Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report

Birnbaum, Yochai; Luna, Antonio; Fiol, Miquel; Nikus, Kjell; Macfarlane, Peter W.; Gorgels, Anton P.M.; Sionís, Alessandro; Cinca, Juan; Barrabés, José A.; Pahlm, Olle; Sclarovsky, Samuel; Wellens, Hein J.J.; Gettes, Leonard S.

doi:10.1016/j.jelectrocard.2012.06.011

Cited by 53 publications

(27 citation statements)

References 35 publications

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“…However, in the current era, such experts are not always involved in the urgent process of acute reperfusion decision support. The currently accepted criteria for STEMI are routinely used, but their limited sensitivity delays definitive treatment in many patients, 6 and their limited specificity causes inappropriate activation of the cardiac catheterization laboratory for many others.7 When STEMI criteria are neither clearly present nor absent, additional leads could be applied; however, their proper application requires accuracy. In this era there is generally poor performance in even the correct application of the standard leads.…”

Section: Discussionmentioning

confidence: 99%

Discrimination of ST deviation caused by acute coronary occlusion from normal variants and other abnormal conditions, using computed electrocardiographic imaging based on 12-lead ECG

Akil

Al-Mashat

Hedén

et al. 2013

Journal of Electrocardiology

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, B. M. (2013). Discrimination of ST deviation caused by acute coronary occlusion from normal variants and other abnormal conditions, using computed electrocardiographic imaging based on 12-lead ECG. Journal of Electrocardiology, 46(3), 197-203. DOI: 10.1016/j.jelectrocard.2013 General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.• Users may download and print one copy of any publication from the public portal for the purpose of private study or research.• You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal AbstractBackground: Many graphical methods for displaying ST-segment deviation in the ECG have been tried for enhancing decision-making in patients with suspected acute coronary syndromes. Computed electrocardiographic imaging (CEI), based on a mathematical inverse solution, has been recently applied to transform ST-J point measurements made in conventional 12-lead ECG into a display of epicardial potentials in bull's-eye format. The purpose of this study is to assess utility of CEI in the clinical setting.

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Section: Discussionmentioning

confidence: 99%

Discrimination of ST deviation caused by acute coronary occlusion from normal variants and other abnormal conditions, using computed electrocardiographic imaging based on 12-lead ECG

Akil

Al-Mashat

Hedén

et al. 2013

Journal of Electrocardiology

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“…Indeed, the statement concerning the direction of the T waves has been removed by the recent 2012 ACCF/AHA guidelines for the management of STEMI [ 6 ]. In anterior subendocardial ischemia, maximal ST depression is usually seen in leads V3-V5, whereas in transmural inferolateral ischemia, maximal ST depression is seen in leads V1-V3 [ 18 ]. Prominent ST depression in V1 suggests LCX induced ischemia rather than anterior subendocardial ischemia.…”

Section: St Depression In Leads V1-v4mentioning

confidence: 99%

“…9.3 and 9.8 ). This stage is short; however, usually lasting only a few minutes, and ST segment elevation quickly develops if ischemia persists [ 10 ] although in rare patients, this pattern persists without appearance of ST elevation (Grade 1 of ischemia) [ 18 ]. This pattern is seen mainly in patients with signifi cant preexisting stenosis of the culprit artery and rich collateral circulation.…”

