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Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola MJ. The high-risk ECG pattern of ST-elevation myocardial infarction: A substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial). Int J Cardiol 2020; 319:40-45. [PMID: 32470531 DOI: 10.1016/j.ijcard.2020.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Useful tools for risk assessment in patients with STEMI are needed. We evaluated the prognostic impact of the evolving myocardial infarction (EMI) and the preinfarction syndrome (PIS) ECG patterns and determined their correlation with angiographic findings and treatment strategy. METHODS This substudy of the randomized Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI (TOTAL) included 7860 patients with STEMI and either the EMI or the PIS ECG pattern. The primary outcome was a composite of death from cardiovascular causes, recurrent MI, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year. RESULTS The primary outcome occurred in 271 of 2618 patients (10.4%) in the EMI group vs. 322 of 5242 patients (6.1%) in the PIS group [AdjustedHR, 1.54; 95% CI, 1.30 to 1.82; p < .001]. The primary outcome occurred in the thrombectomy and PCI alone groups in 131 of 1306 (10.0%) and 140 of 1312 (10.7%) patients with EMI [HR 0.94; 95% CI, 0.74-1.19] and 162 of 2633 (6.2%) and 160 of 2609 (6.1%) patients with PIS [HR 1.00; 95% CI, 0.81-1.25], respectively (pinteraction = 0.679). CONCLUSIONS Patients with the EMI ECG pattern proved to have an increased rate of the primary outcome within one year compared to the PIS pattern. Routine manual thrombectomy did not reduce the risk of primary outcome within the different dynamic ECG patterns. The PIS/EMI dynamic ECG classification could help to triage patients in case of simultaneous STEMI patients with immediate need for pPCI.
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Affiliation(s)
- Joonas Leivo
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland.
| | - Eero Anttonen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Jyri Koivumäki
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Minna Tahvanainen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Kimmo Koivula
- Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland; Internal medicine, Helsinki University Hospital, Finland
| | - Kjell Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
| | | | - Kari Niemelä
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Markku J Eskola
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
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Electrocardiogram to predict reperfusion success in late presenters with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Electrocardiol 2020; 59:74-80. [PMID: 32007909 DOI: 10.1016/j.jelectrocard.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/08/2020] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical decision-making in patients with ST-segment elevation myocardial infarction (STEMI) presenting beyond 12 h of symptom onset (late presenters) is challenging. However, the electrocardiogram (ECG) may provide helpful information. We investigated the association between three ECG-scores and myocardial salvage and infarct size in late presenters treated with primary percutaneous coronary intervention (primary PCI). METHODS Sixty-six patients with STEMI and ongoing symptoms presenting 12-72 h after symptom onset were included. Cardiac magnetic resonance was performed at day 1 (interquartile range [IQR], 1-1) and at follow-up at day 93 (IQR, 90-98). The pre-PCI ECG was analyzed for the presence of pathological QW (early QW) as well as Anderson-Wilkins acuteness score (AW-score), the classic Sclarovsky-Birnbaum Ischemia Grading System (classic SB-IG-score) and a modified SB-IG-score including any T-wave morphologies. RESULTS Early QW was associated with a larger myocardium at risk (39 ± 12 versus 33 ± 12; p = 0.030) and final infarct size (20 ± 11 versus 14 ± 9; p = 0.021) as well as a numerical lower final myocardial salvage (0.52 ± 0.19 versus 0.61 ± 0.23; p = 0.09). The association with final infarct size disappeared after adjusting for myocardium at risk. An AW-score < 3 showed a trend towards a larger final infarct size (18 ± 11 versus 11 ± 11; p = 0.08) and was not associated with salvage index (0.55 ± 0.20 versus 0.65 ± 0.30; p = 0.23). The classic and modified SB-IG-score were not associated with final infarct size (modified SB-IG-score, 17 ± 10 versus 21 ± 13; p = 0.28) or final myocardial salvage (0.53 ± 0.20 versus 0.53 ± 0.26; p = 0.96). CONCLUSION Of three well-established ECG-scores only early QW and AW-score < 3 showed association with myocardium at risk and infarct size to some extent, but the association with myocardial salvage was weak. Hence, neither of the three investigated ECG-scores are sufficient to guide clinical decision-making in patients with STEMI and ongoing symptoms presenting beyond 12 h of symptom onset.
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Koivula K, Nikus K, Viikilä J, Lilleberg J, Huhtala H, Birnbaum Y, Eskola M. Comparison of the prognostic role of Q waves and inverted T waves in the presenting ECG of STEMI patients. Ann Noninvasive Electrocardiol 2018; 24:e12585. [PMID: 30191632 DOI: 10.1111/anec.12585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/15/2018] [Accepted: 06/23/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients. METHODS We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts. RESULTS The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-. CONCLUSION Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification.
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Affiliation(s)
- Kimmo Koivula
- South Karelia Central Hospital, Lappeenranta, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kjell Nikus
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
| | - Juho Viikilä
- Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jyrki Lilleberg
- Department of Internal Medicine, Hyvinkää Hospital, Hyvinkää, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Markku Eskola
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
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Fakhri Y, Sejersten M, Schoos MM, Hansen HS, Dubois-Rande JL, Hall TS, Larsen AI, Jensen SE, Engblom H, Arheden H, Kastrup J, Atar D, Clemmensen P. Electrocardiographic scores of severity and acuteness of myocardial ischemia predict myocardial salvage in patients with anterior ST-segment elevation myocardial infarction. J Electrocardiol 2017; 51:195-202. [PMID: 29174706 DOI: 10.1016/j.jelectrocard.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Terminal "QRS distortion" on the electrocardiogram (ECG) (based on Sclarovsky-Birnbaum's Grades of Ischemia Score) is a sign of severe ischemia, associated with adverse cardiovascular outcome in ST-segment elevation myocardial infarction (STEMI). In addition, ECG indices of the acuteness of ischemia (based on Anderson-Wilkins Acuteness Score) indicate myocardial salvage potential. We assessed whether severe ischemia with or without acute ischemia is predictive of infarct size (IS), myocardial salvage index (MSI) and left ventricular ejection fraction (LVEF) in anterior versus inferior infarct locations. METHODS In STEMI patients, the severity and acuteness scores were obtained from the admission ECG. Based on the ECG patients were assigned with severe or non-severe ischemia and acute or non-acute ischemia. Cardiac magnetic resonance (CMR) was performed 2-6days after primary percutaneous coronary intervention (pPCI). LVEF was measured by echocardiography 30days after pPCI. RESULTS ECG analysis of 85 patients with available CMR resulted in 20 (23%) cases with severe and non-acute ischemia, 43 (51%) with non-severe and non-acute ischemia, 17 (20%) with non-severe and acute ischemia, and 5 (6%) patients with severe and acute ischemia. In patients with anterior STEMI (n=35), ECG measures of severity and acuteness of ischemia identified significant and stepwise differences in myocardial damage and function. Patients with severe and non-acute ischemia had the largest IS, smallest MSI and lowest LVEF. In contrast, no difference was observed in patients with inferior STEMI (n=50). CONCLUSIONS The applicability of ECG indices of severity and acuteness of myocardial ischemia to estimate myocardial damage and salvage potential in STEMI patients treated with pPCI, is confined to anterior myocardial infarction.
