Abstract
The 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 specific patterns of NSTE-ACS, as well as common patterns suggesting non-ischemic ST elevation is crucial.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Wagner GS. Marriott’s practical electrocardiography. Philadelphia: Lippincott Williams & Wilkins; 2001.
Gorgels APM. Electocardiography. In: Willerson JT, Cohn JN, Wellens HJJ, Holmes DR, editors. Cardiovascular medicine. London: Springer; 2007. p. 43–77.
de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103:730–6.
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Lancet. 1994;343:311–22.
Huang HD, Birnbaum Y. ST elevation: differentiation between ST elevation myocardial infarction and nonischemic ST elevation. J Electrocardiol. 2011;44:494.e1–12.
O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):529–55.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Thygesen K, Alpert JS, White HD, Jaffe AS, Katus HA, Apple FS, Lindahl B, Morrow DA, Chaitman BR, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow JJ, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasche P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Morais J, Aguiar C, Almahmeed W, Arnar DO, Barili F, Bloch KD, Bolger AF, Botker HE, Bozkurt B, Bugiardini R, Cannon C, de Lemos J, Eberli FR, Escobar E, Hlatky M, James S, Kern KB, Moliterno DJ, Mueller C, Neskovic AN. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581–98.
Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic diagnosis of ST-elevation myocardial infarction. Cardiol Clin. 2006;24:343–65, vii.
Tran V, Huang HD, Diez JG, Kalife G, Goswami R, Paniagua D, Jneid H, Wilson JM, Sherron SR, Birnbaum Y. Differentiating ST-elevation myocardial infarction from nonischemic ST-elevation in patients with chest pain. Am J Cardiol. 2011;108:1096–101.
Nikus K, Pahlm O, Wagner G, Birnbaum Y, Cinca J, Clemmensen P, Eskola M, Fiol M, Goldwasser D, Gorgels A, Sclarovsky S, Stern S, Wellens H, Zareba W, de Luna AB. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. J Electrocardiol. 2010;43:91–103.
Banerjee S, Hargreaves MR. Transient pathological Q waves in suspected acute myocardial infarction: ‘electrical stunning’. Int J Clin Pract. 2000;54:263–4.
Bandeali SJ, Stone S, Huang HD, Kayani WT, Wilson JM, Birnbaum Y. Comparison of segmental wall motion abnormalities on echocardiography in patients with anteroseptal versus extensive anterior wall ST-segment elevation myocardial infarction. J Electrocardiol. 2012;45:551–5.
Huang HD, Tran V, Jneid H, Wilson JM, Birnbaum Y. Comparison of angiographic findings in patients with acute anteroseptal versus anterior wall ST-elevation myocardial infarction. Am J Cardiol. 2011;107:827–32.
Bayes de Luna A, Wagner G, Birnbaum Y, Nikus K, Fiol M, Gorgels A, Cinca J, Clemmensen PM, Pahlm O, Sclarovsky S, Stern S, Wellens H, Zareba W. A new terminology for left ventricular walls and location of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging: a statement for healthcare professionals from a committee appointed by the International Society for Holter and Noninvasive Electrocardiography. Circulation. 2006;114:1755–60.
Pride YB, Tung P, Mohanavelu S, Zorkun C, Wiviott SD, Antman EM, Giugliano R, Braunwald E, Gibson CM. Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior ST-segment depression: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) substudy. JACC Cardiovasc Interv. 2010;3:806–11.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith Jr SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Ornato JP. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:E1–211.
Porter A, Vaturi M, Adler Y, Sclarovsky S, Strasberg B, Herz I, Kuzniec H, Birnbaum Y. Are there differences among patients with inferior acute myocardial infarction with ST depression in leads V2 and V3 and positive versus negative T waves in these leads on admission? