Time for a DIagnostic Paradigm Shift From ST-elevation/Non-ST-elevation to OCClUsion/Non-occLusion Myocardial infarcTion
Phase: NA
Conditions: Myocardial Infarction, Myocardial Ischemia, Acute Coronary Syndrome, Diagnosis, Morality
Sponsor: Başakşehir Çam & Sakura City Hospital

St u d y Title: Ti me f or a DI a g n ostic p ar a di g m s hift fr o m S T-elev ati o n/ n o n- S T-elev ati o n t o 
O C Cl Usi o n/ n o n- occ L usi o n my oc ar di al i nf arc Ti o n ? 
Acr o n y m:  DI F O C C U L T- 3 St u dy 
Iss ue date: 2 7 N o ve m ber 2 0 2 4 
Steeri n g C o m mittee:  
E mre K. Asla n ger, M D, Pr of. 
Healt h Scie nces U ni versit y 
Basa kse hir Pi ne a n d Sa k ura Cit y H os pital 
De part me nt of Car di ol o g y 
Ista n b ul, T ur ke y 
B urc u A g g ül, M D 
Basa kse hir Pi ne a n d Sa k ura Cit y H os pital 
De part me nt of Car di ol o g y 
Ista n b ul, T ur ke y 
Özle m Yıl dırı mt ür k, M D, Pr of 
Healt h Scie nces U ni versit y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Di visi o n of Car di ol o g y 
Ista n b ul, T ur ke y 
Ca n Y ücel Kara ba y, M D, Pr of 
Healt h Scie nces U ni versit y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Di visi o n of Car di ol o g y 
Ista n b ul, T ur ke y 
M uzaffer De ğerte ki n, M D, Pr of. 
Ista n b ul Atlas U ni versit y 
De part me nt of Car di ol o g y 
DI F O C C U L T- 3 St u d y 
Basa kse hir Pi ne a n d Sa k ura Cit y H os pital 
DI F O C C U L T- 3 St u d y 
Basa kse hir Pi ne a n d Sa k ura Cit y H os pital 
De part me nt of Car di ol o g y 
DI F O C C U L T- 3 St u d y 
De part me nt of Car di ol o g y 
Özle m Yıl dırı mt ür k, M D, Pr of 
DI F O C C U L T- 3 St u d y 
Özle m Yıl dırı mt ür k, M D, Pr of 
Healt h Scie nces U ni versit y 
DI F O C C U L T- 3 St u d y 
Healt h Scie nces U ni versit y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
DI F O C C U L T- 3 St u d y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Di visi o n of Car di ol o g y 
DI F O C C U L T- 3 St u d y 
Di visi o n of Car di ol o g y 
Ista n b ul, T ur ke y 
DI F O C C U L T- 3 St u d y 
Ista n b ul, T ur ke y 
Ca n Y ücel Kara ba y, M D, Pr of 
DI F O C C U L T- 3 St u d y 
Ca n Y ücel Kara ba y, M D, Pr of 
C o nfi d e nti al 
Özle m Yıl dırı mt ür k, M D, Pr of 
C o nfi d e nti al 
Özle m Yıl dırı mt ür k, M D, Pr of 
Healt h Scie nces U ni versit y 
C o nfi d e nti al 
Healt h Scie nces U ni versit y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
C o nfi d e nti al 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Pl e a s e d o n ot di stri b ut e
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Pl e a s e d o n ot di stri b ut e
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Ca n Y ücel Kara ba y, M D, Pr of 
Pl e a s e d o n ot di stri b ut e
Ca n Y ücel Kara ba y, M D, Pr of 
Pl e a s e d o n ot di stri b ut e
Healt h Scie nces U ni versit y 
Pl e a s e d o n ot di stri b ut e
Healt h Scie nces U ni versit y 
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Pl e a s e d o n ot di stri b ut e
Dr. Si ya mi Erse k T h oracic a n d Car di o vasc ular S ur ger y Trai ni n g a n d Researc h H os pital 
Di visi o n of Car di ol o g y 
Pl e a s e d o n ot di stri b ut e
Di visi o n of Car di ol o g y 
Ista n b ul, T ur ke y 
Pl e a s e d o n ot di stri b ut e
Ista n b ul, T ur ke y 

Ista n b ul, T ur ke y 
T ur kis h S ociet y of Car di ol o g y, T he C urre nt Presi de nt 
DI F O C C U L T- 3 St u d y 
C o nfi d e nti al 
Pl e a s e d o n ot di stri b ut e

A b bre vi ati o ns  
A C O, ac ute c or o nar y occl usi o n  
AI, artificial i ntelli ge nce 
E C G, electr ocar di o gra m 
L V E F, left ve ntric ular ejecti o n fracti o n
MI, m y ocar dial i nfarcti o n 
N S T E MI, n o n- S T-se g me nt ele vati o n m y ocar dial i nfarcti o n 
P CI, perc uta ne o us c or o nar y i nter ve nti o n 
S T E, S T-se g me nt ele vati o n 
S T E MI, S T-se g me nt ele vati o n m y ocar dial i nfarcti o n 
TI MI, T hr o m b ol ysis i n M y ocar dial I nfarcti o n St u d y 
U L N, u p per li mit of n or mal  
W M SI, wall m oti o n sc ore i n de x  
DI F O C C U L T- 3 St u d y 
-se g me nt ele vati o n m y ocar dial i nfarcti o n 
DI F O C C U L T- 3 St u d y 
-se g me nt ele vati o n m y ocar dial i nfarcti o n 
S T E MI, S T-se g me nt ele vati o n m y ocar dial i nfarcti o n 
DI F O C C U L T- 3 St u d y 
S T E MI, S T-se g me nt ele vati o n m y ocar dial i nfarcti o n 
TI MI, T hr o m b ol ysis i n M y ocar dial I nfarcti o n St u d y 
DI F O C C U L T- 3 St u d y 
TI MI, T hr o m b ol ysis i n M y ocar dial I nfarcti o n St u d y 
W M SI, wall m oti o n sc ore i n de x  
DI F O C C U L T- 3 St u d y 
W M SI, wall m oti o n sc ore i n de x  
C o nfi d e nti al 
Pl e a s e d o n ot di stri b ut e

I. 
B A C K G R O U N D A N D SI G NI FI C A N C E 
T he patie nts wit h ac ute c or o nar y occl usi o n ( A C O) or p ote ntiall y i m mi ne nt occl usi o n, wit h 
i ns ufficie nt c ollateral circ ulati o n, ha ve m y ocar di u m t hat is at ris k of i nfarcti o n u nless t he y 
u n der g o i m me diate re perf usi o n via t hr o m b ol ytics or perc uta ne o us c or o nar y i nter ve nti o n 
( P CI). O ne of t he m ost i m p orta nt tas ks i n e mer ge nc y car di ol o g y is t o i m me diatel y i de ntif y 
ac ute c or o nar y occl usi o n ( A C O) m y ocar dial i nfarcti o n ( O MI) a m o n g all patie nts w h o prese nt 
wit h s y m pt o ms c o m pati ble wit h ac ute m y ocar dial i nfarcti o n ( MI), a n d disti n g uis h t he m fr o m 
t h ose wit h o ut MI, a n d fr o m t h ose wit h MI t hat d oes n ot ha ve o n g oi n g m y oc yte l oss ( N o n-
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
t his pr ocess.  
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
s u p p orte d E C G para di g m.
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
r o o m f or s u bsta ntial i m pr o ve me nt. Alt h o u g h patie nts wit h A C O are t he gr o u p t hat is belie ve d 
t o be nefit fr o m e mer ge nt re perf usi o n t hera p y, fi bri n ol ytic st u dies di d n ot i n vesti gate t he 
prese nce or a bse nce of A C O a m o n g e nr olle d patie nts. M ore o ver, t he y di d n ot s pecificall y 
f oc us o n E C G fi n di n gs, i ncl u di n g S T E; f o ur of t he ni ne trials e ve n di d n ot use E C G f or 
e nr oll me nt, a n d t he re mai ni n g fi ve defi ne d t heir versi o n of S T E wit h var yi n g c ut offs, a n d 
wit h o ut s pecifie d meas ure me nt met h o ds. T o rec o ncile differe nt S T E criteria use d i n vari o us 
st u dies, se veral i n vesti gat ors c o m pare d S T E i n n or mal s u bjects a n d patie nts wit h MI. 
H o we ver, n o ne of t he st u dies cite d i n t he c urre nt u ni versal defi niti o n of MI use d A C O o n 
DI F O C C U L T- 3 St u d y 
u n der g o i m me diate re perf usi o n via t hr o m b ol ytics or perc uta ne o us c or o nar y i nter ve nti o n 
DI F O C C U L T- 3 St u d y 
u n der g o i m me diate re perf usi o n via t hr o m b ol ytics or perc uta ne o us c or o nar y i nter ve nti o n 
( P CI). O ne of t he m ost i m p orta nt tas ks i n e mer ge nc y car di ol o g y is t o i m me diatel y i de ntif y 
DI F O C C U L T- 3 St u d y 
( P CI). O ne of t he m ost i m p orta nt tas ks i n e mer ge nc y car di ol o g y is t o i m me diatel y i de ntif y 
ac ute c or o nar y occl usi o n ( A C O) m y ocar dial i nfarcti o n ( O MI) a m o n g all patie nts w h o prese nt 
DI F O C C U L T- 3 St u d y 
ac ute c or o nar y occl usi o n ( A C O) m y ocar dial i nfarcti o n ( O MI) a m o n g all patie nts w h o prese nt 
wit h s y m pt o ms c o m pati ble wit h ac ute m y ocar dial i nfarcti o n ( MI), a n d disti n g uis h t he m fr o m 
DI F O C C U L T- 3 St u d y 
wit h s y m pt o ms c o m pati ble wit h ac ute m y ocar dial i nfarcti o n ( MI), a n d disti n g uis h t he m fr o m 
t h ose wit h o ut MI, a n d fr o m t h ose wit h MI t hat d oes n ot ha ve o n g oi n g m y oc yte l oss ( N o n-
DI F O C C U L T- 3 St u d y 
t h ose wit h o ut MI, a n d fr o m t h ose wit h MI t hat d oes n ot ha ve o n g oi n g m y oc yte l oss ( N o n-
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
DI F O C C U L T- 3 St u d y 
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
DI F O C C U L T- 3 St u d y 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
DI F O C C U L T- 3 St u d y 
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
DI F O C C U L T- 3 St u d y 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
DI F O C C U L T- 3 St u d y 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
DI F O C C U L T- 3 St u d y 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
DI F O C C U L T- 3 St u d y 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
s u p p orte d E C G para di g m.
DI F O C C U L T- 3 St u d y 
s u p p orte d E C G para di g m.
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
DI F O C C U L T- 3 St u d y 
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
r o o m f or s u bsta ntial i m pr o ve me nt. Alt h o u g h patie nts wit h A C O are t he gr o u p t hat is belie ve d 
DI F O C C U L T- 3 St u d y 
r o o m f or s u bsta ntial i m pr o ve me nt. Alt h o u g h patie nts wit h A C O are t he gr o u p t hat is belie ve d 
t o be nefit fr o m e mer ge nt re perf usi o n t hera p y, fi bri n ol ytic st u dies di d n ot i n vesti gate t he 
DI F O C C U L T- 3 St u d y 
t o be nefit fr o m e mer ge nt re perf usi o n t hera p y, fi bri n ol ytic st u dies di d n ot i n vesti gate t he 
C o nfi d e nti al 
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
C o nfi d e nti al 
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
C o nfi d e nti al 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
C o nfi d e nti al 
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
C o nfi d e nti al 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
C o nfi d e nti al 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
C o nfi d e nti al 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
C o nfi d e nti al 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
s u p p orte d E C G para di g m.
C o nfi d e nti al 
s u p p orte d E C G para di g m.
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
C o nfi d e nti al 
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
Pl e a s e d o n ot di stri b ut e
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
Pl e a s e d o n ot di stri b ut e
O MI, or N O MI) w h o ca n be ma na ge d wit h me dical t hera p y a n d f or w h o m p ote ntiall y har mf ul 
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
Pl e a s e d o n ot di stri b ut e
i n vasi ve i nter ve nti o ns ca n be deferre d. T he electr ocar di o gra m ( E C G) pla ys a ce ntral r ole i n 
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
Pl e a s e d o n ot di stri b ut e
T he prese nce or a bse nce of S T-se g me nt ele vati o n ( S T E) is pri nci pall y use d t o defi ne 
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
Pl e a s e d o n ot di stri b ut e
patie nts w h o nee d e mer ge nt c or o nar y re vasc ularizati o n, si nce s u b gr o u p a nal yses of t he 
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
Pl e a s e d o n ot di stri b ut e
Fi bri n ol ytic T hera p y Trialists’ ( F T T) meta-a nal ysis i n dicate d t hat patie nts wit h S T E o n E C G 
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
Pl e a s e d o n ot di stri b ut e
gai n a sli g htl y better s ur vi val be nefit fr o m e mer ge nt re perf usi o n. After fi ne-t u ni n g of S T E 
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
Pl e a s e d o n ot di stri b ut e
c ut offs use d i n t his a nal ysis, u ni versall y a gree d S T E MI criteria beca me t he c urre nt g ui deli ne-
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
Pl e a s e d o n ot di stri b ut e
H o we ver, t he e vi de nce acc u m ulate d i n t he past 2 0 years i n dicate t hat t here is still 
r o o m f or s u bsta ntial i m pr o ve me nt. Alt h o u g h patie nts wit h A C O are t he gr o u p t hat is belie ve d 
Pl e a s e d o n ot di stri b ut e
r o o m f or s u bsta ntial i m pr o ve me nt. Alt h o u g h patie nts wit h A C O are t he gr o u p t hat is belie ve d 
t o be nefit fr o m e mer ge nt re perf usi o n t hera p y, fi bri n ol ytic st u dies di d n ot i n vesti gate t he 
Pl e a s e d o n ot di stri b ut e
t o be nefit fr o m e mer ge nt re perf usi o n t hera p y, fi bri n ol ytic st u dies di d n ot i n vesti gate t he 
Pl e a s e d o n ot di stri b ut e
prese nce or a bse nce of A C O a m o n g e nr olle d patie nts. M ore o ver, t he y di d n ot s pecificall y 
Pl e a s e d o n ot di stri b ut e
prese nce or a bse nce of A C O a m o n g e nr olle d patie nts. M ore o ver, t he y di d n ot s pecificall y 
f oc us o n E C G fi n di n gs, i ncl u di n g S T E; f o ur of t he ni ne trials e ve n di d n ot use E C G f or 
Pl e a s e d o n ot di stri b ut e
f oc us o n E C G fi n di n gs, i ncl u di n g S T E; f o ur of t he ni ne trials e ve n di d n ot use E C G f or 
e nr oll me nt, a n d t he re mai ni n g fi ve defi ne d t heir versi o n of S T E wit h var yi n g c ut offs, a n d 
Pl e a s e d o n ot di stri b ut e
e nr oll me nt, a n d t he re mai ni n g fi ve defi ne d t heir versi o n of S T E wit h var yi n g c ut offs, a n d 
wit h o ut s pecifie d meas ure me nt met h o ds. T o rec o ncile differe nt S T E criteria use d i n vari o us 
Pl e a s e d o n ot di stri b ut e
wit h o ut s pecifie d meas ure me nt met h o ds. T o rec o ncile differe nt S T E criteria use d i n vari o us 

a n gi o gra p h y as a n e n d p oi nt, s o t hese criteria were act uall y n ot desi g ne d t o differe ntiate 
S T E MI fr o m n o n- S T E MI.  
I n t he past 2 0 years, se veral i n vesti gat ors, i ncl u di n g o ur gr o u p, ha ve de m o nstrate d t hat 
fact ors ot her t ha n S T E, i ncl u di n g S T E of ma g nit u de less t ha n t h ose rec o m me n de d b y t he 
g ui deli nes ( b ut i n c o m bi nati o n wit h ot her feat ures), ca n hel p i n dia g n osi n g A C O or e xcl u di n g 
it. Pr o p orti o nalit y, w hic h is u nf ort u natel y c o m pletel y a bse nt i n t he S T E MI criteria, is a 
c o m m o n fact or i n m ost of t hese st u dies: pr o p orti o nalit y is t he i dea t hat a n y a m o u nt of S T E or 
S T D, or T- wa ve size, m ust be assesse d relati ve t o t he Q R S a m plit u de. Ma n y ot her cl ues 
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
S T E, w hic h has bee n descri be d i n detail i n rece nt re vie ws p u blis he d b y o ur gr o u p. 
St u dies s h o w c urre nt S T E MI criteria miss nearl y o ne-t hir d of A C O  wit h t he res ult t hat 
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
re perf use d b y t his ti me; u nf ort u natel y, o nl y after a s u bsta ntial l oss of m y ocar di u m. T hese 
fi n di n gs are hi g hl y rele va nt a n d i m p orta nt, as t h ose wit h u nrec o g nize d A C O ha d hi g her s h ort 
a n d l o n g-ter m ris k of m ortalit y. 
It is n ot clear w h y a disease of a k n o w n pat h o p h ysi ol o g y ( A C O) was na me d wit h a n 
i nacc urate s urr o gate E C G si g n ( Q- wa ve MI/ n o n- Q- wa ve MI or S T E MI/ n o n- S T E MI) i nstea d 
of t he pat h ol o gic s u bstrate itself ( A C O- MI/ n o n- A C O- MI or O MI f or s h ort), b ut t his 
f u n da me ntal mista ke create d i m p orta nt i m plicati o ns f or o ur c urre nt practice.  As briefl y 
o utli ne d a b o ve, A C O ca n be relia bl y rec o g nize d wit h t he hel p of ma n y ot her E C G fi n di n gs, 
DI F O C C U L T- 3 St u d y 
fact ors ot her t ha n S T E, i ncl u di n g S T E of ma g nit u de less t ha n t h ose rec o m me n de d b y t he 
DI F O C C U L T- 3 St u d y 
fact ors ot her t ha n S T E, i ncl u di n g S T E of ma g nit u de less t ha n t h ose rec o m me n de d b y t he 
g ui deli nes ( b ut i n c o m bi nati o n wit h ot her feat ures), ca n hel p i n dia g n osi n g A C O or e xcl u di n g 
DI F O C C U L T- 3 St u d y 
g ui deli nes ( b ut i n c o m bi nati o n wit h ot her feat ures), ca n hel p i n dia g n osi n g A C O or e xcl u di n g 
it. Pr o p orti o nalit y, w hic h is u nf ort u natel y c o m pletel y a bse nt i n t he S T E MI criteria, is a 
DI F O C C U L T- 3 St u d y 
it. Pr o p orti o nalit y, w hic h is u nf ort u natel y c o m pletel y a bse nt i n t he S T E MI criteria, is a 
c o m m o n fact or i n m ost of t hese st u dies: pr o p orti o nalit y is t he i dea t hat a n y a m o u nt of S T E or 
DI F O C C U L T- 3 St u d y 
c o m m o n fact or i n m ost of t hese st u dies: pr o p orti o nalit y is t he i dea t hat a n y a m o u nt of S T E or 
S T D, or T- wa ve size, m ust be assesse d relati ve t o t he Q R S a m plit u de. Ma n y ot her cl ues 
DI F O C C U L T- 3 St u d y 
S T D, or T- wa ve size, m ust be assesse d relati ve t o t he Q R S a m plit u de. Ma n y ot her cl ues 
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
DI F O C C U L T- 3 St u d y 
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
, w hic h has bee n descri be d i n detail i n rece nt re vie ws p u blis he d b y o ur gr o u p. 
DI F O C C U L T- 3 St u d y 
, w hic h has bee n descri be d i n detail i n rece nt re vie ws p u blis he d b y o ur gr o u p. 
St u dies s h o w c urre nt S T E MI criteria miss nearl y o ne-t hir d of A C O
DI F O C C U L T- 3 St u d y 
St u dies s h o w c urre nt S T E MI criteria miss nearl y o ne-t hir d of A C O
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
DI F O C C U L T- 3 St u d y 
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
DI F O C C U L T- 3 St u d y 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
DI F O C C U L T- 3 St u d y 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
DI F O C C U L T- 3 St u d y 
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
DI F O C C U L T- 3 St u d y 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
DI F O C C U L T- 3 St u d y 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
DI F O C C U L T- 3 St u d y 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
re perf use d b y t his ti me; u nf ort u natel y, o nl y after a s u bsta ntial l oss of m y ocar di u m.
DI F O C C U L T- 3 St u d y 
re perf use d b y t his ti me; u nf ort u natel y, o nl y after a s u bsta ntial l oss of m y ocar di u m.
fi n di n gs are hi g hl y rele va nt a n d i m p orta nt, as t h ose wit h u nrec o g nize d A C O ha d hi g her s h ort 
DI F O C C U L T- 3 St u d y 
fi n di n gs are hi g hl y rele va nt a n d i m p orta nt, as t h ose wit h u nrec o g nize d A C O ha d hi g her s h ort 
C o nfi d e nti al 
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
C o nfi d e nti al 
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
, w hic h has bee n descri be d i n detail i n rece nt re vie ws p u blis he d b y o ur gr o u p. 
C o nfi d e nti al 
, w hic h has bee n descri be d i n detail i n rece nt re vie ws p u blis he d b y o ur gr o u p. 
St u dies s h o w c urre nt S T E MI criteria miss nearl y o ne-t hir d of A C O
C o nfi d e nti al 
St u dies s h o w c urre nt S T E MI criteria miss nearl y o ne-t hir d of A C O
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
C o nfi d e nti al 
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
C o nfi d e nti al 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
C o nfi d e nti al 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
C o nfi d e nti al 
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
C o nfi d e nti al 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
C o nfi d e nti al 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
C o nfi d e nti al 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
Pl e a s e d o n ot di stri b ut e
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
Pl e a s e d o n ot di stri b ut e
s h o ul d als o be ta ke n i nt o acc o u nt w he n differe ntiati n g S T E d ue t o A C O fr o m ot her ca uses of 
wit h t he res ult t hat 
Pl e a s e d o n ot di stri b ut e
wit h t he res ult t hat 
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
Pl e a s e d o n ot di stri b ut e
t his u nf ort u nate gr o u p of patie nts, la bele d as n o n- S T E MI, are de pri ve d of e mer ge nt 
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
Pl e a s e d o n ot di stri b ut e
re perf usi o n t hera p y. Ma n y st u dies s h o we d t hat a p pr o xi matel y o ne t hir d t o o ne-fift h of t he 
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
Pl e a s e d o n ot di stri b ut e
patie nts wit h A C O ha d e q ual t o or less t ha n 1 m m of S T E, h y perac ute T- wa ves, n o n-
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
Pl e a s e d o n ot di stri b ut e
c o nti g u o us S T E patter ns, etc. T hese patie nts are u nf ort u natel y de pri ve d of e mer ge nt 
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
Pl e a s e d o n ot di stri b ut e
re perf usi o n t hera p y a n d A C O is o nl y f o u n d after risi n g tr o p o ni n le vel i de ntifies t he m as 
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
Pl e a s e d o n ot di stri b ut e
ha vi n g MI a n d t he y u n der g o a ne xt- da y a n gi o gra m. F urt her m ore, t his pr o p orti o n ma y be 
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
Pl e a s e d o n ot di stri b ut e
u n deresti mate d, si nce a lar ge perce nta ge of t otal t hr o m b otic occl usi o ns are s p o nta ne o usl y 
Pl e a s e d o n ot di stri b ut e
re perf use d b y t his ti me; u nf ort u natel y, o nl y after a s u bsta ntial l oss of m y ocar di u m.
Pl e a s e d o n ot di stri b ut e
re perf use d b y t his ti me; u nf ort u natel y, o nl y after a s u bsta ntial l oss of m y ocar di u m.
fi n di n gs are hi g hl y rele va nt a n d i m p orta nt, as t h ose wit h u nrec o g nize d A C O ha d hi g her s h ort 
Pl e a s e d o n ot di stri b ut e
fi n di n gs are hi g hl y rele va nt a n d i m p orta nt, as t h ose wit h u nrec o g nize d A C O ha d hi g her s h ort 
a n d l o n g-ter m ris k of m ortalit y. 
Pl e a s e d o n ot di stri b ut e
a n d l o n g-ter m ris k of m ortalit y. 
It is n ot clear w h y a disease of a k n o w n pat h o p h ysi ol o g y ( A C O) was na me d wit h a n 
Pl e a s e d o n ot di stri b ut e
It is n ot clear w h y a disease of a k n o w n pat h o p h ysi ol o g y ( A C O) was na me d wit h a n 
Pl e a s e d o n ot di stri b ut e
i nacc urate s urr o gate E C G si g n ( Q- wa ve MI/ n o n- Q- wa ve MI or S T E MI/ n o n- S T E MI) i nstea d 
Pl e a s e d o n ot di stri b ut e
i nacc urate s urr o gate E C G si g n ( Q- wa ve MI/ n o n- Q- wa ve MI or S T E MI/ n o n- S T E MI) i nstea d 
of t he pat h ol o gic s u bstrate itself ( A C O- MI/ n o n- A C O- MI or O MI f or s h ort), b ut t his 
Pl e a s e d o n ot di stri b ut e
of t he pat h ol o gic s u bstrate itself ( A C O- MI/ n o n- A C O- MI or O MI f or s h ort), b ut t his 

