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Shahri B, Vojdanparast M, Keihanian F, Eshraghi A. De Winter presentations and considerations: a case series. J Med Case Rep 2022; 16:368. [PMID: 36217174 PMCID: PMC9552431 DOI: 10.1186/s13256-022-03604-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 09/04/2022] [Indexed: 11/22/2022] Open
Abstract
Background The electrocardiogram has a critical role in the diagnosis and risk assessment of patients presenting with chest pain in the emergency ward. Case presentation We present 11 Iranian patients with diagnosis of de Winter referred to our center. Right coronary artery involvement was seen in four cases, left circumflex artery in three cases, proximal left anterior descending artery in two cases, and middle left anterior descending artery in seven cases. We present the case of a 52-year old Iranian male patient in detail. Conclusion Recognizing the electrocardiogram of de Winter as an ST-elevation myocardial infarction equivalent in cases with suspected acute infarction is very important.
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Affiliation(s)
- Bahram Shahri
- Interventional Cardiologist, Faculty of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Vojdanparast
- Interventional Cardiologist, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Faeze Keihanian
- Echocardiologist, Faculty of Medicine, Imam Reza and Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Interventional Cardiologist, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
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2
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McLaren JTT, Taher AK, Kapoor M, Yi SL, Chartier LB. Sharing and Teaching Electrocardiograms to Minimize Infarction (STEMI): reducing diagnostic time for acute coronary occlusion in the emergency department. Am J Emerg Med 2021; 48:18-32. [PMID: 33838470 DOI: 10.1016/j.ajem.2021.03.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/19/2021] [Accepted: 03/21/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Limits to ST-Elevation Myocardial Infarction (STEMI) criteria may lead to prolonged diagnostic time for acute coronary occlusion. We aimed to reduce ECG-to-Activation (ETA) time through audit and feedback on STEMI-equivalents and subtle occlusions, without increasing Code STEMIs without culprit lesions. METHODS This multi-centre, quality improvement initiative reviewed all Code STEMI patients from the emergency department (ED) over a one-year baseline and one-year intervention period. We measured ETA time, from the first ED ECG to the time a Code STEMI was activated. Our intervention strategy involved a grand rounds presentation and an internal website presenting weekly local challenging cases, along with literature on STEMI-equivalents and subtle occlusions. Our outcome measure was ETA time for culprit lesions, our process measure was website views/visits, and our balancing measure was the percentage of Code STEMIs without culprit lesions. RESULTS There were 51 culprit lesions in the baseline period, and 64 in the intervention period. Median ETA declined from 28.0 min (95% confidence interval [CI] 15.0-45.0) to 8.0 min (95%CI 6.0-15.0). The website garnered 70.4 views/week and 27.7 visitors/week in a group of 80 physicians. There was no change in percentage of Code STEMIs without culprit lesions: 28.2% (95%CI 17.8-38.6) to 20.0% (95%CI 11.2-28.8%). Conclusions Our novel weekly web-based feedback to all emergency physicians was associated with a reduction in ETA time by 20 min, without increasing Code STEMIs without culprit lesions. Local ECG audit and feedback, guided by ETA as a quality metric for acute coronary occlusion, could be replicated in other settings to improve care.
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Affiliation(s)
- Jesse T T McLaren
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Ahmed K Taher
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monika Kapoor
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Soojin L Yi
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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McLaren JT, Kapoor M, Yi SL, Chartier LB. Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion. J Emerg Med 2021; 60:25-34. [DOI: 10.1016/j.jemermed.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/24/2020] [Accepted: 09/12/2020] [Indexed: 12/27/2022]
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4
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Heo J, Lee JJ, Kwon S, Kim B, Hwang SO, Yoon YR. A novel method for detecting ST segment elevation myocardial infarction on a 12-lead electrocardiogram with a three-dimensional display. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2019.101700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Costa CM, Silva IS, de Sousa RD, Hortegal RA, Regis CDM. The association between reconstructed phase space and Artificial Neural Networks for vectorcardiographic recognition of myocardial infarction. J Electrocardiol 2018; 51:443-449. [DOI: 10.1016/j.jelectrocard.2018.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Indexed: 12/25/2022]
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Al-Zaiti S, Sejdić E, Nemec J, Callaway C, Soman P, Lux R. Spatial indices of repolarization correlate with non-ST elevation myocardial ischemia in patients with chest pain. Med Biol Eng Comput 2017. [PMID: 28626854 DOI: 10.1007/s11517-017-1659-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Mild-to-moderate ischemia does not result in ST segment elevation on the electrocardiogram (ECG), but rather non-specific changes in the T wave, which are frequently labeled as non-diagnostic for ischemia. Robust methods to quantify such T wave heterogeneity can have immediate clinical applications. We sought to evaluate the effects of spontaneous ischemia on the evolution of spatial T wave changes, based on the eigenvalues of the spatial correlation matrix of the ECG, in patients undergoing nuclear cardiac imaging for evaluating intermittent chest pain. We computed T wave complexity (TWC), the ratio of the second to the first eigenvalue of repolarization, from 5-min baseline and 5-min peak-stress Holter ECG recordings. Our sample included 30 males and 20 females aged 63 ± 11 years. Compared to baseline, significant changes in TWC were only seen in patients with ischemia (n = 10) during stress testing, but not among others. The absolute changes in TWC were significantly larger in the ischemia group compared to others, with a pattern that seemed to depend on the severity or anatomic distribution of ischemia. Our results demonstrate that ischemia-induced changes in T wave morphology can be meaningfully quantified from the surface 12-lead ECG, suggesting an important opportunity for improving diagnostics in patients with chest pain.
