1. Patient Preparation You’ll Need These Materials l 7 Micro-V Alternans™ Sensors * l 7 Standard Electrodes* l Razor l 3M One-Step Skin Prep l Felt-tip Marker or Cosmetic Pen *Do not open electrode packages until needed. Reseal after use.

2. Patient Preparation High-Resolution Electrode Placement I - Right midaxillary line, at 5th intercostal space E - at the front midline at base of sternum M - on back, directly behind V2 H - superior aspect of manubrium at the midline RA - right arm, slightly below right clavicle LA - left arm, slightly below left clavicle LL - left leg, lower edge of left rib cage, midclavicular line RL - right leg, lower edge of right rib cage, midclavicular line V1 - 4th intercostal space at right border of sternum V2 - 4th intercostal space at left border of sternum V3 - midway between V2 and V4 V4 - 5th intercostal space on the midclavicular line V5 - Between V4 and V5 at 5th intercostal space V6 - left midaxillary line at the 5th intercostal space

3. Patient Preparation Prep Electrode Sites l Moist skin, oily skin, or skin areas with lotion may require gentle cleansing. (The use of alcohol is not recommended.) l Allow the skin to dry before shaving and abrading. l Shave each electrode site if necessary. l Shave sufficient area for Micro-V Alternans sensors

4. Patient Preparation Mark All Electrode Locations l With a felt-tipped marker or cosmetic pencil, mark each location with a single dot. l Add triangle pattern to mark Micro-V Alternans Sensors locations as shown here.    

5. Patient Preparation Abrade Electrode Locations l Use 3M One-Step Skin Prep to gently abrade all electrode locations. l A good preparation only removes the surface layer of dead skin cells. l Be sure to abrade sufficient area for the Micro-V Alternans Sensors. l Pay special attention to sites on right arm, left arm, and left leg leads. l Failure to properly prepare electrode locations can cause artifact in the ECG tracing. Excessive abrasion of the skin can increase the risk of contact dermatitis. Stop before skin becomes red. Never apply electrodes to broken skin..

6. Patient Preparation Apply Electrodes l Peel off electrode cover and verify that gel has not dried out. l With the patient seated, apply Micro-V Alternans Sensors and standard electrodes. l Rub High-Resolution electrode surface to assure even contact.

7. Performing a Test Lead Check ( CH2000) l Select “Perform Test” on Cambridge Heart Main Screen to bring up the Lead Check Screen. l Observe the waveforms for low noise. l With the patient at rest, make sure that the Lead Noise bars are below the Rest Level. Note: It will take about 30 seconds for the lead noise bars to appear.

8. Performing the Test Lead Check ( also HearTwave) l Electrode-to-skin contact must be checked by connecting all leads to electrodes and selecting the “Check Leads” screen button. l The electrode panel located in the lower right-hand corner of your screen will show electrode contact as green, yellow, or red. l Green indicates a good connection, and yellow indicates an adequate connection. Both are acceptable to perform a T-wave alternans test. l If electrode shows red, re-prep the site and replace electrode. l If ALL electrodes show red, c heck right leg and right arm leads to ensure leads are properly connected.

9. Performing the Test Lead Check during Practice Exercise (for Ergometer) l Instruct patient on how to keep noise below exercise level by: 1. Placing arms at side, on lap). 2. Adjusting pedaling motion. 3. Maintaining upright posture and pedaling rate according to the metronome or at 40 rpm

10. Gradual Heart rate Increase l It is important that the patient Heart Rate does not increase too rapidly from 90 to 110 Bpm l More than 3 minutes are necessary to increase HR from 90 to 110. False Alternans can appear or real Alternans can be obscured by fast increase of HR. l If the increase of HR is too rapid a message will be dispayed and it is advisable to stop the test, allow the patient HR to decrease below 90 and restart the test.