s uc h as mi n or S T E n ot f ulfilli n g S T E MI criteria, S T E dis pr o p orti o nate t o prece di n g Q R S, 
u n us ual patter ns wit h c o nti g u o us lea ds s h o wi n g o p p osite S T de viati o ns a n d s o me patter ns n ot 
s h o wi n g S T E at all.
Rece ntl y, t he DIa g n ostic acc urac y o F electr ocar di o gra m f or ac ute c or o nar y 
O C Cl Usi o n res u L Ti n g i n m y ocar dial i nfarcti o n ( DI F O C C U L T) st u d y, c o m pare d O MI/ n o n-
O MI a p pr oac h wit h S T E MI/ n o n- S T E MI para di g m. T his is t he lar gest st u d y s pecificall y 
desi g ne d t o q uesti o n t he S T E MI/ n o n- S T E MI para di g m, i n w hic h a set of pre defi ne d E C G 
fi n di n gs i n a d diti o n t o S T E MI criteria were use d, a n d t he fi nal o utc o me was a c o m p osite 
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
S T E/ n o n- S T E MI a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
i nfarct size meas ure d b y pea k tr o p o ni n b ut greater dela ys t o a n gi o gra p h y c o m pare d wit h t he 
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
Se nsiti vit y, s pecificit y, a n d acc urac y of S T E MI criteria vs E x pert 1 f or O MI a m o n g all 8 0 8 
patie nts were 4 1 % vs 8 6 %, 9 4 % vs 9 1 %, a n d 7 7 % vs 8 9 %, a n d f or E x pert 2 a m o n g 2 5 0 
patie nts were 3 6 % vs 8 0 %, 9 1 % vs 9 2 %, a n d 7 6 % vs 8 9 %. O MIs were c orrectl y dia g n ose d a 
me dia n of 1. 5 h o urs ( mea n 3. 0 h o urs) earlier b y str uct ure d e x pert E C G i nter pretati o n t ha n b y 
S T E MI criteria, or b y a n gi o gra m if t he E C G ne ver met S T E MI criteria. 
DI F O C C U L T- 3 St u d y 
Rece ntl y, t he DIa g n ostic acc urac y o F electr ocar di o gra m f or ac ute c or o nar y 
DI F O C C U L T- 3 St u d y 
Rece ntl y, t he DIa g n ostic acc urac y o F electr ocar di o gra m f or ac ute c or o nar y 
O C Cl Usi o n res u L Ti n g i n m y ocar dial i nfarcti o n ( DI F O C C U L T) st u d y, c o m pare d O MI/ n o n-
DI F O C C U L T- 3 St u d y 
O C Cl Usi o n res u L Ti n g i n m y ocar dial i nfarcti o n ( DI F O C C U L T) st u d y, c o m pare d O MI/ n o n-
O MI a p pr oac h wit h S T E MI/ n o n- S T E MI para di g m. T his is t he lar gest st u d y s pecificall y 
DI F O C C U L T- 3 St u d y 
O MI a p pr oac h wit h S T E MI/ n o n- S T E MI para di g m. T his is t he lar gest st u d y s pecificall y 
desi g ne d t o q uesti o n t he S T E MI/ n o n- S T E MI para di g m, i n w hic h a set of pre defi ne d E C G 
DI F O C C U L T- 3 St u d y 
desi g ne d t o q uesti o n t he S T E MI/ n o n- S T E MI para di g m, i n w hic h a set of pre defi ne d E C G 
fi n di n gs i n a d diti o n t o S T E MI criteria were use d, a n d t he fi nal o utc o me was a c o m p osite 
DI F O C C U L T- 3 St u d y 
fi n di n gs i n a d diti o n t o S T E MI criteria were use d, a n d t he fi nal o utc o me was a c o m p osite 
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
DI F O C C U L T- 3 St u d y 
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
DI F O C C U L T- 3 St u d y 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
DI F O C C U L T- 3 St u d y 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
DI F O C C U L T- 3 St u d y 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
DI F O C C U L T- 3 St u d y 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
DI F O C C U L T- 3 St u d y 
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
DI F O C C U L T- 3 St u d y 
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
DI F O C C U L T- 3 St u d y 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
DI F O C C U L T- 3 St u d y 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
DI F O C C U L T- 3 St u d y 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
i nfarct size meas ure d b y pea k tr o p o ni n b ut greater dela ys t o a n gi o gra p h y c o m pare d wit h t he 
DI F O C C U L T- 3 St u d y 
i nfarct size meas ure d b y pea k tr o p o ni n b ut greater dela ys t o a n gi o gra p h y c o m pare d wit h t he 
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
DI F O C C U L T- 3 St u d y 
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
C o nfi d e nti al 
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
C o nfi d e nti al 
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
C o nfi d e nti al 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
C o nfi d e nti al 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
C o nfi d e nti al 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
C o nfi d e nti al 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
C o nfi d e nti al 
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
C o nfi d e nti al 
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
C o nfi d e nti al 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
C o nfi d e nti al 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
C o nfi d e nti al 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
Pl e a s e d o n ot di stri b ut e
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
Pl e a s e d o n ot di stri b ut e
A C O e n d p oi nt. I n acc or da nce wit h t he pre vi o us o bser vati o ns, o ver o ne-f o urt h of t he patie nts 
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
Pl e a s e d o n ot di stri b ut e
i nitiall y classifie d as ha vi n g n o n- S T E MI were re-classifie d b y t he E C G re vie wers, bli n de d t o 
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
Pl e a s e d o n ot di stri b ut e
all o utc o me data, as ha vi n g O MI. T his s u b gr o u p ha d a hi g her fre q ue nc y of A C O, m y ocar dial 
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
Pl e a s e d o n ot di stri b ut e
da ma ge, a n d b ot h i n- h os pital a n d l o n g-ter m m ortalit y c o m pare d t o t he n o n- O MI gr o u p. T he 
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
Pl e a s e d o n ot di stri b ut e
O MI/ n o n- O MI a p pr oac h t o t he E C G ha d a s u peri or dia g n ostic acc urac y c o m pare d t o t he 
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
Pl e a s e d o n ot di stri b ut e
 a p pr oac h i n t he pre dicti o n of b ot h A C O a n d l o n g-ter m m ortalit y.  
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
Pl e a s e d o n ot di stri b ut e
Si milarl y, a n ot her retr os pecti ve case-c o ntr ol st u d y of 8 0 8 patie nts wit h s us pecte d A C S 
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
Pl e a s e d o n ot di stri b ut e
s y m pt o ms c o m pare d t he acc urac y of S T E MI criteria vs. str uct ure d e x pert E C G i nter pretati o n 
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
Pl e a s e d o n ot di stri b ut e
w hic h i nc or p orates ot her fi n di n gs of O MI i ncl u di n g h y perac ute T- wa ves, S T D of p osteri or 
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
Pl e a s e d o n ot di stri b ut e
O MI, S T E less t ha n t he S T E MI criteria c ut offs, etc. S T E MI (-) O MI patie nts ha d si milar 
i nfarct size meas ure d b y pea k tr o p o ni n b ut greater dela ys t o a n gi o gra p h y c o m pare d wit h t he 
Pl e a s e d o n ot di stri b ut e
i nfarct size meas ure d b y pea k tr o p o ni n b ut greater dela ys t o a n gi o gra p h y c o m pare d wit h t he 
Pl e a s e d o n ot di stri b ut e
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
Pl e a s e d o n ot di stri b ut e
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
Pl e a s e d o n ot di stri b ut e
S T E MI ( +) O MI patie nts. Of t he 8 0 8 patie nts, 4 9 % ha d A MI ( 3 3 % O MI; 1 6 % N O MI). 
Pl e a s e d o n ot di stri b ut e
Se nsiti vit y, s pecificit y, a n d acc urac y of S T E MI criteria vs E x pert 1 f or O MI a m o n g all 8 0 8 
Pl e a s e d o n ot di stri b ut e
Se nsiti vit y, s pecificit y, a n d acc urac y of S T E MI criteria vs E x pert 1 f or O MI a m o n g all 8 0 8 
Pl e a s e d o n ot di stri b ut e
patie nts were 4 1 % vs 8 6 %, 9 4 % vs 9 1 %, a n d 7 7 % vs 8 9 %, a n d f or E x pert 2 a m o n g 2 5 0 
Pl e a s e d o n ot di stri b ut e
patie nts were 4 1 % vs 8 6 %, 9 4 % vs 9 1 %, a n d 7 7 % vs 8 9 %, a n d f or E x pert 2 a m o n g 2 5 0 
Pl e a s e d o n ot di stri b ut e
patie nts were 3 6 % vs 8 0 %, 9 1 % vs 9 2 %, a n d 7 6 % vs 8 9 %. O MIs were c orrectl y dia g n ose d a 
Pl e a s e d o n ot di stri b ut e
patie nts were 3 6 % vs 8 0 %, 9 1 % vs 9 2 %, a n d 7 6 % vs 8 9 %. O MIs were c orrectl y dia g n ose d a 
me dia n of 1. 5 h o urs ( mea n 3. 0 h o urs) earlier b y str uct ure d e x pert E C G i nter pretati o n t ha n b y 
Pl e a s e d o n ot di stri b ut e
me dia n of 1. 5 h o urs ( mea n 3. 0 h o urs) earlier b y str uct ure d e x pert E C G i nter pretati o n t ha n b y 

Lastl y, t he S T E MI/ N S T E MI vs. O MI/ N O MI para di g m were c o m pare d i n 4 6 7 
c o nsec uti ve hi g h/ris k ac ute c or o nar y s y n dr o me patie nts. A m o n g t he 1 0 8 patie nts wit h O MI, 
o nl y 6 0 % ha d a n y E C G meeti n g S T E MI criteria. S T E MI (-) O MI patie nts ha d si milar pea k 
tr o p o ni ns, wall m oti o n a b n or malities, left ve ntric ular ejecti o n fracti o n ( L V E F) a n d cli nical 
o utc o mes as c o m pare d wit h t he S T E MI ( +) O MI patie nts, b ut were m uc h less li kel y t o recei ve 
e mer ge nt cat heterizati o n.  
T hese data s u p p ort t he n oti o n t hat t he S T E MI (-) b ut O MI ( +) patie nts li kel y re prese nt 
a misse d o p p ort u nit y u n der t he S T E MI/ N S T E MI para di g m. A ne w O MI/ N O MI a p pr oac h has 
t he p ote ntial of bei n g t he ne xt si g nifica nt i m pr o ve me nt i n m o der n MI care.  
II. 
T H E H Y P O T H E SI S 
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
III.  
M E T H O D S 
1.  A p plic ati o n f or I nstit uti o n al Re vie w B o ar d (I R B)/ Et hics b o ar d a p pr o v al   
I R B/ Et hics b oar d a p pr o val is o btai ne d fr o m Mar mara U ni versit y Et hical B oar d. Eac h 
pri nci pal i n vesti gat or at eac h i n di vi d ual st u d y site will be re q uire d t o o btai n I R B/ Et hics b oar d 
a p pr o val fr o m his/ her o w n i nstit uti o n. 
2.  St u d y p o p ul ati o n  
T he a d ult patie nts (a ge > 1 8 years) w h o are a d mitte d t o t he e mer ge nc y de part me nt wit h a 
DI F O C C U L T- 3 St u d y 
tr o p o ni ns, wall m oti o n a b n or malities, left ve ntric ular ejecti o n fracti o n ( L V E F) a n d cli nical 
DI F O C C U L T- 3 St u d y 
tr o p o ni ns, wall m oti o n a b n or malities, left ve ntric ular ejecti o n fracti o n ( L V E F) a n d cli nical 
o utc o mes as c o m pare d wit h t he S T E MI ( +) O MI patie nts, b ut were m uc h less li kel y t o recei ve 
DI F O C C U L T- 3 St u d y 
o utc o mes as c o m pare d wit h t he S T E MI ( +) O MI patie nts, b ut were m uc h less li kel y t o recei ve 
T hese data s u p p ort t he n oti o n t hat t he S T E MI (-) b ut O MI ( +) patie nts li kel y re prese nt 
DI F O C C U L T- 3 St u d y 
T hese data s u p p ort t he n oti o n t hat t he S T E MI (-) b ut O MI ( +) patie nts li kel y re prese nt 
a misse d o p p ort u nit y u n der t he S T E MI/ N S T E MI para di g m. A ne w O MI/ N O MI a p pr oac h has 
DI F O C C U L T- 3 St u d y 
a misse d o p p ort u nit y u n der t he S T E MI/ N S T E MI para di g m. A ne w O MI/ N O MI a p pr oac h has 
t he p ote ntial of bei n g t he ne xt si g nifica nt i m pr o ve me nt i n m o der n MI care.  
DI F O C C U L T- 3 St u d y 
t he p ote ntial of bei n g t he ne xt si g nifica nt i m pr o ve me nt i n m o der n MI care.  
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
DI F O C C U L T- 3 St u d y 
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
DI F O C C U L T- 3 St u d y 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
DI F O C C U L T- 3 St u d y 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
III.
DI F O C C U L T- 3 St u d y 
III.
M E T H O D S 
DI F O C C U L T- 3 St u d y 
M E T H O D S 
1.  A p plic ati o n f or I nstit uti o n al Re vie w B o ar d (I R B)/ Et hics b o ar d a p pr o v al
DI F O C C U L T- 3 St u d y 
1.  A p plic ati o n f or I nstit uti o n al Re vie w B o ar d (I R B)/ Et hics b o ar d a p pr o v al
C o nfi d e nti al 
t he p ote ntial of bei n g t he ne xt si g nifica nt i m pr o ve me nt i n m o der n MI care.  
C o nfi d e nti al 
t he p ote ntial of bei n g t he ne xt si g nifica nt i m pr o ve me nt i n m o der n MI care.  
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
C o nfi d e nti al 
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
C o nfi d e nti al 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
C o nfi d e nti al 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
Pl e a s e d o n ot di stri b ut e
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
Pl e a s e d o n ot di stri b ut e
O ur h y p ot hesis is t hat t he ne w O MI/ N O MI a p pr oac h will be s u peri or t o t he esta blis he d 
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
Pl e a s e d o n ot di stri b ut e
S T E MI/ N S T E MI para di g m i n earl y detecti o n of A C O, li miti n g i nfarct size, re d uci n g 
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
Pl e a s e d o n ot di stri b ut e
re h os pitalizati o ns a n d m ost i m p orta nt of all, re d uci n g m ortalit y. 
Pl e a s e d o n ot di stri b ut e
1.  A p plic ati o n f or I nstit uti o n al Re vie w B o ar d (I R B)/ Et hics b o ar d a p pr o v al
Pl e a s e d o n ot di stri b ut e
1.  A p plic ati o n f or I nstit uti o n al Re vie w B o ar d (I R B)/ Et hics b o ar d a p pr o v al
Pl e a s e d o n ot di stri b ut e
I R B/ Et hics b oar d a p pr o val is o btai ne d fr o m Mar mara U ni versit y Et hical B oar d. Eac h 
Pl e a s e d o n ot di stri b ut e
I R B/ Et hics b oar d a p pr o val is o btai ne d fr o m Mar mara U ni versit y Et hical B oar d. Eac h 
pri nci pal i n vesti gat or at eac h i n di vi d ual st u d y site will be re q uire d t o o btai n I R B/ Et hics b oar d 
Pl e a s e d o n ot di stri b ut e
pri nci pal i n vesti gat or at eac h i n di vi d ual st u d y site will be re q uire d t o o btai n I R B/ Et hics b oar d 
Pl e a s e d o n ot di stri b ut e
a p pr o val fr o m his/ her o w n i nstit uti o n. 
Pl e a s e d o n ot di stri b ut e
a p pr o val fr o m his/ her o w n i nstit uti o n. 

cli nical pict ure c o m pati ble wit h ac ute c or o nar y s y n dr o me will be scree ne d f or e nr oll me nt i nt o 
t he st u d y. patie nts wit h a n E C G or cli nical (see bel o w) dia g n osis of ac ute m y ocar dial 
i nfarcti o n will be e nr olle d i nt o t he st u d y.  
A n E C G will be ac q uire d as s o o n as p ossi ble i n all scree ne d patie nts a n d serial E C Gs 
will be ta ke n if t he first o ne is n ot dia g n ostic. T he E C Gs will be sca n ne d a n d di gitize d via a n 
artificial i ntelli ge nce ( AI)- p o were d m o bile p h o ne a p plicati o n. If t he patie nt gets a S T E MI or 
O MI dia g n osis b y t he E C G or cli nical gestalt (refract or y pai n, he m o d y na mic i nsta bilit y, 
arr h yt h mia, car diac arrest) t he y will be i ncl u de d i n t he st u d y e ve n if t he later tr o p o ni n res ults 
t ur n ne gati ve. If t he E C G is n ot dia g n ostic f or O MI or S T E MI, a m y ocar dial i nfarcti o n 
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
t o 4t h u ni versal defi niti o n of MI, t he ter m ac ute MI will be use d w he n t here is ac ute 
my oc ar di al i nj ury  ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
ac ute m y ocar dial isc he mia: 
• 
S y m pt o ms of m y ocar dial isc he mia; 
•  
Ne w isc he mic E C G c ha n ges; 
•  
De vel o p me nt of pat h ol o gical Q wa ves; 
• 
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
a b n or malit y i n a patter n c o nsiste nt wit h a n isc he mic eti ol o g y; 
• 
I de ntificati o n of a c or o nar y t hr o m b us b y a n gi o gra p h y or a ut o ps y; 
• 
P ost- m orte m de m o nstrati o n of ac ute at her ot hr o m b osis i n t he arter y s u p pl yi n g t he 
i nfarcte d m y ocar di u m. 
All n o n- pr oce d ure relate d (e xcl u di n g t y pe 4a a n d 5 MIs), i ncl u di n g t y pe 1 ( MI ca use d b y 
at her ot hr o m b otic c or o nar y arter y disease w hic h is us uall y preci pitate d b y at her oscler otic 
pla q ue disr u pti o n (r u pt ure or er osi o n)), t y pe 2 (e vi de nce of a n i m bala nce bet wee n m y ocar dial 
o x y ge n s u p pl y a n d de ma n d u nrelate d t o ac ute at her ot hr o m b osis), t y pe 3 (car diac deat h i n 
DI F O C C U L T- 3 St u d y 
 scree ne d patie nts a n d serial E C Gs 
DI F O C C U L T- 3 St u d y 
 scree ne d patie nts a n d serial E C Gs 
e E C Gs will be sca n ne d a n d di gitize d via a n 
DI F O C C U L T- 3 St u d y 
e E C Gs will be sca n ne d a n d di gitize d via a n 
artificial i ntelli ge nce ( AI)- p o were d m o bile p h o ne a p plicati o n. If t he patie nt gets a S T E MI or 
DI F O C C U L T- 3 St u d y 
artificial i ntelli ge nce ( AI)- p o were d m o bile p h o ne a p plicati o n. If t he patie nt gets a S T E MI or 
O MI dia g n osis b y t he E C G or cli nical gestalt (refract or y pai n, he m o d y na mic i nsta bilit y, 
DI F O C C U L T- 3 St u d y 
O MI dia g n osis b y t he E C G or cli nical gestalt (refract or y pai n, he m o d y na mic i nsta bilit y, 
arr h yt h mia, car diac arrest) t he y will be i ncl u de d i n t he st u d y e ve n if t he later tr o p o ni n res ults 
DI F O C C U L T- 3 St u d y 
arr h yt h mia, car diac arrest) t he y will be i ncl u de d i n t he st u d y e ve n if t he later tr o p o ni n res ults 
t ur n ne gati ve. If t he E C G is n ot dia g n ostic f or O MI or S T E MI, a m y ocar dial i nfarcti o n 
DI F O C C U L T- 3 St u d y 
t ur n ne gati ve. If t he E C G is n ot dia g n ostic f or O MI or S T E MI, a m y ocar dial i nfarcti o n 
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
DI F O C C U L T- 3 St u d y 
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
, t he ter m ac ute 
DI F O C C U L T- 3 St u d y 
, t he ter m ac ute MI
DI F O C C U L T- 3 St u d y 
MI  will be use d w he n t here is 
DI F O C C U L T- 3 St u d y 
 will be use d w he n t here is 
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
DI F O C C U L T- 3 St u d y 
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
DI F O C C U L T- 3 St u d y 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
ac ute m y ocar dial isc he mia: 
DI F O C C U L T- 3 St u d y 
ac ute m y ocar dial isc he mia: 
S y m pt o ms of m y ocar dial isc he mia; 
DI F O C C U L T- 3 St u d y 
S y m pt o ms of m y ocar dial isc he mia; 
•
DI F O C C U L T- 3 St u d y 
•
Ne w isc he mic E C G c ha n ges; 
DI F O C C U L T- 3 St u d y 
Ne w isc he mic E C G c ha n ges; 
•
DI F O C C U L T- 3 St u d y 
•
De vel o p me nt of pat h ol o gical Q wa ves; 
DI F O C C U L T- 3 St u d y 
De vel o p me nt of pat h ol o gical Q wa ves; 
•
DI F O C C U L T- 3 St u d y 
•
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
DI F O C C U L T- 3 St u d y 
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
C o nfi d e nti al 
t ur n ne gati ve. If t he E C G is n ot dia g n ostic f or O MI or S T E MI, a m y ocar dial i nfarcti o n 
C o nfi d e nti al 
t ur n ne gati ve. If t he E C G is n ot dia g n ostic f or O MI or S T E MI, a m y ocar dial i nfarcti o n 
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
C o nfi d e nti al 
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
 will be use d w he n t here is 
C o nfi d e nti al 
 will be use d w he n t here is 
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
C o nfi d e nti al 
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
C o nfi d e nti al 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
S y m pt o ms of m y ocar dial isc he mia; 
C o nfi d e nti al 
S y m pt o ms of m y ocar dial isc he mia; 
C o nfi d e nti al 
Ne w isc he mic E C G c ha n ges; 
C o nfi d e nti al 
Ne w isc he mic E C G c ha n ges; 
De vel o p me nt of pat h ol o gical Q wa ves; 
C o nfi d e nti al 
De vel o p me nt of pat h ol o gical Q wa ves; 
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
C o nfi d e nti al 
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
Pl e a s e d o n ot di stri b ut e
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
Pl e a s e d o n ot di stri b ut e
dia g n osis wit h a p ositi ve tr o p o ni n will be necessar y f or t he i ncl usi o n i n t he st u d y. Acc or di n g 
ac ute 
Pl e a s e d o n ot di stri b ut e
ac ute 
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
Pl e a s e d o n ot di stri b ut e
 ( detecti o n of a rise a n d/ or fall of c T n val ues wit h at least o ne val ue a b o ve 
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
Pl e a s e d o n ot di stri b ut e
t he 9 9t h perce ntile u p per ra n ge li mit) wit h at least o ne of t he f oll o wi n g cli nical i n dicat ors of 
Pl e a s e d o n ot di stri b ut e
De vel o p me nt of pat h ol o gical Q wa ves; 
Pl e a s e d o n ot di stri b ut e
De vel o p me nt of pat h ol o gical Q wa ves; 
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
Pl e a s e d o n ot di stri b ut e
I ma gi n g e vi de nce of ne w l oss of via ble m y ocar di u m or ne w re gi o nal wall m oti o n 
a b n or malit y i n a patter n c o nsiste nt wit h a n isc he mic eti ol o g y; 
Pl e a s e d o n ot di stri b ut e
a b n or malit y i n a patter n c o nsiste nt wit h a n isc he mic eti ol o g y; 
I de ntificati o n of a c or o nar y t hr o m b us b y a n gi o gra p h y or a ut o ps y; 
Pl e a s e d o n ot di stri b ut e
I de ntificati o n of a c or o nar y t hr o m b us b y a n gi o gra p h y or a ut o ps y; 
P ost- m orte m de m o nstrati o n of ac ute at her ot hr o m b osis i n t he arter y s u p pl yi n g t he 
Pl e a s e d o n ot di stri b ut e
P ost- m orte m de m o nstrati o n of ac ute at her ot hr o m b osis i n t he arter y s u p pl yi n g t he 
Pl e a s e d o n ot di stri b ut e
i nfarcte d m y ocar di u m. 
Pl e a s e d o n ot di stri b ut e
i nfarcte d m y ocar di u m. 
n o n- pr oce d ure relate d (e xcl u di n g t y pe 4a a n d 5 MIs), i ncl u di n g t y pe 1 ( MI ca use d b y 
Pl e a s e d o n ot di stri b ut e
n o n- pr oce d ure relate d (e xcl u di n g t y pe 4a a n d 5 MIs), i ncl u di n g t y pe 1 ( MI ca use d b y 
at her ot hr o m b otic c or o nar y arter y disease w hic h is us uall y preci pitate d b y at her oscler otic 
Pl e a s e d o n ot di stri b ut e
at her ot hr o m b otic c or o nar y arter y disease w hic h is us uall y preci pitate d b y at her oscler otic 

patie nts wit h s y m pt o ms s u g gesti ve of m y ocar dial isc he mia a n d pres u me d ne w isc he mic E C G 
c ha n ges bef ore c T n val ues bec o me a vaila ble or a b n or mal) a n d t y pe 4 b a n d c (ste nt/scaff ol d 
t hr o m b osis or reste n osis ass ociate d wit h perc uta ne o us c or o nar y i nter ve nti o n) will be i ncl u de d 
i n t he st u d y. Patie nts wit h my oc ar di al i nj ury  (eit her ac ute, as i n ac ute heart fail ure or 
m y ocar ditis, or c hr o nic, as i n c hr o nic ki d ne y disease or sta ble i ncrease d tr o p o ni n le vels wit h 
str uct ural heart disease) wit h o ut isc he mi a (a b o ve me nti o ne d f oll o wi n g cli nical i n dicat ors of 
ac ute m y ocar dial isc he mia) will be e xcl u de d fr o m t he st u d y. 
T he i ncl usi o n a n d e xcl usi o n criteria are s u m marize d bel o w. 
I ncl usi o n criteri a 
A ge > 1 8 years 
E C G a n d/ or cli nical dia g n osis of ac ute m y ocar dial i nfarcti o n 
E xcl usi o n criteri a 
Acti ve pre g na nc y or a s us pici o n of pre g na nc y 
Rejecti o n or wit h dra wal of c o nse nt  
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
N o n-isc he mic m y ocar dial i nj ur y 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
Re- occl usi o n of t he c ul prit lesi o n after i nter ve nti o n * 
Ne w vessel occl usi o n d uri n g h os pital sta y * 
* E xcl usi o n fr o m fi nal a nal yses. 
R a n d o miz ati o n 
T he patie nts will be ra n d o mize d t o t he c urre nt S T E MI/ N S T E MI vers us O MI/ N O MI 
a p pr oac hes usi n g a cl uster ra n d o mize d trial desi g n. Alt h o u g h t he S T E MI/ N S T E MI a p pr oac h 
DI F O C C U L T- 3 St u d y 
 (eit her ac ute, as i n ac ute heart fail ure or 
DI F O C C U L T- 3 St u d y 
 (eit her ac ute, as i n ac ute heart fail ure or 
m y ocar ditis, or c hr o nic, as i n c hr o nic ki d ne y disease or sta ble i ncrease d tr o p o ni n le vels wit h 
DI F O C C U L T- 3 St u d y 
m y ocar ditis, or c hr o nic, as i n c hr o nic ki d ne y disease or sta ble i ncrease d tr o p o ni n le vels wit h 
(a b o ve me nti o ne d f oll o wi n g cli nical i n dicat ors of 
DI F O C C U L T- 3 St u d y 
(a b o ve me nti o ne d f oll o wi n g cli nical i n dicat ors of 
ac ute m y ocar dial isc he mia) will be e xcl u de d fr o m t he st u d y. 
DI F O C C U L T- 3 St u d y 
ac ute m y ocar dial isc he mia) will be e xcl u de d fr o m t he st u d y. 
T he i ncl usi o n a n d e xcl usi o n criteria are s u m marize d bel o w. 
DI F O C C U L T- 3 St u d y 
T he i ncl usi o n a n d e xcl usi o n criteria are s u m marize d bel o w. 
E C G a n d/ or cli nical dia g n osis of ac ute m y ocar dial i nfarcti o n 
DI F O C C U L T- 3 St u d y 
E C G a n d/ or cli nical dia g n osis of ac ute m y ocar dial i nfarcti o n 
E xcl usi o n criteri a 
DI F O C C U L T- 3 St u d y 
E xcl usi o n criteri a 
Acti ve pre g na nc y or a s us pici o n of pre g na nc y 
DI F O C C U L T- 3 St u d y 
Acti ve pre g na nc y or a s us pici o n of pre g na nc y 
Rejecti o n or wit h dra wal of c o nse nt  
DI F O C C U L T- 3 St u d y 
Rejecti o n or wit h dra wal of c o nse nt  
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
DI F O C C U L T- 3 St u d y 
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
N o n-isc he mic m y ocar dial i nj ur y 
DI F O C C U L T- 3 St u d y 
N o n-isc he mic m y ocar dial i nj ur y 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
DI F O C C U L T- 3 St u d y 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
Re- occl usi o n of t he c ul prit lesi o n after i nter ve nti o n * 
DI F O C C U L T- 3 St u d y 
Re- occl usi o n of t he c ul prit lesi o n after i nter ve nti o n * 
C o nfi d e nti al 
E C G a n d/ or cli nical dia g n osis of ac ute m y ocar dial i nfarcti o n 
C o nfi d e nti al 
E C G a n d/ or cli nical dia g n osis of ac ute m y ocar dial i nfarcti o n 
Acti ve pre g na nc y or a s us pici o n of pre g na nc y 
C o nfi d e nti al 
Acti ve pre g na nc y or a s us pici o n of pre g na nc y 
Rejecti o n or wit h dra wal of c o nse nt  
C o nfi d e nti al 
Rejecti o n or wit h dra wal of c o nse nt  
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
C o nfi d e nti al 
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
N o n-isc he mic m y ocar dial i nj ur y 
C o nfi d e nti al 
N o n-isc he mic m y ocar dial i nj ur y 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
C o nfi d e nti al 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
Pl e a s e d o n ot di stri b ut e
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
Pl e a s e d o n ot di stri b ut e
Fail ure t o ac q uire a n y of t he pre- partici pati o n E C Gs 
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
Pl e a s e d o n ot di stri b ut e
A p plicati o n of t hr o m b ol ytic t hera p y i nstea d of pri mar y P CI 
Re- occl usi o n of t he c ul prit lesi o n after i nter ve nti o n * 
Pl e a s e d o n ot di stri b ut e
Re- occl usi o n of t he c ul prit lesi o n after i nter ve nti o n * 
Ne w vessel occl usi o n d uri n g h os pital sta y * 
Pl e a s e d o n ot di stri b ut e
Ne w vessel occl usi o n d uri n g h os pital sta y * 
* E xcl usi o n fr o m fi nal a nal yses. 
Pl e a s e d o n ot di stri b ut e
* E xcl usi o n fr o m fi nal a nal yses. 
R a n d o miz ati o n 
Pl e a s e d o n ot di stri b ut e
R a n d o miz ati o n 

