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Hayıroğlu Mİ, Lakhani I, Tse G, Çınar T, Çinier G, Tekkeşin Aİ. In-Hospital Prognostic Value of Electrocardiographic Parameters Other Than ST-Segment Changes in Acute Myocardial Infarction: Literature Review and Future Perspectives. Heart Lung Circ 2020; 29:1603-1612. [PMID: 32624331 DOI: 10.1016/j.hlc.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/11/2020] [Accepted: 04/26/2020] [Indexed: 01/25/2023]
Abstract
Electrocardiography (ECG) remains an irreplaceable tool in the management of the patients with myocardial infarction, with evaluation of the QRS and ST segment being the present major focus. Several ECG parameters have already been proposed to have prognostic value with regard to both in-hospital and long-term follow-up of patients. In this review, we discuss various ECG parameters other than ST segment changes, particularly with regard to their in-hospital prognostic importance. Our review not only evaluates the prognostic segments and parts of ECG, but also highlights the need for an integrative approach in big data to re-assess the parameters reported to predict in-hospital prognosis. The evolving importance of artificial intelligence in evaluation of ECG, particularly with regard to predicting prognosis, and the potential integration with other patient characteristics to predict prognosis, are discussed.
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Affiliation(s)
- Mert İlker Hayıroğlu
- Department of Cardiology, Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey.
| | - Ishan Lakhani
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, China
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, China; Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Tufan Çınar
- Department of Cardiology, Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Göksel Çinier
- Department of Cardiology, Kaçkar State Hospital, Rize, Turkey
| | - Ahmet İlker Tekkeşin
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Wong CK, White HD. In the transition from fibrinolysis to primary PCI, the HERO trials help refine STEMI ECG interpretation and Q wave analysis potentially alters future management. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:26-33. [PMID: 30117751 DOI: 10.1177/2048872618795513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Electrocardiogram sub-studies from the Hirulog Early Reperfusion/Occlusion 1 and 2 trials, which tested bivalirudin as an adjunctive anticoagulant to fibrinolysis in ST-elevation myocardial infarction, have contributed to the literature. The concept of using the presence of infarct lead Q waves to determine reperfusion benefit has subsequently been explored in multiple primary percutaneous coronary intervention studies. The angiographic findings before percutaneous coronary intervention combine with the baseline electrocardiogram to accurately diagnose ST-elevation myocardial infarction and evaluate its potential territory. This review discusses the relative merits of the presence of infarct lead Q waves versus time duration from symptom onset using observational data from cohorts of patients from multiple clinical trials. The presence of infarct lead Q waves at presentation has been repeatedly shown to be superior to time duration from symptom onset in determining prognosis, despite that continuous variable (time duration) statistically should be more powerful than dichotomous variable (Q wave). If quantitative or semi-quantitative measurement of Q waves correlates well with irreversible myocardial injury in vivo (a research goal of many cardiac magnetic resonance imaging studies), Q waves measurements by mirroring ST-elevation myocardial infarction evolution better than the current metric of time duration of symptoms will impact future ST-elevation myocardial infarction reperfusion management. Newer methodology will more quickly capture and transmit electrocardiogram information including infarct lead Q waves potentially before first medical contact, and help differentiate new evolving Q waves of the ongoing ST-elevation myocardial infarction from old changes. Q waves as the new metric in ST-elevation myocardial infarction reperfusion should be tested in upcoming trials.
