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Gaspardone C, Romagnolo D, Fasolino A, Falasconi G, Beneduce A, Fiore G, Didelon E, Fortunato F, Galdieri C, Posteraro GA, Ingallina G, Ancona F, Biondi F, Maio SD, Casiraghi A, Slavich M, Borio G, Savastano S, Leonardi S, Margonato A, Agricola E, Oppizzi M, Gaspardone A, Pappone C, Montorfano M. A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction. Am Heart J 2023; 255:94-105. [PMID: 36272451 DOI: 10.1016/j.ahj.2022.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice. METHODS We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort. RESULTS In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor). CONCLUSIONS Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.
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Affiliation(s)
| | | | | | | | | | | | - Emma Didelon
- Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | | | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele, Milan, Italy
| | - Federico Biondi
- Unit of Cardiovascular Imaging, IRCCS San Raffaele, Milan, Italy
| | | | | | - Massimo Slavich
- Unit of Clinical Cardiology, IRCCS San Raffaele, Milan, Italy
| | | | | | - Sergio Leonardi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Alberto Margonato
- Vita-Salute San Raffaele University, Milan, Italy.; Unit of Clinical Cardiology, IRCCS San Raffaele, Milan, Italy
| | - Eustachio Agricola
- Vita-Salute San Raffaele University, Milan, Italy.; Unit of Cardiovascular Imaging, IRCCS San Raffaele, Milan, Italy
| | - Michele Oppizzi
- Unit of Clinical Cardiology, IRCCS San Raffaele, Milan, Italy
| | | | - Carlo Pappone
- Vita-Salute San Raffaele University, Milan, Italy.; Department of Arrhythmology, IRCCS San Donato, Milan, Italy
| | - Matteo Montorfano
- Vita-Salute San Raffaele University, Milan, Italy.; Unit of Interventional Cardiology, IRCCS San Raffaele, Milan, Italy..
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Gao Q, Bie F, Hu Y, Chen Y, Yang B. Characteristics and mechanism of reciprocal ST-segment depression in acute ST segment elevation myocardial infarction: Reciprocal ST-segment depression and ST segment elevation myocardial infarction. Medicine (Baltimore) 2022; 101:e31238. [PMID: 36343047 PMCID: PMC9646491 DOI: 10.1097/md.0000000000031238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
At present, the mechanism of reciprocal ST-segment depression (RSTD) is unclear. ST-segment changes may be caused by the potential difference between the positive and negative electrodes, although this requires further investigation. The characteristics of RSTD and their relationship with ST-segment elevation in acute ST segment elevation myocardial infarction (STEMI) patients were analyzed. We replaced the negative electrode of the precordial leads of an inferior wall myocardial infarction patient and observed the changes in the ST-segment of the precordial leads. A total of 85 patients were included, of which 75 were patients with RSTD. All 45 patients with inferior myocardial infarction had limb lead RSTD, and 37 had anterior lead ST-segment depression. All ST-segment changes in STEMI can be explained by the proposed mechanism, and the value of ST segment depression in limb leads can be calculated by the value of ST segment elevation. In summary, the mechanism of RSTD in acute myocardial infarction may be that the action potential (AP) of the negative electrode of the lead weakens or disappears and the AP of the positive electrode may not be completely offset, resulting in ST-segment depression. Animal experimental studies are needed for further confirmation. When the negative electrode of the precordial lead is changed in acute inferior wall myocardial infarction patient, the ST-segment of the precordial lead changes accordingly. All the changes are consistent with our analysis.
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Affiliation(s)
- Qijun Gao
- Department of Cardiology, First People's Hospital of Jingmen, Jingmen, Hubei Province, P.R. China
| | - Fangfang Bie
- Department of Cardiology, First People's Hospital of Jingmen, Jingmen, Hubei Province, P.R. China
| | - Yingfu Hu
- Department of Cardiology, First People's Hospital of Jingmen, Jingmen, Hubei Province, P.R. China
| | - Yafeng Chen
- Department of Cardiology, First People's Hospital of Jingmen, Jingmen, Hubei Province, P.R. China
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, P.R. China
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Birnbaum Y, Rankinen J, Jneid H, Atar D, Nikus K. The Role of ECG in the Diagnosis and Risk Stratification of Acute Coronary Syndromes: an Old but Indispensable Tool. Curr Cardiol Rep 2022; 24:109-118. [PMID: 35028816 DOI: 10.1007/s11886-021-01628-7] [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] [Accepted: 10/14/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Since its inception in 1902 by Willem Einthoven, the electrocardiogram (ECG) has fundamentally undergone minimal technological advances. Nevertheless, its clinical utility is critical, and it remains an essential tool to diagnose, risk stratify, and guide reperfusion and invasive strategies in patients with suspected acute coronary syndromes. ECG reading can be demanding, with many healthcare professionals lacking the necessary expertise to accurately interpret them. This is exacerbated by the need to constantly revisit old dogmas pertinent to the interpretation of ECGs. RECENT FINDINGS Notably, ECG leads record the global electrical activity of the heart toward and away from each electrode rather than local events. The long-held central paradigm that the various ECG leads record local events underneath specific electrodes should therefore be reassessed. For example, ST segment elevation in leads V1 and V2 usually denote antero-apical rather than septal infarction, often a misnomer utilized by the majority of clinicians. The ECG diagnosis of ST-elevation myocardial infarction (STEMI) is sometimes challenging and discerning it from non-ST-elevation myocardial infarction (NSTEMI) is of paramount importance to implement timely acute reperfusion therapy. In fact, when qualifications for emergency reperfusion therapy are based on STEMI ECG criteria, nearly one-third of cases with acute coronary occlusion are missed. Diagnostic ST elevation in the absence of left ventricular (LV) hypertrophy or left bundle-branch block (LBBB) is defined by a specific set of sex-specific criteria for new ST elevation at the J point in contiguous precordial or limb leads. However, other ECG criteria need to be kept in mind. These include, but are not limited to, new or presumably new left bundle branch block (LBBB), which is often considered as an STEMI-equivalent; ST depression in two or more precordial leads (V1-V4), denoting a true inferolateral transmural myocardial infarction; and the infrequent presentation with hyperacute T-wave changes. As our understanding of the pathology of ischemic reperfusion injury has evolved and following the introduction of new imaging modalities such as cardiac magnetic resonance imaging, we need to re-assess the old dogmas pertinent to the interpretation of ECGs and update the terms and classifications.
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Affiliation(s)
- Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, MS: BCM620, 77030, USA.
| | - Jani Rankinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, MS: BCM620, 77030, USA
| | - Dan Atar
- Dept. of Cardiology, Institute of Clinical Medicine, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway, Norway
| | - Kjell Nikus
- Heart Center, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere University, Tampere, Finland
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Kumar T, Sharma A, Dhaka M. Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Res Cardiovasc Med 2021. [DOI: 10.4103/rcm.rcm_42_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Namdar H, Imani L, Ghaffari S, Aslanabadi N, Reshadati N, Samani Z, Davarmoin G, Moayyednia N, Nazer Y, Sarhangzadeh S, Separham A. ST-segment depression in left precordial leads in electrocardiogram of patients with acute inferior myocardial infarction undergoing primary percutaneous coronary intervention. Interv Med Appl Sci 2018; 10:191-197. [PMID: 30792911 PMCID: PMC6376358 DOI: 10.1556/1646.10.2018.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The early identification of patients with acute inferior ST-segment elevation myocardial infarction (STEMI) with high risk features is particularly important. Acute inferior STEMI may be associated with ST-segment depression in the left precordial leads (V4-V6). This study assessed prognostic value of ST-segment depression in these left precordial leads during the admission of patients with acute inferior STEMI treated with primary percutaneous coronary intervention. METHODS This retrospective study enrolled 1,374 patients with acute inferior STEMI who underwent primary percutaneous coronary angioplasty between March 2011 and June 2014. The patients were divided into two groups: one group (n = 687) with left precordial ST-segment depression and the other (n = 687) without such ST-segment changes. RESULTS The patients with left precordial ST-segment depression were older and had higher incidence of hypertension, diabetes mellitus, and higher levels of troponin. In-hospital mortality was higher in patients with left precordial ST-segment depression. Advanced coronary artery disease was more observed in these patients. CONCLUSION In patients with acute inferior STEMI treated with primary coronary intervention, left precordial ST-segment depression during admission of ECG is associated with more advanced coronary artery disease, and worse in-hospital clinical outcomes.
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Affiliation(s)
- Hossein Namdar
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leyla Imani
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Aslanabadi
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Najmeh Reshadati
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zhila Samani
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ghiti Davarmoin
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Moayyednia
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yalda Nazer
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahla Sarhangzadeh
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Department of Cardiology, Cardiovascular Research Center, Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
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D'Angelo C, Zagnoni S, Gallo P, Tortorici G, Casella G, Di Pasquale G. Electrocardiographic changes in patients with acute myocardial infarction caused by left main trunk occlusion. J Cardiovasc Med (Hagerstown) 2018; 19:439-445. [PMID: 29889168 DOI: 10.2459/jcm.0000000000000684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Left main trunk (LMT) occlusion is a rare angiographic finding. The primary purpose was to investigate the ECG pattern of patients with angiographic confirmation of LMT as culprit lesion. METHODS Forty-eight patients (32 men; mean age 73 years) with angiographic total (21 patients; 44%) or subtotal (27 patients; 56%) occlusion of the LMT were analyzed. Twenty patients (42%) were found to have concomitant coronary lesions. Eighteen patients (38%) required intra-aortic balloon pump support. RESULTS A significant left axis deviation was observed in 26 cases (54%) and an intraventricular conduction delay in 32 patients (67%). The average QRS width and QTc interval were 122 and 433 ms, respectively. ST-segment elevation in lead aVR occurred in 32 patients (67%). ST-segment elevation in leads V2-5 and in leads I and aVL [classic left anterior descending (LAD) type] was frequently observed (18 cases; 35%). In six patients (13%), a partial LAD type was observed with ST-segment elevation in leads I and aVL, but not in peripheral leads. The remaining patients showed ST-segment elevation only in peripheral leads (12 cases), in inferior leads III + aVF (six cases), whereas six patients had no ST-segment elevation. Diffuse ST-segment depression only (>6 leads) was observed in 15 cases (31%). Eighteen patients (38%) died during hospitalization. CONCLUSION ST-segment elevation in lead aVR or a LAD-type pattern can be associated with LMT disease. Other relevant aspects are the presence of cardiogenic shock at admission, the left axis deviation and marked prolongation of QTc interval and QRS width.
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Jia X, Heiberg E, Ripa MS, Engblom H, Halvorsen S, Arheden H, Atar D, Clemmensen P, Birnbaum Y. Correlation of ST changes in leads V4-V6 to area of ischemia by CMR in inferior STEMI. SCAND CARDIOVASC J 2018; 52:189-195. [PMID: 29595340 DOI: 10.1080/14017431.2018.1458145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We aim to determine the correlation between ST-segment changes in leads V4-V6 and the extent of myocardial injury by cardiac magnetic resonance (CMR) in patients with inferior ST elevation (STE) myocardial infarction (iSTEMI). DESIGN Admission electrocardiogram and CMR data from the MITOCARE trial were used. Differences in mean myocardium at risk, infarct size, ejection fraction and myocardial segment involvement by CMR were compared in patients with first iSTEMI with STE, ST depression (STD) or no ST changes (NST) in V4-V6. Myocardial segment involvement was further evaluated by comparing proportion of patients in each group with ≥25% and ≥50% segment involvement. RESULTS Fifty-four patients were included. Patients with STE (n = 22) and STD (n = 16) in V4-V6 had significantly lower ejection fraction compared to NST (n = 16) (48% vs 48% vs 54%, p = .02). STE showed more apical, apical lateral and mid-inferolateral involvement but less basal inferior involvement than NST. STD exhibited greater basal inferoseptal involvement compared to STE. There were more patients with STE that had ≥25% and ≥50% apical lateral involvement compared with STD and NST groups. Patients with STD were more likely to have ≥25% and ≥50% basal inferoseptal involvement compared with STE and NST groups. CONCLUSION Our study suggests that in iSTEMI, ST changes in the precordial leads V4-V6 correlates with greater myocardial injury and distribution of myocardium at risk.
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Affiliation(s)
- Xiaoming Jia
- a Department of Medicine, Section of Cardiology , Baylor College of Medicine , Houston , TX , USA
| | - Einar Heiberg
- b Department of Clinical Physiology , Lund University and Lund University Hospital , Lund , Sweden
| | - Maria Sejersten Ripa
- c Department of Cardiology, The Heart Centre , Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Henrik Engblom
- b Department of Clinical Physiology , Lund University and Lund University Hospital , Lund , Sweden
| | - Sigrun Halvorsen
- d Department of Cardiology, Division of Medicine , Oslo University Hospital and Institute of Clinical Sciences, University of Oslo , Oslo , Norway
| | - Håkan Arheden
- b Department of Clinical Physiology , Lund University and Lund University Hospital , Lund , Sweden
| | - Dan Atar
- d Department of Cardiology, Division of Medicine , Oslo University Hospital and Institute of Clinical Sciences, University of Oslo , Oslo , Norway
| | - Peter Clemmensen
- e Department of Medicine, Division of Cardiology , Nykøbing Falster Hospital , Nykøbing Falster , Denmark.,f Institute of Regional Health Research , University of Southern Denmark , Odense , Denmark.,g Department of General and Interventional Cardiology , University Heart Center Hamburg , Hamburg , Germany
| | - Yochai Birnbaum
- a Department of Medicine, Section of Cardiology , Baylor College of Medicine , Houston , TX , USA
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Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications. J Electrocardiol 2017; 50:47-73. [DOI: 10.1016/j.jelectrocard.2016.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Huang X, Ramdhany SK, Zhang Y, Yuan Z, Mintz GS, Guo N. New ST-segment algorithms to determine culprit artery location in acute inferior myocardial infarction. Am J Emerg Med 2016; 34:1772-8. [DOI: 10.1016/j.ajem.2016.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/29/2016] [Accepted: 06/01/2016] [Indexed: 11/28/2022] Open
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Consideration of QRS complex in addition to ST-segment abnormalities in the estimation of the “risk region” during acute anterior or inferior myocardial infarction. J Electrocardiol 2014; 47:535-9. [DOI: 10.1016/j.jelectrocard.2014.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Indexed: 11/21/2022]
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Pitfalls in diagnosing ST elevation among patients with acute myocardial infarction. J Electrocardiol 2013; 46:653-9. [DOI: 10.1016/j.jelectrocard.2013.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Indexed: 11/23/2022]
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Chen TE, Lo PH, Li TC, Lin KH, Lin JJ, Hsieh LC, Chang CP, Chen YP, Chang KC, Wang HJ. Prognostic significance of reciprocal ST-segment depression in patients with acute STEMI undergoing immediate invasive intervention. Am J Emerg Med 2012; 30:1865-71. [DOI: 10.1016/j.ajem.2012.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 03/19/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022] Open
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Factors associated with failure to identify the culprit artery by the electrocardiogram in inferior ST-elevation myocardial infarction. J Electrocardiol 2011; 44:495-501. [DOI: 10.1016/j.jelectrocard.2011.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Indexed: 11/18/2022]
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Choi WS, Lee JH, Park SH, Kim KH, Kang JK, Kim NY, Cho HJ, Yoon JY, Lee SH, Bae MH, Ryu HM, Yang DH, Park HS, Cho Y, Chae SC, Jun JE, Park WH. Prognostic value of standard electrocardiographic parameters for predicting major adverse cardiac events after acute myocardial infarction. Ann Noninvasive Electrocardiol 2011; 16:56-63. [PMID: 21251135 DOI: 10.1111/j.1542-474x.2010.00409.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The prognostic value of electrocardiographic (ECG) variables in predicting major adverse cardiac events (MACEs) after acute myocardial infarction (AMI) in the era of modern therapy is unclear. This study was conducted to evaluate the prognostic significance of ECG parameters in predicting 1-year MACEs for AMI patients. METHODS Between January 2006 and January 2008, 529 AMI patients were included. ECG variables were analyzed from the ECG taken on discharge day. The 1-year MACEs were defined as death, nonfatal MI, and revascularization including repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Mean follow-up duration was 360 ± 119 days. RESULTS Of these patients, 497 (94%) patients provided complete follow-up data (355 males; 67 ± 12 years old). The rate of 1-year MACEs was 16%. In univariate analysis, heart rate, corrected QT interval, left ventricular (LV) hypertrophy, voltage (SV(1) + RV(5) ), lateral ST-depression (V(5-6) or I, aVL), pathologic Q wave (V(1-4) , V(5-6) ), ST-elevation (V(1-4) , V(5-6) or I, aVL), and T-wave inversion (V(1-4) , V(5-6) , or I, aVL) had a significant association with 1-year MACEs. In the Cox regression hazard model, lateral ST-depression (hazard ratio [HR] 2.260, 95% confidence interval [CI] 1.204 to 4.241, P = 0.011) and corrected QT interval (HR 1.007, 95% CI 1.002 to 1.011, P = 0.004) were independent predictors of 1-year MACEs. After adjustment for all risk variables, lateral ST-depression (HR 3.781, 95% CI 1.047 to 13.656, P = 0.042) was the only ECG variable that independently predicted 1-year MACEs. CONCLUSION Lateral ST-depression on discharge day ECG is an independent predictor of 1-year MACEs after AMI.
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Affiliation(s)
- Won Suk Choi
- Department of Internal Medicine, Kyungpook National University Hospital, 200 Dongduk-ro, Jung-gu, Daegu, Republic of Korea
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Vales L, Kanei Y, Schweitzer P. Electrocardiographic predictors of culprit artery in acute inferior ST elevation myocardial infarction. J Electrocardiol 2011; 44:31-5. [DOI: 10.1016/j.jelectrocard.2010.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Indexed: 11/24/2022]
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Wong CK, Gao W, Stewart RAH, Benatar J, French JK, Aylward PEG, White HD. aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction. Eur Heart J 2010; 31:1845-53. [PMID: 20513728 DOI: 10.1093/eurheartj/ehq161] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI). METHODS AND RESULTS The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation > or =1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of > or =1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of > or =1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with > or = 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation > or =1 mm was associated with higher mortality. CONCLUSION aVR ST elevation is an important adverse prognostic sign in AMI.
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Affiliation(s)
- Cheuk-Kit Wong
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Andersen MP, Terkelsen CJ, Sørensen JT, Kaltoft AK, Nielsen SS, Struijk JJ, Bøtker HE. The ST injury vector: electrocardiogram-based estimation of location and extent of myocardial ischemia. J Electrocardiol 2010; 43:121-31. [DOI: 10.1016/j.jelectrocard.2009.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Indexed: 02/05/2023]
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Andersen MP, Terkelsen CJ, Sørensen JT, Struijk JJ. Performance of an ST dipole model for description of ST deviations in myocardial ischemia. J Electrocardiol 2009; 42:462-8. [DOI: 10.1016/j.jelectrocard.2009.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Indexed: 01/04/2023]
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Abstract
BACKGROUND Lead aVR is a neglected, however, potentially useful tool in electrocardiography. Our aim was to evaluate its value in clinical practice, by reviewing existing literature regarding its utility for identifying the culprit lesion in acute myocardial infarction (AMI). METHODS Based on a systematic search strategy, 16 studies were assessed with the intent to pool data; diagnostic test rates were calculated as key results. RESULTS Five studies investigated if ST-segment elevation (STE) in aVR is valuable for the diagnosis of left main stem stenosis (LMS) in non-ST-segment AMI (NSTEMI). The studies were too heterogeneous to pool, but the individual studies all showed that STE in aVR has a high negative predictive value (NPV) for LMS. Six studies evaluated if STE in aVR is valuable for distinguishing proximal from distal lesions in the left anterior descending artery (LAD) in anterior ST-segment elevation AMI (STEMI). Pooled data showed a sensitivity of 47%, a specificity of 96%, a positive predicative value (PPV) of 91% and a NPV of 69%. Five studies examined if ST-segment depression (STD) in lead aVR is valuable for discerning lesions in the circumflex artery from those in the right coronary artery in inferior STEMI. Pooled data showed a sensitivity of 37%, a specificity of 86%, a PPV of 42%, and an NPV of 83%. CONCLUSION The absence of aVR STE appears to exclude LMS as the underlying cause in NSTEMI; in the context of anterior STEMI, its presence indicates a culprit lesion in the proximal segment of LAD.
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Affiliation(s)
- Jørgen Tobias Kühl
- Department of Cardiology, The Heart Centre, University Hospital Rigshospitalet, Copenhagen, Denmark.
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Electrocardiographic algorithms for predicting the complexity of coronary artery lesions in ST-segment elevation myocardial infarction in ED. Am J Emerg Med 2008; 26:10-7. [DOI: 10.1016/j.ajem.2007.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 03/12/2007] [Accepted: 03/12/2007] [Indexed: 11/18/2022] Open
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21
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Atar S, Fu Y, Wagner GS, Rosanio S, Barbagelata A, Birnbaum Y. Usefulness of ST depression with T-wave inversion in leads V(4) to V(6) for predicting one-year mortality in non-ST-elevation acute coronary syndrome (from the Electrocardiographic Analysis of the Global Use of Strategies to Open Occluded Coronary Arteries IIB Trial). Am J Cardiol 2007; 99:934-8. [PMID: 17398187 DOI: 10.1016/j.amjcard.2006.11.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 11/08/2006] [Accepted: 11/08/2006] [Indexed: 12/22/2022]
Abstract
ST-segment depression (ST-D) on the admission electrocardiogram of patients with non-ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have evaluated the effect of location of ST-D and T-wave polarity on long-term prognosis of patients with NSTEACS. Electrocardiographic (ECG) and clinical data from 6,770 patients with NSTEACS randomly assigned in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIB trial were analyzed retrospectively. One-year mortality was correlated with location of ST-D (leads I and aVL; II, III, and aVF; V1 to V3; or V4 to V6) and T-wave polarity. ST-D in any of the ECG locations was associated with higher mortality compared with patients without ST-D. Patients with ST-D and T-wave inversion in leads V4 to V6 had the highest 1-year mortality rate of all groups (16.2%), significantly higher compared with patients with ST-D without T-wave inversion in those leads (9.0%, p=0.001). Logistic regression analysis showed that age, hyperlipidemia, Killip class>I, history of myocardial infarction, history of heart failure, history of angina pectoris, systolic blood pressure, heart rate, sum of ST-D (odds ratio 1.061, 95% confidence interval 1.035 to 1.087, p<0.001), and ST-D with T-wave inversion in leads V4 to V6 (odds ratio 1.374, 95% CI 1.023 to 1.844, p=0.035) were independent predictors of 1-year mortality. Conversely, ST-D without T-wave inversion in leads V4 to V6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V4 to V6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA
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22
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Sun TW, Wang LX, Zhang YZ. The value of ECG lead aVR in the differential diagnosis of acute inferior wall myocardial infarction. Intern Med 2007; 46:795-9. [PMID: 17575369 DOI: 10.2169/internalmedicine.46.6411] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To investigate whether the ST changes in the aVR lead on 12-lead ECG can be used to identify infarct-related artery (IRA) in patients with acute inferior myocardial infarction. METHODS The ECG features were studied in 90 patients with acute inferior myocardial infarction where IRA was confirmed by coronary angiography. RESULTS Right coronary artery (RCA) and the left circumflex coronary artery (LCX) were identified as IRA in 70 and 20 patients, respectively. ST depression in aVR > or = 0.1 mV was found in 14 (70%) patients who had LCX as the IRA, and in 4 (5.7%, p<0.001) patients with RCA as IRA. Using ST segment depression > or = 0.1 mV in aVR as a criterion, the sensitivity and specificity in differentiating LCX as IRA was 70.0% and 94.3%, respectively. CONCLUSIONS ST depression in aVR is common in patients with LCX-related acute inferior myocardial infarction. The ST changes in this lead are associated with an excellent specificity and a good sensitivity in differentiating LCX from RCA as the IRA.
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Affiliation(s)
- Tong-Wen Sun
- Department of Emergency Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
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23
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Abstract
The ECG is an essential part of the initial evaluation of patients who have chest pain, especially in the immediate decision-making process in patients who have ST-elevation myocardial infarction. This article reviews and summarizes the current information that can be obtained from the admission ECG in patients who have ST-elevation acute myocardial infarction, with an emphasis on: (1) prediction of final infarct size, (2) estimation of prognosis, and (3) the correlations between various ECG patterns and the localization of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555, USA
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24
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Hirano T, Tsuchiya K, Nishigaki K, Sou K, Kubota T, Ojio S, Kawasaki M, Minatoguchi S, Fujiwara H, Ueno K, Hosokawa H, Morita N, Nagano T, Suzuki T, Watanabe S. Clinical Features of Emergency Electrocardiography in Patients With Acute Myocardial Infarction Caused by Left Main Trunk Obstruction. Circ J 2006; 70:525-9. [PMID: 16636484 DOI: 10.1253/circj.70.525] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To diagnose left main trunk (LMT) infarction by 12-lead standard electrocardiogram (ECG) is an important emergency technique, but the features in LMT infarctions have not been clarified. METHODS AND RESULTS The study enrolled 140 subjects who were divided into 4 groups according to the location of the culprit artery: 35 with LMT, 35 with left anterior descending artery (LAD), 35 with right coronary artery and 35 with left circumflex artery. Various parameters obtained from the ECGs were analyzed. Average QTc interval (0.51 +/- 0.06 s) in LMT group was markedly longer than that in the 3 other groups. Average QRS axis (-10 +/- 77 degrees) in LMT infarction showed a remarkable left deviation. ST-segment elevation in lead aVR occurred in 28 patients (80.0%) in the LMT group. The ECG features of the LMT group could be classified into 2 main groups: right bundle branch block (RBBB) with a marked left axis deviation (RBBB + LADEV type) and ST-segment elevation in leads V2-5, I and aVL without abnormal axis deviation (LAD type). CONCLUSION Either ST-segment elevation in lead aVR and marked prolongation of both the QRS width and QTc interval with a prominent abnormal axis deviation or ST-segment elevation in the broad anterior precordial lead with a normal QRS axis strongly suggests LMT infarction.
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Affiliation(s)
- Tomohisa Hirano
- Department of Regenerative and Cardiovascular Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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25
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Atar S, Birnbaum Y. Ischemia-induced ST-segment elevation: classification, prognosis, and therapy. J Electrocardiol 2005; 38:1-7. [PMID: 16226066 DOI: 10.1016/j.jelectrocard.2005.06.098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) remains the most useful tool for the diagnosis, early risk stratification, triage, and guidance of therapy in patients with acute coronary syndromes. However, the initial and the terminal part of the QRS complex, the ST segments, and the T waves are influenced by anatomical and metabolic factors such as the "myocardium at risk" and "severity" and "duration" of ischemia. Moreover, there are complex interactions between all these factors. The ECG can identify potential candidates for reperfusion therapy as well as the completeness and success of reperfusion, whereas it can also identify those patients who will have no benefit from reperfusion because of either late arrival or nonischemic etiologies of ECG changes. These patients may have a "pseudo" ST-elevation acute myocardial infarction (STEAMI) or "pseudo-pseudo" STEAMI. The presence of Q waves and additional ST-segment depression and T-wave inversion on the admission ECG in patients with STEAMI may provide us information regarding the potential myocardial reserves, and various ECG scoring systems are in current use for that purpose. The pattern and timing of changes in Q waves, ST segment, and T waves may all be markers of the patency status of the infarct-related artery. We review and discuss each of the dynamic ECG variables during ischemia and reperfusion: the initial QRS (Q and R waves), the terminal QRS (Sclarovsky-Birnbaum score), the ST segment, and the T waves.
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Affiliation(s)
- Shaul Atar
- The Division of Cardiology, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
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26
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Abstract
As the population ages and survival from ischaemic heart disease improves, the incidence and prevalence of congestive cardiac failure has increased dramatically. Medical treatments including ACE inhibitors, beta blockers, and aldosterone antagonists have improved the outlook for most patients. However, despite optimal medical treatment there is a significant group of patients who continue to suffer poor morbidity and mortality. Device based treatment consisting of implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy (CRT) devices offer new modes of treatment to patients with symptomatic heart failure despite optimal medical therapy. ICDs have been shown to reduce mortality in patients with severe heart failure while CRT leads to an improvement in functional class, quality of life scores, physiological measures such as peak Vo(2), and reduce hospitalisations. Combination devices, which provide both ICD and CRT functions, have now been seen to provide synergistic benefits in selected patients.
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Affiliation(s)
- A Y Patwala
- The Cardiothoracic Centre, Thomas Drive, Liverpool, UK.
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27
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Sonoda K, Ikeda S, Seki M, Koga S, Futagawa K, Yoshitake T, Miyahara Y, Kohno S. Chest pain and ST segment depression caused by expansion of gastric tube used for esophageal reconstruction. Intern Med 2005; 44:217-21. [PMID: 15805710 DOI: 10.2169/internalmedicine.44.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 76-year-old man in whom a gastric tube was used for esophageal reconstruction via the anterior mediastinum after esophagectomy for esophageal cancer. Stenosis of the tube resulted in fluid accumulation, which directly compressed the heart and caused angina-like chest pain associated with ST-segment depression in lead V(2-3) on the electrocardiogram (ECG). Coronary angiography revealed no stenosis. Drainage of the fluid in the gastric tube resulted in immediate relief of symptoms and normalization of ECG. Angina-like chest pain associated with ST segment changes were caused by expansion of the gastric tube and compression of the heart.
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Affiliation(s)
- Koichiro Sonoda
- Department of Internal Medicine, Nagasaki Memorial Hospital, 1-11-54 Fukahori-machi, Nagasaki 851-0301
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28
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Eskola MJ, Nikus KC, Niemelä KO, Sclarovsky S. How to use ECG for decision support in the catheterization laboratory. J Electrocardiol 2004; 37:257-66. [PMID: 15484153 DOI: 10.1016/j.jelectrocard.2004.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Treatment of acute myocardial infarction has changed considerably during the last few years with the introduction of primary coronary angioplasty. In the acute phase risk stratification is largely based on simple clinical parameters, laboratory markers of myocardial injury and 12-lead electrocardiography. The electrocardiogram is of crucial importance especially during the first few hours after initiation of chest pain when important therapeutic decisions are made. Biochemical markers of myocardial injury are usually not elevated at that time point. Cases with inferior ST-elevation myocardial infarction from our hospital are presented to show how anatomical interpretation of ECG recorded during chest pain helps to risk stratify patients.
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Affiliation(s)
- Markku J Eskola
- Heart Center, Tampere University Hospital, 33520 Tampere, Finland.
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29
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Rotondo N, Pollack ML, Chan TC, Brady WJ, Harrigan RA. Electrocardiographic manifestations: acute inferior wall myocardial infarction. J Emerg Med 2004; 26:433-40. [PMID: 15093851 DOI: 10.1016/j.jemermed.2004.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The 12-lead electrocardiogram (EKG) is an important tool in evaluating the patient with acute myocardial infarction (MI). Patients with acute inferior wall myocardial infarction (IWMI) represent a heterogeneous group in terms of morbidity, mortality, Emergency Department (ED) management, and site of occlusion in the culprit coronary artery. The standard 12-lead EKG, right-sided chest leads and posterior chest leads, in conjunction with clinical findings often provide the necessary information for the Emergency Physician (EP) to predict complications, morbidity and mortality. IWMI patients may have associated right ventricular infarction (RVI) or lateral and posterior wall extension. Each of these entities is associated with specific hemodynamic abnormalities and increased mortality. In addition, various atrioventricular (AV) blocks are commonly associated with IWMI. This article presents several cases of IWMI with EKGs and a discussion of EKG interpretation in the setting of IWMI.
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Affiliation(s)
- Noelle Rotondo
- Department of Emergency Medicine, York Hospital, York, Pennsylvania 17405, USA
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30
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Birnbaum Y, Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. Postgrad Med J 2003; 79:490-504. [PMID: 13679544 PMCID: PMC1742828 DOI: 10.1136/pmj.79.935.490] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The electrocardiogram is considered an essential part of the diagnosis and initial evaluation of patients with chest pain. This review summarises the information that can be obtained from the admission electrocardiogram in patients with ST elevation acute myocardial infarction, with emphasis on: (1) prediction of infarct size, (2) estimation of prognosis, and (3) the correlations between various electrocardiographic patterns and the localisation of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Y Birnbaum
- University of Texas Medical Branch, Galveston, Texas 77555-0553, USA.
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31
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Lehmann G, Schmitt C, Kehl V, Schmieder S, Schömig A. Electrocardiographic algorithm for assignment of occluded vessel in acute myocardial infarction. Int J Cardiol 2003; 89:79-85. [PMID: 12727008 DOI: 10.1016/s0167-5273(02)00408-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study was performed to elaborate an electrocardiographic (ECG) algorithm enabling assignment of an occluded coronary artery in acute myocardial infarction (AMI). PATIENTS AND INTERVENTIONS In 109 patients (age, 59+/-12 years) with AMI (pain onset, 3.6+/-1.7 h), coronary angiography with PTCA/stenting of the culprit lesion was performed. The diagnosis of AMI was confirmed by emergency coronary angiography and laboratory analyses. Admission ECG parameters (amplitude of R-wave, ST-segment deviation, presence of Q-wave, deflection of T-wave) in standard 12-lead ECG plus extended (V(3)R to V(6)R and V(7-9)) leads were subjected to classification and regression tree (CART) analysis. RESULTS Continuous CART analysis assessed ST-segment deviations in V(2) and V(5)R. AMI of the left anterior descending (LAD), right coronary artery (RCA) and left circumflex coronary artery (CX) were correctly classified in 94, 64, and 91% of cases, respectively. Dichotomised CART analysis assessed ST-segment deviations in V(2), V(5)R, and aVF. True classification rates for LAD, RCA, and CX amounted to 84, 74, and 71%, respectively. CONCLUSIONS Dichotomised CART analysis is a simple means of differentiation of CX from RCA occlusion during AMI.
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Affiliation(s)
- Günter Lehmann
- Deutsches Herzzentrum München and I. Med. Klinik, Klinikum rechts der Isar, Technischen Universität München, Lazarettstrasse 36, D-80636 Munich, Germany.
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32
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Nair R, Glancy DL. ECG discrimination between right and left circumflex coronary arterial occlusion in patients with acute inferior myocardial infarction: value of old criteria and use of lead aVR. Chest 2002; 122:134-9. [PMID: 12114348 DOI: 10.1378/chest.122.1.134] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY OBJECTIVES Prior studies have proposed several ECG criteria for identifying the culprit artery in patients with acute inferior myocardial infarction (MI). We applied each criterion to our patients to assess its utility. In doing so, we discovered a previously unreported, but highly useful, criterion utilizing lead aVR. STUDY DESIGN Retrospective review. PATIENTS Thirty consecutive patients with symptoms of acute MI, ST-segment elevation in the inferior ECG leads, an appropriate rise and fall of creatine kinase and troponin I levels, and coronary arteriography within 7 days of the onset of symptoms. MEASUREMENTS The ECG recorded within 24 h of the onset of symptoms that had the most prominent ST-segment changes was analyzed. In the 12 standard leads and in lead V(4)R, ST-segment elevation or depression was measured 0.06 s after the J point. RESULTS Four previously described criteria were useful in identifying the right coronary artery (RCA) or the left circumflex coronary artery (LCX) as the culprit: ST-segment elevation in lead I, ST-segment more or less elevated in lead II than in lead III, ST-segment elevation >or= 0.5 mm in lead V(4)R, and various combinations of ST-segment elevation or depression in leads V(1) and V(2). A new criterion was found to be at least as useful as any previously described: the presence and amount of ST-segment depression in lead aVR. CONCLUSIONS At least five different ST-segment criteria help to identify the RCA or the LCX as the culprit artery in patients with acute inferior MI. One of these, the amount of ST-segment depression in lead aVR, has not been reported previously and needs validation in a larger study.
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Affiliation(s)
- Radhakrishnan Nair
- Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center and the Medical Center of Louisiana, New Orleans, LA 70112, USA
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33
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Gibson CM, Chen M, Angeja BG, Murphy SA, Marble SJ, Barron HV, Cannon CP. Precordial ST-segment depression in inferior myocardial infarction is associated with slow flow in the non-culprit left anterior descending artery. J Thromb Thrombolysis 2002; 13:9-12. [PMID: 11994554 DOI: 10.1023/a:1015355722670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Anterior precordial ST-segment depression (APSTD) is common in the setting of inferior myocardial infarction (IMI). The presence of APSTD correlates with increased risk of adverse outcomes in patients with acute IMI as well as more myocardium at risk as assessed by sestamibi, larger infarcts, lower ejection fractions, and more severe wall motion abnormalities in the infarct region. The ECG leads associated with APSTD (V1-V3) are generally thought to represent electrical activity subtended by the anterior myocardium, which is perfused by the left anterior descending artery (LAD). To determine whether APSTD is associated with abnormal blood flow in the uninvolved or non-culprit LAD, we assessed TIMI flow grades and corrected TIMI frame counts (CTFC) in both the culprit and non-culprit arteries of IMI patients. METHODS Data were drawn from the TIMI 10B trial of tenecteplase versus front-loaded tissue plasminogen activator in acute MI. Baseline ECGs were obtained within 12 hours of symptom onset, and angiography was performed 90 minutes following thrombolytic administration. A patient was considered to have precordial ST-segment depression if any ST-segment depression was present in any of leads V1-V3. RESULTS The majority of IMI's were due to right coronary artery occlusions, both in patients with APSTD (79.6%) and without APSTD (77.9%). In patients in whom the LAD was not the culprit artery but with APSTD were significantly less likely to have TIMI 3 flow at 90 minutes and more likely to have TIMI 2 flow. There was a trend toward slower CTFC in APSTD patients (27.2 +/- 13.4 vs. 22.6 +/- 8.5 frames/sec, p = 0.07). CONCLUSIONS Among patients with acute IMI associated with precordial ST-segment depression, flow in the non-culprit left anterior descending artery was slower than that in patients without APSTD. This finding may partially explain the occurrence of APSTD in IMI.
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Affiliation(s)
- C Michael Gibson
- Harvard Clinical Research Institute and Brigham & Women's Hospital, Boston, MA 02215, USA.
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Schmitt C, Lehmann G, Schmieder S, Karch M, Neumann FJ, Schömig A. Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel : limitations of ST-segment elevation in standard and extended ECG leads. Chest 2001; 120:1540-6. [PMID: 11713132 DOI: 10.1378/chest.120.5.1540] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The majority of thrombolysis studies require defined ST-segment elevations as an inclusion criterion for the diagnosis of acute myocardial infarction (AMI). However, depending on the occluded infarct vessel and the criteria applied, the ECG diagnosis of AMI can be difficult to establish. Accordingly, this study was performed to evaluate the sensitivity of ST-segment elevation of standard and extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of AMI. PATIENTS AND METHODS In 418 patients (mean +/- SD age, 60 +/- 13 years) with AMI (pain onset, 4.8 +/- 3.0 h), coronary angiography with percutaneous transluminal coronary angioplasty/stenting of the culprit lesion was performed. The diagnosis of AMI was confirmed by emergency coronary angiography and laboratory analyses. ST-segment elevation (in two contiguous leads) of 1 mm in standard lead I through aVF and ST-segment elevations of 2 mm (or 1 mm, corresponding values presented in parentheses) in V(1) through V(6) were considered significant. In a subset of 102 AMI patients, additional right precordial leads V(3)R through V(6)R for evaluation of right ventricular infarction and additional chest leads V(7) through V(9) for evaluation of posterior infarction were recorded. ST-segment elevations of 1 mm in the right precordial leads and 1 mm or 0.5 mm in the posterior leads were considered significant. RESULTS Standard leads I through V(6) showed ST-segment elevation in 85% (96%) of patients with left anterior descending artery occlusion, in 46% (61%) of patients with left circumflex coronary artery (CX) occlusion, and in 85% (90%) of patients with right coronary artery occlusion. On consideration of additional ECG tracings in the subgroup of 102 patients (V(3)R through V(6)R and V(7) through V(9)), the respective numbers increased by 2 to 8% depending on different criteria for ST-segment elevation; in patients with CX occlusion, the increase amounted to 6 to 14%. There was a trend toward an extended infarct size (maximum creatine kinase [CK] values) with concomitant ST-segment elevation in additional ECG leads as assessed by maximum CK levels. CONCLUSIONS The sensitivity of the ECG diagnosis of AMI is only marginally increased by extended precordial chest leads. There is a trend toward an extended infarct size in those patients with concomitant ST-segment elevation in additional ECG leads.
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Affiliation(s)
- C Schmitt
- Deutsches Herzzentrum München and I. Med. Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
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35
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Asfour W, Bell S, Amkieh AM, Sgarbossa EB, Azzam RK, Clemmensen P, Cohen M, Eisenstein E, Goodman S, Grinfeld L, Holmvang L, Maynard C, Pahlm O, Selvester RH, Heden B, Shah A, Vaught C, Warner RA, Glancy DL, Wagner GS, Barbagelata A. The correlation between presenting ST-segment depression and the final size of acute myocardial infarcts in patients with acute coronary syndromes. J Electrocardiol 2001; 33 Suppl:61-3. [PMID: 11269243 DOI: 10.1054/jelc.2000.20338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The use of reperfusion therapy in patients with ST elevation acute coronary syndromes had been established. However, reperfusion therapy is usually considered contra-indicated in those with ST depression, despite the knowledge that regional posterior infarction is typically indicated by ST depression maximal in leads V1 to V3 and nonregional subendocardial infarction is typically indicated by marked ST depression maximal in other leads. This study of patients with non-ST-elevation acute coronary syndromes investigates the quantitative relationship between presenting ST depression and final QRS changes in both of these subgroups. The final QRS score was significantly higher (2.44 points) than that of a control group with not ST depression, (1.55 points) in the group with maximal ST depression in V1 to V3 (P = 0.04). However, in the entire population, there was a highly significant correlation (P = .003) between the sum of the presenting ST depression and the final QRS score. Trials of reperfusion therapy will be required to determine if such evolution to electrocardiogram documented acute myocardial infarction can be prevented in patient with marked ST depression acute coronary syndromes.