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Affiliation(s)
- Yama Fakhri
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark; Department of Medicine, Division of Cardiology, Nykøbing F Hospital, Nykøbing F, Denmark.
| | - Maria Sejersten
- Department of Cardiology, Herlev University Hospital, Herlev, Denmark
| | | | | | | | - Trygve S Hall
- Department of Cardiology B, Oslo University Hospital Ullevål, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Alf-Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway, Institute of Clinical Science, University of Begen, Norway
| | | | - Henrik Engblom
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hakon Arheden
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jens Kastrup
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital Ullevål, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Peter Clemmensen
- Department of Medicine, Division of Cardiology, Nykøbing F Hospital, Nykøbing F, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Eppendorf, Germany
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Algorithm for the automatic computation of the modified Anderson–Wilkins acuteness score of ischemia from the pre-hospital ECG in ST-segment elevation myocardial infarction. J Electrocardiol 2017; 50:97-101. [DOI: 10.1016/j.jelectrocard.2016.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 01/17/2023]
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Fakhri Y, Schoos MM, Sejersten M, Ersbøll M, Valeur N, Køber L, Hassager C, Wagner GS, Kastrup J, Clemmensen P. Prehospital electrocardiographic acuteness score of ischemia is inversely associated with neurohormonal activation in STEMI patients with severe ischemia. J Electrocardiol 2017; 50:90-96. [DOI: 10.1016/j.jelectrocard.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 01/07/2023]
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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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8
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Evaluation of acute ischemia in pre-procedure ECG predicts myocardial salvage after primary PCI in STEMI patients with symptoms >12hours. J Electrocardiol 2016; 49:278-83. [DOI: 10.1016/j.jelectrocard.2016.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Indexed: 11/23/2022]
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Fakhri Y, Ersbøll M, Køber L, Hassager C, Hesselfeldt R, Steinmetz J, Wagner GS, Sejersten M, Kastrup J, Clemmensen P, Schoos MM. Pre-hospital electrocardiographic severity and acuteness scores predict left ventricular function in patients with ST elevation myocardial infarction. J Electrocardiol 2016; 49:284-91. [PMID: 26962019 DOI: 10.1016/j.jelectrocard.2016.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES System delay (time from first medical contact to primary percutaneous coronary intervention) is associated with heart failure and mortality in patients with ST segment elevation myocardial infarction (STEMI). We evaluated the impact of system delay on left ventricular function (LVF) according to the combination of ischemia severity (Sclarovsky-Birnbaum grades) and acuteness (Anderson-Wilkins scores) in the pre-hospital electrocardiogram (ECG). METHODS In a predefined secondary analysis of a prospective study, the severity and acuteness scores were performed on the pre-hospital ECG. Patients were assessed with respect to 4 classifications which were not mutually exclusive: severe ischemia (+SI) or non-severe ischemia (-SI) and acute ischemia (+AI) or non-acute ischemia (-AI). LVF was assessed by global longitudinal strain (GLS) within 48hours of admission. Adjusted linear regression investigated the association of system delay with GLS in each group. RESULTS In total 262 patients were eligible for analysis of the ECG, which resulted in 42 (16%) with (+SI, -AI), 110 (42%) with (-SI, -AI), 90 (34%) with (-SI, +AI), and 20 (8%) patients with (+SI, +AI). Although system delay did not differ between groups, patients with severe and non-acute ischemia had the most impaired LVF. System delay correlated weakly with GLS in the entire population (r=0.133, p=0.031), and well with GLS in the (+SI, +AI) group (r=0.456, p=0.04), while there was no correlation in the other groups. By adjusted analysis, system delay predicted impaired GLS only in the (+SI, +AI) group (β=0.578, p=0.002). CONCLUSION Pre-hospital risk stratification by ECG identifies patients with acute and severe ischemia who are at increased risk for reduced ventricular function (assessed by GLS) after STEMI. Optimizing reperfusion delays in these patients can therefore be of particular benefit in improving clinical outcome after STEMI.
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Affiliation(s)
- Yama Fakhri
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Medicine, Division of Cardiology, Nykøbing F Hospital, Copenhagen University Hospital, Nykøbing F, Denmark.
| | - Mads Ersbøll
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rasmus Hesselfeldt
- Department of Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Galen S Wagner
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Maria Sejersten
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Medicine, Division of Cardiology, Nykøbing F Hospital, Nykøbing F, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; University Clinic Hamburg-Eppendorf, The Heart Center, Department of General and Interventional Cardiology, Hamburg, Germany
| | - Mikkel Malby Schoos
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Zealand University Hospital, Denmark
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Klein LR, Shroff GR, Beeman W, Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med 2015; 33:786-90. [DOI: 10.1016/j.ajem.2015.03.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022] Open
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Demidova MM, Carlson J, Erlinge D, Platonov PG. Predictors of ventricular fibrillation at reperfusion in patients with acute ST-elevation myocardial infarction treated by primary percutaneous coronary intervention. Am J Cardiol 2015; 115:417-22. [PMID: 25549882 DOI: 10.1016/j.amjcard.2014.11.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/07/2014] [Accepted: 11/07/2014] [Indexed: 11/24/2022]
Abstract
Ventricular fibrillation (VF) during reperfusion (rVF) in ST-segment elevation myocardial infarction (STEMI) is an infrequent but serious event that complicates coronary interventions. The aim of this study was to analyze clinical predictors of rVF in an unselected population of patients with STEMI treated with percutaneous coronary intervention (PCI). Consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2012 were retrospectively assessed for the presence of rVF. Admission electrocardiograms, stored in a digital format, were analyzed for a maximal ST-segment elevation in a single lead and the sum of ST-segment deviations in all leads. Clinical, electrocardiographic, and angiographic characteristics were tested for associations with rVF using logistic regression analysis. Among 3,724 patients with STEMI admitted from 2007 to 2012, 71 (1.9%) had rVF. In univariate analysis, history of myocardial infarction, aspirin and β-blocker use, VF before PCI, left main coronary artery disease, inferior myocardial infarction localization, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV were associated with increased risk for rVF. In a multivariate analysis, sum of ST-segment deviations in all leads >1500 μV (odds ratio 3.7, 95% confidence interval 1.45 to 9.41, p = 0.006) before PCI remained an independent predictor of rVF. In-hospital mortality was 18.3% in the rVF group and 3.3% in the group without VF (p <0.001), but rVF was not an independent predictor of in-hospital death. In conclusion, the magnitude of ST-segment elevation before PCI for STEMI independently predicts rVF and should be considered in periprocedural arrhythmic risk assessment. Despite higher in-hospital mortality in patients with rVF, rVF itself has no independent prognostic value for prognosis.
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Koivumäki JK, Nikus KC, Huhtala H, Ryödi E, Leivo J, Zhou SH, Gregg RE, Selvester RH, Eskola MJ. Agreement between cardiologists and fellows in interpretation of ischemic electrocardiographic changes in acute myocardial infarction. J Electrocardiol 2014; 48:213-7. [PMID: 25576457 DOI: 10.1016/j.jelectrocard.2014.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND Time from symptom onset may not be the best indicator for choosing reperfusion therapy for patients presenting with acute ST-elevation myocardial infarction (STEMI); consequently ECG-based methods have been developed. METHODS This study evaluated the inter-observer agreement between experienced cardiologists and junior doctors in identifying the ECG findings of the pre-infarction syndrome (PIS) and evolving myocardial infarction (EMI). The ECGs of 353 STEMI patients were independently analyzed by two cardiologists, one fellow in cardiology, one fellow in internal medicine and a medical student. The last two were given a half-hour introduction of the PIS/EMI-algorithm. RESULTS The inter-observer reliability between all the investigators was found to be good according to kappa statistics (κ 0.632-0.790) for the whole study population. When divided into different subgroups, the inter-observer agreements were from good to very good between the cardiologists and the fellow in cardiology (κ 0.652 -0.813) and from moderate to good (κ 0.464-0.784) between the fellow in internal medicine, medical student and the others. CONCLUSIONS The PIS and EMI ECG patterns are reliably identified by experienced cardiologists and can be easily adopted by junior doctors.
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Affiliation(s)
- Jyri K Koivumäki
- Tays Heart Hospital, Tampere University Hospital, and Medical School, Tampere University, Tampere, Finland.
| | - Kjell C Nikus
- Tays Heart Hospital, Tampere University Hospital, and Medical School, Tampere University, Tampere, Finland
| | - Heini Huhtala
- University of Tampere, School of Public Health, Tampere Finland
| | - Essi Ryödi
- Tays Heart Hospital, Tampere University Hospital, and Medical School, Tampere University, Tampere, Finland
| | - Joonas Leivo
- Tays Heart Hospital, Tampere University Hospital, and Medical School, Tampere University, Tampere, Finland
| | - Sophia H Zhou
- Clinical Decision Support Solution Department, Philips Research North America, Briarcliff Manor, NY
| | - Richard E Gregg
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA
| | | | - Markku J Eskola
- Tays Heart Hospital, Tampere University Hospital, and Medical School, Tampere University, Tampere, Finland
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Rinta-Kiikka I, Tuohinen S, Ryymin P, Kosonen P, Huhtala H, Gorgels A, Bayés de Luna A, Nikus K. Correlation of electrocardiogram and regional cardiac magnetic resonance imaging findings in ST-elevation myocardial infarction: a literature review. Ann Noninvasive Electrocardiol 2014; 19:509-23. [PMID: 25201553 DOI: 10.1111/anec.12210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with acute ST-elevation myocardial infarction (STEMI) benefit substantially from emergent coronary reperfusion. The principal mechanism is to open the occluded coronary artery to minimize myocardial injury. Thus the size of the area at risk is a critical determinant of the patient outcome, although other factors, such as reperfusion injury, have major impact on the final infarct size. Acute coronary occlusion almost immediately induces metabolic changes within the myocardium, which can be assessed with both the electrocardiogram (ECG) and cardiac magnetic resonance (CMR) imaging. METHODS The 12-lead ECG is the principal diagnostic method to detect and risk-stratify acute STEMI. However, to achieve a correct diagnosis, it is paramount to compare different ECG parameters with golden standards in imaging, such as CMR. In this review, we discuss aspects of ECG and CMR in the assessment of acute regional ischemic changes in the myocardium using the 17 segment model of the left ventricle presented by American Heart Association (AHA), and their relation to coronary artery anatomy. RESULTS Using the 17 segment model of AHA, the segments 12 and 16 remain controversial. There is an important overlap in myocardial blood supply at the antero-lateral region between LAD and LCx territories concerning these two segments. CONCLUSION No all-encompassing correlation can be found between ECG and CMR findings in acute ischemia with respect to coronary anatomy.