Section: Tall Peaked T Wavesmentioning

confidence: 99%

The Electrocardiogram in Coronary Artery Disease

Birnbaum

Wilson

Nikus

2015

Coronary Artery Disease

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The fi rst human electrocardiogram (ECG) was performed by AD Waller in 1887. Willem Einthoven was the fi rst one to use the term ECG in 1901 and named the waves P, Q, R, S and T. The ECG remains a major non-invasive cardiac imaging tool. In the last 30 years newer and more direct imaging modalities, such as echocardiography, nuclear scanning, cardiac computerized tomography (CT) and magnetic resonance imaging (MRI) have been developed, adding to the information gained from the ECG in the assessment of the heart in various stable conditions. Yet, due to its wide availability, low-cost and rapid interpretation, the ECG remains the most commonly used and, perhaps most important of available cardiovascular diagnostic tools; especially for rapid assessment of patients with symptoms compatible with acute coronary syndromes (ACS) and/or arrhythmia. The Electrocardiogram in Coronary AbstractThe electrocardiogram (ECG) remains the most commonly used and, perhaps most important of available cardiovascular diagnostic tools; especially for rapid assessment of patients with symptoms compatible with acute coronary syndromes (ACS) and/or arrhythmia. ST elevation is thought to represent transmural ischemia due to thrombotic occlusion of an epicardial artery. Emergent reperfusion therapy by primary percutaneous intervention (PCI) or thrombolytic therapy is usually indicated. In contrast, patients without ST segment elevation are treated conservatively in the initial stages. However, the distinction between ST elevation myocardial infarction (STEMI) and non ST elevation ACS (NSTE-ACS) is not always clear. Many patients with compatible symptoms have ST elevation not due to "transmural ischemia". On the other hand, occasionally, patients may have acute ischemia due to complete occlusion of an epicardial artery, but their ECG may show minor degree of ST elevation. Moreover, certain distinct ECG patterns have been described in patients presenting without ST elevation that are associated with higher risk. Recognition of these specifi c patterns of NSTE-ACS, as well as common patterns suggesting non-ischemic ST elevation is crucial.

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“…(3) Isolated T-wave inversion: In the ACS setting, T-wave inversion without concomitant ST depression is a sign of reperfusion of prior active ischemia, not of ongoing active ischemia itself. 37,40,56,57 This is to be distinguished from the isolated chronic localized T waves that may persist after resolution of an acute event.…”

Section: The Ecg In Patients After Resolution Of Symptomsmentioning

confidence: 99%

“…Thus, this pattern should be considered as a marker of a high risk, though the patient does not have active ongoing ischemia. 40,57 In other cases, T-wave inversion may be less prominent or biphasic T waves with inversion of the terminal portion of the T waves can be seen as a sign of reperfusion. Although there is no indication for emergent reperfusion therapy to prevent ongoing necrosis, this ECG evidence of reperfusion points toward the presence of a culprit coronary lesion that may progress and lead to reischemia/ reinfarction.…”

Section: The Ecg In Patients After Resolution Of Symptomsmentioning

confidence: 99%

The Role of the ECG in Diagnosis, Risk Estimation, and Catheterization Laboratory Activation in Patients with Acute Coronary Syndromes: A Consensus Document

Birnbaum

Nikus

Kligfield

et al. 2014

Noninvasive Electrocardiol

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The electrocardiogram (ECG) is the most widely used imaging tool helping in diagnosis and initial management of patients presenting with symptoms compatible with acute coronary syndrome. Acute ischemia affects the configuration of the QRS complexes, the ST segments and the T waves. The ECG should be read along with the clinical assessment of the patient. ST segment elevation (and ST depression in leads V 1 -V 3 ) in patients with active symptoms usually indicates acute occlusion of an epicardial artery with ongoing transmural ischemia. These patients should be triaged for emergent reperfusion therapy per current guidelines. However, many patients have ST segment elevation secondary to nonischemic causes. ST depression in leads other than V 1 -V 3 usually are indicative of subendocardial ischemia secondary to subocclusion of the epicardial artery, distal embolization to small arteries or spasm supply/demand mismatch. ST depression may also be secondary to nonischemic etiologies, such as left ventricular hypertrophy, cardiomyopathies, etc. Knowing the clinical scenario, comparison to previous ECG and subsequent ECGs (in cases that there are changes in the quality or severity of symptoms) may add in the diagnosis and interpretation in difficult cases. This review addresses the different ECG patterns, typically seen in patients with active symptoms, after resolution of symptoms and the significance of such changes when seen in asymptomatic patients. Ann Noninvasive Electrocardiol 2014;19(5):412-425noninvasive techniques-electrocardiography; Acute coronary syndrome; ischemia; ST elevation; ST depression; myocardial infarctionThe electrical activity of the heart, as depicted by the surface electrocardiogram (ECG) is affected by ischemia, reperfusion and presence of necrosis or scar. Therefore, the ECG has remained the most widely utilized ancillary tool, along with focused history taking and physical examination,

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Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report

Cited by 53 publications

References 35 publications

Discrimination of ST deviation caused by acute coronary occlusion from normal variants and other abnormal conditions, using computed electrocardiographic imaging based on 12-lead ECG

Discrimination of ST deviation caused by acute coronary occlusion from normal variants and other abnormal conditions, using computed electrocardiographic imaging based on 12-lead ECG

The Electrocardiogram in Coronary Artery Disease

The Role of the ECG in Diagnosis, Risk Estimation, and Catheterization Laboratory Activation in Patients with Acute Coronary Syndromes: A Consensus Document

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