is t he c urre nt n or m (a dia g n osis of S T E MI re q uires e mer ge nt cat heterizati o n, w hereas t he 
patie nts wit h N S T E MI are sta bilize d first a n d t he n electi vel y u n der g o cat heterizati o n u nless 
t here are hi g h-ris k feat ures), it w o ul d be u net hical f or a E C G re vie wer, w h o is trai ne d i n 
rec o g nizi n g t he si g ns of A C O n ot f ulfilli n g t he c urre nt S T E MI criteria, t o s us pe n d e mer ge nt 
re perf usi o n t hera p y after a n O MI dia g n osis has bee n ma de. T heref ore, t he E C G i nter preters 
w h o are trai ne d i n O MI dia g n osis ca n n ot be ra n d o mize d t o S T E MI/ N S T E MI vers us 
O MI/ N O MI a p pr oac hes. He nce, we will ra n d o mize t he gr o u ps i n t he f oll o wi n g fas hi o n: I n 
eac h ce nter, a S T E MI/ N S T E MI a n d a n O MI/ N O MI i nter ve nti o n gr o u p will be f or me d. After 
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
a n gi o gra p h y a n d pri mar y P CI c o u nts i n t he past year).   
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
or a car di ol o gist) will be pr o vi de d wit h a n AI- p o were d a p plicati o n f or E C G dia g n osis. T hese 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
O MI. If a S T E MI tea m me m ber is o n- d ut y, t he E C G i nter pretati o n will be disa ble d a n d will 
rea d “f oll o w sta n dar d care”. T he patie nt will t h us be electe d t o g o f or cat heterizati o n base d o n 
t his a p pr oac h a n d, w het her t hat is b y O MI or S T E MI para di g m, t he patie nt will be e nr olle d 
acc or di n gl y a n d t he reas o n f or pr ocee di n g t o t he cat heterizati o n la b orat or y will be writte n o n 
t he st u d y f or m ( or electr o nic s heet o n t he de dicate d we bsite).  
I n t he S T E MI/ N S T E MI ar m, t he c o ntri b ut ors will bli n dl y c o nti n ue t heir us ual 
practice, t he E C G i nter pretati o n a n d decisi o n t o acti vate t he cat heterizati o n la b orat or y will be 
d o ne as us ual. T he S T E MI/ N S T E MI gr o u p will use t he f oll o wi n g criteria f or t he dia g n osis of 
DI F O C C U L T- 3 St u d y 
rec o g nizi n g t he si g ns of A C O n ot f ulfilli n g t he c urre nt S T E MI criteria, t o s us pe n d e mer ge nt 
DI F O C C U L T- 3 St u d y 
rec o g nizi n g t he si g ns of A C O n ot f ulfilli n g t he c urre nt S T E MI criteria, t o s us pe n d e mer ge nt 
re perf usi o n t hera p y after a n O MI dia g n osis has bee n ma de. T heref ore, t he E C G i nter preters 
DI F O C C U L T- 3 St u d y 
re perf usi o n t hera p y after a n O MI dia g n osis has bee n ma de. T heref ore, t he E C G i nter preters 
w h o are trai ne d i n O MI dia g n osis ca n n ot be ra n d o mize d t o S T E MI/ N S T E MI vers us 
DI F O C C U L T- 3 St u d y 
w h o are trai ne d i n O MI dia g n osis ca n n ot be ra n d o mize d t o S T E MI/ N S T E MI vers us 
O MI/ N O MI a p pr oac hes. He nce, we will ra n d o mize t he gr o u ps i n t he f oll o wi n g fas hi o n: I n 
DI F O C C U L T- 3 St u d y 
O MI/ N O MI a p pr oac hes. He nce, we will ra n d o mize t he gr o u ps i n t he f oll o wi n g fas hi o n: I n 
eac h ce nter, a S T E MI/ N S T E MI a n d a n O MI/ N O MI i nter ve nti o n gr o u p will be f or me d. After 
DI F O C C U L T- 3 St u d y 
eac h ce nter, a S T E MI/ N S T E MI a n d a n O MI/ N O MI i nter ve nti o n gr o u p will be f or me d. After 
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
DI F O C C U L T- 3 St u d y 
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
DI F O C C U L T- 3 St u d y 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
DI F O C C U L T- 3 St u d y 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
DI F O C C U L T- 3 St u d y 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
a n gi o gra p h y a n d pri mar y P CI c o u nts i n t he past year).   
DI F O C C U L T- 3 St u d y 
a n gi o gra p h y a n d pri mar y P CI c o u nts i n t he past year).   
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
DI F O C C U L T- 3 St u d y 
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
DI F O C C U L T- 3 St u d y 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
or a car di ol o gist) will be pr o vi de d wit h a n 
DI F O C C U L T- 3 St u d y 
or a car di ol o gist) will be pr o vi de d wit h a n 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
DI F O C C U L T- 3 St u d y 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
DI F O C C U L T- 3 St u d y 
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
O MI. If a S T E MI tea m me m ber is o n- d ut y, t he E C G i nter pretati o n will be disa ble d a n d 
DI F O C C U L T- 3 St u d y 
O MI. If a S T E MI tea m me m ber is o n- d ut y, t he E C G i nter pretati o n will be disa ble d a n d 
rea d “f oll o w sta n dar d care”. T he patie nt will t h us be 
DI F O C C U L T- 3 St u d y 
rea d “f oll o w sta n dar d care”. T he patie nt will t h us be 
C o nfi d e nti al 
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
C o nfi d e nti al 
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
C o nfi d e nti al 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
C o nfi d e nti al 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
C o nfi d e nti al 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
a n gi o gra p h y a n d pri mar y P CI c o u nts i n t he past year).   
C o nfi d e nti al 
a n gi o gra p h y a n d pri mar y P CI c o u nts i n t he past year).   
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
C o nfi d e nti al 
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
C o nfi d e nti al 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
or a car di ol o gist) will be pr o vi de d wit h a n 
C o nfi d e nti al 
or a car di ol o gist) will be pr o vi de d wit h a n 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
C o nfi d e nti al 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
C o nfi d e nti al 
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
C o nfi d e nti al 
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
Pl e a s e d o n ot di stri b ut e
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
Pl e a s e d o n ot di stri b ut e
t hese t w o gr o u ps are f or me d, t he patie nts will be bl oc k-ra n d o mize d i nt o S T E MI/ N S T E MI a n d 
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
Pl e a s e d o n ot di stri b ut e
O MI/ N O MI c o h orts acc or di n g t o t he tea m o n- d ut y, i.e., t he a p pr oac h t hat ce nter will f oll o w 
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
Pl e a s e d o n ot di stri b ut e
o n a certai n da y will be defi ne d b y t he tea m o n d ut y. T he i nter ve nti o nal car di ol o gists i n b ot h 
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
Pl e a s e d o n ot di stri b ut e
gr o u ps will be e ns ure d t o ha ve a si milar e x perie nce le vel (i n ter ms of years of trai ni n g, a n d 
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
Pl e a s e d o n ot di stri b ut e
All p ossi ble first res p o n ders i n t he net w or k of a st u d y ce nter ( w h o c o ntact t he patie nt 
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
Pl e a s e d o n ot di stri b ut e
first, acc or di n g t o t he ce nter t his ca n be eit her a referri n g p h ysicia n, a n e mer ge nc y p h ysicia n 
- p o were d a p plicati o n f or E C G dia g n osis. T hese 
Pl e a s e d o n ot di stri b ut e
- p o were d a p plicati o n f or E C G dia g n osis. T hese 
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
Pl e a s e d o n ot di stri b ut e
res p o n ders will recei ve dia g n ostic pr o m pts fr o m t he a p plicati o n acc or di n g t o t he ce nter’s o n-
Pl e a s e d o n ot di stri b ut e
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
Pl e a s e d o n ot di stri b ut e
d ut y tea m. If a n O MI tea m me m ber is o n d ut y, t he E C G i nter pretati o n will be O MI or n ot-
O MI. If a S T E MI tea m me m ber is o n- d ut y, t he E C G i nter pretati o n will be disa ble d a n d 
Pl e a s e d o n ot di stri b ut e
O MI. If a S T E MI tea m me m ber is o n- d ut y, t he E C G i nter pretati o n will be disa ble d a n d 
rea d “f oll o w sta n dar d care”. T he patie nt will t h us be 
Pl e a s e d o n ot di stri b ut e
rea d “f oll o w sta n dar d care”. T he patie nt will t h us be 
t his a p pr oac h a n d, w het her t hat is b y O MI or S T E MI para di g m, t he patie nt will be e nr olle d 
Pl e a s e d o n ot di stri b ut e
t his a p pr oac h a n d, w het her t hat is b y O MI or S T E MI para di g m, t he patie nt will be e nr olle d 
Pl e a s e d o n ot di stri b ut e
acc or di n gl y a n d t he reas o n f or pr ocee di n g t o t he cat heterizati o n la b orat or y will be writte n o n 
Pl e a s e d o n ot di stri b ut e
acc or di n gl y a n d t he reas o n f or pr ocee di n g t o t he cat heterizati o n la b orat or y will be writte n o n 
t he st u d y f or m ( or electr o nic s heet o n t he de dicate d we bsite).  
Pl e a s e d o n ot di stri b ut e
t he st u d y f or m ( or electr o nic s heet o n t he de dicate d we bsite).  
I n t he S T E MI/ N S T E MI ar m, t he c o ntri b ut ors will bli n dl y c o nti n ue t heir us ual 
Pl e a s e d o n ot di stri b ut e
I n t he S T E MI/ N S T E MI ar m, t he c o ntri b ut ors will bli n dl y c o nti n ue t heir us ual 

S T E MI: ( 1) Ne w S T-se g me nt ele vati o n at t he J- p oi nt i n t w o c o nti g u o us lea ds wit h t he c ut-
p oi nt: ≥ 1 m m i n all lea ds ot her t ha n lea ds V 2 – V 3 w here t he f oll o wi n g c ut- p oi nts a p pl y: ≥2 
m m i n me n ≥4 0 years; ≥2. 5 m m i n me n < 4 0 years, or ≥1. 5 m m i n w o me n re gar dless of a ge, 
a n d ( 2) a pea k tr o p o ni n le vel a b o ve 9 9t h perce ntile wit h a c haracteristic ra pi d rise a n d fall 
(retr os pecti vel y) a n d ( 3) a cli nical pict ure c o m pati ble wit h ac ute c or o nar y s y n dr o me. If t he 
decisi o n t o pr ocee d t o t he cat h la b was d o ne o nl y wit h t he first criteri o n, t he partici pa nt will 
re mai n i n t he st u d y, e ve n if t he sec o n d criteri o n is n ot met. T he patie nts meeti n g o nl y criteria 
( 2) a n d ( 3) will be classifie d as N S T E MI.  
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
t he i nter ve nti o nalist o n d ut y.  A dj u nct m o dalities i ncl u de be dsi de ec h ocar di o gra p h y 
de m o nstrati n g ne w or pres u me d ne w wall m oti o n a b n or malities i n patie nts wit h o n g oi n g or 
rec urre nt c hest pai n, a n d si g nifica ntl y ele vate d i nitial tr o p o ni n le vels. F or hi g h-se nsiti ve 
car diac tr o p o ni n ( hs-c T n) T, it has bee n s h o w n t hat a le vel e xcee di n g 1 0 0 0 n g. m L - 1 is hi g hl y 
s pecific f or maj or e picar dial c or o nar y arter y occl usi o n. Si milarl y, a hs-c T n I > 2 0 0 ti mes t he 
u p per li mit of n or mal (e. g., Arc hitect, A b b ott Dia g n ostics, Illi n ois, U S A: 5 0 0 0 n g/ L; A D VI A 
Ce nta ur, Sie me ns Healt hcare, Tarr yt o w n, U S A: 5 0 0 0 n g/ L; Access, Bec k ma n C o ulter, Brea, 
U S A: 2 4 0 0 n g/ L) is defi ne d as a mar ker f or O MI i n patie nts wit h o n g oi n g or fl uct uati n g c hest 
pai n. I n patie nts dia g n ose d wit h O MI, i m me diate cat heterizati o n la b orat or y acti vati o n wit h 
DI F O C C U L T- 3 St u d y 
d ( 2) a pea k tr o p o ni n le vel a b o ve 9 9t h perce ntile wit h a c haracteristic ra pi d rise a n d fall 
DI F O C C U L T- 3 St u d y 
d ( 2) a pea k tr o p o ni n le vel a b o ve 9 9t h perce ntile wit h a c haracteristic ra pi d rise a n d fall 
(retr os pecti vel y) a n d ( 3) a cli nical pict ure c o m pati ble wit h ac ute c or o nar y s y n dr o me. If t he 
DI F O C C U L T- 3 St u d y 
(retr os pecti vel y) a n d ( 3) a cli nical pict ure c o m pati ble wit h ac ute c or o nar y s y n dr o me. If t he 
decisi o n t o pr ocee d t o t he cat h la b was d o ne o nl y wit h t he first criteri o n, t he partici pa nt will 
DI F O C C U L T- 3 St u d y 
decisi o n t o pr ocee d t o t he cat h la b was d o ne o nl y wit h t he first criteri o n, t he partici pa nt will 
re mai n i n t he st u d y, e ve n if t he sec o n d criteri o n is n ot met. T he patie nts meeti n g o nl y criteria 
DI F O C C U L T- 3 St u d y 
re mai n i n t he st u d y, e ve n if t he sec o n d criteri o n is n ot met. T he patie nts meeti n g o nl y criteria 
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
DI F O C C U L T- 3 St u d y 
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
DI F O C C U L T- 3 St u d y 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
DI F O C C U L T- 3 St u d y 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
DI F O C C U L T- 3 St u d y 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
DI F O C C U L T- 3 St u d y 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
DI F O C C U L T- 3 St u d y 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
DI F O C C U L T- 3 St u d y 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
DI F O C C U L T- 3 St u d y 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
DI F O C C U L T- 3 St u d y 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
t he i nter ve nti o nalist o n d ut y.
DI F O C C U L T- 3 St u d y 
t he i nter ve nti o nalist o n d ut y.
de m o nstrati n g ne w or pres u me d ne w wall m oti o n a b n or malities i n patie nts wit h o n g oi n g or 
DI F O C C U L T- 3 St u d y 
de m o nstrati n g ne w or pres u me d ne w wall m oti o n a b n or malities i n patie nts wit h o n g oi n g or 
rec urre nt c hest pai n, a n d si g nifica ntl y ele vate d i nitial tr o p o ni n le vels. F or hi g h-se nsiti v
DI F O C C U L T- 3 St u d y 
rec urre nt c hest pai n, a n d si g nifica ntl y ele vate d i nitial tr o p o ni n le vels. F or hi g h-se nsiti v
C o nfi d e nti al 
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
C o nfi d e nti al 
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
C o nfi d e nti al 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
C o nfi d e nti al 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
C o nfi d e nti al 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
C o nfi d e nti al 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
C o nfi d e nti al 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
C o nfi d e nti al 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
C o nfi d e nti al 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
C o nfi d e nti al 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
t he i nter ve nti o nalist o n d ut y.
C o nfi d e nti al 
t he i nter ve nti o nalist o n d ut y. A dj u nct m o dalities i ncl u de be dsi de ec h ocar di o gra p h y 
C o nfi d e nti al 
A dj u nct m o dalities i ncl u de be dsi de ec h ocar di o gra p h y 
Pl e a s e d o n ot di stri b ut e
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
Pl e a s e d o n ot di stri b ut e
I n t he O MI/ N O MI gr o u p, t he dia g n osis of O MI ca n be base d o n cli nical gestalt, E C G 
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
Pl e a s e d o n ot di stri b ut e
fi n di n gs, a n d a dj u nct m o dalities. Cli nical gestalt i ncl u des hall mar k prese ntati o ns s uc h as 
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
Pl e a s e d o n ot di stri b ut e
al m ost pat h o g n o m o nic c hest pai n, a n d isc he mic arr h yt h mias, he m o d y na mic i nsta bilit y, or 
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
Pl e a s e d o n ot di stri b ut e
car diac arrest f oll o wi n g t y pical s y m pt o ms. E C G dia g n osis, w het her i nter prete d b y p h ysicia ns 
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
Pl e a s e d o n ot di stri b ut e
or ai de d b y a n AI- p o were d s mart p h o ne a p plicati o n, i nc or p orates static or serial c ha n ges f or 
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
Pl e a s e d o n ot di stri b ut e
A C O usi n g t he DI F O C C U L T- 1 st u d y al g orit h m ( Asla n ger et al. I n J Car di ol Heart Vasc, 
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
Pl e a s e d o n ot di stri b ut e
2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). O n 
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
Pl e a s e d o n ot di stri b ut e
O MI/ N O MI da ys, t he s mart p h o ne a p plicati o n is acti vate d a n d a vaila ble t o all first res p o n ders 
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
Pl e a s e d o n ot di stri b ut e
ass ociate d wit h t his ce nter. T his a p plicati o n assists dia g n osis, b ut t he fi nal decisi o n is left t o 
A dj u nct m o dalities i ncl u de be dsi de ec h ocar di o gra p h y 
Pl e a s e d o n ot di stri b ut e
A dj u nct m o dalities i ncl u de be dsi de ec h ocar di o gra p h y 
de m o nstrati n g ne w or pres u me d ne w wall m oti o n a b n or malities i n patie nts wit h o n g oi n g or 
Pl e a s e d o n ot di stri b ut e
de m o nstrati n g ne w or pres u me d ne w wall m oti o n a b n or malities i n patie nts wit h o n g oi n g or 
Pl e a s e d o n ot di stri b ut e
rec urre nt c hest pai n, a n d si g nifica ntl y ele vate d i nitial tr o p o ni n le vels. F or hi g h-se nsiti v
Pl e a s e d o n ot di stri b ut e
rec urre nt c hest pai n, a n d si g nifica ntl y ele vate d i nitial tr o p o ni n le vels. F or hi g h-se nsiti v
car diac tr o p o ni n ( hs-c T n) T, it has bee n s h o w n t hat a le vel e xcee di n g 1 0 0 0 n g.
Pl e a s e d o n ot di stri b ut e
car diac tr o p o ni n ( hs-c T n) T, it has bee n s h o w n t hat a le vel e xcee di n g 1 0 0 0 n g.
s pecific f or maj or e picar dial c or o nar y arter y occl usi o n. Si milarl y, a hs-c
Pl e a s e d o n ot di stri b ut e
s pecific f or maj or e picar dial c or o nar y arter y occl usi o n. Si milarl y, a hs-c
u p per li mit of n or mal (e. g., Arc hitect, A b b ott Dia g n ostics, Illi n ois, 
Pl e a s e d o n ot di stri b ut e
u p per li mit of n or mal (e. g., Arc hitect, A b b ott Dia g n ostics, Illi n ois, 
Ce nta ur, Sie me ns Healt hcare, Tarr yt o w n, 
Pl e a s e d o n ot di stri b ut e
Ce nta ur, Sie me ns Healt hcare, Tarr yt o w n, 

t he i nte nt t o perf or m P CI is p urs ue d. I n N O MI patie nts, i nitial me dical sta bilizati o n is 
pri oritize d, f oll o we d b y electi ve cat heterizati o n per t he N S T E MI pat h wa y u nless hi g h-ris k 
feat ures are i de ntifie d. 
S T E MI a n d O MI patie nts ( will be ta ke n as S T E MI e q ui vale nts f or t hera pe utic 
p ur p oses) will be ma na ge d acc or di n g t o t he c urre nt S T E MI g ui deli nes, w hereas N S T E MI a n d 
N O MI patie nts are ma na ge d acc or di n g t o t he c urre nt N S T E MI g ui deli nes. A se parate 
dia g n ostic gr o u p wit h ‘ pr o ba ble O MI’ a n d ‘ hi g h-ris k S T E MI’ is als o all o we d f or patie nts w h o 
d o n ot f ulfil S T E MI/ O MI criteria b ut nee d ur ge nt cat heterizati o n f or ot her hi g h-ris k feat ures 
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
st u d y.       
E n d p oi nts 
T he pri mar y c o m p osite e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n d uri n g 
f oll o w- u p. T he c o- pri mar y e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n i n 
O MI ( +) S T E MI (-) patie nt s u b gr o u ps. T he sec o n dar y c o m paris o ns will be d o ne f or t he 
prese nce of A C O o n a n gi o gra m, false p ositi ve cat heterizati o n la b orat or y acti vati o n rate, t he 
i nfarct size as defi ne d b y 2 4- 7 2 h o ur pea k tr o p o ni n, wall m oti o n sc ore i n de x ( W M SI), left 
DI F O C C U L T- 3 St u d y 
S T E MI a n d O MI patie nts ( will be ta ke n as S T E MI e q ui vale nts f or t hera pe utic 
DI F O C C U L T- 3 St u d y 
S T E MI a n d O MI patie nts ( will be ta ke n as S T E MI e q ui vale nts f or t hera pe utic 
p ur p oses) will be ma na ge d acc or di n g t o t he c urre nt S T E MI g ui deli nes, w hereas N S T E MI a n d 
DI F O C C U L T- 3 St u d y 
p ur p oses) will be ma na ge d acc or di n g t o t he c urre nt S T E MI g ui deli nes, w hereas N S T E MI a n d 
N O MI patie nts are ma na ge d acc or di n g t o t he c urre nt N S T E MI g ui deli nes. A se parate 
DI F O C C U L T- 3 St u d y 
N O MI patie nts are ma na ge d acc or di n g t o t he c urre nt N S T E MI g ui deli nes. A se parate 
dia g n ostic gr o u p wit h ‘ pr o ba ble O MI’ a n d ‘ hi g h-ris k S T E MI’ is als o all o we d f or patie nts w h o 
DI F O C C U L T- 3 St u d y 
dia g n ostic gr o u p wit h ‘ pr o ba ble O MI’ a n d ‘ hi g h-ris k S T E MI’ is als o all o we d f or patie nts w h o 
d o n ot f ulfil S T E MI/ O MI criteria b ut nee d ur ge nt cat heterizati o n f or ot her hi g h-ris k feat ures 
DI F O C C U L T- 3 St u d y 
d o n ot f ulfil S T E MI/ O MI criteria b ut nee d ur ge nt cat heterizati o n f or ot her hi g h-ris k feat ures 
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
DI F O C C U L T- 3 St u d y 
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
DI F O C C U L T- 3 St u d y 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
DI F O C C U L T- 3 St u d y 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
DI F O C C U L T- 3 St u d y 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
DI F O C C U L T- 3 St u d y 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
DI F O C C U L T- 3 St u d y 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
DI F O C C U L T- 3 St u d y 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
DI F O C C U L T- 3 St u d y 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
DI F O C C U L T- 3 St u d y 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
DI F O C C U L T- 3 St u d y 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
st u d y.       
DI F O C C U L T- 3 St u d y 
st u d y.       
C o nfi d e nti al 
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
C o nfi d e nti al 
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
C o nfi d e nti al 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
C o nfi d e nti al 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
C o nfi d e nti al 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
C o nfi d e nti al 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
C o nfi d e nti al 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
C o nfi d e nti al 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
C o nfi d e nti al 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
C o nfi d e nti al 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
C o nfi d e nti al 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
Pl e a s e d o n ot di stri b ut e
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
Pl e a s e d o n ot di stri b ut e
or hi g h cli nical s us pici o n f or ha vi n g a n A C O. T hese patie nts will als o be ma na ge d acc or di n g 
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
Pl e a s e d o n ot di stri b ut e
t o t he c urre nt g ui deli nes. H o we ver, patie nts will be e xcl u de d fr o m a nal ysis if t heir earl y 
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
Pl e a s e d o n ot di stri b ut e
cat heterizati o n is base d s olel y o n s ocial or l o gistical c o nsi derati o ns, a n d n ot base d o n t he 
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
Pl e a s e d o n ot di stri b ut e
me dical nee d.  F or e xa m ple, a patie nt w o ul d be e xcl u de d if he/s he is br o u g ht t o t he cat h la b 
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
Pl e a s e d o n ot di stri b ut e
earl y base d o n t he i m me diate a vaila bilit y of cat h la b or beca use t he patie nt is alrea d y 
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
Pl e a s e d o n ot di stri b ut e
sc he d ule d f or electi ve c or o nar y a n gi o gra p h y. T he patie nts w h o ha ve alter nati ve dia g n oses 
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
Pl e a s e d o n ot di stri b ut e
( m y ocar ditis, pericar ditis, p ul m o nar y e m b olis m etc.) b ut were n ot i ncl u de d d ue t o a cli nical or 
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
Pl e a s e d o n ot di stri b ut e
E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he st u d y. 
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
Pl e a s e d o n ot di stri b ut e
Si milarl y, t he patie nts wit h o ut a c haracteristic tr o p o ni n ki netics w h o were n ot i ncl u de d d ue t o 
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
Pl e a s e d o n ot di stri b ut e
a cli nical or E C G dia g n osis of S T E MI/ N S T E MI or O MI/ N O MI will be e xcl u de d fr o m t he 
Pl e a s e d o n ot di stri b ut e
T he pri mar y c o m p osite e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n d uri n g 
Pl e a s e d o n ot di stri b ut e
T he pri mar y c o m p osite e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n d uri n g 
f oll o w- u p. T he c o- pri mar y e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n i n 
Pl e a s e d o n ot di stri b ut e
f oll o w- u p. T he c o- pri mar y e n d p oi nt is all-ca use m ortalit y a n d all-ca use re- h os pitalizati o n i n 
O MI ( +) S T E MI (-) patie nt s u b gr o u ps. T he sec o n dar y c o m paris o ns will be d o ne f or t he 
Pl e a s e d o n ot di stri b ut e
O MI ( +) S T E MI (-) patie nt s u b gr o u ps. T he sec o n dar y c o m paris o ns will be d o ne f or t he 

ve ntric ular ejecti o n fracti o n ( L V E F), i n- h os pital C P R, i nt u bati o n a n d m ortalit y. T hese will be 
a nal yze d b ot h wit h i nte nti o n t o treat a n d per pr ot oc ol a p pr oac hes. 
T o defi ne t his s u b gr o u p i n t he O MI/ N O MI ar m, all E C Gs dia g n ose d as O MI d uri n g 
t he st u d y will be ra n d o ml y assi g ne d t o researc hers i n t he S T E MI/ N S T E MI ar m after st u d y 
c o m pleti o n. T he researc hers will t he n assess w het her t he E C G is c o m pati ble wit h S T E MI or 
N S T E MI. Patie nts dia g n ose d as N S T E MI wit hi n t he O MI gr o u p will be classifie d as t he O MI 
( +) N S T E MI s u b gr o u p i n t he O MI/ N O MI ar m. I n t he S T E MI/ N S T E MI ar m, patie nts 
dia g n ose d wit h N S T E MI will ha ve t heir E C Gs sca n ne d a n d i nter prete d b y t he AI- p o were d 
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
O MI b y t he AI- p o were d a p plicati o n. 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
(e- n a bız), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
nati o n wi de. T o e ns ure t he c o m plete ness a n d acc urac y of data, direct p h o ne c o ntact wit h 
partici pa nts or t heir fa milies will be c o n d ucte d as a sec o n dar y meas ure. All c ollecte d 
o utc o mes will be re vie we d b y a n i n de pe n de nt o utc o me a dj u dicati o n b oar d bli n de d t o t he st u d y 
ar ms. 
Esti m ate d n u m ber of s u bjects t o be s u b mitte d:
We esti mate d t hat t he e nr oll me nt of 3 4 7 2 partici pa nts w o ul d pr o vi de t he st u d y wit h a statistical 
p o wer of 9 5 % t o detect a 4 % a bs ol ute decrease i n c o m bi ne d pri mar y e n d p oi nt i n O MI/ N O MI 
DI F O C C U L T- 3 St u d y 
t he st u d y will be ra n d o ml y assi g ne d t o researc hers i n t he S T E MI/ N S T E MI ar m after st u d y 
DI F O C C U L T- 3 St u d y 
t he st u d y will be ra n d o ml y assi g ne d t o researc hers i n t he S T E MI/ N S T E MI ar m after st u d y 
c o m pleti o n. T he researc hers will t he n assess w het her t he E C G is c o m pati ble wit h S T E MI or 
DI F O C C U L T- 3 St u d y 
c o m pleti o n. T he researc hers will t he n assess w het her t he E C G is c o m pati ble wit h S T E MI or 
T E MI. Patie nts dia g n ose d as N S T E MI wit hi n t he O MI gr o u p will be classifie d as t he O MI 
DI F O C C U L T- 3 St u d y 
T E MI. Patie nts dia g n ose d as N S T E MI wit hi n t he O MI gr o u p will be classifie d as t he O MI 
( +) N S T E MI s u b gr o u p i n t he O MI/ N O MI ar m. I n t he S T E MI/ N S T E MI ar m, patie nts 
DI F O C C U L T- 3 St u d y 
( +) N S T E MI s u b gr o u p i n t he O MI/ N O MI ar m. I n t he S T E MI/ N S T E MI ar m, patie nts 
dia g n ose d wit h N S T E MI will ha ve t heir E C Gs sca n ne d a n d i nter prete d b y t he AI- p o were d 
DI F O C C U L T- 3 St u d y 
dia g n ose d wit h N S T E MI will ha ve t heir E C Gs sca n ne d a n d i nter prete d b y t he AI- p o were d 
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
DI F O C C U L T- 3 St u d y 
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
DI F O C C U L T- 3 St u d y 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
DI F O C C U L T- 3 St u d y 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
DI F O C C U L T- 3 St u d y 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
DI F O C C U L T- 3 St u d y 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
DI F O C C U L T- 3 St u d y 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
DI F O C C U L T- 3 St u d y 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
O MI b y t he AI- p o were d a p plicati o n. 
DI F O C C U L T- 3 St u d y 
O MI b y t he AI- p o were d a p plicati o n. 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
DI F O C C U L T- 3 St u d y 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
(
DI F O C C U L T- 3 St u d y 
(e- n a bız
DI F O C C U L T- 3 St u d y 
e- n a bız), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
DI F O C C U L T- 3 St u d y 
), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
nati o n wi de. T o e ns ure t he c o m plete ness a n d acc urac y of data, direct p h o ne c o ntact wit h 
DI F O C C U L T- 3 St u d y 
nati o n wi de. T o e ns ure t he c o m plete ness a n d acc urac y of data, direct p h o ne c o ntact wit h 
partici pa nts or t heir fa milies will be c o n d ucte d as a sec o n dar y meas ure. All c ollecte d 
DI F O C C U L T- 3 St u d y 
partici pa nts or t heir fa milies will be c o n d ucte d as a sec o n dar y meas ure. All c ollecte d 
C o nfi d e nti al 
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
C o nfi d e nti al 
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
C o nfi d e nti al 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
C o nfi d e nti al 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
C o nfi d e nti al 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
C o nfi d e nti al 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
C o nfi d e nti al 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
C o nfi d e nti al 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
O MI b y t he AI- p o were d a p plicati o n. 
C o nfi d e nti al 
O MI b y t he AI- p o were d a p plicati o n. 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
C o nfi d e nti al 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
C o nfi d e nti al 
), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
C o nfi d e nti al 
), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
Pl e a s e d o n ot di stri b ut e
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
Pl e a s e d o n ot di stri b ut e
a p plicati o n. If t he E C G is i nter prete d as O MI, t hese patie nts will be i ncl u de d i n t he O MI ( +) 
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
Pl e a s e d o n ot di stri b ut e
N S T E MI s u b gr o u p wit hi n t he S T E MI/ N S T E MI ar m. T he O MI dia g n osis als o i ncl u des cli nical 
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
Pl e a s e d o n ot di stri b ut e
varia bles, s uc h as cli nical gestalt a n d ver y hi g h first tr o p o ni n le vels. H o we ver, cli nical gestalt 
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
Pl e a s e d o n ot di stri b ut e
ca n n ot be acte d u p o n retr os pecti vel y (e. g., be dsi de ec h ocar di o gra p h y or serial E C Gs). 
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
Pl e a s e d o n ot di stri b ut e
Ne vert heless, if a patie nt is rec or de d wit h o n g oi n g c hest pai n a n d a ver y hi g h first tr o p o ni n 
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
Pl e a s e d o n ot di stri b ut e
le vel ( base d o n ce nter-s pecific a n d tr o p o ni n kit-s pecific val ues), t his will be i ncl u de d i n t he 
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
Pl e a s e d o n ot di stri b ut e
O MI ( +) N S T E MI s u b gr o u p i n t he S T E MI/ N S T E MI ar m, e ve n if t he E C G is n ot i nter prete d as 
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
Pl e a s e d o n ot di stri b ut e
T he pri mar y s o urce of o utc o me data will be t he T ur kis h nati o nal electr o nic data base 
Pl e a s e d o n ot di stri b ut e
), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
Pl e a s e d o n ot di stri b ut e
), w hic h pr o vi des c o m pre he nsi ve, real-ti me u p dates o n all deat hs a n d h os pitalizati o ns 
nati o n wi de. T o e ns ure t he c o m plete ness a n d acc urac y of data, direct p h o ne c o ntact wit h 
Pl e a s e d o n ot di stri b ut e
nati o n wi de. T o e ns ure t he c o m plete ness a n d acc urac y of data, direct p h o ne c o ntact wit h 
partici pa nts or t heir fa milies will be c o n d ucte d as a sec o n dar y meas ure. All c ollecte d 
Pl e a s e d o n ot di stri b ut e
partici pa nts or t heir fa milies will be c o n d ucte d as a sec o n dar y meas ure. All c ollecte d 
o utc o mes will be re vie we d b y a n i n de pe n de nt o utc o me a dj u dicati o n b oar d bli n de d t o t he st u d y 
Pl e a s e d o n ot di stri b ut e
o utc o mes will be re vie we d b y a n i n de pe n de nt o utc o me a dj u dicati o n b oar d bli n de d t o t he st u d y 
Esti m ate d n u m ber of s u bjects t o be s u b mitte d:
Pl e a s e d o n ot di stri b ut e
Esti m ate d n u m ber of s u bjects t o be s u b mitte d:

a p pr oac h c o m pare d t o S T E MI/ N S T E MI a p pr oac h (fr o m 2 5 % t o 2 1 %) wit h t he use of a t w o-
si de d  test  at  t he  0. 0 5  le vel,  wit h  a  pre dicti o n  of  a n  a d diti o nal  3 0 %  O MI  i n  N S T E MI 
c o h ort. Si milarl y, 2 3 5 1 partici pa nts w o ul d be necessar y t o detect a 5 % differe nce i n area u n der 
c ur ve  ( A U C,  fr o m  0. 7 5 0  t o  0. 7 0 0)  f or  t he  c o m paris o n  of  t he  pre dicti ve  acc urac y  of  t w o 
a p pr oac hes f or pri mar y o utc o mes. F or t he c o- pri mar y o utc o me, a t otal of 8 8 0 O MI ( +) S T E MI 
(-) partici pa nts w o ul d pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect a 5 0 % relati ve 
decrease i n c o m bi ne d pri mar y e n d p oi nt i n O MI/ N O MI a p pr oac h c o m pare d t o S T E MI/ N S T E MI 
a p pr oac h (fr o m 2 0 % t o 1 3 %) wit h t he use of a t w o-si de d test at t he 0. 0 5 le vel. T his c orres p o n ds 
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. T his t otal n u m ber 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
wall- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
3. Ce nters a n d Pers o n nel  
T he patie nt e nr oll me nt will ta ke place i n t he f oll o wi n g ce nters:  
-
A n k ar a Etli k City H os pit al 
C hief i nvesti g at or: Bel m a K al aycı 
-
A nt aly a City H os pit al 
C hief i nvesti g at or: D urs u n Ak asl a n 
-
B a gcil ar Tr ai ni n g a n d Rese arc h H os pit al 
C hief i nvesti g at or: Esr a D ö n mez 
DI F O C C U L T- 3 St u d y 
c ur ve  ( A U C,  fr o m  0. 7 5 0  t o  0. 7 0 0)  f or  t he  c o m paris o n  of  t he  pre dicti ve  acc urac y  of  t w o 
DI F O C C U L T- 3 St u d y 
c ur ve  ( A U C,  fr o m  0. 7 5 0  t o  0. 7 0 0)  f or  t he  c o m paris o n  of  t he  pre dicti ve  acc urac y  of  t w o 
a p pr oac hes f or pri mar y o utc o mes. F or t he c o- pri mar y o utc o me, a t otal of 8 8 0 O MI ( +) S T E MI 
DI F O C C U L T- 3 St u d y 
a p pr oac hes f or pri mar y o utc o mes. F or t he c o- pri mar y o utc o me, a t otal of 8 8 0 O MI ( +) S T E MI 
(-) partici pa nts w o ul d pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect a 5 0 % relati ve 
DI F O C C U L T- 3 St u d y 
(-) partici pa nts w o ul d pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect a 5 0 % relati ve 
decrease i n c o m bi ne d pri mar y e n d p oi nt i n O MI/ N O MI a p pr oac h c o m pare d t o S T E MI/ N S T E MI 
DI F O C C U L T- 3 St u d y 
decrease i n c o m bi ne d pri mar y e n d p oi nt i n O MI/ N O MI a p pr oac h c o m pare d t o S T E MI/ N S T E MI 
a p pr oac h (fr o m 2 0 % t o 1 3 %) wit h t he use of a t w o-si de d test at t he 0. 0 5 le vel. T his c orres p o n ds 
DI F O C C U L T- 3 St u d y 
a p pr oac h (fr o m 2 0 % t o 1 3 %) wit h t he use of a t w o-si de d test at t he 0. 0 5 le vel. T his c orres p o n ds 
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
DI F O C C U L T- 3 St u d y 
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
DI F O C C U L T- 3 St u d y 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
DI F O C C U L T- 3 St u d y 
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
DI F O C C U L T- 3 St u d y 
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
DI F O C C U L T- 3 St u d y 
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. 
DI F O C C U L T- 3 St u d y 
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
DI F O C C U L T- 3 St u d y 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
DI F O C C U L T- 3 St u d y 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
DI F O C C U L T- 3 St u d y 
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
DI F O C C U L T- 3 St u d y 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
DI F O C C U L T- 3 St u d y 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
3. Ce nters a n d Pers o n nel  
DI F O C C U L T- 3 St u d y 
3. Ce nters a n d Pers o n nel  
T he patie nt e nr oll me nt will ta ke place i n t he f oll o wi n g ce nters:  
DI F O C C U L T- 3 St u d y 
T he patie nt e nr oll me nt will ta ke place i n t he f oll o wi n g ce nters:  
C o nfi d e nti al 
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
C o nfi d e nti al 
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
C o nfi d e nti al 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
C o nfi d e nti al 
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
C o nfi d e nti al 
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
C o nfi d e nti al 
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. 
C o nfi d e nti al 
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
C o nfi d e nti al 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
C o nfi d e nti al 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
C o nfi d e nti al 
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
C o nfi d e nti al 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
C o nfi d e nti al 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
Pl e a s e d o n ot di stri b ut e
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
Pl e a s e d o n ot di stri b ut e
t o  a n  a p pr o xi mate  t otal  sa m ple  size  of  4 0 0 0  patie nts,  wit h  a  pre dicti o n  of  1: 1. 5- 2 
Pl e a s e d o n ot di stri b ut e
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
Pl e a s e d o n ot di stri b ut e
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
Pl e a s e d o n ot di stri b ut e
S T E MI/ N S T E MI rati o a n d a fre q ue nc y of 2 5 % O MI i n N S T E MI c o h ort. H o we ver, gi ve n t he 
Pl e a s e d o n ot di stri b ut e
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
Pl e a s e d o n ot di stri b ut e
pla n ne d o ne- year e nr oll me nt d urati o n a n d u ncertai nties re gar di n g t he treat me nt effect i n O MI 
Pl e a s e d o n ot di stri b ut e
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. 
Pl e a s e d o n ot di stri b ut e
patie nts, we deci de d t o tar get t he e nr oll me nt of 6, 0 0 0 patie nts f or t he st u d y. T h
Pl e a s e d o n ot di stri b ut e
T h is t otal n u m ber 
Pl e a s e d o n ot di stri b ut e
is t otal n u m ber 
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
Pl e a s e d o n ot di stri b ut e
is als o e x pecte d t o pr o vi de t he st u d y wit h a statistical p o wer of 9 5 % t o detect at least a 1 0 % 
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
Pl e a s e d o n ot di stri b ut e
relati ve  decrease  i n  i nfarct  size,  1 0 %  better  left  ve ntric ular  ejecti o n  fracti o n  a n d  1 0 %  better 
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
Pl e a s e d o n ot di stri b ut e
- m oti o n sc ore i n de x S T E MI (-) O MI ( +) patie nts w h o u n der we nt earl y re vasc ularizati o n i n 
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
Pl e a s e d o n ot di stri b ut e
O MI  ar m  c o m pare d  t o  t h ose  w h o  u n der we nt  re vasc ularizati o n  wit h  sta n dar d  ti mi n g  i n 
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
Pl e a s e d o n ot di stri b ut e
S T E MI/ N S T E MI a p pr oac h, wit h a pre dicti o n of a n a d diti o nal 2 5 % O MI i n N S T E MI c o h ort. 
Pl e a s e d o n ot di stri b ut e
T he patie nt e nr oll me nt will ta ke place i n t he f oll o wi n g ce nters:  
Pl e a s e d o n ot di stri b ut e
T he patie nt e nr oll me nt will ta ke place i n t he f oll o wi n g ce nters:  
A n k ar a Etli k City H os pit al 
Pl e a s e d o n ot di stri b ut e
A n k ar a Etli k City H os pit al 
C hief i nvesti g at or: Bel m a K al aycı 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: Bel m a K al aycı 
A nt aly a City H os pit al 
Pl e a s e d o n ot di stri b ut e
A nt aly a City H os pit al 
C hief i nvesti g at or: D urs u n Ak asl a n 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: D urs u n Ak asl a n 

-
B as a kse hir Pi ne a n d S a k ur a City H os pit al 
C hief i nvesti g at or: E mre Asl a n ger 
-
Dr. Siy a mi Erse k T h or acic a n d C ar di ov asc ul ar S ur gery Tr ai ni n g a n d Rese arc h 
H os pit al 
C hief i nvesti g at or: C a n Y ücel K ar a b ay 
-
Erz ur u m At at ür k U niversity, F ac ulty of Me dici ne, Rese arc h H os pit al 
C hief i nvesti g at or: O ğ uz h a n Bir d al  
-
Es kise hir Os m a n g azi U niversity H os pit al  
C hief i nvesti g at or: K a dir U ğ ur Mert   
-
Es kise hir City H os pit al  
C hief i nvesti g at or: Ez gi Ç a mlı B a b ayi ğit  
-
K art al K os uy ol u Tr ai ni n g a n d Rese arc h H os pit al  
C hief i nvesti g at or: Se d at K alk a n 
-
K ut a hy a He alt h Scie nces U niversity 
C hief i nvesti g at or: T a ner Şe n 
-
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
C hief i nvesti g at or: Zekeriy a D o ğ a n 
-
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
H os pit al    
C hief i nvesti g at or: Ü mit B ul ut 
-
M u gl a Sit ki K oc m a n U niversity
C hief i nvesti g at or: Özc a n B aş ar a n 
-
Nec metti n Er b a k a n Mer a m F ac ulty of Me dici ne H os pit al  
C hief i nvesti g at or: Me h met Akif D üze nli 
-
Sir n a k St ate H os pit al 
C hief i nvesti g at or: B arış G üve n 
DI F O C C U L T- 3 St u d y 
Erz ur u m At at ür k U niversity, F ac ulty of Me dici ne, Rese arc h H os pit al 
DI F O C C U L T- 3 St u d y 
Erz ur u m At at ür k U niversity, F ac ulty of Me dici ne, Rese arc h H os pit al 
H os pit al  
DI F O C C U L T- 3 St u d y 
H os pit al  
C hief i nvesti g at or: K a dir U ğ ur Mert   
DI F O C C U L T- 3 St u d y 
C hief i nvesti g at or: K a dir U ğ ur Mert   
C hief i nvesti g at or: Ez gi Ç a mlı B a b ayi ğit  
DI F O C C U L T- 3 St u d y 
C hief i nvesti g at or: Ez gi Ç a mlı B a b ayi ğit  
K art al K os uy ol u Tr ai ni n g a n d Rese arc h H os pit al  
DI F O C C U L T- 3 St u d y 
K art al K os uy ol u Tr ai ni n g a n d Rese arc h H os pit al  
C hief i nvesti g at or: Se d at K alk a n 
DI F O C C U L T- 3 St u d y 
C hief i nvesti g at or: Se d at K alk a n 
K ut a hy a He alt h Scie nces U niversity 
DI F O C C U L T- 3 St u d y 
K ut a hy a He alt h Scie nces U niversity 
C hief i nvesti g at or: T a ner Şe n 
DI F O C C U L T- 3 St u d y 
C hief i nvesti g at or: T a ner Şe n 
-
DI F O C C U L T- 3 St u d y 
-
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
DI F O C C U L T- 3 St u d y 
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
C hief i nvesti g at or: Zekeriy a D o ğ a n 
DI F O C C U L T- 3 St u d y 
C hief i nvesti g at or: Zekeriy a D o ğ a n 
-
DI F O C C U L T- 3 St u d y 
-
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
DI F O C C U L T- 3 St u d y 
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
C o nfi d e nti al 
K art al K os uy ol u Tr ai ni n g a n d Rese arc h H os pit al  
C o nfi d e nti al 
K art al K os uy ol u Tr ai ni n g a n d Rese arc h H os pit al  
K ut a hy a He alt h Scie nces U niversity 
C o nfi d e nti al 
K ut a hy a He alt h Scie nces U niversity 
C hief i nvesti g at or: T a ner Şe n 
C o nfi d e nti al 
C hief i nvesti g at or: T a ner Şe n 
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
C o nfi d e nti al 
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
C hief i nvesti g at or: Zekeriy a D o ğ a n 
C o nfi d e nti al 
C hief i nvesti g at or: Zekeriy a D o ğ a n 
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
C o nfi d e nti al 
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
Pl e a s e d o n ot di stri b ut e
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
Pl e a s e d o n ot di stri b ut e
M ar m ar a U niversity, Pe n di k Tr ai ni n g a n d Rese arc h H os pit al   
C hief i nvesti g at or: Zekeriy a D o ğ a n 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: Zekeriy a D o ğ a n 
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
Pl e a s e d o n ot di stri b ut e
Me h met A kif Ers oy C ar di ov asc ul ar a n d T hr o acic Tr ai ni n g a n d Rese arc h 
C hief i nvesti g at or: Ü mit B ul ut 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: Ü mit B ul ut 
gl a Si
Pl e a s e d o n ot di stri b ut e
gl a Si t k
Pl e a s e d o n ot di stri b ut e
t k
Pl e a s e d o n ot di stri b ut e
i K oc m a n 
Pl e a s e d o n ot di stri b ut e
i K oc m a n U niversity
Pl e a s e d o n ot di stri b ut e
U niversity
C hief i nvesti g at or: Özc a n B aş ar a n 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: Özc a n B aş ar a n 
Nec metti n Er b a k a n Mer a m F ac ulty of Me dici ne H os pit al  
Pl e a s e d o n ot di stri b ut e
Nec metti n Er b a k a n Mer a m F ac ulty of Me dici ne H os pit al  
C hief i nvesti g at or: Me h met Akif D üze nli 
Pl e a s e d o n ot di stri b ut e
C hief i nvesti g at or: Me h met Akif D üze nli 

-
T o k at G azi Os m a n P aş a U niversity H os pit al 
C hief i nvesti g at or: Ç a ğrı Z orl u 
-
V a n Tr ai ni n g a n d Rese arc h H os pit al  
C hief i nvesti g at or: Re mzi S arık ay a 
-
Y uz u nc u Yil U niversity H os pit al  
C hief i nvesti g at or: Y üksel K ay a 
4. D at a C ollecti o n 
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data is 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at a 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
ma n dat or y. A d at a m o nit ori n g b o ar d  e ns ures t he c o m plete ness, i nte grit y, a n d acc urac y of t he 
e ntries, pr o vi di n g fee d bac k t o t he data e ntr y tea m a n d re q uesti n g e x pla nati o ns or 
m o dificati o ns as nee de d. 
B aseli ne v ari a bles  
C ollecte d baseli ne varia bles a n d t heir defi niti o ns are liste d i n t he R E D Ca p pri nt o ut i n t he 
s u p ple me ntal file. I n brief, t he f oll o wi n g baseli ne varia bles will be e ntere d t o t he st u d y 
s prea ds heet: Ce nter s pecific e nr oll me nt n o., pr ot oc ol n o., c o h ort, a ge, ge n der, pri or hist or y of 
DI F O C C U L T- 3 St u d y 
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
DI F O C C U L T- 3 St u d y 
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
DI F O C C U L T- 3 St u d y 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data 
DI F O C C U L T- 3 St u d y 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
DI F O C C U L T- 3 St u d y 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
DI F O C C U L T- 3 St u d y 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
DI F O C C U L T- 3 St u d y 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
DI F O C C U L T- 3 St u d y 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
DI F O C C U L T- 3 St u d y 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
DI F O C C U L T- 3 St u d y 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
DI F O C C U L T- 3 St u d y 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
ma n dat or y. A 
DI F O C C U L T- 3 St u d y 
ma n dat or y. A 
e ntries, pr o vi di n g fee d bac k t o t he data e ntr y tea m a n d re q uesti n g e x pla nati o ns or 
DI F O C C U L T- 3 St u d y 
e ntries, pr o vi di n g fee d bac k t o t he data e ntr y tea m a n d re q uesti n g e x pla nati o ns or 
C o nfi d e nti al 
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
C o nfi d e nti al 
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
C o nfi d e nti al 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data 
C o nfi d e nti al 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
C o nfi d e nti al 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
C o nfi d e nti al 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
C o nfi d e nti al 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
C o nfi d e nti al 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
C o nfi d e nti al 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
C o nfi d e nti al 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
C o nfi d e nti al 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
Pl e a s e d o n ot di stri b ut e
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
Pl e a s e d o n ot di stri b ut e
Fr o m Se pte m ber 1, 2 0 2 4, AI- p o were d E C G A p p will be distri b ute d t o t he referri n g h os pitals 
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
Pl e a s e d o n ot di stri b ut e
b y t he partici pati n g ce nters. T he st u d y will start at all partici pati n g ce nters o n Oct o ber 1, 2 0 2 4. 
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data 
Pl e a s e d o n ot di stri b ut e
A de dicate d we bsite ( dif occ ult. or g) will be use d f or data e ntr y a n d st ora ge. St u d y data is 
Pl e a s e d o n ot di stri b ut e
is 
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
Pl e a s e d o n ot di stri b ut e
c ollecte d a n d ma na ge d usi n g R E D Ca p ( Researc h Electr o nic Data Ca pt ure) t o ol h oste d at 
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
Pl e a s e d o n ot di stri b ut e
de dicate d ser ver. R E D Ca p  is a sec ure, we b- base d s oft ware platf or m desi g ne d t o s u p p ort data 
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
Pl e a s e d o n ot di stri b ut e
ca pt ure f or researc h st u dies, pr o vi di n g ( 1) a n i nt uiti ve i nterface f or vali date d data ca pt ure; ( 2) 
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
Pl e a s e d o n ot di stri b ut e
a u dit trails f or trac ki n g data ma ni p ulati o n a n d e x p ort pr oce d ures; ( 3) a ut o mate d e x p ort 
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
Pl e a s e d o n ot di stri b ut e
pr oce d ures f or sea mless data d o w nl oa ds t o c o m m o n statistical pac ka ges; a n d ( 4) pr oce d ures 
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
Pl e a s e d o n ot di stri b ut e
f or data i nte grati o n a n d i nter o pera bilit y wit h e xter nal s o urces. T he researc hers were i nstr ucte d 
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
Pl e a s e d o n ot di stri b ut e
t hat t he e ntr y of c ollecte d data i nt o t he R E D Ca p s yste m wit hi n t hree da ys of ac q uisiti o n is 
d at a m o nit ori n g b o ar d
Pl e a s e d o n ot di stri b ut e
d at a m o nit ori n g b o ar d  e ns ures t he c o m plete ness, i nte grit y, a n d acc urac y of t he 
Pl e a s e d o n ot di stri b ut e
 e ns ures t he c o m plete ness, i nte grit y, a n d acc urac y of t he 
d at a m o nit ori n g b o ar d  e ns ures t he c o m plete ness, i nte grit y, a n d acc urac y of t he 
d at a m o nit ori n g b o ar d
Pl e a s e d o n ot di stri b ut e
d at a m o nit ori n g b o ar d  e ns ures t he c o m plete ness, i nte grit y, a n d acc urac y of t he 
d at a m o nit ori n g b o ar d
Pl e a s e d o n ot di stri b ut e
e ntries, pr o vi di n g fee d bac k t o t he data e ntr y tea m a n d re q uesti n g e x pla nati o ns or 
Pl e a s e d o n ot di stri b ut e
e ntries, pr o vi di n g fee d bac k t o t he data e ntr y tea m a n d re q uesti n g e x pla nati o ns or 
m o dificati o ns as nee de d. 
Pl e a s e d o n ot di stri b ut e
m o dificati o ns as nee de d. 
B aseli ne v ari a bles  
Pl e a s e d o n ot di stri b ut e
B aseli ne v ari a bles  
C ollecte d baseli ne varia bles a n d t heir defi niti o ns are liste d i n t he R E D Ca p pri nt o ut i n t he 
Pl e a s e d o n ot di stri b ut e
C ollecte d baseli ne varia bles a n d t heir defi niti o ns are liste d i n t he R E D Ca p pri nt o ut i n t he 