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Affiliation(s)
- W Asfour
- Department of Cardiology, Louisiana State University, New Orleans, USA
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Sgarbossa EB, Birnbaum Y, Parrillo JE. Electrocardiographic diagnosis of acute myocardial infarction: Current concepts for the clinician. Am Heart J 2001; 141:507-17. [PMID: 11275913 DOI: 10.1067/mhj.2001.113571] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Over the past 2 decades, the 12-lead electrocardiogram has attained special significance for the diagnosis and triage of patients with chest pain because timely detection of myocardial injury and a rapid assessment of myocardium at risk proved pivotal to implementing effective reperfusion therapies during acute myocardial infarction. However, this wealth of information could still be underutilized by clinicians who may restrict their diagnostic quest in patients with chest pain to the more classic electrocardiographic signs. METHODS The medical literature on electrocardiographic manifestations of acute myocardial infarction was extensively reviewed. RESULTS The widespread utilization of both coronary angiography and methods to determine myocardial function and metabolism in patients with acute myocardial infarction over the last 10 years has provided the means for rigorous comparisons with electrocardiographic information. We summarize these electrocardiographic signs and patterns in terms of their relevance to the clinician to help reduce the incidence of "nondiagnostic electrocardiograms" and improve timely decision-making. CONCLUSIONS The electrocardiogram continues to be an invaluable tool in the initial evaluation of patients with chest pain. The plethora of data currently available on electrocardiographic changes correlating with myocardial injury allows clinicians to make faster and better decisions than ever before.
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Affiliation(s)
- E B Sgarbossa
- Section of Cardiology, Rush Presbyterian-St. Luke's Medical Center, 1750 W. Harrison St., Chicago, IL 60612, USA.
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37
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Mager A, Sclarovsky S, Herz I, Adler Y, Strasberg B, Birnbaum Y. Value of the initial electrocardiogram in patients with inferior-wall acute myocardial infarction for prediction of multivessel coronary artery disease. Coron Artery Dis 2000; 11:415-20. [PMID: 10895408 DOI: 10.1097/00019501-200007000-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with inferior-wall acute myocardial infarction (AMI) who have ST-segment depression in the left precordial leads (LSTD+) on the initial electrocardiogram were reported to have more diffuse coronary artery disease (CAD) than had those without this finding (LSTD-). This suggests that LSTD+ patients may need extensive revascularization interventions more often than do LSTD- patients. However, this has not yet been confirmed. OBJECTIVE To compare the coronary angiographic findings and treatment strategies for patients with inferior-wall AMI according to the LSTD pattern. METHODS The clinical outcomes and the angiographic findings for 238 consecutive patients aged < or = 75 years who had been admitted to our hospital between 1 February 1995 and 1 February 1997 with inferior-wall AMI were retrospectively analyzed. The patients were divided into two groups according to the pattern of precordial ST-segment depression: LSTD+, ST-segment depression in leads V4-V6; and LSTD-, absence of this finding. All patients were treated according to current practice guidelines including with thrombolysis and revascularization interventions. RESULTS The final study population included 217 patients; 83 were LSTD+ and 134 were LSTD-. All underwent coronary angiography within 30 days of the infarction. Compared with LSTD- patients, LSTD+ patients tended to be older (mean age 62.7 +/- 11.7 versus 58.3 +/- 9.6 years, P = 0.004), and had higher incidences of hypertension (39.8 versus 24.6%, P = 0.019) previous myocardial infarction (45.8 versus 20.1%, P = 0.0001) and congestive heart failure (21.7 versus 3.7%, P = 0.00008). Three-vessel CAD was much more common, and single-vessel CAD much less common, in the LSTD+ than in LSTD- group (62.7 versus 13.4% and 8.4 versus 50.7%, P < 0.00001 for both). Coronary-artery-bypass surgery and multivessel percutaneous coronary interventions (PCI) were used in treating 65.1% of the LSTD+ versus only 6.0% of the LSTD- patients (P < 0.00001), whereas single-vessel PCI was used in treating 71.6% of the LSTD- patients versus only 24.1% of the LSTD+ patients (P < 0.00001). Thus, the LSTD- pattern predicted single-vessel disease and single-vessel PCI only, whereas the LSTD+ pattern was predictive of multivessel CAD and of use of coronary-artery-bypass surgery or multivessel PCI (predictive values of 94.0 and 65.1%, respectively). CONCLUSIONS Among patients with inferior-wall AMI, left precordial ST-segment depression predicts a very high prevalence of multivessel CAD and use of extensive revascularization interventions. The absence of this finding predicts nondiffuse CAD and lack of a need for extensive revascularization.
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Affiliation(s)
- A Mager
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.
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Barrabés JA, Figueras J, Moure C, Cortadellas J, Soler-Soler J. Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation. J Am Coll Cardiol 2000; 35:1813-9. [PMID: 10841229 DOI: 10.1016/s0735-1097(00)00630-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation. BACKGROUND ST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear. METHODS In 432 patients with a first acute MI without Q waves or > or = 0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death. RESULTS The presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V5, or V6) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 +/- 96 vs. 122 +/- 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 +/- 12% vs. 66 +/- 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001). CONCLUSIONS In patients with a first non-ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.
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Affiliation(s)
- J A Barrabés
- Unitat Coronària, Servicio de Cardiología, Hospital General Universitari Vall d'Hebron, Barcelona, Spain.
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Birnbaum Y, Wagner GS. The initial electrocardiographic pattern in acute myocardial infarction: correlation with infarct size. J Electrocardiol 2000; 32 Suppl:122-8. [PMID: 10688315 DOI: 10.1016/s0022-0736(99)90061-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Y Birnbaum
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel
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