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Affiliation(s)
- Salah Al-Zaiti
- Department of Acute & Tertiary Care Nursing, School of Nursing, University of Pittsburgh, 336 Victoria Building, 3500 Victoria St, Pittsburgh, PA, 15261, USA. .,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Ervin Sejdić
- Department of Computer & Electrical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jan Nemec
- Department of Cardiac Electrophysiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Prem Soman
- Department of Nuclear Cardiology, University of Pittsburgh, Pittsburgh,, PA, USA
| | - Robert Lux
- Department of Cardiovascular Medicine, University of Utah, Salt Lake, UT, USA
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Misumida N, Kobayashi A, Schweitzer P, Kanei Y. Prevalence and Clinical Significance of Up-Sloping ST-Segment Depression in Patients With Non-ST-Segment Elevation Myocardial Infarction. Cardiol Res 2015; 6:306-310. [PMID: 28197247 PMCID: PMC5295568 DOI: 10.14740/cr422w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 01/21/2023] Open
Abstract
Background Up-sloping ST-segment depression has not been historically considered as representing ischemia as this electrocardiographic change can be seen in normal subjects during exercise stress testing or tachycardia. We aimed to clarify the prevalence and clinical significance of up-sloping ST-segment depression in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Methods We performed a retrospective analysis of 330 consecutive patients with NSTEMI who underwent coronary angiography. ST-segment depression ≥ 0.05 mV in more than two contiguous leads was recorded and categorized as being up-sloping or non-up-sloping. Results Of 330 patients, 109 patients (33%) had ST-segment depression; six of these patients had up-sloping ST-segment depression. All six patients with up-sloping ST-segment depression had a culprit lesion and underwent in-hospital revascularization. Three of these six patients had a culprit lesion in the left anterior descending artery; the culprit lesion in two others was in the left circumflex artery, while one patient had severe three-vessel disease. No statistically significant difference was found in the rate of in-hospital revascularization between patients with up-sloping and non-up-sloping ST-segment depression (100% vs. 75%, P = 0.33). Conclusions Patients with up-sloping ST-segment depression had a comparable rate of in-hospital revascularization compared to those with non-up-sloping ST-segment depression, suggesting that up-sloping ST-segment depression should be recognized as a manifestation of ischemia in NSTEMI.
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Affiliation(s)
- Naoki Misumida
- Department of Internal Medicine, Mount Sinai Beth Israel Hospital, New York, USA
| | - Akihiro Kobayashi
- Department of Internal Medicine, Mount Sinai Beth Israel Hospital, New York, USA
| | - Paul Schweitzer
- Department of Cardiology, Mount Sinai Beth Israel Hospital, New York, USA
| | - Yumiko Kanei
- Department of Cardiology, Mount Sinai Beth Israel Hospital, New York, USA
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Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalence. J Electrocardiol 2015; 49:76-80. [PMID: 26560436 DOI: 10.1016/j.jelectrocard.2015.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 12/16/2022]
Abstract
Timely reperfusion therapy by means of primary percutaneous coronary intervention (PCI) is the preferred treatment for patients with ST-segment elevation myocardial infarction. A significant number of patients with large acute myocardial infarction, caused by occlusion of an epicardial coronary artery, do not show ST-elevation on the electrocardiogram. Other ECG abnormalities may be present, the so called STEMI-equivalents. One such STEMI equivalent, junctional ST-segment depression followed by tall symmetrical T-waves in the precordial leads, often in combination with slight ST-elevation in lead AVR, has been associated with proximal occlusion of the left anterior descending coronary artery. Recognition of this ECG pattern by ambulance staff, emergency physicians and interventional cardiologists envolved in STEMI networks, is important to ensure timely reperfusion therapy in these patients. In this paper we present three patients with typical symptoms of acute myocardial infarction and the ECG pattern with slight J-point depression combined with tall, symmetrical T-waves.