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The stability of myocardial area at risk estimated electrocardiographically in patients with ST elevation myocardial infarction. J Electrocardiol 2014; 47:540-5. [DOI: 10.1016/j.jelectrocard.2014.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Indexed: 11/20/2022]
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Fakhri Y, Schoos MM, Clemmensen P, Sejersten M. Clinical use of the combined Sclarovsky Birnbaum Severity and Anderson Wilkins Acuteness scores from the pre-hospital ECG in ST-segment elevation myocardial infarction. J Electrocardiol 2014; 47:566-70. [DOI: 10.1016/j.jelectrocard.2014.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Indexed: 01/19/2023]
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Meijs LPB, Galeotti L, Pueyo EP, Romero D, Jennings RB, Ringborn M, Warren SG, Wagner GS, Strauss DG. An electrocardiographic sign of ischemic preconditioning. Am J Physiol Heart Circ Physiol 2014; 307:H80-7. [PMID: 24778173 PMCID: PMC4080176 DOI: 10.1152/ajpheart.00419.2013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 04/21/2014] [Indexed: 11/22/2022]
Abstract
Ischemic preconditioning is a form of intrinsic cardioprotection where an episode of sublethal ischemia protects against subsequent episodes of ischemia. Identifying a clinical biomarker of preconditioning could have important clinical implications, and prior work has focused on the electrocardiographic ST segment. However, the electrophysiology biomarker of preconditioning is increased action potential duration (APD) shortening with subsequent ischemic episodes, and APD shortening should primarily alter the T wave, not the ST segment. We translated findings from simulations to canine to patient models of preconditioning to test the hypothesis that the combination of increased [delta (Δ)] T wave amplitude with decreased ST segment elevation characterizes preconditioning. In simulations, decreased APD caused increased T wave amplitude with minimal ST segment elevation. In contrast, decreased action potential amplitude increased ST segment elevation significantly. In a canine model of preconditioning (9 mongrel dogs undergoing 4 ischemia-reperfusion episodes), ST segment amplitude increased more than T wave amplitude during the first ischemic episode [ΔT/ΔST slope = 0.81, 95% confidence interval (CI) 0.46-1.15]; however, during subsequent ischemic episodes the T wave increased significantly more than the ST segment (ΔT/ΔST slope = 2.43, CI 2.07-2.80) (P < 0.001 for interaction of occlusions 2 vs. 1). A similar result was observed in patients (9 patients undergoing 2 consecutive prolonged occlusions during elective percutaneous coronary intervention), with an increase in slope of ΔT/ΔST of 0.13 (CI -0.15 to 0.42) in the first occlusion to 1.02 (CI 0.31-1.73) in the second occlusion (P = 0.02). This integrated analysis of the T wave and ST segment goes beyond the standard approach to only analyze ST elevation, and detects cellular electrophysiology changes of preconditioning.
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Affiliation(s)
- Loek P B Meijs
- Department of Cardiology, Catharina Hospital Eindhoven, The Netherlands
| | - Loriano Galeotti
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Michael Ringborn
- Department of Cardiology, Lund University, Lund, Sweden/Center for Integrative Electrocardiology at Lund University, Lund, Sweden/Thoracic Center, Blekingesjukhuset, Karlskrona, Sweden; and
| | | | | | - David G Strauss
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland;
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Pahlm O, Wagner GS. QRS, ST and T changes of acute transmural myocardial ischemia: Overview editorial. J Electrocardiol 2014; 47:397-401. [DOI: 10.1016/j.jelectrocard.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Schoos MM, Lønborg J, Vejlstrup N, Engstrøm T, Bang L, Kelbæk H, Clemmensen P, Sejersten M. A Novel Prehospital Electrocardiogram Score Predicts Myocardial Salvage in Patients with ST-Segment Elevation Myocardial Infarction Evaluated by Cardiac Magnetic Resonance. Cardiology 2013; 126:97-106. [DOI: 10.1159/000351226] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 04/08/2013] [Indexed: 11/19/2022]
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Electrocardiographic Differentiation of Early Repolarization From Subtle Anterior ST-Segment Elevation Myocardial Infarction. Ann Emerg Med 2012; 60:45-56.e2. [DOI: 10.1016/j.annemergmed.2012.02.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 01/17/2012] [Accepted: 02/06/2012] [Indexed: 11/17/2022]
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Engblom H, Strauss DG, Heden B, Hedström E, Jovinge S, Götberg M, Erlinge D, Wagner GS, Arheden H. The evaluation of an electrocardiographic myocardial ischemia acuteness score to predict the amount of myocardial salvage achieved by early percutaneous coronary intervention. J Electrocardiol 2011; 44:525-32. [DOI: 10.1016/j.jelectrocard.2011.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Indexed: 10/18/2022]
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21
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Bouwmeester S, van Hellemond IE, Maynard C, Bekkers SC, van der Weg K, Wagner GS, Gorgels AP. The relationship between initial ST-segment deviation and final QRS complex changes related to the posterolateral wall in acute inferior myocardial infarction. J Electrocardiol 2011; 44:509-15. [DOI: 10.1016/j.jelectrocard.2011.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Indexed: 11/28/2022]
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22
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Johanson P, Fu Y, Wagner GS, Goodman SG, Granger CB, Wallentin L, Van de Werf F, Armstrong PW. ST resolution 1 hour after fibrinolysis for prediction of myocardial infarct size: insights from ASSENT 3. Am J Cardiol 2009; 103:154-8. [PMID: 19121428 DOI: 10.1016/j.amjcard.2008.08.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 08/31/2008] [Accepted: 08/31/2008] [Indexed: 10/21/2022]
Abstract
Acute ST-segment elevation myocardial infarction requires prompt restoration of myocardial perfusion to salvage myocardium at risk of ischemic necrosis and improve clinical outcome. Early resolution of ST-segment elevation during the time after reperfusion has been associated with both these end points. From the ASsessment of the Safety and Efficacy of a New Thrombolytic regimen (ASSENT) 3 trial, 3,425 patients were analyzed to investigate whether the amount of ST-segment resolution, divided into 3 groups (complete, >70%; partial, 30% to 70%; and no resolution, <30%), in the first hour after initiation of therapy was a predictor of final infarct size, estimated by peak creatine kinase and Selvester QRS score on the discharge electrocardiogram. Complete compared with partial and no ST resolution resulted in significantly (p<0.001) smaller infarct sizes of 10.5%, 13.2%, and 15.0% of the left ventricle and significantly (p=0.001) fewer patients with peak creatine >5 times the upper reference level at 50.3%, 71.8%, and 76.3%, respectively. In conclusion, our findings supported previous smaller studies suggesting that early resolution of ST elevation, as a sign of early myocardial reperfusion, resulted in less myocardial damage and preservation of left ventricular function.
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23
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Sejersten M, Ripa RS, Maynard C, Grande P, Andersen HR, Wagner GS, Clemmensen P. Timing of ischemic onset estimated from the electrocardiogram is better than historical timing for predicting outcome after reperfusion therapy for acute anterior myocardial infarction: a DANish trial in Acute Myocardial Infarction 2 (DANAMI-2) substudy. Am Heart J 2007; 154:61.e1-8. [PMID: 17584552 DOI: 10.1016/j.ahj.2007.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 04/01/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute treatment strategy and subsequently prognosis are influenced by the duration of ischemia in patients with ST-elevation acute myocardial infarction (AMI). However, timing of ischemia may be difficult to access by patient history (historical timing) alone. We hypothesized that an electrocardiographic acuteness score is better than historical timing for predicting myocardial salvage and prognosis in patients with anterior AMI treated with fibrinolysis or primary percutaneous coronary intervention. METHODS One hundred seventy-five patients with anterior infarct without electrocardiogram (ECG) confounding factors were included. The ECG method for estimating timing of AMI was calculated using core laboratory measurements from the initial 12-lead ECG. Historical timing was recorded as time from symptom onset to initiation of reperfusion therapy. Myocardial salvage was determined by ECG, using the Aldrich score to determine the initially predicted myocardial infarct size and the Selvester score to determine the final QRS-estimated myocardial infarct size. RESULTS The mean amount of myocardium salvage depended on ECG timing (43% [+/-38%] for "early" vs 1% [+/-56%] for "late"; P < .001), whereas myocardial salvage was independent of historical timing (P = .9). One-year mortality was predicted from ECG timing (P = .04). CONCLUSIONS The ECG method of timing was superior to historical timing in predicting myocardial salvage and prognosis after reperfusion therapy. This study suggests that ECG estimated duration of ischemia might provide a better and objective means to select acute reperfusion therapy rather than the subjective patient history, which could preclude proper reperfusion in some patients with salvageable myocardium.
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Affiliation(s)
- Maria Sejersten
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Johanson P. Electrocardiogram dynamics for risk stratification in ST-segment elevation myocardial infarction—immediate and serially updated information on outcome. J Electrocardiol 2006; 39:S75-8. [PMID: 16962128 DOI: 10.1016/j.jelectrocard.2006.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Revised: 06/02/2006] [Accepted: 06/02/2006] [Indexed: 11/27/2022]
Abstract
Early and serially updated predictions of final infarct-size and clinical outcome--before, during and after reperfusion treatment of ST-elevation myocardial infarction might allow a more individualized treatment: High-risk patients with a predicted major loss of viable myocardium can be identified immediately or during therapy, at a stage when treatment may still be modified; and low-risk patients with predictions of small infarcts and good outcome already after standard primary reperfusion therapy can be identified and thereby avoid a possibly harmful intensified treatment. The necessary information for such predictions seem to be available from the standard 12-lead ECG and from ST-segment monitoring. Today this information, however, is not readily available in clinical practice. Automated algorithms need to be engineered for a broader use and for possibilities of a refined triage and thus for a more individualized strategy of reperfusion therapy.
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Affiliation(s)
- Per Johanson
- Department of Medicine/Cardiology, Coronary Intensive Care Unit, Sahlgrenska University Hospital, Ostra, 416 85 Göteborg, Sweden.
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25
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Wagner G, Lim T, Gettes L, Gorgels A, Josephson M, Wellens H, Anderson S, Childers R, Clemmensen P, Kligfield P, Macfarlane P, Pahlm O, Selvester R. Consideration of Pitfalls in and Omissions from the Current ECG Standards for Diagnosis of Myocardial Ischemia/Infarction in Patients Who Have Acute Coronary Syndromes. Cardiol Clin 2006; 24:331-42, vii. [PMID: 16939827 DOI: 10.1016/j.ccl.2006.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The ECG is the key clinical test available for the emergency determination of which patients who presenting with acute coronary syndromes indeed have acute myocardial ischemia/infarction. Because typically the etiology is thrombosis, the correct clinical decision regarding reperfusion therapy is crucial. This review follows the efforts of an AHA working group to develop new standards for clinical application of electrocardiology. The pitfalls in the current diagnostic standards regarding ischemia/infarction that have been identified by sufficiently documented studies are corrected in their report. This article focuses on the pitfalls for which new standards will emerge in future years.
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Affiliation(s)
- Galen Wagner
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 2400 Pratt Street, RM 0306, Durham, NC 27705, USA, and Department of Clinical Physiology, Lund University Hospital, Sweden.
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26
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Abstract
Despite technologic advances in many diagnostic fields, the 12-lead ECG remains the basis for early identification and management of an acute coronary syndrome. This article reviews the use of the ECG in acute coronary syndromes.
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Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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27
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Johanson P, Armstrong PW, Barbagelata NA, Chaitman BR, Clemmensen P, Dellborg M, French J, Goodman SG, Green CL, Krucoff MW, Langer A, Pahlm O, Reilly P, Wagner GS. An Academic ECG Core Lab Perspective of the FDA Initiative for Digital ECG Capture and Data Management in Large-Scale Clinical Trials. ACTA ACUST UNITED AC 2005. [DOI: 10.1177/009286150503900402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Birnbaum Y, Ware DL. Electrocardiogram of acute ST-elevation myocardial infarction: the significance of the various "scores". J Electrocardiol 2005; 38:113-8. [PMID: 15892020 DOI: 10.1016/j.jelectrocard.2005.01.003] [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 Electrocardiogram has extensively been used for evaluation and triage of patients with acute chest pain. The clinician admitting a patient with ST elevation acute myocardial infarction should be able to estimate the size and location of the ischemic area at risk, how much of the ischemic myocardium has already undergone irreversible necrosis by the time of presentation, and the "severity of ischemia" (or what is the rate of progression of necrosis as long as ischemia continues). The electrocardiographic variables that are used to make these estimates are the initial portion of the QRS (Q and R waves), the terminal portion of the QRS (the S waves and the J-point), the ST segment, and the configuration of the T waves. This editorial discuss the ability to predict each of the "physiological" parameters using the above mentioned electrocardiographic variables.
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Affiliation(s)
- Yochai Birnbaum
- Division of Cardiology, Department of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA.