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Affiliation(s)
- Cheuk-Kit Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand
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Kosmidou I, Redfors B, Crowley A, Gersh B, Chen S, Dizon JM, Embacher M, Mehran R, Ben-Yehuda O, Mintz GS, Stone GW. Prognostic implications of Q waves at presentation in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: An analysis of the HORIZONS-AMI study. Clin Cardiol 2017; 40:982-987. [PMID: 28696573 DOI: 10.1002/clc.22751] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 05/31/2017] [Accepted: 06/03/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Presence of Q waves on the presenting electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with worse prognosis; however, whether the prognostic value of Q waves is influenced by baseline characteristics and/or rapidity of revascularization based on the guideline-based metric of door-to-balloon time remains unknown. HYPOTHESIS We hypothesized that Q waves in the presenting ECG will be predictive of long term mortality regardless of time to reperfusion. METHODS The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial enrolled 3602 patients with STEMI undergoing primary percutaneous coronary intervention. We stratified patients without prior history of myocardial infarction or coronary revascularization according to presence or absence of pathological Q waves on their presenting ECG. Associations between Q waves, death, and cardiovascular outcomes within 3 years were assessed using Cox proportional hazards regression. RESULTS Among 2723 patients with evaluable ECGs, 1084 (39.8%) had Q waves on their presenting ECG. Male sex and time from symptom onset to balloon inflation were independent predictors of presence of Q waves. Patients with Q waves had higher adjusted risks of all-cause death (adjusted hazard ratio: 1.45, 95% confidence interval: 1.02-2.05, P = 0.04) and cardiac death (adjusted hazard ratio: 1.72, 95% confidence interval: 1.08-2.72, P = 0.02). The association between Q waves and cardiac death was consistent regardless of sex, diabetes status, target vessel, or door-to-balloon time (Pinteraction > 0.4 for all). CONCLUSIONS Presence of Q waves on the presenting ECG in patients undergoing primary percutaneous coronary intervention due to STEMI is an independent predictor of mortality and adds prognostic value, regardless of sex or rapidity of revascularization.
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Affiliation(s)
- Ioanna Kosmidou
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York.,Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York City
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - Bernard Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - José M Dizon
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York.,Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York City
| | - Monica Embacher
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - Gary S Mintz
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York City, New York.,Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York City
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Wong CK, Bucciarelli-Ducci C. Q waves and failed ST resolution: Will intra-myocardial haemorrhage be a concern in reperfusing “late presenting” STEMIs? Int J Cardiol 2015; 182:203-10. [DOI: 10.1016/j.ijcard.2014.12.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/24/2014] [Accepted: 12/21/2014] [Indexed: 11/26/2022]
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Wong CK. Reperfusion therapy for ST-segment elevation myocardial infarction: has ECG information been underutilized? Expert Rev Cardiovasc Ther 2014; 12:803-13. [PMID: 24813345 DOI: 10.1586/14779072.2014.918504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This perspective makes a contentious viewpoint that ECG information is underutilized in ST-segment elevation myocardial infarction (STEMI) and the next breakthrough rests on its full utilization. This is to better diagnose difficult cases such as ST changes during bundle branch block, posterior ST elevation and right-sided ST elevation during normal conduction, and aVR ST elevation. More importantly, this is to better characterize the STEMI for tailored reperfusion. The proposal is to develop a system capable of recording from multiple electrodes that one can apply onto oneself, and having analysis coordinated centrally via phone-internet transmission. This provides 'longitudinal' in addition to 'cross-sectional' ECG information. STEMI will be classified on a gray-scale according to its potential size and speed of Q wave evolution. The hypothesis is that large rapidly progressive STEMI is best treated by on-site fibrinolysis with prompt transferral to a percutaneous coronary intervention center; while small stuttering STEMI is best treated by primary percutaneous coronary intervention despite a long delay.
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Affiliation(s)
- Cheuk-Kit Wong
- Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin Public Hospital, Dunedin, New Zealand
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Wong CK, White HD. The HERO-2 ECG sub-studies in patients with ST elevation myocardial infarction: Implications for clinical practice. Int J Cardiol 2013; 170:17-23. [DOI: 10.1016/j.ijcard.2013.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/31/2013] [Accepted: 10/05/2013] [Indexed: 11/15/2022]
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Wong CK, Leon de la Barra S, Herbison P. Role of routine early angiography post-fibrinolysis for ST elevation myocardial infarction — A meta-regression analysis using angiography rate in the non-routine arm. Int J Cardiol 2013; 167:1888-91. [DOI: 10.1016/j.ijcard.2012.04.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/24/2012] [Accepted: 04/28/2012] [Indexed: 11/26/2022]
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