MI, pri or hist or y of P CI or C A B G, prese nce or a bse nce of dia betes ( me dicati o n use or 
H b A 1c > 6. 5), d ysli pi de mia ( L D L ≥1 6 0 m g/ d L or a nti-li pi d me dicati o n use), h y perte nsi o n 
( me dicati o n use or a vera ge bl o o d press ure o ver 1 4 0/ 9 0 m m H g d uri n g h os pital sta y), s m o ki n g 
(c urre nt s m o ker or past s m o ker wit h i n 1 year), c hr o nic ki d ne y disease ( baseli ne creati ni ne 
le vel greater t ha n t he u p per li mit of n or mal), a d missi o n s yst olic bl o o d press ure, a d missi o n 
heart rate, a d missi o n creati ni ne le vel, a d missi o n he m o gl o bi n le vel, Killi p class o n a d missi o n, 
a d missi o n tr o p o ni n T le vel (fr o m a bl o o d sa m ple c ollecte d bef ore, d uri n g or j ust after 
c or o nar y a n gi o gra p h y or at a d missi o n t o t he e mer ge nc y de part me nt), 2 4, 4 8 a n d 7 2 h tr o p o ni n 
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
Electr oc ar di o gr a m 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
i n t he a nal yses. If all of t he m are n o n- dia g n ostic t he p h ysicia n ma y still use a d diti o nal t o ols 
s uc h as t he cli nical pict ure, be dsi de ec h ocar di o gra m, tr o p o ni n res ults t o dia g n ose ‘ hi g h-ris k 
N S T E MI’ or ‘ p ossi ble O MI’. All pre-i nter ve nti o n E C Gs a n d at least o ne pre- disc har ge E C G 
will be u pl oa de d t o a ce ntral cl o u d data base t o be retr os pecti vel y re vie we d b y c ore la b 
i n vesti gat ors. T he a bse nce of a tec h nicall y a de q uate pre-cat h E C G will be a reas o n f or t he 
e xcl usi o n of t he partici pa nt. If E C G dia g n osis is n ot c o m pati ble wit h t he i ncl usi o n criteria f or 
t he assi g ne d gr o u p, t his will be n ote d a n d t he patie nt will be e xcl u de d fr o m t he per- pr ot oc ol 
a nal yses. F oll o wi n g c o di n g will be use d f or E C Gs:  
DI F O C C U L T- 3 St u d y 
(c urre nt s m o ker or past s m o ker wit h i n 1 year), c hr o nic ki d ne y disease ( baseli ne creati ni ne 
DI F O C C U L T- 3 St u d y 
(c urre nt s m o ker or past s m o ker wit h i n 1 year), c hr o nic ki d ne y disease ( baseli ne creati ni ne 
le vel greater t ha n t he u p per li mit of n or mal), a d missi o n s yst olic bl o o d press ure, a d missi o n 
DI F O C C U L T- 3 St u d y 
le vel greater t ha n t he u p per li mit of n or mal), a d missi o n s yst olic bl o o d press ure, a d missi o n 
heart rate, a d missi o n creati ni ne le vel, a d missi o n he m o gl o bi n le vel, Killi p class o n a d missi o n, 
DI F O C C U L T- 3 St u d y 
heart rate, a d missi o n creati ni ne le vel, a d missi o n he m o gl o bi n le vel, Killi p class o n a d missi o n, 
a d missi o n tr o p o ni n T le vel (fr o m a bl o o d sa m ple c ollecte d bef ore, d uri n g or j ust after 
DI F O C C U L T- 3 St u d y 
a d missi o n tr o p o ni n T le vel (fr o m a bl o o d sa m ple c ollecte d bef ore, d uri n g or j ust after 
c or o nar y a n gi o gra p h y or at a d missi o n t o t he e mer ge nc y de part me nt), 2 4, 4 8 a n d 7 2 h tr o p o ni n 
DI F O C C U L T- 3 St u d y 
c or o nar y a n gi o gra p h y or at a d missi o n t o t he e mer ge nc y de part me nt), 2 4, 4 8 a n d 7 2 h tr o p o ni n 
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
DI F O C C U L T- 3 St u d y 
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
DI F O C C U L T- 3 St u d y 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
DI F O C C U L T- 3 St u d y 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
DI F O C C U L T- 3 St u d y 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
DI F O C C U L T- 3 St u d y 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
DI F O C C U L T- 3 St u d y 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
Electr oc ar di o gr a m 
DI F O C C U L T- 3 St u d y 
Electr oc ar di o gr a m 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
DI F O C C U L T- 3 St u d y 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
DI F O C C U L T- 3 St u d y 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
i n t he a nal yses. If all of t he m are n o n- dia g n ostic t he p h ysicia n ma y still use a d diti o nal t o ols 
DI F O C C U L T- 3 St u d y 
i n t he a nal yses. If all of t he m are n o n- dia g n ostic t he p h ysicia n ma y still use a d diti o nal t o ols 
s uc h as t he cli nical pict ure, be dsi de ec h ocar di o gra m, tr o p o ni n res ults t o dia g n ose ‘ hi g h-ris k 
DI F O C C U L T- 3 St u d y 
s uc h as t he cli nical pict ure, be dsi de ec h ocar di o gra m, tr o p o ni n res ults t o dia g n ose ‘ hi g h-ris k 
C o nfi d e nti al 
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
C o nfi d e nti al 
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
C o nfi d e nti al 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
C o nfi d e nti al 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
C o nfi d e nti al 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
C o nfi d e nti al 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
C o nfi d e nti al 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
C o nfi d e nti al 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
C o nfi d e nti al 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
Pl e a s e d o n ot di stri b ut e
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
Pl e a s e d o n ot di stri b ut e
le vel (t he ma xi m u m tr o p o ni n le vel d uri n g h os pital sta y), ejecti o n fracti o n, wall m oti o n sc ore 
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
Pl e a s e d o n ot di stri b ut e
i n de x, ti me fr o m c o nsta nt pai n t o E C G, ti me fr o m E C G t o P CI ( will be calc ulate d fr o m 
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
Pl e a s e d o n ot di stri b ut e
s yste m rec or di n gs), i nfarct relate d arter y, n u m ber of disease d vessels, t he n u m ber of 
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
Pl e a s e d o n ot di stri b ut e
a d diti o nal lesi o ns treate d, i n- h os pital m ortalit y, i n- h os pital res uscitati o n, i n- h os pital 
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
Pl e a s e d o n ot di stri b ut e
i nt u bati o n, l o n g ter m m ortalit y. Fr o m t hese para meters, baseli ne G R A C E ris k sc ore, t he 
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
Pl e a s e d o n ot di stri b ut e
c ha n ge wit hi n tr o p o ni n val ue i n t he first 2 4 h o urs will be calc ulate d. 
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
Pl e a s e d o n ot di stri b ut e
E C Gs will be ac q uire d usi n g sta n dar d c o n ve nti o ns. If t he first E C G is n o n- dia g n ostic, serial 
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
Pl e a s e d o n ot di stri b ut e
E C Gs will be ac q uire d e ver y 1 5 mi n utes f or a n h o ur a n d t he first dia g n ostic E C G will be use d 
i n t he a nal yses. If all of t he m are n o n- dia g n ostic t he p h ysicia n ma y still use a d diti o nal t o ols 
Pl e a s e d o n ot di stri b ut e
i n t he a nal yses. If all of t he m are n o n- dia g n ostic t he p h ysicia n ma y still use a d diti o nal t o ols 
s uc h as t he cli nical pict ure, be dsi de ec h ocar di o gra m, tr o p o ni n res ults t o dia g n ose ‘ hi g h-ris k 
Pl e a s e d o n ot di stri b ut e
s uc h as t he cli nical pict ure, be dsi de ec h ocar di o gra m, tr o p o ni n res ults t o dia g n ose ‘ hi g h-ris k 
Pl e a s e d o n ot di stri b ut e
N S T E MI’ or ‘ p ossi ble O MI’. 
Pl e a s e d o n ot di stri b ut e
N S T E MI’ or ‘ p ossi ble O MI’. Al
Pl e a s e d o n ot di stri b ut e
Al l pre-i nter ve nti o n E C Gs a n d at least o ne pre- disc har ge E C G 
Pl e a s e d o n ot di stri b ut e
l pre-i nter ve nti o n E C Gs a n d at least o ne pre- disc har ge E C G 
will be u pl oa de d t o a ce ntral cl o u d data base t o be retr os pecti vel y re vie we d b y c ore la b 
Pl e a s e d o n ot di stri b ut e
will be u pl oa de d t o a ce ntral cl o u d data base t o be retr os pecti vel y re vie we d b y c ore la b 
Pl e a s e d o n ot di stri b ut e
i n vesti gat ors. T he a bse nce of a tec h nicall y a de q uate pre-cat h E C G will be a reas o n f or t he 
Pl e a s e d o n ot di stri b ut e
i n vesti gat ors. T he a bse nce of a tec h nicall y a de q uate pre-cat h E C G will be a reas o n f or t he 
e xcl usi o n of t he partici pa nt. If E C G dia g n osis is n ot c o m pati ble wit h t he i ncl usi o n criteria f or 
Pl e a s e d o n ot di stri b ut e
e xcl usi o n of t he partici pa nt. If E C G dia g n osis is n ot c o m pati ble wit h t he i ncl usi o n criteria f or 

T y pe 1 E G Gs: Ne w S T-se g me nt ele vati o n at t he J- p oi nt i n t w o c o nti g u o us lea ds wit h 
t he c ut- p oi nt: ≥ 1 m m i n all lea ds ot her t ha n lea ds V 2 – V 3 w here t he f oll o wi n g c ut- p oi nts 
a p pl y: ≥ 2 m m i n me n ≥ 4 0 years; ≥ 2. 5 m m i n me n < 4 0 years, or ≥ 1. 5 m m i n w o me n 
re gar dless of a ge. 
Ty pe 1 a:  T he a m plit u de, m or p h ol o g y, e xte nt of S T E a n d t he prese nce of a d diti o nal 
fi n di n gs ( h y perac ute T wa ves, Q- wa ves, ter mi nal Q R S dist orti o n) ma ke E C G hi g hl y 
o b vi o us f or MI pres u ma bl y d ue t o ac ute, t hr o m b otic occl usi o n. T hese E C Gs will be 
i ncl u de d i n b ot h S T E MI a n d O MI defi niti o ns. 
Ty pe 1 b:  T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut it is 
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
ma g nit u de is e q ual or greater t ha n 1 5 % (t he n i n dicates O MI, T y pe 2 b) ( Ar mstr o n g EJ 
et al. A m J Car di ol, 2 0 1 2, Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). Differe ntial 
dia g n osis f or is olate d left b u n dle bra nc h bl oc k: Will be c o de d as T y pe 1 b , u nless o ne 
of t he m o difie d S gar b ossa criteria is p ositi ve (t he n i n dicates O MI, T y pe 2 b): ≥ 1 lea d 
wit h ≥1 m m of c o nc or da nt S T ele vati o n, ≥ 1 lea d of V 1- V 3 wit h ≥ 1 m m of 
c o nc or da nt S T de pressi o n, ≥ 1 lea d a n y w here wit h ≥ 1 m m S T E a n d pr o p orti o nall y 
e xcessi ve disc or da nt S T E, as defi ne d b y ≥ 2 5 % of t he de pt h of t he prece di n g S- wa ve 
DI F O C C U L T- 3 St u d y 
 T he a m plit u de, m or p h ol o g y, e xte nt of S T E a n d t he prese nce of a d diti o nal 
DI F O C C U L T- 3 St u d y 
 T he a m plit u de, m or p h ol o g y, e xte nt of S T E a n d t he prese nce of a d diti o nal 
fi n di n gs ( h y perac ute T wa ves, Q- wa ves, ter mi nal Q R S dist orti o n) ma ke E C G hi g hl y 
DI F O C C U L T- 3 St u d y 
fi n di n gs ( h y perac ute T wa ves, Q- wa ves, ter mi nal Q R S dist orti o n) ma ke E C G hi g hl y 
o b vi o us f or MI pres u ma bl y d ue t o ac ute, t hr o m b otic occl usi o n. T hese E C Gs will be 
DI F O C C U L T- 3 St u d y 
o b vi o us f or MI pres u ma bl y d ue t o ac ute, t hr o m b otic occl usi o n. T hese E C Gs will be 
i ncl u de d i n b ot h S T E MI a n d O MI defi niti o ns. 
DI F O C C U L T- 3 St u d y 
i ncl u de d i n b ot h S T E MI a n d O MI defi niti o ns. 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut it is 
DI F O C C U L T- 3 St u d y 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut it is 
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
DI F O C C U L T- 3 St u d y 
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
DI F O C C U L T- 3 St u d y 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
DI F O C C U L T- 3 St u d y 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
DI F O C C U L T- 3 St u d y 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
DI F O C C U L T- 3 St u d y 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
DI F O C C U L T- 3 St u d y 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
DI F O C C U L T- 3 St u d y 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
DI F O C C U L T- 3 St u d y 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
DI F O C C U L T- 3 St u d y 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
ma g nit u de is e q ual or greater t ha n 1 5 % (t he n i n dicates O MI, T y pe 2 b) ( Ar mstr o n g EJ 
DI F O C C U L T- 3 St u d y 
ma g nit u de is e q ual or greater t ha n 1 5 % (t he n i n dicates O MI, T y pe 2 b) ( Ar mstr o n g EJ 
C o nfi d e nti al 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut it is 
C o nfi d e nti al 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut it is 
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
C o nfi d e nti al 
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
C o nfi d e nti al 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
C o nfi d e nti al 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
C o nfi d e nti al 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
C o nfi d e nti al 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
C o nfi d e nti al 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
C o nfi d e nti al 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
C o nfi d e nti al 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
C o nfi d e nti al 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
Pl e a s e d o n ot di stri b ut e
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
Pl e a s e d o n ot di stri b ut e
u ncertai n w het her it is d ue t o MI or t o a n ot her c o n diti o n, s uc h as be ni g n varia nt S T E, 
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
Pl e a s e d o n ot di stri b ut e
left ve ntric ular h y pertr o p h y, left b u n dle bra nc h bl oc k, pri or MI, pericar ditis, etc. T hese 
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
Pl e a s e d o n ot di stri b ut e
E C Gs will be i ncl u de d i n t he S T E MI defi niti o n b ut n ot i n t he O MI defi niti o n, u nless 
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
Pl e a s e d o n ot di stri b ut e
t here are a d diti o nal fi n di n gs s us pici o us f or ac ute c or o nar y occl usi o n as f oll o ws: 
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
Pl e a s e d o n ot di stri b ut e
Differe ntial dia g n osis f or be ni g n varia nt S T E: T y pe 1 b, if f ulfills S T E MI criteria. B ut 
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
Pl e a s e d o n ot di stri b ut e
re-classifie d as T y pe 2 b, if t he Asla n ger/ S mit h f or m ula is p ositi ve. Asla n ger’s 
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
Pl e a s e d o n ot di stri b ut e
f or m ula: ( R- wa ve a m plit u de i n lea d V 4  +  Q R S a m plit u de i n V 2) – ( Q T i nter val i n 
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
Pl e a s e d o n ot di stri b ut e
milli meters  +  S T E 6 0 i n V 3) < 1 2 ( Asla n ger E A m J Car di ol, 2 0 1 8). Differe ntial 
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
Pl e a s e d o n ot di stri b ut e
dia g n osis f or left ve ntric ular h y pertr o p h y: T y pe 1 b u nless S T se g me nt t o R- S- wa ve 
ma g nit u de is e q ual or greater t ha n 1 5 % (t he n i n dicates O MI, T y pe 2 b) ( Ar mstr o n g EJ 
Pl e a s e d o n ot di stri b ut e
ma g nit u de is e q ual or greater t ha n 1 5 % (t he n i n dicates O MI, T y pe 2 b) ( Ar mstr o n g EJ 
et al. A m J Car di ol, 2 0 1 2, Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). Differe ntial 
Pl e a s e d o n ot di stri b ut e
et al. A m J Car di ol, 2 0 1 2, Asla n ger et al. Arc h T ur k S oc Car di ol, 2 0 2 1). Differe ntial 
Pl e a s e d o n ot di stri b ut e
dia g n osis f or is olate d left b u n dle bra nc h bl oc k: Will be c o de d as T y pe 1 b
Pl e a s e d o n ot di stri b ut e
dia g n osis f or is olate d left b u n dle bra nc h bl oc k: Will be c o de d as T y pe 1 b
of t he m o difie d S gar b ossa criteria is p ositi ve (t he n i n dicates O MI, T y pe 2 b): ≥ 1 lea d 
Pl e a s e d o n ot di stri b ut e
of t he m o difie d S gar b ossa criteria is p ositi ve (t he n i n dicates O MI, T y pe 2 b): ≥ 1 lea d 
wit h ≥1 m m of c o nc or da nt S T ele vati o n, ≥ 1 lea d of V 1- V 3 wit h ≥ 1 m m of 
Pl e a s e d o n ot di stri b ut e
wit h ≥1 m m of c o nc or da nt S T ele vati o n, ≥ 1 lea d of V 1- V 3 wit h ≥ 1 m m of 
c o nc or da nt S T de pressi o n, ≥ 1 lea d a n y w here wit h ≥ 1 m m S T E a n d pr o p orti o nall y 
Pl e a s e d o n ot di stri b ut e
c o nc or da nt S T de pressi o n, ≥ 1 lea d a n y w here wit h ≥ 1 m m S T E a n d pr o p orti o nall y 

( S mit h S W et al. A n n E mer g Me d 2 0 1 2). Differe ntial dia g n osis f or pri or MI: T y pe 1 b, 
u nless S mit h’s r ule is p ositi ve (t he n i n dicates O MI, T y pe 2 b): S mit h’s r ule: If a n y 1 
lea d bet wee n V 1- V 4 has a T- wa ve a m plit u de t o Q R S a m plit u de rati o greater t ha n or 
e q ual t o 0. 3 6 ( Klei n L R et al. A m J E mer g Me d 2 0 1 5). Differe ntial dia g n osis f or 
pericar ditis: T y pe 1 b, u nless t here is S T- de pressi o n i n a V L (t he n i n dicates O MI, T y pe 
2 b) ( Bisc h of J E et al. A m J E mer g Me d. 2 0 1 6). 
Ty pe 1c : T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut t here is 
als o T- wa ve i n versi o n a n d pat h ol o gic Q wa ves i n dicati ve of s u bac ute MI. T hese E C Gs 
will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ha ve A C O o n 
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
patter n) will be i ncl u de d i n t y pe 2c E C Gs. 
T y pe 2 E G Gs:  E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
f o urt h u ni versal defi niti o n of MI. 
Ty pe 2 a : T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
Ty pe 2 b:  D oes n ot meet rec o m me n de d criteria f or S T E MI, b ut hi g hl y s u g gesti ve f or 
A C O, des pite bei n g s u btle a n d diffic ult. P ossi ble fi n di n gs are mi n or S T E wit h or wit h o ut 
mi n or reci pr ocal S T- de pressi o n n ot f ulfilli n g S T E MI criteria, h y perac ute T- wa ves or 
De Wi nter’s patter n, s u btle a nteri or S T E har d t o differe ntiate fr o m be ni g n varia nt S T E a n d 
n o nc o nsec uti ve S T E. T hese E C Gs will be i ncl u de d i n t he O MI defi niti o n b ut n ot i n t he 
S T E MI defi niti o n. T he detaile d al g orit h m defi ne d i n t he DI F O C C U L T trial ( Asla n ger et al. I n 
J Car di ol Heart Vasc, 2 0 2 0; Asla n ger et al. J Electr ocar di ol, 2 0 2 1; Asla n ger et al. Arc h T ur k 
S oc Car di ol, 2 0 2 1) will be use d f or rec o g nizi n g t hese E C Gs. 
DI F O C C U L T- 3 St u d y 
e q ual t o 0. 3 6 ( Klei n L R et al. A m J E mer g Me d 2 0 1 5). Differe ntial dia g n osis f or 
DI F O C C U L T- 3 St u d y 
e q ual t o 0. 3 6 ( Klei n L R et al. A m J E mer g Me d 2 0 1 5). Differe ntial dia g n osis f or 
pericar ditis: T y pe 1 b, u nless t here is S T- de pressi o n i n a V L (t he n i n dicates O MI, T y pe 
DI F O C C U L T- 3 St u d y 
pericar ditis: T y pe 1 b, u nless t here is S T- de pressi o n i n a V L (t he n i n dicates O MI, T y pe 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut t here is 
DI F O C C U L T- 3 St u d y 
 T here is S T-se g me nt ele vati o n t hat meets criteria f or S T E MI, b ut t here is 
als o T- wa ve i n versi o n a n d pat h ol o gic Q wa ves i n dicati ve of s u bac ute MI. T hese E C Gs 
DI F O C C U L T- 3 St u d y 
als o T- wa ve i n versi o n a n d pat h ol o gic Q wa ves i n dicati ve of s u bac ute MI. T hese E C Gs 
will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ha ve A C O o n 
DI F O C C U L T- 3 St u d y 
will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ha ve A C O o n 
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
DI F O C C U L T- 3 St u d y 
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
DI F O C C U L T- 3 St u d y 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
patter n) will be i ncl u de d i n t y pe 2c E C Gs. 
DI F O C C U L T- 3 St u d y 
patter n) will be i ncl u de d i n t y pe 2c E C Gs. 
T y pe 2 E G Gs:
DI F O C C U L T- 3 St u d y 
T y pe 2 E G Gs:  E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
DI F O C C U L T- 3 St u d y 
 E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
f o urt h u ni versal defi niti o n of MI. 
DI F O C C U L T- 3 St u d y 
f o urt h u ni versal defi niti o n of MI. 
Ty pe 2 a
DI F O C C U L T- 3 St u d y 
Ty pe 2 a :
DI F O C C U L T- 3 St u d y 
: T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
DI F O C C U L T- 3 St u d y 
 T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
DI F O C C U L T- 3 St u d y 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
DI F O C C U L T- 3 St u d y 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
Ty pe 2 b:
DI F O C C U L T- 3 St u d y 
Ty pe 2 b:
A C O, des pite bei n g s u btle a n d diffic ult. P ossi ble fi n di n gs are mi n or S T E wit h or wit h o ut 
DI F O C C U L T- 3 St u d y 
A C O, des pite bei n g s u btle a n d diffic ult. P ossi ble fi n di n gs are mi n or S T E wit h or wit h o ut 
C o nfi d e nti al 
will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ha ve A C O o n 
C o nfi d e nti al 
will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ha ve A C O o n 
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
C o nfi d e nti al 
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
C o nfi d e nti al 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
 E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
C o nfi d e nti al 
 E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
 T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
C o nfi d e nti al 
 T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
C o nfi d e nti al 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
C o nfi d e nti al 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
Pl e a s e d o n ot di stri b ut e
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
Pl e a s e d o n ot di stri b ut e
a n gi o gra m a n d hi g her l o n g-ter m m ortalit y b ut gai n little, if n ot a n y, be nefit fr o m 
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
Pl e a s e d o n ot di stri b ut e
re perf usi o n wit h b ot h a p pr oac hes. Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ 
 E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
Pl e a s e d o n ot di stri b ut e
 E C G t hat meets ac ute m y ocar dial isc he mia criteria rec o m me n de d b y 
 T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
Pl e a s e d o n ot di stri b ut e
 T he E C G has " pri mar y'', i.e. ca n n ot be c o m pletel y e x plai ne d as sec o n dar y t o 
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
Pl e a s e d o n ot di stri b ut e
a de p olarizati o n dis or der, S T-se g me nt de pressi o n or T- wa ve i n versi o n t hat is n o n dia g n ostic of 
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
Pl e a s e d o n ot di stri b ut e
S T E MI b ut is dia g n ostic of m y ocar dial isc he mia.  
Pl e a s e d o n ot di stri b ut e
 D oes n ot meet rec o m me n de d criteria f or S T E MI, b ut hi g hl y s u g gesti ve f or 
Pl e a s e d o n ot di stri b ut e
 D oes n ot meet rec o m me n de d criteria f or S T E MI, b ut hi g hl y s u g gesti ve f or 
A C O, des pite bei n g s u btle a n d diffic ult. P ossi ble fi n di n gs are mi n or S T E wit h or wit h o ut 
Pl e a s e d o n ot di stri b ut e
A C O, des pite bei n g s u btle a n d diffic ult. P ossi ble fi n di n gs are mi n or S T E wit h or wit h o ut 
mi n or reci pr ocal S T- de pressi o n n ot f ulfilli n g S T E MI criteria, h y perac ute T- wa ves or 
Pl e a s e d o n ot di stri b ut e
mi n or reci pr ocal S T- de pressi o n n ot f ulfilli n g S T E MI criteria, h y perac ute T- wa ves or 
Pl e a s e d o n ot di stri b ut e
De Wi nter’s patter n, s u btle a nteri or S T E har d t o differe ntiate fr o m be ni g n varia nt S T E a n d 
Pl e a s e d o n ot di stri b ut e
De Wi nter’s patter n, s u btle a nteri or S T E har d t o differe ntiate fr o m be ni g n varia nt S T E a n d 
n o nc o nsec uti ve S T E. T hese E C Gs will be i ncl u de d i n t he O MI defi niti o n b ut n ot i n t he 
Pl e a s e d o n ot di stri b ut e
n o nc o nsec uti ve S T E. T hese E C Gs will be i ncl u de d i n t he O MI defi niti o n b ut n ot i n t he 
S T E MI defi niti o n. T he detaile d al g orit h m defi ne d i n t he DI F O C C U L T trial ( Asla n ger et al. I n 
Pl e a s e d o n ot di stri b ut e
S T E MI defi niti o n. T he detaile d al g orit h m defi ne d i n t he DI F O C C U L T trial ( Asla n ger et al. I n 