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29
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Johanson P, Fu Y, Goodman SG, Dellborg M, Armstrong PW, Krucoff MW, Wallentin L, Wagner GS. A dynamic model forecasting myocardial infarct size before, during, and after reperfusion therapy: an ASSENT-2 ECG/VCG substudy. Eur Heart J 2005; 26:1726-33. [PMID: 15824078 DOI: 10.1093/eurheartj/ehi221] [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: 11/13/2022] Open
Abstract
AIMS Serial forecasts of final myocardial infarct (MI) size during fibrinolytic treatment (Rx) of ST-elevation MI would allow the identification of high-risk patients with a predicted major loss of viable myocardium, at a point when treatment may still be modified. We investigated a model for such forecasting, using time and the ECG. METHODS AND RESULTS We collected 234 patients with ST-elevation MI, without signs of previous MI, bundle branch block, or hypertrophy. MI size was determined by the Selvester score and was "forecasted" at: admission with patients stratified by delay time and an ECG acuteness score into three groups (EARLY, DISCORDANT, and LATE); 90 min after Rx by > or =70% ST-recovery or not and occurrence of "reperfusion peaks"; 4 h after Rx by ST re-elevations. EARLY patients had smaller final infarct sizes than LATE (9.4 vs. 20%, P=0.01). EARLY patients with > or =70% ST-recovery without a reperfusion peak had smaller infarct sizes than those with (3.1 vs. 12.5%, P=0.001). EARLY patients without ST re-elevations had smaller infarct sizes (1.5%) than those with some (9%) or many re-elevations (12%), P<0.001. CONCLUSION Final infarct size can be forecasted using delay time and serial ECGs. Serially updated forecasts seem especially important when both clock-time and initial ECG- signs indicate earliness.
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Affiliation(s)
- Per Johanson
- Division of Cardiology, Sahlgrenska University Hospital/Ostra, SE-41685 Göteborg, Sweden.
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30
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Ripa RS, Persson E, Hedén B, Maynard C, Christian TF, Hammill S, Pahlm O, Wagner GS. Comparison between human and automated electrocardiographic waveform measurements for calculating the Anderson-Wilkins acuteness score in patients with acute myocardial infarction. J Electrocardiol 2005; 38:96-9. [PMID: 15892017 DOI: 10.1016/j.jelectrocard.2004.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Anderson-Wilkins (AW) electrocardiographic (ECG) acuteness score complements time from pain onset in prognostic stratification of patients with acute myocardial infarction (AMI). However, for the AW acuteness score to be of practical use in the acute situation, it must be an integral component of a commercial automated ECG analysis program. The objective of this study was to determine the concordance between human and computer measurements and calculation of the AW acuteness score. The mean difference in AW acuteness score was 0.11 +/- 0.66 for anterior and -0.07 +/- 1.24 for inferior AMI. Ninety-nine percent of the differences were found to be 1.0 or less for the anterior AMI group, and 91.7% were 1.0 or less in the inferior AMI group. The differences were primarily caused by minor disagreements in measurements. In conclusion, the AW acuteness score established using manual ECG waveform measurements can be implemented into commercial automated ECG analysis programs to achieve practical use in clinical decision support for patients with AMI.
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Affiliation(s)
- Rasmus S Ripa
- The Heart Centre, Department of Medicine, Copenhagen University Hospital, Copenhagen, Denmark
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31
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Billgren T, Birnbaum Y, Sgarbossa EB, Sejersten M, Hill NE, Engblom H, Maynard C, Pahlm O, Wagner GS. Refinement and interobserver agreement for the electrocardiographic Sclarovsky-Birnbaum Ischemia Grading System. J Electrocardiol 2004; 37:149-56. [PMID: 15286927 DOI: 10.1016/j.jelectrocard.2004.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Electrocardiogram-derived grades of ischemia at the time of patient presentation with acute myocardial infarction have proved useful in predicting the salvageability by reperfusion therapy, final infarct size, severity of left ventricular dysfunction, and short- and long-term prognosis. SUBJECTS AND METHODS The Sclarovsky-Birnbaum Ischemia Grading System based on the relation between the acute appearances of the T wave, the ST segment, and the QRS complex was considered as a means of enhanced ECG analysis in this group of patients. The evaluation of a training population (n = 46) resulted in refinement of the published description of the Sclarovsky-Birnbaum Ischemia Grading System, and a test population (n = 50) was utilized for investigating the interobserver agreement among 5 observers in determining the grade of ischemia. RESULTS The agreement among the observers applying the "refined" Sclarovsky-Birnbaum Ischemia Grading System was 0.89. Complete agreement was found for the ECGs of 80% of the patients, and the most common reason for disagreement was the application of the terminal T-negativity criterion. CONCLUSIONS The refined Sclarovsky-Birnbaum Ischemia Grading System can be performed manually with low interobserver variability. It has potential for support of the acute myocardial infarction triage decision as an electrocardiographic method for evaluating the level of ischemic protection at the time of either pre-hospital or emergency-department presentation.
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Affiliation(s)
- Therese Billgren
- Departmentof Cardiology, Duke Clinical Research Institute, Durham, NC, USA
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32
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Hedén B, Ripa R, Persson E, Song Q, Maynard C, Leibrandt P, Wall T, Christian TF, Hammill SC, Bell SS, Pahlm O, Wagner GS. A modified Anderson-Wilkins electrocardiographic acuteness score for anterior or inferior myocardial infarction. Am Heart J 2004; 146:797-803. [PMID: 14597927 DOI: 10.1016/s0002-8703(03)00404-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Optimal treatment of acute myocardial infarction (AMI) depends on the duration of the ischemia. The Anderson Wilkins (AW) electrocardiographic acuteness score has been shown to complement the historical timing in estimating the time interval from acute thrombotic coronary occlusion in patients presenting with chest pain and evolving myocardial infarction. The purposes of this study were to (1) compare the distributions of the previously developed AW acuteness score in a training population with either anterior or inferior AMI and (2) propose modifications to the formula to achieve distributions similar to the observed distributions of historical times from onset of pain. METHODS Two hundred three and 177 patients were included as training and testing population, respectively. All patients had an anterior or an inferior AMI and were without confounding factors on the electrocardiogram. RESULTS The training population had similar distributions of historical times from onset of pain, but differences in distributions of AW acuteness scores, between patients with anterior and inferior AMI (P <.0001). Eighty percent of the inferior AMI group had the highest possible AW acuteness score. Modification of a Q-wave criterion from > or =30 to > or =20 ms resulted in similar distributions in patients with anterior and inferior AMI both in the training and an independent testing population. CONCLUSIONS These results suggest that a modified AW acuteness score using a lower Q-wave duration criterion provides similar AMI timing information in patients with anterior and inferior locations. Clinical use of the AW acuteness score will only be practical if the calculation is automated.
