaneous
measurements
EASI winner significantly more often in
treadmill and supine to L in precordial.
Traditional winner significantly more often in
Supine to R limb and precordial leads

13

APPENDIX 2. Summary Table by Parameter
Parameter
Examined
Drew (1992) Rautaharju,
(2002)
Welinder,
(2004)
Drew (1997) Sejersten,
(2003)
Drew (1999) Horacek
(2000)
Acute
Ischaemia
Inflation
induced
ischaemia using
100 V as
threshold 85%
agreement,
27/40 positive
and 7/40
negative
3.4%
differences in
New Q MI
6.1% difference
in ST-T
segments
99% agreement
in Cx artery
peak ST in V3
for derived and
V3 or V4 for
standard
138 patients with 238 ST
events. 26 had acute ST
elevation patterns. 63
angioplasty induced
ischaemia and 150
spontaneous ischaemia. 89%
agreement, the (14 standard
and 3 EASI) events with
discrepancy were not
associated with chest pain
and none involved large
changes (>200 V). EASI
detected 93% of ischaemic
events while the leads
routinely used for bedside
monitoring (II and V1)
detected 42%.
EASI low amplitude ST
changes ? clinical
significance, none resulted
in clinical interventions or
poor outcomes..

14

Parameter
Examined
(2002)
Welinder,
(2004)
Drew (1997) Sejersten, (2003) Drew (1999) Horacek
(2000)
Prior MI (Q-
wave)
92%
agreement
85% agreement
with computer,
57% agreement
for isolated ST-
T in old MI
Agreement 95% for
anterior and 92% for
inferior. In prior
inferior MI, EASI had
greater sensitivity than
standard (59% vs 55%)
but lower specificity
(95% vs 99%)
Correlations
between
EASI and
standard less
than 90% in
leads II, III,
aVL, aVF,
V4 and V5
for q wave
MI.
Normal ECG 80% agreement
with computer
98%
agreement
Similar deviations
between paramedic
and EASI.

Lead
differences
Transition
zone V2-V3
in EASI and
V3-V4 in
traditional
EASI-Gold
compared with
Paramedic-Gold
revealed significant
differences; inc Q
amp in V6, smaller
R amp in V1, V2
and V4. Less ST in
V1, inc ST in V4
and V5 and inc T
amp in V6
Correlations
less than
90% in III,
aVL for
normal and
post MI
patients with
no Q, Q and
VT

15

Parameter
Examined
(2002)
Welinder,
(2004)
Drew (1997) Sejersten, (2003) Drew (1999) Horacek
(2000)
Axis Frontal plane
Axis in
Precordial
leads only
Difference 19
deg. 95% CI
of 14-24 deg.
Mean differences in P
wave and QRS and T-
wave axis were 21
degrees, t-wave axis
differed more between
the two ECG types
mean 30 degrees.

Conduction 100%
agreement on
BBB and
fascicular
blocks
Agreement for BBB
and fascicular blocks
ranged from 95-99%.
EASI closer to expert
in RBBB.

False
diagnosis
EASI False
positive in 2
and false
negative in 4
with prior MI
and traditional
False negative
in 6 pts with
prior MI
10% clinically
significant
differences B/W
EASI and
traditional 3.4%
q-MI and 11 ST
changes. None
of normal
classed as old
MI and none of
Q-wave missed.
No false
positives and
1 false
negative with
derived ECG
2 misdiagnosed by
both the EASI and
standard 12 lead due to
low amplitude p
waves.

16

Parameter
Examined
(2002)
Welinder,
(2004)
(2003)
Drew (1999) Horacek
(2000)
Cardiac
rhythm
100% agreement
in diagnosis and
misdiagnosis for
Wide complex
tachycardia
Difference in axis
17 deg with CI
95% 12-22 deg.
SVT Vs VT
criteria agreement
in V1, V2, V6
100% agreement Correlations
less than
90% for
leads II, III,
aVL, aVF,
V3, V4, V5
between
EASI and
patients with
VT.
Chamber
enlargement
Lower V3-V4
voltages, leading
to inability to
detect LVH in 1/3
of patients with
wide complex
tachycardia 39%
in V3 and 55% in
V4
177 evaluated for atrial
enlargement using Echo.
RAH in 17 patients and
LAH in 46 patients, RVH
in 15 and LVH in 68.
Agreement was between
84-98%. Both methods
had low sensitivity but
high specificity. For LVH
EASI had higher
specificity than standard
(98% vs 88% respectively)
Both methods insensitive
to chamber enlargement.

17

Parameter
Examined
(2002)
Welinder,
(2004)
(2003)
Drew (1999) Horacek
(2000)
Others Ventricular pre-
excitation
patterns 100%
agreement
Cardiac intervals for PR,
QRS, QT and QTC varied
by 0-2ms. The observed
difference of 1ms in QRS
was statistically significant
but not clinically
significant.

Artifact Less muscle
artifact after
DCCR and on
arm movement.
Similar
baseline
wander,
EASI less
noise for
treadmill
and supine
to L.

No MI 80%
agreement

18

Other Variables to consider:
Parameter
Examined
(2002)
Welinder,
(2004)
(2003)
Drew (1999) Horacek
(2000)
Electrodes
used
Not identified Not identified Identified Not identified No specified
Method of
deriving
traditional
ECG
(machine
used)
Marquette
computer
program.
Simultaneous
measurement
Standard
measure
ECGs
collected in
time sequence
Identified
Simultaneou
s collection
of ECGs
Described
ECGs
collected
simultaneousl
y during
procedure
Identified
Three
independent
recordings on
same subject.
Identified
Simultaneous monitoring
Simultaneou
s recording
supine for 15
seconds
Application
of electrodes
by whom/
position
In the ED and
PCTA procedure
Not identified
Method of
application
Not identified,
position id.
Identified I V4 used in
study and
EASI for
latter
Paramedic
and expert
(Traditional
and EASI)
Position
described
Not identified, presumed
to be in the ED/ cath lab
Nor
specified.
Setting ED & EP studies, PCTA, AMI
pts with
enzyme ?
from location
suggests
clinical
situations.
Laboratory
Healthy
participants.
PCTA. Experimental
conditions at
conference
Healthy
participants.
ED and catheter lab Not specified
but presumed
to be a
clinical
environment
and clinical
diagnostic
criteria used.

19
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