Ty pe 2c:  Patie nts wit h preser ve d Q R S c o m ple xes ( Welle ns’ patter n), wit h or wit h o ut 
s o me S T E, b ut wit h si g nifica nt T wa ve ne gati vit y will be i ncl u de d i n t y pe 2c E C Gs.  T hese 
E C Gs will be e xcl u de d fr o m per- pr ot oc ol a nal yses, si nce t hese patie nts ma y n ot gai n be nefit 
fr o m e mer ge nt re perf usi o n i n b ot h a p pr oac hes.  
T y pe 3 E C Gs:  N o ns pecific E C G t hat is a b n or mal b ut n o n dia g n ostic of a n y ki n d of 
ac ute c or o nar y s y n dr o me. Mi n or a b n or malities i ncl u di n g left ve ntric ular h y pertr o p h y wit h o ut 
S T- T c ha n ges, arr h yt h mias, i m p ulse ge nerati o n a n d c o n d ucti o n diseases etc. 
T y pe 4 E C Gs:  C o m pletel y n or mal E C G.  
AI- P o were d E C G A p plic ati o n 
I n  O MI/ N O MI  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
pr os pecti vel y. I n S T E MI/ N S T E MI ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
All  first  res p o n ders  will  be  e q ui p pe d  wit h  a  de dicate d  AI- p o were d  s mart p h o ne 
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
res p o n ders  will  be  li n ke d  e xcl usi vel y  t o  a  si n gle  partici pati n g  ce nter,  e ns uri n g  n o  o verla p 
bet wee n ce nters. 
T he a p plicati o n’s f u ncti o nalit y will var y base d o n t he st u d y ar m deter mi ne d b y t he tea m 
o n d ut y. O n O MI/ N O MI da ys, t he AI a p plicati o n will be f ull y acti vate d a n d accessi ble t o all 
first  res p o n ders  ass ociate d  wit h  t hat  ce nter.  W he n  a  user  ca pt ures  a  p h ot o  of  a n  E C G,  t he 
a p plicati o n will di gitalize t he i ma ge, i nter pret t he data, a n d dis pla y o ne of t w o messa ges: “ O MI” 
or “ N ot- O MI.” First res p o n ders will be i nstr ucte d t o pr o m ptl y i nf or m t he i nter ve nti o nalist o n 
DI F O C C U L T- 3 St u d y 
 N o ns pecific E C G t hat is a b n or mal b ut n o n dia g n ostic of a n y ki n d of 
DI F O C C U L T- 3 St u d y 
 N o ns pecific E C G t hat is a b n or mal b ut n o n dia g n ostic of a n y ki n d of 
ac ute c or o nar y s y n dr o me. Mi n or a b n or malities i ncl u di n g left ve ntric ular h y pertr o p h y wit h o ut 
DI F O C C U L T- 3 St u d y 
ac ute c or o nar y s y n dr o me. Mi n or a b n or malities i ncl u di n g left ve ntric ular h y pertr o p h y wit h o ut 
- T c ha n ges, arr h yt h mias, i m p ulse ge nerati o n a n d c o n d ucti o n diseases etc. 
DI F O C C U L T- 3 St u d y 
- T c ha n ges, arr h yt h mias, i m p ulse ge nerati o n a n d c o n d ucti o n diseases etc. 
 C o m pletel y n or mal E C G.  
DI F O C C U L T- 3 St u d y 
 C o m pletel y n or mal E C G.  
- P o were d E C G A p plic ati o n 
DI F O C C U L T- 3 St u d y 
- P o were d E C G A p plic ati o n 
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
DI F O C C U L T- 3 St u d y 
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
S T
DI F O C C U L T- 3 St u d y 
S T E MI
DI F O C C U L T- 3 St u d y 
E MI / N
DI F O C C U L T- 3 St u d y 
/ NS T
DI F O C C U L T- 3 St u d y 
S T E MI
DI F O C C U L T- 3 St u d y 
E MI  ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
DI F O C C U L T- 3 St u d y 
 ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
All  first  res p o n ders 
DI F O C C U L T- 3 St u d y 
All  first  res p o n ders will
DI F O C C U L T- 3 St u d y 
will
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
DI F O C C U L T- 3 St u d y 
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
DI F O C C U L T- 3 St u d y 
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
DI F O C C U L T- 3 St u d y 
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
DI F O C C U L T- 3 St u d y 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
res p o n ders  will  be  li n ke d  e xcl usi vel y  t o  a  si n gle  partici pati n g  ce nter,  e ns uri n g  n o  o verla p 
DI F O C C U L T- 3 St u d y 
res p o n ders  will  be  li n ke d  e xcl usi vel y  t o  a  si n gle  partici pati n g  ce nter,  e ns uri n g  n o  o verla p 
bet wee n ce nters. 
DI F O C C U L T- 3 St u d y 
bet wee n ce nters. 
C o nfi d e nti al 
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
C o nfi d e nti al 
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
 ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
C o nfi d e nti al 
 ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
will
C o nfi d e nti al 
will   be  e q ui p pe d  wit h  a  de dicate d  AI- p o were d  s mart p h o ne 
C o nfi d e nti al 
  be  e q ui p pe d  wit h  a  de dicate d  AI- p o were d  s mart p h o ne 
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
C o nfi d e nti al 
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
C o nfi d e nti al 
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
C o nfi d e nti al 
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
C o nfi d e nti al 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
Pl e a s e d o n ot di stri b ut e
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
Pl e a s e d o n ot di stri b ut e
I  ar m  E C Gs  ca n  be  di gitize d  a n d  i nter prete d  b y  AI- p o were d  E C G  a p plicati o n 
 ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
Pl e a s e d o n ot di stri b ut e
 ar m, i nter pretati o n will be d o ne retr os pecti vel y.  
  be  e q ui p pe d  wit h  a  de dicate d  AI- p o were d  s mart p h o ne 
Pl e a s e d o n ot di stri b ut e
  be  e q ui p pe d  wit h  a  de dicate d  AI- p o were d  s mart p h o ne 
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
Pl e a s e d o n ot di stri b ut e
a p plicati o n  ( P o werf ul  Me dical,  Sa m ori n,  Sl o va kia),  trai ne d  b y  e x pert  E C G  i nter preters  a n d 
Pl e a s e d o n ot di stri b ut e
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
Pl e a s e d o n ot di stri b ut e
vali date d i n a lar ge c o h ort. T he a p plicati o n will be pr o vi de d o ne m o nt h pri or t o t he first patie nt 
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
Pl e a s e d o n ot di stri b ut e
e nr oll me nt,  a n d  eac h  res p o n der's  l o g-i n  stat us  was  verifie d  t hr o u g h  a n  o nli ne  s yste m.  First 
res p o n ders  will  be  li n ke d  e xcl usi vel y  t o  a  si n gle  partici pati n g  ce nter,  e ns uri n g  n o  o verla p 
Pl e a s e d o n ot di stri b ut e
res p o n ders  will  be  li n ke d  e xcl usi vel y  t o  a  si n gle  partici pati n g  ce nter,  e ns uri n g  n o  o verla p 
Pl e a s e d o n ot di stri b ut e
T he a p plicati o n’s f u ncti o nalit y 
Pl e a s e d o n ot di stri b ut e
T he a p plicati o n’s f u ncti o nalit y 
o n d ut y. O n O MI/ N O MI da ys, t he AI a p plicati o n will be f ull y acti vate d a n d accessi ble t o all 
Pl e a s e d o n ot di stri b ut e
o n d ut y. O n O MI/ N O MI da ys, t he AI a p plicati o n will be f ull y acti vate d a n d accessi ble t o all 
Pl e a s e d o n ot di stri b ut e
first  res p o n ders  ass ociate d  wit h  t hat  ce nter.  W he n  a  user  ca pt ures  a  p h ot o  of  a n  E C G,  t he 
Pl e a s e d o n ot di stri b ut e
first  res p o n ders  ass ociate d  wit h  t hat  ce nter.  W he n  a  user  ca pt ures  a  p h ot o  of  a n  E C G,  t he 

d ut y  f or  p ote ntial  cat heterizati o n  la b orat or y  acti vati o n  if  res ult  s h o ws  “ O MI”.  O n 
S T E MI/ N S T E MI da ys, t he AI-s u p p orte d a p plicati o n will be deacti vate d f or t hat ce nter. If a first 
res p o n der atte m pts t o ca pt ure a p h ot o of a n E C G, a war ni n g messa ge will be dis pla ye d: “ We 
are  n o w  f oll o wi n g  t he  sta n dar d  S T E MI/ N S T E MI  a p pr oac h.  Please  c o nti n ue  y o ur  us ual 
practice.”  
A c o m mercial versi o n of t he sa me s mart p h o ne a p plicati o n b y t he sa me c o m pa n y is 
als o a vaila ble o n t he mar ket. D uri n g t he st u d y, if a net w or k a d dress is detecte d accessi n g b ot h 
t he c o m mercial a n d st u d y-s pecific a p plicati o ns, t he c o m mercial versi o n will be deacti vate d b y 
t he c o m pa n y, a n d a n otificati o n mail will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
will be e xcl u de d fr o m t he st u d y. 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d as 
defi ne d a b o ve f or i nte nti o n-t o-treat a n d per- pr ot oc ol a nal yses. T his will be d o ne b y t w o se parate 
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S T E MI. T y pe 1a, 2 b a n d 
2c E C Gs will be dee me d c o m pati ble wit h O MI dia g n osis.  
Tr o p o ni ns 
T he tr o p o ni n le vels will be meas ure d at a d missi o n, h o url y if nee de d f or t he dia g n osis, e ver y 6 
h o urs u ntil it pea ks after a n MI dia g n osis is ma de, a n d t he n dail y. T he 2 4- 7 2 h o ur pea k 
tr o p o ni n le vel ( us uall y 4 8 h) will be use d as a s urr o gate f or i nfarct size.   
   
DI F O C C U L T- 3 St u d y 
are  n o w  f oll o wi n g  t he  sta n dar d  S T E MI/ N S T E MI  a p pr oac h.  Please  c o nti n ue  y o ur  us ual 
DI F O C C U L T- 3 St u d y 
are  n o w  f oll o wi n g  t he  sta n dar d  S T E MI/ N S T E MI  a p pr oac h.  Please  c o nti n ue  y o ur  us ual 
A c o m mercial versi o n of t he sa me s mart p h o ne a p plicati o n b y t he sa me c o m pa n y 
DI F O C C U L T- 3 St u d y 
A c o m mercial versi o n of t he sa me s mart p h o ne a p plicati o n b y t he sa me c o m pa n y 
als o a vaila ble o n t he mar ket. D uri n g t he st u d y, if a net w or k a d dress is detecte d accessi n g b ot h 
DI F O C C U L T- 3 St u d y 
als o a vaila ble o n t he mar ket. D uri n g t he st u d y, if a net w or k a d dress is detecte d accessi n g b ot h 
t he c o m mercial a n d st u d y-s pecific a p plicati o ns, t he c o m mercial versi o n will be deacti vate d b y 
DI F O C C U L T- 3 St u d y 
t he c o m mercial a n d st u d y-s pecific a p plicati o ns, t he c o m mercial versi o n will be deacti vate d b y 
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
DI F O C C U L T- 3 St u d y 
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
DI F O C C U L T- 3 St u d y 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
DI F O C C U L T- 3 St u d y 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
DI F O C C U L T- 3 St u d y 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
will be e xcl u de d fr o m t he st u d y. 
DI F O C C U L T- 3 St u d y 
will be e xcl u de d fr o m t he st u d y. 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
DI F O C C U L T- 3 St u d y 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
defi ne d a b o ve f or i nte nti o n-
DI F O C C U L T- 3 St u d y 
defi ne d a b o ve f or i nte nti o n- t o
DI F O C C U L T- 3 St u d y 
t o
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
DI F O C C U L T- 3 St u d y 
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
DI F O C C U L T- 3 St u d y 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
DI F O C C U L T- 3 St u d y 
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
2c E C Gs will be dee me d c o m pati ble wit h O MI dia g n osis.  
DI F O C C U L T- 3 St u d y 
2c E C Gs will be dee me d c o m pati ble wit h O MI dia g n osis.  
C o nfi d e nti al 
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
C o nfi d e nti al 
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
C o nfi d e nti al 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
C o nfi d e nti al 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
C o nfi d e nti al 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
C o nfi d e nti al 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
-treat a n d per- pr ot oc ol a nal yses. T his will be d o ne b y t w o se parate 
C o nfi d e nti al 
-treat a n d per- pr ot oc ol a nal yses. T his will be d o ne b y t w o se parate 
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
C o nfi d e nti al 
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
C o nfi d e nti al 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
C o nfi d e nti al 
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
Pl e a s e d o n ot di stri b ut e
t he c o m mercial a n d st u d y-s pecific a p plicati o ns, t he c o m mercial versi o n will be deacti vate d b y 
Pl e a s e d o n ot di stri b ut e
t he c o m mercial a n d st u d y-s pecific a p plicati o ns, t he c o m mercial versi o n will be deacti vate d b y 
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
Pl e a s e d o n ot di stri b ut e
 will be se nt e x plai ni n g t hat t he c o m mercial s mart p h o ne 
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
Pl e a s e d o n ot di stri b ut e
a p plicati o n will n ot be a vaila ble t o users i n T ür ki ye f or t he d urati o n of t he st u d y. A d diti o nall y, 
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
Pl e a s e d o n ot di stri b ut e
all E C Gs st ore d i n t he st u d y data base will be cr oss-refere nce d wit h t he c o m mercial 
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
Pl e a s e d o n ot di stri b ut e
s mart p h o ne a p plicati o n’s E C G hist or y. If a n y matc hes are i de ntifie d, t he c orres p o n di n g patie nt 
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
Pl e a s e d o n ot di stri b ut e
After t he st u d y c o m pleti o n, E C Gs i n b ot h st u d y ar ms will be re vie we d a n d c o de d 
-treat a n d per- pr ot oc ol a nal yses. T his will be d o ne b y t w o se parate 
Pl e a s e d o n ot di stri b ut e
-treat a n d per- pr ot oc ol a nal yses. T his will be d o ne b y t w o se parate 
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
Pl e a s e d o n ot di stri b ut e
E C G i nter preter. S h o ul d t here be a n y discre pa nc y bet wee n t hese i nter preters, a t hir d i nter preter 
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
Pl e a s e d o n ot di stri b ut e
(fr o m data m o nit ori n g b oar d) will be c o ns ulte d.   
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
Pl e a s e d o n ot di stri b ut e
T y pe 1a, 1 b a n d 1c E C Gs will be dee me d as c o m pati ble wit h S
Pl e a s e d o n ot di stri b ut e
2c E C Gs will be dee me d c o m pati ble wit h O MI dia g n osis.  
Pl e a s e d o n ot di stri b ut e
2c E C Gs will be dee me d c o m pati ble wit h O MI dia g n osis.  
T he tr o p o ni n le vels will be meas ure d at a d missi o n, h o url y if nee de d f or t he dia g n osis, e ver y 6 
Pl e a s e d o n ot di stri b ut e
T he tr o p o ni n le vels will be meas ure d at a d missi o n, h o url y if nee de d f or t he dia g n osis, e ver y 6 
Pl e a s e d o n ot di stri b ut e
h o urs u ntil it pea ks after a n MI dia g n osis is ma de, a n d t he n dail y. T he 2 4- 7 2 h o ur pea k 
Pl e a s e d o n ot di stri b ut e
h o urs u ntil it pea ks after a n MI dia g n osis is ma de, a n d t he n dail y. T he 2 4- 7 2 h o ur pea k 

A n gi o gr a ms 
C or o nar y  a n gi o gra p h y  will  be  u n derta ke n  acc or di n g  t o  t he  sta n dar d  c o n ve nti o ns.  Eac h 
a n gi o gra m will be re vie we d b y t w o i nter ve nti o nalist. S h o ul d t here be a n y discre pa nc y bet wee n 
t hese i nter preters, a t hir d i nter preter (fr o m data m o nit ori n g b oar d) will be c o ns ulte d.  
   
F oll o wi n g p oi nts will be n ote d f or t he prese nce of a n A C O: ( 1) t he T hr o m b ol ysis i n 
M y ocar dial I nfarcti o n St u d y ( TI MI) fl o w le vel i n t he i nfarct-relate d vessel. T he prese nce of 
well- de vel o pe d c ollaterals t o t he distal vessel, a p peara nce of t he t otal occl usi o n, easi ness of 
g ui de wire cr ossi n g will als o be assesse d t o deter mi ne if t he t otal occl usi o n is ac ute i n nat ure. 
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
stai ni n g. 
A C O A dj u dic ati o n 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
( 1)  A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
P L U S
a pea k tr o p o ni n le vel e q ual t o or greater 5 t ha n fi ve ti mes t he U L N  
P L U S
at least 2 0 % rise wit hi n t he first 2 4 h o urs  
( 2)  A hi g hl y ele vate d pea k (f or tr o p o ni n T > 1 0 0 0 n g/ m L a n d f or tr o p o ni n I 2 0 0 ti mes of 
t he a vera ge of U L N ( k n o w n t o be hi g hl y c orrelate d wit h A C O)) wit h o ut a n o b vi o us 
alter nati ve dia g n osis or wit h s u p p orti n g e vi de nce ( E C G e v ol uti o n, c ul prit-l o o ki n g 
DI F O C C U L T- 3 St u d y 
t hese i nter preters, a t hir d i nter preter (fr o m data m o nit ori n g b oar d) will be c o ns ulte d.  
DI F O C C U L T- 3 St u d y 
t hese i nter preters, a t hir d i nter preter (fr o m data m o nit ori n g b oar d) will be c o ns ulte d.  
   
F oll o wi n g p oi nts will be n ote d f or t he prese nce of a n A C O: ( 1) t he T hr o m b ol ysis i n 
DI F O C C U L T- 3 St u d y 
   
F oll o wi n g p oi nts will be n ote d f or t he prese nce of a n A C O: ( 1) t he T hr o m b ol ysis i n 
M y ocar dial I nfarcti o n St u d y ( TI MI) fl o w le vel i n t he i nfarct-relate d vessel. T he prese nce of 
DI F O C C U L T- 3 St u d y 
M y ocar dial I nfarcti o n St u d y ( TI MI) fl o w le vel i n t he i nfarct-relate d vessel. T he prese nce of 
- de vel o pe d c ollaterals t o t he distal vessel, a p peara nce of t he t otal occl usi o n, easi ness of 
DI F O C C U L T- 3 St u d y 
- de vel o pe d c ollaterals t o t he distal vessel, a p peara nce of t he t otal occl usi o n, easi ness of 
g ui de wire cr ossi n g will als o be assesse d t o deter mi ne if t he t otal occl usi o n is ac ute i n nat ure. 
DI F O C C U L T- 3 St u d y 
g ui de wire cr ossi n g will als o be assesse d t o deter mi ne if t he t otal occl usi o n is ac ute i n nat ure. 
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
DI F O C C U L T- 3 St u d y 
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
DI F O C C U L T- 3 St u d y 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
DI F O C C U L T- 3 St u d y 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
A C O A dj u dic ati o n 
DI F O C C U L T- 3 St u d y 
A C O A dj u dic ati o n 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
DI F O C C U L T- 3 St u d y 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
DI F O C C U L T- 3 St u d y 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
( 1)
DI F O C C U L T- 3 St u d y 
( 1) A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
DI F O C C U L T- 3 St u d y 
A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
C o nfi d e nti al 
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
C o nfi d e nti al 
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
C o nfi d e nti al 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
C o nfi d e nti al 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
C o nfi d e nti al 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
C o nfi d e nti al 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
C o nfi d e nti al 
A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
Pl e a s e d o n ot di stri b ut e
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
Pl e a s e d o n ot di stri b ut e
If necessar y, t he pri mar y o perat or will als o be c o ntacte d. ( 2) T he prese nce of a n ac ute lesi o n 
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
Pl e a s e d o n ot di stri b ut e
wit h defi niti ve c ul prit feat ures, w hic h was defi ne d base d o n se veral a n gi o gra p hic pr o perties 
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
Pl e a s e d o n ot di stri b ut e
i ncl u di n g critical ste n osis, irre g ular lesi o n b or ders, prese nce of a n gi o gra p hic t hr o m b us or 
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
Pl e a s e d o n ot di stri b ut e
Beca use t he i nfarct-relate d arter y ma y s p o nta ne o usl y o pe n b y t he ti me of t he a n gi o gra m or t otal 
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
Pl e a s e d o n ot di stri b ut e
occl usi o n ma y be c hr o nic i n nat ure, we defi ne d a c o m p osite A C O usi n g f oll o wi n g criteria:  
A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
Pl e a s e d o n ot di stri b ut e
A n ac ute c ul prit lesi o n wit h TI MI 0- 2 fl o w 
a pea k tr o p o ni n le vel e q ual t o or greater 5 t ha n fi ve ti mes t he 
Pl e a s e d o n ot di stri b ut e
a pea k tr o p o ni n le vel e q ual t o or greater 5 t ha n fi ve ti mes t he 
P L U S
Pl e a s e d o n ot di stri b ut e
P L U S
at least 2 0 % rise wit hi n t he first 2 4 h o urs  
Pl e a s e d o n ot di stri b ut e
at least 2 0 % rise wit hi n t he first 2 4 h o urs  
A hi g hl y ele vate d pea k (f or tr o p o ni n T > 1 0 0 0 n g/ m L a n d f or tr o p o ni n I 2 0 0 ti mes of 
Pl e a s e d o n ot di stri b ut e
A hi g hl y ele vate d pea k (f or tr o p o ni n T > 1 0 0 0 n g/ m L a n d f or tr o p o ni n I 2 0 0 ti mes of 

lesi o n o n a n gi o gra m i n a c or o nar y territ or y c o m pati ble wit h E C G/ec h ocar di o gra p hic 
area at c o ncer n) 
( 3) car diac arrest bef ore a n y tr o p o ni n rise has bee n d oc u me nte d wit h s u p p orti n g cli nical 
e vi de nce of p ossi ble A C O.  
F oll o w- u p 
T he last partici pa nt i n t he st u d y will be f oll o we d u p t o o ne year. T he s ur vi val stat us a n d re-
h os pitalizati o n will be c hec ke d fr o m t he nati o nal data base a n d a p h o ne call, if re q uire d.  
St atistic al A n alysis 
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
a l o g-ra n k test. A C o x-re gressi o n m o del will be use d t o perf or m a s ur vi val a nal ysis acc or di n g 
t o basal G R A C E ris k sc ore, i nter ve nti o n ti mi n g a n d treat me nt stat us. Baseli ne c haracteristics 
wit h  a  P  val ue  of  0. 0 5  or  less  i n  t he  u ni variate  a nal ysis  will  be  i ncl u de d  a n d  a  ste p- d o w n 
pr oce d ure will be a p plie d f or selecti o n of fi nal c o variates.  
T he se nsiti vit y, s pecificit y a n d dia g n ostic acc urac y of S T E MI/ N S T E MI or O MI/ N O MI 
E C G a p pr oac hes will be calc ulate d usi n g recei ver o perati n g c haracteristics a nal ysis. As t hese 
para meters  are  hi g hl y  de pe n de nt  o n  t he  pre-test  pr o ba bilit y  of  t he  disease  a n d  pre-test 
pr o ba bilit y of A C O a n d l o n g-ter m m ortalit y are cl osel y ass ociate d wit h t he prese ntati o n t y pe, 
DI F O C C U L T- 3 St u d y 
car diac arrest bef ore a n y tr o p o ni n rise has bee n d oc u me nte d wit h s u p p orti n g cli nical 
DI F O C C U L T- 3 St u d y 
car diac arrest bef ore a n y tr o p o ni n rise has bee n d oc u me nte d wit h s u p p orti n g cli nical 
DI F O C C U L T- 3 St u d y 
T he last partici pa nt i n t he st u d y will be f oll o we d u p t o o ne year. T he s ur vi val stat us a n d re-
DI F O C C U L T- 3 St u d y 
T he last partici pa nt i n t he st u d y will be f oll o we d u p t o o ne year. T he s ur vi val stat us a n d re-
DI F O C C U L T- 3 St u d y 
h os pitalizati o n will be c hec ke d fr o m t he nati o nal data base a n d a p h o ne call, if re q uire d.  
DI F O C C U L T- 3 St u d y 
h os pitalizati o n will be c hec ke d fr o m t he nati o nal data base a n d a p h o ne call, if re q uire d.  
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
DI F O C C U L T- 3 St u d y 
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
DI F O C C U L T- 3 St u d y 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
DI F O C C U L T- 3 St u d y 
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
DI F O C C U L T- 3 St u d y 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
DI F O C C U L T- 3 St u d y 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
DI F O C C U L T- 3 St u d y 
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
DI F O C C U L T- 3 St u d y 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
a l o g-ra n k test. A C o x-re gressi o n m o del will be use d t o perf or m a s ur vi val a nal ysis acc or di n g 
DI F O C C U L T- 3 St u d y 
a l o g-ra n k test. A C o x-re gressi o n m o del will be use d t o perf or m a s ur vi val a nal ysis acc or di n g 
t o basal G R A C E ris k sc ore, i nter ve nti o n ti mi n g a n d treat me nt stat us. Baseli ne c haracteristics 
DI F O C C U L T- 3 St u d y 
t o basal G R A C E ris k sc ore, i nter ve nti o n ti mi n g a n d treat me nt stat us. Baseli ne c haracteristics 
C o nfi d e nti al 
C o nfi d e nti al 
h os pitalizati o n will be c hec ke d fr o m t he nati o nal data base a n d a p h o ne call, if re q uire d.  
C o nfi d e nti al 
h os pitalizati o n will be c hec ke d fr o m t he nati o nal data base a n d a p h o ne call, if re q uire d.  
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
C o nfi d e nti al 
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
C o nfi d e nti al 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
C o nfi d e nti al 
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
C o nfi d e nti al 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
C o nfi d e nti al 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
C o nfi d e nti al 
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
C o nfi d e nti al 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
Pl e a s e d o n ot di stri b ut e
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
Pl e a s e d o n ot di stri b ut e
Baseli ne c haracteristics will be s u m marize d usi n g sta n dar d descri pti ve statistics. C o m paris o ns 
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
Pl e a s e d o n ot di stri b ut e
of  rele va nt  para meters  bet wee n  gr o u ps  will  be  perf or me d  b y  c hi-s q uare,  Fis her’s  e xact  test,
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
Pl e a s e d o n ot di stri b ut e
Ma n n- W hit ne y  U,  a n d  st u de nt  t-test,  as  a p pr o priate.  Patie nts  wit h  missi n g  val ues  will  be 
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
Pl e a s e d o n ot di stri b ut e
e xcl u de d pair wise fr o m a nal yses. A C o he n's κ test will be use d f or deter mi nati o n of t he i ntra- 
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
Pl e a s e d o n ot di stri b ut e
a n d i nter- o bser ver a gree me nt f or E C G classificati o ns a n d A C O a dj u dicati o n.  
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
Pl e a s e d o n ot di stri b ut e
Ka pla n- Meier  a nal ysis  will  be  perf or me d  t o  deter mi ne  t he  c u m ulati ve  l o n g-ter m 
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
Pl e a s e d o n ot di stri b ut e
m ortalit y rates i n differe nt E C G s u b gr o u ps. T he m ortalit y acr oss gr o u ps will be c o m pare d usi n g 
a l o g-ra n k test. A C o x-re gressi o n m o del will be use d t o perf or m a s ur vi val a nal ysis acc or di n g 
Pl e a s e d o n ot di stri b ut e
a l o g-ra n k test. A C o x-re gressi o n m o del will be use d t o perf or m a s ur vi val a nal ysis acc or di n g 
t o basal G R A C E ris k sc ore, i nter ve nti o n ti mi n g a n d treat me nt stat us. Baseli ne c haracteristics 
Pl e a s e d o n ot di stri b ut e
t o basal G R A C E ris k sc ore, i nter ve nti o n ti mi n g a n d treat me nt stat us. Baseli ne c haracteristics 
wit h  a  P  val ue  of  0. 0 5  or  less  i n  t he  u ni variate  a nal ysis  will  be  i ncl u de d  a n d  a  ste p- d o w n 
Pl e a s e d o n ot di stri b ut e
wit h  a  P  val ue  of  0. 0 5  or  less  i n  t he  u ni variate  a nal ysis  will  be  i ncl u de d  a n d  a  ste p- d o w n 
pr oce d ure will be a p plie d f or selecti o n of fi nal c o variates.  
Pl e a s e d o n ot di stri b ut e
pr oce d ure will be a p plie d f or selecti o n of fi nal c o variates.  
Pl e a s e d o n ot di stri b ut e
T he se nsiti vit y, s pecificit y a n d dia g n ostic acc urac y of S T E MI/ N S T E MI or O MI/ N O MI 
Pl e a s e d o n ot di stri b ut e
T he se nsiti vit y, s pecificit y a n d dia g n ostic acc urac y of S T E MI/ N S T E MI or O MI/ N O MI 
E C G a p pr oac hes will be calc ulate d usi n g recei ver o perati n g c haracteristics a nal ysis. As t hese 
Pl e a s e d o n ot di stri b ut e
E C G a p pr oac hes will be calc ulate d usi n g recei ver o perati n g c haracteristics a nal ysis. As t hese 