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Síndrome de Wellens: reconociendo el peligro. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Rationale, development, and implementation of the Electrocardiographic Methods for the Prehospital Identification of Non-ST Elevation Myocardial Infarction Events (EMPIRE). J Electrocardiol 2015; 48:921-6. [PMID: 26346296 DOI: 10.1016/j.jelectrocard.2015.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The serum rise of cardiac troponin remains the gold standard for diagnosing non-ST elevation (NSTE) myocardial infarction (MI) despite its delayed response. Novel methods for real-time detection of NSTEMI would result in more immediate initiation of definitive medical therapy and faster transport to facilities that can provide specialized cardiac care. METHODS EMPIRE is an ongoing prospective, observational cohort study designed to quantify the magnitude of ischemia-induced repolarization dispersion for the early detection of NSTEMI. In this ongoing study, prehospital ECG data is gathered from patients who call 9-1-1 with a chief complaint of non-traumatic chest pain. This data is then analyzed using the principal component analysis (PCA) technique of 12-lead ECGs to fully characterize the spatial and temporal qualities of STT waveforms. RESULTS Between May and December of 2013, Pittsburgh EMS obtained and transmitted 351 prehospital ECGs of the 1149 patients with chest pain-related emergency dispatches transported to participating hospitals. After excluding those with poor ECG signal (n=40, 11%) and those with pacing or LBBB (n=50, 14%), there were 261 eligible patients (age 57±16years, 45% female, 45% Black). In this preliminary sample, there were 19 STEMI (7%) and 33 NSTEMI (12%). More than 50% of those with infarction (STEMI or NSTEMI) had initially negative troponin values upon presentation. We present ECG data of such NSTEMI case that was identified correctly using our methods. CONCLUSIONS Concrete ECG algorithms that can quantify NSTE ischemia and allow differential treatment based on such ECG changes could have an immediate clinical impact on patient outcomes. We describe the rationale, development, design, and potential usefulness of the EMPIRE study. The findings may provide insights that can influence guidelines revisions and improve public health.
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Tan NS, Goodman SG, Yan RT, Tan MK, Fox KA, Gore JM, Brieger D, Steg PG, Langer A, Yan AT. Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes. Int J Cardiol 2015; 190:34-9. [DOI: 10.1016/j.ijcard.2015.04.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/05/2015] [Accepted: 04/12/2015] [Indexed: 12/22/2022]
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IJkema BBLM, Bonnier JJRM, Schoors D, Schalij MJ, Swenne CA. Role of the ECG in initial acute coronary syndrome triage: primary PCI regardless presence of ST elevation or of non-ST elevation. Neth Heart J 2014; 22:484-90. [PMID: 25200324 PMCID: PMC4391175 DOI: 10.1007/s12471-014-0598-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The major initial triaging decision in acute coronary syndrome (ACS) is whether or not percutaneous coronary intervention (PCI) is the primary treatment. Current guidelines recommend primary PCI in ST-elevation ACS (STEACS) and initial antithrombotic therapy in non-ST-elevation ACS (NSTEACS). This review probes the question whether this decision can indeed be based on the ECG. Genesis of STE/NSTE ECGs depends on the coronary anatomy, collateral circulation and site of the culprit lesion. Other causes than ischaemia may also result in ST-segment changes. It has been demonstrated that the area at risk cannot reliably be estimated by the magnitude of the ST change, that complete as well as incomplete occlusions can cause STE as well as NSTE ECGs, and that STE and NSTE patterns cannot differentiate between transmural and non-transmural ischaemia. Furthermore, unstable angina can occur with STE and NSTE ECGs. We conclude that the ECG can be used to assist in detecting ischaemia, but that electrocardiographic STE and NSTE patterns are not uniquely related to distinctly different pathophysiological mechanisms. Hence, in ACS, primary PCI might be considered regardless of the nature of the ST deviation, and it should be done with the shortest possible delay, because ‘time is muscle’.
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Affiliation(s)
- B B L M IJkema
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
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