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Affiliation(s)
- Bo Hedén
- Department of Clinical Physiology, Lund University, Lund, Sweden
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33
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Corey KE, Maynard C, Pahlm O, Wilkins ML, Anderson ST, Cerqueira MD, Pryor AD, Raitt MH, Startt Selvester RH, Turner J, Weaver WD, Wagner GS. Combined historical and electrocardiographic timing of acute anterior and inferior myocardial infarcts for prediction of reperfusion achievable size limitation. Am J Cardiol 1999; 83:826-31. [PMID: 10190393 DOI: 10.1016/s0002-9149(98)01042-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The historical time of acute symptom onset is not always an accurate indication of the timing of onset of an acute myocardial infarction (AMI). Consideration of electrocardiographic (ECG) timing parameters could supplement historical timing alone as a clinical guide for decisions regarding the use of reperfusion therapy. Three hundred ninety-five patients from 4 trials of thrombolytic therapy conducted in the northwestern United States and western Canada are included in the present study. A total of 316 patients received either streptokinase or tissue plasminogen activator, and 79 received no reperfusion therapy. Historical time of symptom onset was acquired by emergency or cardiology department personnel and recorded on patient report forms. An ECG method for estimating the timing of the AMI, the Anderson-Wilkins (AW) acuteness score, was calculated from the initial standard 12-lead recording by investigators blinded to the knowledge of symptom duration or any other study variables. Tomographic thallium-201 imaging 7 weeks after hospital admission was used to measure final AMI size. The ECG timing method achieved a relation with final AMI size similar to that previously reported for historical timing. The AW acuteness score proved most useful for anterior AMI location when there was a > or = 2 hour delay following symptom onset, but was most useful for the inferior AMI location when there was a < 2 hour delay. Despite a longer delay, patients with high AW acuteness scores had 50% lower final anterior AMI size than those with low scores; and despite a shorter delay, those with low ECG acuteness scores had 50% greater final inferior AMI size than those with high scores. The AW acuteness score combined with the historical estimation of symptom duration should provide a more accurate basis for predicting the potential for limitation of final AMI size than either method alone. These results could potentially provide the basis for developing a new method for noninvasive guidance of clinical decisions regarding administration of reperfusion therapy in the initial evaluation of patients with AMI.
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Affiliation(s)
- K E Corey
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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Serrano CV, Bortolotto LA, César LA, Solimene MC, Mansur AP, Nicolau JC, Ramires JA. Sinus bradycardia as a predictor of right coronary artery occlusion in patients with inferior myocardial infarction. Int J Cardiol 1999; 68:75-82. [PMID: 10077404 DOI: 10.1016/s0167-5273(98)00344-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Differentiation of right coronary artery (RCA) from left circumflex artery (LCxA) occlusion may be difficult since both can present an electrocardiographic pattern of inferior myocardial infarction (IMI). We studied 133 patients with IMI, 92 patients with RCA occlusion and 41 patients with LCxA occlusion. Risk factors such as previous MI, arterial hypertension, diabetes, smoking, and dislipemia, were similar for RCA and LCxA occlusions. Patients with RCA occlusion had a higher incidence of isolated IMI than patients with LCxA occlusion, 50% vs. 17%, respectively (P<0.001). Arterial hypotension was more prevalent (P<0.05) among patients with RCA (18%) rather than those with LCxA occlusion (2%). RCA occlusion presented an association with sinus bradycardia, an association not observed with LCxA occlusion (15% vs. 0%, respectively; P<0.01). Total atrioventricular block was only present among patients with RCA (18%). Proximal occlusions of the RCA presented lower heart rates (sinus bradycardia) than medial and distal occlusions (13% vs. 1% and 1%, respectively; P<0.0001 and P<0.001). Therefore, regarding patients with IMI: (1) sinus bradycardia is more frequent when the infarct-related artery is the RCA; (2) proximal occlusions of the right coronary predispose low heart rates; and (3) occlusion of the LCxA rarely induces sinus bradycardia.
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Affiliation(s)
- C V Serrano
- Heart Institute, Coronary Care Unit, São Paulo, SP, Brazil.
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35
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Hochrein J, Sun F, Pieper KS, Lee KL, Gates KB, Armstrong PW, Weaver WD, Goodman SG, Topol EJ, Califf RM, Granger CB, Wagner GS. Higher T-wave amplitude associated with better prognosis in patients receiving thrombolytic therapy for acute myocardial infarction (a GUSTO-I substudy). Global Utilization of Streptokinase and Tissue plasminogen Activator for Occluded Coronary Arteries. Am J Cardiol 1998; 81:1078-84. [PMID: 9605045 DOI: 10.1016/s0002-9149(98)00112-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Increased T-wave amplitude is one of the earliest electrocardiographic (ECG) changes following coronary artery occlusion. Therefore, higher T waves in the presenting electrocardiogram should represent earlier time to treatment and thus be associated with lower mortality following thrombolytic therapy. However, T-wave amplitude has never been evaluated as a prognostic marker in this setting. We examined clinical outcomes in 3,317 patients with acute myocardial infarction (AMI) who underwent thrombolysis in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) Study. Patients were classified as either those with high T waves or those with low T waves. Higher T waves were defined as those >98th percentile of the upper limit of normal. T-wave amplitude was also evaluated as a continuous variable according to infarct location (maximum T-wave amplitude) and as the amount of excess T-wave amplitude above normal (excess T-wave amplitude). Patients with higher T waves had lower 30-day mortality than those without (5.2% vs 8.6%, p = 0.001) and were less likely to develop congestive heart failure (15% vs 24%, p <0.001) or cardiogenic shock (6.1% vs 8.6%, p = 0.023). Higher maximum T-wave amplitude and excess T-wave amplitude were predictive of lower 30-day mortality (chi-square = 67, p <0.001 and chi-square = 33, p <0.001, respectively). These differences remain significant after controlling for other prognostic baseline ECG variables. In addition, T-wave amplitude added prognostic significance after controlling for time to treatment. T-wave amplitude, an often-overlooked component of the electrocardiogram, can add significant prognostic information in initial evaluation of patients with AMI.