we  will  als o  re peat  t hese  a nal yses  after  wei g hi n g  cases  f or  t he  t otal  n u m ber  of  h os pital 
a d missi o ns i n t he st u d y peri o d.  
T o a d dress p ote ntial varia bilit y i n o utc o mes d ue t o i nter ve nti o nist or ce nter-relate d 
fact ors, we will i nc or p orate a ra n d o m effects (frailt y) ter m i nt o t he C o x m o del. 
T he c ali br ati o n c o h ort  (t he patie nts wit h t y pe 1a E C Gs, w h o are getti n g t he sa me treat me nt i n 
b ot h st u d y ar ms) will be use d t o esti mate varia bilit y attri b uta ble t o i nter ve nti o nist practices. 
T he ra n d o m effect varia nce ( σ 2) calc ulate d fr o m t his c o h ort will i nf or m t he frailt y ter m i n t he 
f ull C o x m o del, e ns uri n g t hat differe nces i n o utc o mes d ue t o i nter ve nti o nist-relate d varia bilit y 
are a p pr o priatel y a dj uste d. T he fi nal m o del will i ncl u de patie nt-le vel c o variates, ra n d o m 
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
c o h ort.  
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base ( e- n a bız). F or a n y 
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
statistical p o wer. 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
S T E MI/ N S T E MI a p pr oac hes i n i n- h os pital m ortalit y a n d i nfarct size b y pea k tr o p o ni n, L V E F 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
A C O; ( 3) ti me relate d be nefit a nal ysis i n all E C G a n d MI s u bt y pes; ( 4) t he de gree of t he 
a d o pti o n of O MI a p pr oac h i n t he earl y a n d late p hase of t he st u d y.   
Statistical a nal yses will be perf or me d wit h S P S S ( versi o n 2 4. 0; S P S S I nc., C hica g o, I L) 
a n d  Me d Calc  S oft ware  ( versi o n  1 8. 2. 1  [ E val uati o n  versi o n];  Me d Calc  S oft ware,  Oste n d, 
Bel gi u m).  
DI F O C C U L T- 3 St u d y 
fact ors, we will i nc or p orate a ra n d o m effects (frailt y) ter m i nt o t he C o x m o del. 
DI F O C C U L T- 3 St u d y 
fact ors, we will i nc or p orate a ra n d o m effects (frailt y) ter m i nt o t he C o x m o del. 
 (t he patie nts wit h t y pe 1a E C Gs, w h o are getti n g t he sa me treat me nt i n 
DI F O C C U L T- 3 St u d y 
 (t he patie nts wit h t y pe 1a E C Gs, w h o are getti n g t he sa me treat me nt i n 
b ot h st u d y ar ms) will be use d t o esti mate varia bilit y attri b uta ble t o i nter ve nti o nist practices. 
DI F O C C U L T- 3 St u d y 
b ot h st u d y ar ms) will be use d t o esti mate varia bilit y attri b uta ble t o i nter ve nti o nist practices. 
) calc ulate d fr o m t his c o h ort will i nf or m t he frailt y ter m i n t he 
DI F O C C U L T- 3 St u d y 
) calc ulate d fr o m t his c o h ort will i nf or m t he frailt y ter m i n t he 
f ull C o x m o del, e ns uri n g t hat differe nces i n o utc o mes d ue t o i nter ve nti o nist-relate d varia bilit y 
DI F O C C U L T- 3 St u d y 
f ull C o x m o del, e ns uri n g t hat differe nces i n o utc o mes d ue t o i nter ve nti o nist-relate d varia bilit y 
are a p pr o priatel y a dj uste d. T he fi nal m o del will i ncl u de patie nt-le vel c o variates, ra n d o m 
DI F O C C U L T- 3 St u d y 
are a p pr o priatel y a dj uste d. T he fi nal m o del will i ncl u de patie nt-le vel c o variates, ra n d o m 
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
DI F O C C U L T- 3 St u d y 
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
DI F O C C U L T- 3 St u d y 
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base (
DI F O C C U L T- 3 St u d y 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base (
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
DI F O C C U L T- 3 St u d y 
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
statistical p o wer. 
DI F O C C U L T- 3 St u d y 
statistical p o wer. 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
DI F O C C U L T- 3 St u d y 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
S T E MI/ N S T E MI a p pr oac hes i n 
DI F O C C U L T- 3 St u d y 
S T E MI/ N S T E MI a p pr oac hes i n 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
DI F O C C U L T- 3 St u d y 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
A C O; ( 3) ti me relate d be nefit a nal ysis i n all E C G a n d MI s u bt y pes; ( 4) t he de gree of t he 
DI F O C C U L T- 3 St u d y 
A C O; ( 3) ti me relate d be nefit a nal ysis i n all E C G a n d MI s u bt y pes; ( 4) t he de gree of t he 
a d o pti o n of O MI a p pr oac h i n t he earl y a n d late p hase of t he st u d y.   
DI F O C C U L T- 3 St u d y 
a d o pti o n of O MI a p pr oac h i n t he earl y a n d late p hase of t he st u d y.   
C o nfi d e nti al 
are a p pr o priatel y a dj uste d. T he fi nal m o del will i ncl u de patie nt-le vel c o variates, ra n d o m 
C o nfi d e nti al 
are a p pr o priatel y a dj uste d. T he fi nal m o del will i ncl u de patie nt-le vel c o variates, ra n d o m 
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
C o nfi d e nti al 
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
C o nfi d e nti al 
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base (
C o nfi d e nti al 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base (
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
C o nfi d e nti al 
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
C o nfi d e nti al 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
S T E MI/ N S T E MI a p pr oac hes i n 
C o nfi d e nti al 
S T E MI/ N S T E MI a p pr oac hes i n i n
C o nfi d e nti al 
i n
C o nfi d e nti al 
- h os pital m ortalit y a n d i nfarct size b y pea k tr o p o ni n, L V E F 
C o nfi d e nti al 
- h os pital m ortalit y a n d i nfarct size b y pea k tr o p o ni n, L V E F 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
C o nfi d e nti al 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
Pl e a s e d o n ot di stri b ut e
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
Pl e a s e d o n ot di stri b ut e
effects f or i nter ve nti o nists or ce nters, a n d cali brati o n a dj ust me nts base d o n t he cali brati o n 
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
Pl e a s e d o n ot di stri b ut e
We a ntici pate mi ni mal missi n g data f or t he c o m p osite e n d p oi nt, as deat h a n d 
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base (
Pl e a s e d o n ot di stri b ut e
h os pitalizati o n e ve nts are c o vere d i n t he electr o nic nati o nal data base ( e- n a bız
Pl e a s e d o n ot di stri b ut e
e- n a bız). F or a n y 
Pl e a s e d o n ot di stri b ut e
). F or a n y 
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
Pl e a s e d o n ot di stri b ut e
missi n g baseli ne c o variates, m ulti ple i m p utati o n will be e m pl o ye d t o a v oi d bias a n d ma xi mize 
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
Pl e a s e d o n ot di stri b ut e
Ot her pre defi ne d sec o n dar y a nal yses i ncl u de: ( 1) c o m paris o n of O MI/ N O MI a n d 
Pl e a s e d o n ot di stri b ut e
- h os pital m ortalit y a n d i nfarct size b y pea k tr o p o ni n, L V E F 
Pl e a s e d o n ot di stri b ut e
- h os pital m ortalit y a n d i nfarct size b y pea k tr o p o ni n, L V E F 
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
Pl e a s e d o n ot di stri b ut e
a n d W M SI, ( 2) a recei ver o perati n g c haracteristics c ur ve a nal ysis f or O MI c o m p o ne nts f or 
A C O; ( 3) ti me relate d be nefit a nal ysis i n all E C G a n d MI s u bt y pes; ( 4) t he de gree of t he 
Pl e a s e d o n ot di stri b ut e
A C O; ( 3) ti me relate d be nefit a nal ysis i n all E C G a n d MI s u bt y pes; ( 4) t he de gree of t he 
a d o pti o n of O MI a p pr oac h i n t he earl y a n d late p hase of t he st u d y.   
Pl e a s e d o n ot di stri b ut e
a d o pti o n of O MI a p pr oac h i n t he earl y a n d late p hase of t he st u d y.   
Pl e a s e d o n ot di stri b ut e
Statistical a nal yses will be perf or me d wit h S P S S ( versi o n 2 4. 0; S P S S I nc., C hica g o, I L) 
Pl e a s e d o n ot di stri b ut e
Statistical a nal yses will be perf or me d wit h S P S S ( versi o n 2 4. 0; S P S S I nc., C hica g o, I L) 
a n d  Me d Calc  S oft ware  ( versi o n  1 8. 2. 1  [ E val uati o n  versi o n];  Me d Calc  S oft ware,  Oste n d, 
Pl e a s e d o n ot di stri b ut e
a n d  Me d Calc  S oft ware  ( versi o n  1 8. 2. 1  [ E val uati o n  versi o n];  Me d Calc  S oft ware,  Oste n d, 
Bel gi u m).  
Pl e a s e d o n ot di stri b ut e
Bel gi u m).  

5. S afet y m o nit ori n g a n d re p orti n g 
St u d y R E D Ca p f or ms necessitate i n- h os pital a d verse e ve nts t o be acti vel y c ollecte d t o m o nit or 
a n d re p ort a n y i n- h os pital a d verse e ve nts. A n i n de pe n de nt Data Safet y M o nit ori n g B oar d 
( D S M B) has bee n esta blis he d t o o versee t he safet y a n d pr o gress of t he trial. T he D S M B 
c o n ve ne d via telec o nfere nce d uri n g t he pretrial peri o d, u p o n e nr oll me nt of 2 5 % of t he 
partici pa nt sa m ple size, a n d will c o nti n ue t o meet after eac h s u bse q ue nt 2 5 % e nr oll me nt 
milest o ne. T he pri mar y o bjecti ve of t he D S M B is t o m o nit or e nr oll me nt milest o nes a n d t he 
safet y of t he i nter ve nti o ns. A t hree- p oi nt c o m bi ne d safet y e n d p oi nt will be cl osel y m o nit ore d:  
( 1) i n- h os pital car di o p ul m o nar y res uscitati o n, ( 2) i n- h os pital i nt u bati o n, ( 3) i n- h os pital 
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
partici pa nts or t he st u d y ce nter. 
6. St u d y i nte grit y  
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
t he trial desi g n a n d or ga nizi n g t he partici pati n g ce nters. T he steeri n g c o m mittee o versees t he 
pr ocesses of recr uit me nt, c o nse nt a n d asse nt, f oll o w- u p, a n d e ns ures t he vali dit y a n d i nte grit y 
of data ac q uisiti o n. T he trial has bee n a p pr o ve d b y t he Et hical B oar d of Mar mara U ni versit y 
( 0 9. 2 0 2 1. 5 2 3), a n y c ha n ge i n pr ot oc ol or ce nters will be a d dresse d b y t his b oar d. T he st u d y will
be c o n d ucte d i n acc or da nce wit h G o o d Cli nical Practice g ui deli nes. 
We ac k n o wle d ge t hat t he i m ple me ntati o n of t he ne w O MI/ N O MI para di g m, e ve n i n a 
ra n d o mize d c o ntr olle d trial, ma y p ose c halle n ges d ue t o c o nce pt ual, l o gistical, a n d i n di vi d ual 
DI F O C C U L T- 3 St u d y 
( D S M B) has bee n esta blis he d t o o versee t he safet y a n d pr o gress of t he trial. T he D S M B 
DI F O C C U L T- 3 St u d y 
( D S M B) has bee n esta blis he d t o o versee t he safet y a n d pr o gress of t he trial. T he D S M B 
c o n ve ne d via telec o nfere nce d uri n g t he pretrial peri o d, u p o n e nr oll me nt of 2 5 % of t he 
DI F O C C U L T- 3 St u d y 
c o n ve ne d via telec o nfere nce d uri n g t he pretrial peri o d, u p o n e nr oll me nt of 2 5 % of t he 
partici pa nt sa m ple size, a n d will c o nti n ue t o meet after eac h s u bse q ue nt 2 5 % e nr oll me nt 
DI F O C C U L T- 3 St u d y 
partici pa nt sa m ple size, a n d will c o nti n ue t o meet after eac h s u bse q ue nt 2 5 % e nr oll me nt 
milest o ne. T he pri mar y o bjecti ve of t he D S M B is t o m o nit or e nr oll me nt milest o nes a n d t he 
DI F O C C U L T- 3 St u d y 
milest o ne. T he pri mar y o bjecti ve of t he D S M B is t o m o nit or e nr oll me nt milest o nes a n d t he 
t hree- p oi nt c o m bi ne d safet y e n d p oi nt will be cl osel y m o nit ore d:  
DI F O C C U L T- 3 St u d y 
t hree- p oi nt c o m bi ne d safet y e n d p oi nt will be cl osel y m o nit ore d:  
( 1) i n- h os pital car di o p ul m o nar y res uscitati o n, ( 2) i n- h os pital i nt u bati o n, ( 3) i n- h os pital 
DI F O C C U L T- 3 St u d y 
( 1) i n- h os pital car di o p ul m o nar y res uscitati o n, ( 2) i n- h os pital i nt u bati o n, ( 3) i n- h os pital 
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
DI F O C C U L T- 3 St u d y 
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
DI F O C C U L T- 3 St u d y 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
DI F O C C U L T- 3 St u d y 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
DI F O C C U L T- 3 St u d y 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
partici pa nts or t he st u d y ce nter. 
DI F O C C U L T- 3 St u d y 
partici pa nts or t he st u d y ce nter. 
6. St u d y i nte grit y  
DI F O C C U L T- 3 St u d y 
6. St u d y i nte grit y  
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
DI F O C C U L T- 3 St u d y 
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
DI F O C C U L T- 3 St u d y 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
t he trial desi g n a n d or ga nizi n g t he partici pati n g ce nters. T he steeri n g c o m mittee o versees t he 
DI F O C C U L T- 3 St u d y 
t he trial desi g n a n d or ga nizi n g t he partici pati n g ce nters. T he steeri n g c o m mittee o versees t he 
C o nfi d e nti al 
( 1) i n- h os pital car di o p ul m o nar y res uscitati o n, ( 2) i n- h os pital i nt u bati o n, ( 3) i n- h os pital 
C o nfi d e nti al 
( 1) i n- h os pital car di o p ul m o nar y res uscitati o n, ( 2) i n- h os pital i nt u bati o n, ( 3) i n- h os pital 
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
C o nfi d e nti al 
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
C o nfi d e nti al 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
C o nfi d e nti al 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
C o nfi d e nti al 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
C o nfi d e nti al 
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
C o nfi d e nti al 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
Pl e a s e d o n ot di stri b ut e
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
Pl e a s e d o n ot di stri b ut e
m ortalit y. If a statisticall y si g nifica nt i ncrease i n t his t hree- p oi nt c o m bi ne d safet y e n d p oi nt is 
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
Pl e a s e d o n ot di stri b ut e
o bser ve d i n eit her of t he st u d y ar ms after a dj usti n g f or t he baseli ne G R A C E ris k sc ore, d uri n g 
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
Pl e a s e d o n ot di stri b ut e
t he e nr oll me nt of a n y 2 5 % of t he partici pa nt sa m ple size, t he D S M B will ma ke a 
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
Pl e a s e d o n ot di stri b ut e
rec o m me n dati o n re gar di n g t he re visi o n, rearra n ge me nt or p ote ntial e xcl usi o n of t he st u d y 
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
Pl e a s e d o n ot di stri b ut e
T he st u d y is a n i n vesti gat or-i nitiate d trial c o n d ucte d u n der t he a us pices of t he T ur kis h S ociet y 
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
Pl e a s e d o n ot di stri b ut e
of Car di ol o g y. T he T ur kis h S ociet y of Car di ol o g y s u p p orts t he i n vesti gat or tea m i n de vel o pi n g 
t he trial desi g n a n d or ga nizi n g t he partici pati n g ce nters. T he steeri n g c o m mittee o versees t he 
Pl e a s e d o n ot di stri b ut e
t he trial desi g n a n d or ga nizi n g t he partici pati n g ce nters. T he steeri n g c o m mittee o versees t he 
pr ocesses of recr uit me nt, c o nse nt a n d asse nt, f oll o w- u p, a n d e ns ures t he vali dit y a n d i nte grit y 
Pl e a s e d o n ot di stri b ut e
pr ocesses of recr uit me nt, c o nse nt a n d asse nt, f oll o w- u p, a n d e ns ures t he vali dit y a n d i nte grit y 
Pl e a s e d o n ot di stri b ut e
of data ac q uisiti o n. T he trial has bee n a p pr o ve d b y t he Et hical B oar d of Mar mara U ni versit y 
Pl e a s e d o n ot di stri b ut e
of data ac q uisiti o n. T he trial has bee n a p pr o ve d b y t he Et hical B oar d of Mar mara U ni versit y 
( 0 9. 2 0 2 1. 5 2 3), a n y c ha n ge i n pr ot oc ol or ce nters will be a d dresse d b y t his b oar d. T he st u d y 
Pl e a s e d o n ot di stri b ut e
( 0 9. 2 0 2 1. 5 2 3), a n y c ha n ge i n pr ot oc ol or ce nters will be a d dresse d b y t his b oar d. T he st u d y 
Pl e a s e d o n ot di stri b ut e
be c o n d ucte d i n acc or da nce wit h G o o d Cli nical Practice g ui deli nes. 
Pl e a s e d o n ot di stri b ut e
be c o n d ucte d i n acc or da nce wit h G o o d Cli nical Practice g ui deli nes. 

or i nstit uti o n-le vel barriers. T o pr o m ote a d here nce, all i nter ve nti o nists i n t he O MI/ N O MI ar m 
partici pate d  i n  a  c o m pre he nsi ve  trai ni n g  pr o gra m,  i ncl u di n g  lect ures  a n d  case  si m ulati o ns, 
f oc usi n g  o n  t he  O MI/ N O MI  fra me w or k,  s u btle  E C G  fi n di n gs,  a n d  t he  i nte grati o n  of  AI-
p o were d dia g n ostic t o ols pri or t o t he st u d y’s c o m me nce me nt. A d diti o nall y, t he R E D Ca p s yste m 
was desi g ne d t o iss ue war ni n g messa ges if patie nt ma na ge me nt de viate d fr o m t he O MI pr ot oc ol. 
D uri n g  t he  trial,  t he  data  m o nit ori n g  b oar d  o versees  a d here nce,  c o n d ucts  re g ular  a u dits,  a n d 
pr o vi des fee d bac k o n pr ot oc ol c o m plia nce. A n y de viati o ns are metic ul o usl y d oc u me nte d a n d 
a nal yze d t o i de ntif y barriers, wit h a da pti ve fee d bac k mec ha nis ms e m pl o ye d t o a d dress t hese 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
t he pri mar y i nte nti o n-t o-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
practice. 
DI F O C C U L T- 3 St u d y 
p o were d dia g n ostic t o ols pri or t o t he st u d y’s c o m me nce me nt. A d diti o nall y, t he R E D Ca p s yste m 
DI F O C C U L T- 3 St u d y 
p o were d dia g n ostic t o ols pri or t o t he st u d y’s c o m me nce me nt. A d diti o nall y, t he R E D Ca p s yste m 
was desi g ne d t o iss ue war ni n g messa ges if patie nt ma na ge me nt de viate d fr o m t he O MI pr ot oc ol. 
DI F O C C U L T- 3 St u d y 
was desi g ne d t o iss ue war ni n g messa ges if patie nt ma na ge me nt de viate d fr o m t he O MI pr ot oc ol. 
D uri n g  t he  trial,  t he  data  m o nit ori n g  b oar d  o versees  a d here nce,  c o n d ucts  re g ular  a u dits,  a n d 
DI F O C C U L T- 3 St u d y 
D uri n g  t he  trial,  t he  data  m o nit ori n g  b oar d  o versees  a d here nce,  c o n d ucts  re g ular  a u dits,  a n d 
pr o vi des fee d bac k o n pr ot oc ol c o m plia nce. A n y de viati o ns are metic ul o usl y d oc u me nte d a n d 
DI F O C C U L T- 3 St u d y 
pr o vi des fee d bac k o n pr ot oc ol c o m plia nce. A n y de viati o ns are metic ul o usl y d oc u me nte d a n d 
a nal yze d t o i de ntif y barriers, wit h a da pti ve fee d bac k mec ha nis ms e m pl o ye d t o a d dress t hese 
DI F O C C U L T- 3 St u d y 
a nal yze d t o i de ntif y barriers, wit h a da pti ve fee d bac k mec ha nis ms e m pl o ye d t o a d dress t hese 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
DI F O C C U L T- 3 St u d y 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
DI F O C C U L T- 3 St u d y 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
DI F O C C U L T- 3 St u d y 
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
DI F O C C U L T- 3 St u d y 
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
DI F O C C U L T- 3 St u d y 
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
DI F O C C U L T- 3 St u d y 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
C o nfi d e nti al 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
C o nfi d e nti al 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
C o nfi d e nti al 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
C o nfi d e nti al 
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
C o nfi d e nti al 
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
C o nfi d e nti al 
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
C o nfi d e nti al 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
Pl e a s e d o n ot di stri b ut e
a nal yze d t o i de ntif y barriers, wit h a da pti ve fee d bac k mec ha nis ms e m pl o ye d t o a d dress t hese 
Pl e a s e d o n ot di stri b ut e
a nal yze d t o i de ntif y barriers, wit h a da pti ve fee d bac k mec ha nis ms e m pl o ye d t o a d dress t hese 
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
Pl e a s e d o n ot di stri b ut e
iss ues  pr o m ptl y.  I n vesti gat ors  als o  recei ve  o n g oi n g  case  re vie ws  a n d  tar gete d  disc ussi o ns  t o 
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
Pl e a s e d o n ot di stri b ut e
rei nf orce pr ot oc ol fi delit y. F urt her m ore, per- pr ot oc ol a n d se nsiti vit y a nal yses will c o m ple me nt 
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
Pl e a s e d o n ot di stri b ut e
-treat a nal ysis t o e val uate t he i m pact of pr ot oc ol a d here nce o n o utc o mes. 
Pl e a s e d o n ot di stri b ut e
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
Pl e a s e d o n ot di stri b ut e
T hese meas ures c ollecti vel y e ns ure t he r o b ust ness of t he st u d y fi n di n gs w hile offeri n g val ua ble 
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 
Pl e a s e d o n ot di stri b ut e
i nsi g hts  i nt o  t he  feasi bilit y  of  i m ple me nti n g  t he  O MI/ N O MI  para di g m  i n  real- w orl d  cli nical 

  
  
    
 
 
MI
MI
S T E MI/ O M I 
A d ult patie nts ( ≥1 8 years) wit h a cli nical pict ure c o m pati ble 
wit h ac ute c or o nar y s y n dr o me 
                          E C G ( < 1 0 mi n) 
I ncl usi o n 
-
MI dia g n ose d b y 
E C G  
-
MI dia g n ose d 
cli nicall y 
Serial E C G a n d T n  
± ot her tests 
Cli nical dia g n osis 
He m o d y na mic i nsta bilit y 
Arr h yt h mias or c ar dia c arrest 
-
MI dia g n ose d b y 
serial E C G, T n or 
ot her test (ec h o, C T 
etc.) 
R ule d o ut f or MI via 0/ 2 h  
E S C al g orit h m  
E xcl usi o n
-
T he patie nt was 
i ncl u de d b/c T n, b ut 
T n e x plai ne d b y a n 
alter nati ve D x a n d 
C A G was a b orte d. 
-
Acti ve or p ossi ble 
pre g na nc y 
-
T hr o m b ol ysis (i v) 
Scree ni n g p hase 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
C o nfi d e nti al 
C o nfi d e nti al 
C o nfi d e nti al 
C o nfi d e nti al 
C o nfi d e nti al 
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e

O MI/ N O MI 
S T E MI/ N S T E MI 
First E C G 
Serial E C Gs ( q 1 5 mi n x 4) 
Serial tr o p o ni n ( 0 a n d 2 h) 
C or o nar y a n gi o gra p h y 
Earlier C A G f or S T E MI – 
b ut O MI + patie nts 
De m o gra p hics 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
Ec h ocar di o gra m 
Treat me nt 
L o n g-ter m s ur veilla nce 
Pre h os pital/ E R 
Cat h
H os pital 
L o n g- ter m
First E C G 
Serial E C Gs ( q 1 5 mi n x 4) 
Serial tr o p o ni n ( 0 a n d 2 h) 
C or o nar y a n gi o gra p h y 
De m o gra p hics 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
Ec h ocar di o gra m 
Treat me nt 
L o n g-ter m s ur veilla nce 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
DI F O C C U L T- 3 St u d y 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
DI F O C C U L T- 3 St u d y 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
Serial tr o p o ni n ( 0 a n d 2 h) 
DI F O C C U L T- 3 St u d y 
Serial tr o p o ni n ( 0 a n d 2 h) 
C or o nar y a n gi o gra p h y 
DI F O C C U L T- 3 St u d y 
C or o nar y a n gi o gra p h y 
C o nfi d e nti al 
C o nfi d e nti al 
C o nfi d e nti al 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
C o nfi d e nti al 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
C o nfi d e nti al 
7 2) 
De m o gra p hics 
7 2) 
De m o gra p hics 
C o nfi d e nti al 
De m o gra p hics 
7 2) 
De m o gra p hics 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
C o nfi d e nti al 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
P ost- P CI E C Gs ( 0, 2 4, 4 8, 
7 2) 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
7 2) 
C o nfi d e nti al 
7 2) 
P ost- P CI T n ( 2 4, 4 8, 7 2) 
7 2) 
7 2) 
Ec h ocar di o gra m 
7 2) 
C o nfi d e nti al 
7 2) 
Ec h ocar di o gra m 
7 2) 
7 2) 
Treat me nt 
7 2) 
C o nfi d e nti al 
7 2) 
Treat me nt 
7 2) 
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
Pl e a s e d o n ot di stri b ut e
P ost- P CI T n ( 2 4, 4 8, 7 2) 
Pl e a s e d o n ot di stri b ut e
P ost- P CI T n ( 2 4, 4 8, 7 2) 
Ec h ocar di o gra m 
Pl e a s e d o n ot di stri b ut e
Ec h ocar di o gra m 

I nf or me d C o nse nt f or m f or p atie nt.  
T his I nf or me d C o nse nt F or m is f or t he patie nts w h o are bei n g i n vite d t o partici pate i n researc h 
o n Ti me  f or  a  DI a g n ostic  p ar a di g m  s hift  Fr o m  S T-elev ati o n/ n o n- S T-elev ati o n  t o 
O C Cl Usi o n/ n o n- occ L usi o n my oc ar di al i nf arc Ti o n ?  ( DI F O C C U L T 3) St u d y. 
T his I nf or me d C o nse nt F or m has t w o parts a n d f o ur pa ges: 
I nf or mati o n S heet (t o s hare i nf or mati o n a b o ut t he researc h wit h y o u)  
Certificate of C o nse nt (f or si g nat ures if y o u a gree t o ta ke part)  
Y o u will be gi ve n a c o p y of t he f ull I nf or me d C o nse nt F or m  
P A R T I:  I nf or mati o n S heet I ntr o d ucti o n  
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
me, t he st u d y d oct or or t he staff.)  
P ur p ose of t he researc h  
We belie ve t hat c urre nt u n dersta n di n g of electr ocar di o gra m i n m y ocar dial i nfarcti o n is bel o w 
o pti mal le vel. T o da y, we perf or m e mer ge nt c or o nar y a n gi o gra p h y i n patie nts wit h a s pecific 
si g n  o n  electr ocar di o gra m,  calle d  S T-se g me nt  ele vati o n,  a n d  it  is  pr o ve n  effecti ve  i n  t his 
sit uati o n.  H o we ver,  ma n y  ot her  fi n di n gs  ha ve  bee n  pr o ve d  t o  s h o w  a n  o bstr ucte d  c or o nar y 
arter y.  We d o n ot k n o w if perf or mi n g t his pr oce d ure as a n e mer ge nc y is be neficial or har mf ul 
DI F O C C U L T- 3 St u d y 
 ( DI F O C C U L T 3) St u d y. 
DI F O C C U L T- 3 St u d y 
 ( DI F O C C U L T 3) St u d y. 
I nf or mati o n S heet (t o s hare i nf or mati o n a b o ut t he researc h wit h y o u)  
DI F O C C U L T- 3 St u d y 
I nf or mati o n S heet (t o s hare i nf or mati o n a b o ut t he researc h wit h y o u)  
Certificate of C o nse nt (f or si g nat ures if y o u a gree t o ta ke part)  
DI F O C C U L T- 3 St u d y 
Certificate of C o nse nt (f or si g nat ures if y o u a gree t o ta ke part)  
Y o u will be gi ve n a c o p y of t he f ull I nf or me d C o nse nt F or m  
DI F O C C U L T- 3 St u d y 
Y o u will be gi ve n a c o p y of t he f ull I nf or me d C o nse nt F or m  
 I nf or mati o n S heet I ntr o d ucti o n  
DI F O C C U L T- 3 St u d y 
 I nf or mati o n S heet I ntr o d ucti o n  
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
DI F O C C U L T- 3 St u d y 
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
DI F O C C U L T- 3 St u d y 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
DI F O C C U L T- 3 St u d y 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
DI F O C C U L T- 3 St u d y 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
DI F O C C U L T- 3 St u d y 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
DI F O C C U L T- 3 St u d y 
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
DI F O C C U L T- 3 St u d y 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
me, t he st u d y d oct or or t he staff.)  
DI F O C C U L T- 3 St u d y 
me, t he st u d y d oct or or t he staff.)  
C o nfi d e nti al 
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
C o nfi d e nti al 
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
C o nfi d e nti al 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
C o nfi d e nti al 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
C o nfi d e nti al 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
C o nfi d e nti al 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
C o nfi d e nti al 
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
C o nfi d e nti al 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
Pl e a s e d o n ot di stri b ut e
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
Pl e a s e d o n ot di stri b ut e
I  a m  … … … … … … … … … ….,  t he  c hief  researc her  i n  t he  pr oject  DI F O C C U L T  3  St u d y  at 
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
Pl e a s e d o n ot di stri b ut e
… … … … … … … … … … … … … …...  We  are  d oi n g  researc h  o n  electr ocar di o gra m  i n 
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
Pl e a s e d o n ot di stri b ut e
m y ocar dial  i nfarcti o n.  I  a m  g oi n g  t o  gi ve  y o u  i nf or mati o n  a n d  i n vite  y o u  t o  be  part  of  t his 
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
Pl e a s e d o n ot di stri b ut e
researc h. Y o u d o n ot ha ve t o deci de t o da y w het her or n ot y o u will partici pate i n t he researc h. 
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
Pl e a s e d o n ot di stri b ut e
Bef ore y o u deci de, y o u ca n tal k t o a n y o ne y o u feel c o mf orta ble wit h a b o ut t he researc h.  
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
Pl e a s e d o n ot di stri b ut e
T here ma y be s o me w or ds t hat y o u d o n ot u n dersta n d. Please as k me t o st o p as we g o t hr o u g h 
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
Pl e a s e d o n ot di stri b ut e
t he i nf or mati o n a n d I will ta ke ti me t o e x plai n. If y o u ha ve q uesti o ns later, y o u ca n as k t he m of 
me, t he st u d y d oct or or t he staff.)  
Pl e a s e d o n ot di stri b ut e
me, t he st u d y d oct or or t he staff.)  
P ur p ose of t he researc h  
Pl e a s e d o n ot di stri b ut e
P ur p ose of t he researc h  
We belie ve t hat c urre nt u n dersta n di n g of electr ocar di o gra m i n m y ocar dial i nfarcti o n is bel o w 
Pl e a s e d o n ot di stri b ut e
We belie ve t hat c urre nt u n dersta n di n g of electr ocar di o gra m i n m y ocar dial i nfarcti o n is bel o w 
o pti mal le vel. T o da y, we perf or m e mer ge nt c or o nar y a n gi o gra p h y i n patie nts wit h a s pecific 
Pl e a s e d o n ot di stri b ut e
o pti mal le vel. T o da y, we perf or m e mer ge nt c or o nar y a n gi o gra p h y i n patie nts wit h a s pecific 
si g n  o n  electr ocar di o gra m,  calle d  S T-se g me nt  ele vati o n,  a n d  it  is  pr o ve n  effecti ve  i n  t his 
Pl e a s e d o n ot di stri b ut e
si g n  o n  electr ocar di o gra m,  calle d  S T-se g me nt  ele vati o n,  a n d  it  is  pr o ve n  effecti ve  i n  t his 

or neit her.   If we pr o ve t hat a ge neral a p pr oac h t o s u btleties of electr ocar di o gra m s h o ws a better 
o utc o me i n patie nts wit h m y ocar dial i nfarcti o n, c urre nt treat me nt sta n dar ds will c ha n ge i n t his 
directi o n.  
T y pe of Researc h I nter ve nti o n  
T his  researc h  will  use  y o ur  de m o gra p hic  data,  bl o o d  tests,  a n gi o gra m  res ults  a n d 
electr ocar di o gra ms st ore d i n t he h os pital s yste m a n d n o ne w st u d y will be nee de d.  
Partici pa nt selecti o n  
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
t he researc h. 
V ol u ntar y Partici pati o n  
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
c o nti n ue a n d n ot hi n g will c ha n ge.  
Pr oce d ures a n d Pr ot oc ol  
T he data rec or de d i n t he h os pital s yste m d uri n g y o ur sta y i n t he h os pital will be use d a n d n o 
ne w test will be d o ne. After a peri o d y o ur s ur vi val stat us will be c hec ke d fr o m t he nati o nal 
data base.  
D urati o n  
T he researc h ta kes place o ver 1 t o 2 years.  
Ris ks  
DI F O C C U L T- 3 St u d y 
T his  researc h  will  use  y o ur  de m o gra p hic  data,  bl o o d  tests,  a n gi o gra m  res ults  a n d 
DI F O C C U L T- 3 St u d y 
T his  researc h  will  use  y o ur  de m o gra p hic  data,  bl o o d  tests,  a n gi o gra m  res ults  a n d 
electr ocar di o gra ms st ore d i n t he h os pital s yste m a n d n o ne w st u d y will be nee de d.  
DI F O C C U L T- 3 St u d y 
electr ocar di o gra ms st ore d i n t he h os pital s yste m a n d n o ne w st u d y will be nee de d.  
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
DI F O C C U L T- 3 St u d y 
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
V ol u ntar y Partici pati o n  
DI F O C C U L T- 3 St u d y 
V ol u ntar y Partici pati o n  
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
DI F O C C U L T- 3 St u d y 
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
DI F O C C U L T- 3 St u d y 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
c o nti n ue a n d n ot hi n g will c ha n ge.  
DI F O C C U L T- 3 St u d y 
c o nti n ue a n d n ot hi n g will c ha n ge.  
Pr oce d ures a n d Pr ot oc ol  
DI F O C C U L T- 3 St u d y 
Pr oce d ures a n d Pr ot oc ol  
T he data rec or de d i n t he h os pital s yste m d uri n g y o ur sta y i n t he h os pital will be use d a n d n o 
DI F O C C U L T- 3 St u d y 
T he data rec or de d i n t he h os pital s yste m d uri n g y o ur sta y i n t he h os pital will be use d a n d n o 
ne w test will be d o ne. After a peri o d y o ur s ur vi val stat us will be c hec ke d fr o m t he nati o nal 
DI F O C C U L T- 3 St u d y 
ne w test will be d o ne. After a peri o d y o ur s ur vi val stat us will be c hec ke d fr o m t he nati o nal 
C o nfi d e nti al 
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
C o nfi d e nti al 
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
C o nfi d e nti al 
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
C o nfi d e nti al 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
c o nti n ue a n d n ot hi n g will c ha n ge.  
C o nfi d e nti al 
c o nti n ue a n d n ot hi n g will c ha n ge.  
Pl e a s e d o n ot di stri b ut e
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
Pl e a s e d o n ot di stri b ut e
We are scree ni n g all a d ults wit h ac ute c hest pai n i n t he e mer ge nc y de part me nt t o partici pate i n 
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
Pl e a s e d o n ot di stri b ut e
Y o ur partici pati o n i n t his researc h is e ntirel y v ol u ntar y. It is y o ur c h oice w het her t o partici pate 
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
Pl e a s e d o n ot di stri b ut e
or n ot. W het her y o u c h o ose t o partici pate or n ot, all t he ser vices y o u recei ve at t his cli nic will 
Pl e a s e d o n ot di stri b ut e
T he data rec or de d i n t he h os pital s yste m d uri n g y o ur sta y i n t he h os pital will be use d a n d n o 
Pl e a s e d o n ot di stri b ut e
T he data rec or de d i n t he h os pital s yste m d uri n g y o ur sta y i n t he h os pital will be use d a n d n o 
ne w test will be d o ne. After a peri o d y o ur s ur vi val stat us will be c hec ke d fr o m t he nati o nal 
Pl e a s e d o n ot di stri b ut e
ne w test will be d o ne. After a peri o d y o ur s ur vi val stat us will be c hec ke d fr o m t he nati o nal 
T he researc h ta kes place o ver 1 t o 2 years.  
Pl e a s e d o n ot di stri b ut e
T he researc h ta kes place o ver 1 t o 2 years.  

As t here is n o ne w i nter ve nti o n i n t his st u d y, t here is n o a d de d ris k d uri n g t he data c ollecti o n 
pr ocess.  T he  healt hcare  w or kers  will  be  l o o ki n g  after  y o u  a n d  t he  ot her  partici pa nts  ver y 
caref ull y irres pecti ve of y o ur decisi o n o n gi vi n g c o nse nt a b o ut y o ur data t o be use d i n t he st u d y.  
Be nefits  
T here ma y n ot be a n y be nefit f or y o u, b ut y o ur partici pati o n is li kel y t o hel p us fi n d t he a ns wer 
t o t he researc h q uesti o n.  
Rei m b urse me nts  
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
researc h, n or will y o u ha ve t o pa y a n y e xtra e x pe nses  
C o nfi de ntialit y  
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
of y o ur na me.  
S hari n g t he Res ults  
T he k n o wle d ge t hat we get fr o m d oi n g t his researc h will be s hare d wit h y o u t hr o u g h c o m m u nit y 
meeti n gs bef ore it is ma de wi del y a vaila ble t o t he p u blic. C o nfi de ntial i nf or mati o n will n ot be 
s hare d.  
Ri g ht t o Ref use or Wit h dra w  
Y o u d o n ot ha ve t o ta ke part i n t his researc h if y o u d o n ot wis h t o d o s o. It is y o ur c h oice a n d 
all of y o ur ri g hts will still be res pecte d.  
DI F O C C U L T- 3 St u d y 
T here ma y n ot be a n y be nefit f or y o u, b ut y o ur partici pati o n is li kel y t o hel p us fi n d t he a ns wer 
DI F O C C U L T- 3 St u d y 
T here ma y n ot be a n y be nefit f or y o u, b ut y o ur partici pati o n is li kel y t o hel p us fi n d t he a ns wer 
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
DI F O C C U L T- 3 St u d y 
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
researc h, n or will y o u ha ve t o pa y a n y e xtra e x pe nses  
DI F O C C U L T- 3 St u d y 
researc h, n or will y o u ha ve t o pa y a n y e xtra e x pe nses  
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
DI F O C C U L T- 3 St u d y 
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
DI F O C C U L T- 3 St u d y 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
DI F O C C U L T- 3 St u d y 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
of y o ur na me.  
DI F O C C U L T- 3 St u d y 
of y o ur na me.  
S hari n g t he Res ults  
DI F O C C U L T- 3 St u d y 
S hari n g t he Res ults  
T he k n o wle d ge t hat we get fr o m d oi n g t his researc h will be s hare d wit h y o u t hr o u g h c o m m u nit y 
DI F O C C U L T- 3 St u d y 
T he k n o wle d ge t hat we get fr o m d oi n g t his researc h will be s hare d wit h y o u t hr o u g h c o m m u nit y 
C o nfi d e nti al 
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
C o nfi d e nti al 
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
C o nfi d e nti al 
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
C o nfi d e nti al 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
C o nfi d e nti al 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
Pl e a s e d o n ot di stri b ut e
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
Pl e a s e d o n ot di stri b ut e
Y o ur partici pati o n is free. Y o u will n ot be gi ve n a n y ot her m o ne y or gifts t o ta ke part i n t his 
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
Pl e a s e d o n ot di stri b ut e
T he i nf or mati o n t hat we c ollect fr o m t his researc h pr oject will be ke pt c o nfi de ntial. I nf or mati o n 
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
Pl e a s e d o n ot di stri b ut e
a b o ut  y o u  t hat  will  be  c ollecte d  d uri n g  t he  researc h  will  be  p ut  a wa y  a n d  n o  o ne  b ut  t he 
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
Pl e a s e d o n ot di stri b ut e
researc hers will be a ble t o see it. A n y i nf or mati o n a b o ut y o u will ha ve a n u m ber o n it i nstea d 
Pl e a s e d o n ot di stri b ut e
T he k n o wle d ge t hat we get fr o m d oi n g t his researc h will be s hare d wit h y o u t hr o u g h c o m m u nit y 
Pl e a s e d o n ot di stri b ut e
T he k n o wle d ge t hat we get fr o m d oi n g t his researc h will be s hare d wit h y o u t hr o u g h c o m m u nit y 
meeti n gs bef ore it is ma de wi del y a vaila ble t o t he p u blic. C o nfi de ntial i nf or mati o n will n ot be 
Pl e a s e d o n ot di stri b ut e
meeti n gs bef ore it is ma de wi del y a vaila ble t o t he p u blic. C o nfi de ntial i nf or mati o n will n ot be 
Ri g ht t o Ref use or Wit h dra w  
Pl e a s e d o n ot di stri b ut e
Ri g ht t o Ref use or Wit h dra w  

W h o m t o C o ntact  
If y o u ha ve a n y q uesti o ns y o u ma y as k t he m n o w or later, e ve n after t he st u d y has starte d. If 
y o u wis h t o as k q uesti o ns later, y o u ma y c o ntact me or t he pri mar y researc h ce nter ( 0 2 1 2 9 0 9 
6 0 0 0). 
T his  pr o p osal  has  bee n  re vie we d  a n d  a p pr o ve d  b y  t he  l ocal  et hical  c o m mittee,  w hic h  is  a 
c o m mittee w h ose tas k it is t o ma ke s ure t hat researc h partici pa nts are pr otecte d fr o m har m.  
Y o u ca n as k me a n y m ore q uesti o ns a b o ut a n y part of t he researc h st u d y, if y o u wis h t o. D o 
y o u ha ve a n y q uesti o ns?  
P A R T II:  Certificate of C o nse nt  
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
Na me of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
If illiterate  
A literate wit ness m ust si g n (if p ossi ble, t his pers o n s h o ul d be selecte d b y t he partici pa nt a n d 
s h o ul d ha ve n o c o n necti o n t o t he researc h tea m). Partici pa nts w h o are illiterate s h o ul d i ncl u de 
t heir t h u m b- pri nt as well.  
I ha ve wit nesse d t he acc urate rea di n g of t he c o nse nt f or m t o t he p ote ntial partici pa nt, a n d t he 
i n di vi d ual  has  ha d  t he  o p p ort u nit y  t o  as k  q uesti o ns.  I  c o nfir m  t hat  t he  i n di vi d ual  has  gi ve n 
c o nse nt freel y.  
Pri nt na me of wit ness _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A N D  
Si g nat ure of wit ness _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
DI F O C C U L T- 3 St u d y 
y o u wis h t o as k q uesti o ns later, y o u ma y c o ntact me or t he pri mar y researc h ce nter ( 0 2 1 2 9 0 9 
DI F O C C U L T- 3 St u d y 
y o u wis h t o as k q uesti o ns later, y o u ma y c o ntact me or t he pri mar y researc h ce nter ( 0 2 1 2 9 0 9 
T his  pr o p osal  has  bee n  re vie we d  a n d  a p pr o ve d  b y  t he  l ocal  et hical  c o m mittee,  w hic h  is  a 
DI F O C C U L T- 3 St u d y 
T his  pr o p osal  has  bee n  re vie we d  a n d  a p pr o ve d  b y  t he  l ocal  et hical  c o m mittee,  w hic h  is  a 
c o m mittee w h ose tas k it is t o ma ke s ure t hat researc h partici pa nts are pr otecte d fr o m har m.  
DI F O C C U L T- 3 St u d y 
c o m mittee w h ose tas k it is t o ma ke s ure t hat researc h partici pa nts are pr otecte d fr o m har m.  
Y o u ca n as k me a n y m ore q uesti o ns a b o ut a n y part of t he researc h st u d y, if y o u wis h t o. D o 
DI F O C C U L T- 3 St u d y 
Y o u ca n as k me a n y m ore q uesti o ns a b o ut a n y part of t he researc h st u d y, if y o u wis h t o. D o 
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
DI F O C C U L T- 3 St u d y 
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
DI F O C C U L T- 3 St u d y 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
DI F O C C U L T- 3 St u d y 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
Na me of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
DI F O C C U L T- 3 St u d y 
Na me of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
DI F O C C U L T- 3 St u d y 
Si g nat ure of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
DI F O C C U L T- 3 St u d y 
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
If illiterate  
DI F O C C U L T- 3 St u d y 
If illiterate  
A literate wit ness m ust si g n (if p ossi ble, t his pers o n s h o ul d be selecte d b y t he partici pa nt a n d 
DI F O C C U L T- 3 St u d y 
A literate wit ness m ust si g n (if p ossi ble, t his pers o n s h o ul d be selecte d b y t he partici pa nt a n d 
s h o ul d ha ve n o c o n necti o n t o t he researc h tea m). Partici pa nts w h o are illiterate s h o ul d i ncl u de 
DI F O C C U L T- 3 St u d y 
s h o ul d ha ve n o c o n necti o n t o t he researc h tea m). Partici pa nts w h o are illiterate s h o ul d i ncl u de 
C o nfi d e nti al 
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
C o nfi d e nti al 
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
C o nfi d e nti al 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
C o nfi d e nti al 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
Na me of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
C o nfi d e nti al 
Na me of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
C o nfi d e nti al 
Si g nat ure of Partici pa nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
C o nfi d e nti al 
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
Pl e a s e d o n ot di stri b ut e
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
Pl e a s e d o n ot di stri b ut e
I ha ve rea d t he f ore g oi n g i nf or mati o n, or it has bee n rea d t o me. I ha ve ha d t he o p p ort u nit y t o 
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
Pl e a s e d o n ot di stri b ut e
as k  q uesti o ns  a b o ut  it  a n d  a n y  q uesti o ns  t hat  I  ha ve  as ke d  ha ve  bee n  a ns were d  t o  m y 
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
Pl e a s e d o n ot di stri b ut e
satisfacti o n. I c o nse nt v ol u ntaril y t o partici pate as a partici pa nt i n t his researc h.  
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
Pl e a s e d o n ot di stri b ut e
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
A literate wit ness m ust si g n (if p ossi ble, t his pers o n s h o ul d be selecte d b y t he partici pa nt a n d 
Pl e a s e d o n ot di stri b ut e
A literate wit ness m ust si g n (if p ossi ble, t his pers o n s h o ul d be selecte d b y t he partici pa nt a n d 
s h o ul d ha ve n o c o n necti o n t o t he researc h tea m). Partici pa nts w h o are illiterate s h o ul d i ncl u de 
Pl e a s e d o n ot di stri b ut e
s h o ul d ha ve n o c o n necti o n t o t he researc h tea m). Partici pa nts w h o are illiterate s h o ul d i ncl u de 
t heir t h u m b- pri nt as well.  
Pl e a s e d o n ot di stri b ut e
t heir t h u m b- pri nt as well.  
I ha ve wit nesse d t he acc urate rea di n g of t he c o nse nt f or m t o t he p ote ntial partici pa nt, a n d t he 
Pl e a s e d o n ot di stri b ut e
I ha ve wit nesse d t he acc urate rea di n g of t he c o nse nt f or m t o t he p ote ntial partici pa nt, a n d t he 
i n di vi d ual  has  ha d  t he  o p p ort u nit y  t o  as k  q uesti o ns.  I  c o nfir m  t hat  t he  i n di vi d ual  has  gi ve n 
Pl e a s e d o n ot di stri b ut e
i n di vi d ual  has  ha d  t he  o p p ort u nit y  t o  as k  q uesti o ns.  I  c o nfir m  t hat  t he  i n di vi d ual  has  gi ve n 
c o nse nt freel y.  
Pl e a s e d o n ot di stri b ut e
c o nse nt freel y.  

Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
T h u m b pri nt of partici pa nt  
State me nt  
b y  
t he  
researc her/ pers o n  
ta ki n g  
c o nse nt 
I ha ve acc uratel y rea d o ut t he i nf or mati o n s heet t o t he p ote ntial partici pa nt, a n d t o t he best of 
m y  a bilit y  ma de  s ure  t hat  t he  partici pa nt  u n dersta n ds  t hat  t he  f oll o wi n g  will  be  d o ne: 
1. I will be pr o vi de d wit h t he sta n dar d t hera p y if I a m i n t he c o ntr ol gr o u p. 
2. I will be referre d t o a n earlier a n gi o gra m if I a m i n t he acti ve st u d y gr o u p a n d m y E C G has 
si g ns of ac ute vessel bl oc ka ge. 
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
call.  
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
has bee n gi ve n freel y a n d v ol u ntaril y.  
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
Pri nt Na me of Researc her/ pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Researc her / pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
DI F O C C U L T- 3 St u d y 
State me nt  
b y  
t he  
researc her/ pers o n  
ta ki n g  
c o nse nt 
DI F O C C U L T- 3 St u d y 
State me nt  
b y  
t he  
researc her/ pers o n  
ta ki n g  
c o nse nt 
I ha ve acc uratel y rea d o ut t he i nf or mati o n s heet t o t he p ote ntial partici pa nt, a n d t o t he best of 
DI F O C C U L T- 3 St u d y 
I ha ve acc uratel y rea d o ut t he i nf or mati o n s heet t o t he p ote ntial partici pa nt, a n d t o t he best of 
m y  a bilit y  ma de  s ure  t hat  t he  partici pa nt  u n dersta n ds  t hat  t he  f oll o wi n g  will  be  d o ne: 
DI F O C C U L T- 3 St u d y 
m y  a bilit y  ma de  s ure  t hat  t he  partici pa nt  u n dersta n ds  t hat  t he  f oll o wi n g  will  be  d o ne: 
1. I will be pr o vi de d wit h t he sta n dar d t hera p y if I a m i n t he c o ntr ol gr o u p. 
DI F O C C U L T- 3 St u d y 
1. I will be pr o vi de d wit h t he sta n dar d t hera p y if I a m i n t he c o ntr ol gr o u p. 
2. I will be referre d t o a n earlier a n gi o gra m if I a m i n t he acti ve st u d y gr o u p a n d m y E C G has 
DI F O C C U L T- 3 St u d y 
2. I will be referre d t o a n earlier a n gi o gra m if I a m i n t he acti ve st u d y gr o u p a n d m y E C G has 
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
DI F O C C U L T- 3 St u d y 
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
DI F O C C U L T- 3 St u d y 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
DI F O C C U L T- 3 St u d y 
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
DI F O C C U L T- 3 St u d y 
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
DI F O C C U L T- 3 St u d y 
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
DI F O C C U L T- 3 St u d y 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
has bee n gi ve n freel y a n d v ol u ntaril y.  
DI F O C C U L T- 3 St u d y 
has bee n gi ve n freel y a n d v ol u ntaril y.  
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
DI F O C C U L T- 3 St u d y 
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
Pri nt Na me of Researc her/ pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
DI F O C C U L T- 3 St u d y 
Pri nt Na me of Researc her/ pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Researc her / pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
DI F O C C U L T- 3 St u d y 
Si g nat ure of Researc her / pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
C o nfi d e nti al 
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
C o nfi d e nti al 
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
C o nfi d e nti al 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
C o nfi d e nti al 
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
C o nfi d e nti al 
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
C o nfi d e nti al 
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
C o nfi d e nti al 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
has bee n gi ve n freel y a n d v ol u ntaril y.  
C o nfi d e nti al 
has bee n gi ve n freel y a n d v ol u ntaril y.  
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
C o nfi d e nti al 
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
Pl e a s e d o n ot di stri b ut e
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
Pl e a s e d o n ot di stri b ut e
3. S o me of m y i nf or mati o n st ore d i n t he electr o nic h os pital data base will be use d. M y s ur vi val 
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
Pl e a s e d o n ot di stri b ut e
or re h os pitalizati o n stat us will be c o nfir me d via nati o nal electr o nic data base or/a n d o ne p h o ne 
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
Pl e a s e d o n ot di stri b ut e
I c o nfir m t hat t he partici pa nt was gi ve n a n o p p ort u nit y t o as k q uesti o ns a b o ut t he st u d y, a n d all 
Pl e a s e d o n ot di stri b ut e
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
Pl e a s e d o n ot di stri b ut e
t he  q uesti o ns  as ke d  b y  t he  partici pa nt  ha ve  bee n  a ns were d  c orrectl y  a n d  t o  t he  best  of  m y 
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
Pl e a s e d o n ot di stri b ut e
a bilit y. I c o nfir m t hat t he i n di vi d ual has n ot bee n c oerce d i nt o gi vi n g c o nse nt, a n d t he c o nse nt 
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
Pl e a s e d o n ot di stri b ut e
A c o p y of t his I C F has bee n pr o vi de d t o t he partici pa nt. 
Pl e a s e d o n ot di stri b ut e
Pri nt Na me of Researc her/ pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Pl e a s e d o n ot di stri b ut e
Pri nt Na me of Researc her/ pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Si g nat ure of Researc her / pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Pl e a s e d o n ot di stri b ut e
Si g nat ure of Researc her / pers o n ta ki n g t he c o nse nt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
Pl e a s e d o n ot di stri b ut e
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year  
Pl e a s e d o n ot di stri b ut e
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Da y/ m o nt h/ year