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Affiliation(s)
- J Hochrein
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705, USA
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36
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Birnbaum Y, Sclarovsky S, Herz I, Zlotikamien B, Chetrit A, Olmer L, Barbash GI. Admission clinical and electrocardiographic characteristics predicting in-hospital development of high-degree atrioventricular block in inferior wall acute myocardial infarction. Am J Cardiol 1997; 80:1134-8. [PMID: 9359538 DOI: 10.1016/s0002-9149(97)00628-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study assessed the ability of simple clinical and electrocardiographic variables routinely obtained on admission to identify patients who are at high risk of developing high-degree atrioventricular (AV) block during hospitalization in 1,336 patients with inferior wall acute myocardial infarction (AMI). Patients were classified into 2 initial electrocardiographic patterns based on the J-point to R-wave amplitude ratio: pattern 1: those with J point/R wave <0.5 and pattern 2: patients with J point/R wave > or =0.5 in > or =2 leads of the inferior leads II, III, and aVF. High-degree AV block was found in 6.7% of patients (41 of 615) with pattern 1 versus 11.8% of the patients (85 of 721) with pattern 2 on admission electrocardiogram (p = 0.0008). Multivariate logistic regression analysis revealed that the only variables found to be independently associated with high-degree AV block were female gender (odds ratio [OR] 1.48; 95% confidence interval [CI] 0.98 to 2.23; p = 0.06); Killip class on admission > or =2 (OR 2.24; CI 1.43 to 3.51; p = 0.0004); initial electrocardiographic pattern 2 versus pattern 1 (OR 1.82; CI 1.22 to 2.21; p = 0.003); and absence of abnormal Q waves on admission (OR yes vs no 0.68; CI 0.44 to 1.05; p = 0.08). A simple electrocardiographic sign (J point/R wave > or =0.5 in > or =2 leads) is a reliable predictor of the development of advanced AV block among patients receiving thrombolytic therapy for inferior wall AMI.
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Affiliation(s)
- Y Birnbaum
- Beilinson Medical Center, Petah-Tiqva, Israel
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MAYNARD CHARLES, EVERY NATHANR, MARTIN JENNYS, HALLSTROM ALFREDP, KENNEDY JWARD, WEAVER WDOUGLAS. The Western Washington and Myocardial Infarction Triage and Intervention Trials of Thrombolytic Therapy: 15 Years of Collaboration in the Pacific Northwest. J Interv Cardiol 1997. [DOI: 10.1111/j.1540-8183.1997.tb00028.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Christian TF, Gibbons RJ, Clements IP, Berger PB, Selvester RH, Wagner GS. Estimates of myocardium at risk and collateral flow in acute myocardial infarction using electrocardiographic indexes with comparison to radionuclide and angiographic measures. J Am Coll Cardiol 1995; 26:388-93. [PMID: 7608439 DOI: 10.1016/0735-1097(95)80011-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to determine the accuracy of the initial 12-lead electrocardiogram (ECG) in predicting final infarct size after direct coronary angioplasty for myocardial infarction and to examine which physiologic variables known to be determinants of outcome the ST segment changes most closely reflect. BACKGROUND Myocardium at risk, collateral flow and time to reperfusion have been shown to be independent physiologic predictors of infarct size in animal and clinical models. However, such measurements may be difficult to perform on a routine basis in patients with myocardial infarction. The standard 12-lead ECG is inexpensive and readily available. METHODS Sixty-seven patients with acute myocardial infarction, ST segment elevation and duration of chest pain < 12 h had an initial injection of technetium-99m sestamibi. Tomographic imaging was performed 1 to 8 h later (after direct coronary angioplasty), and the images were quantified to measure perfusion defect size (myocardium at risk) and severity (a measure of collateral flow). Contrast agent injection and tomographic acquisition were repeated at hospital discharge to measure infarct size. The ST segment elevation score was calculated for each patient according to infarct location and using previously described formulas. RESULTS ST segment elevation score correlated closest with the radionuclide measure of collateral flow (r = -0.44, p < or = 0.0001), as well as an angiographic measure of collateral flow (r = -0.38, p = 0.05). Although ST segment elevation score correlated weakly with the magnitude of myocardium at risk by technetium-99m sestamibi, it was not as strong as infarct location alone in predicting myocardium at risk ([mean +/- SD] anterior 51 +/- 13% left ventricle vs. inferior 17 +/- 10% left ventricle, p < 0.0001). ST segment elevation score was weakly associated with final infarct size (r = 0.34, p = 0.005). A multivariate ECG model was constructed with infarct location as a surrogate for myocardium at risk, ST segment elevation score as a surrogate for estimated collateral flow, and elapsed time to reperfusion from onset of chest pain. All three variables were independently associated with infarct size. CONCLUSIONS The initial standard 12-lead ECG can provide insight into myocardium at risk and, to a greater extent, collateral flow and can consequently provide some estimate of subsequent infarct size. However, the confidence limits for such predictors are wide.
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Affiliation(s)
- T F Christian
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Gambill CL, Wilkins ML, Haisty WK, Anderson ST, Maynard C, Wagner NB, Selvester RH, Wagner GS. T wave amplitudes in normal populations. Variation with ECG lead, sex, and age. J Electrocardiol 1995; 28:191-7. [PMID: 7595121 DOI: 10.1016/s0022-0736(05)80257-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Consideration of increased T wave amplitude (tall T waves), either alone or in association with other electrocardiographic (ECG) parameters, may be beneficial for the early detection of acute transmural ischemia, and quantification of the increase might be used in quantifying the ischemic area. The primary purpose of this study was to quantify normal T wave amplitude limits according to ECG lead, sex, and age. One thousand nine hundred thirty-five subjects in two normal populations were analyzed, and the 98th percentile of the positive T wave amplitude for each ECG lead (including -aVR) was considered the upper limit of normal. Normal T wave amplitude was two times greater in the precordial than in the limb leads, and it was approximately 25% greater in men than in women in all leads. There was approximately a 10% decrease in normal T wave amplitude between 18-39- and 40-59-year-old patients and a 15% decrease between 40-59- and 60-79-year-old patients. The upper limit of normal T wave amplitudes identified in this study confirm those developed by Lepeschkin for use as means for each lead when age and sex are not considered. These limits might be incorporated into both normograms and automated ECG analysis systems to determine the presence or absence of tall T waves in patients presenting with symptoms of acute transmural ischemia.
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Affiliation(s)
- C L Gambill
- Department of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
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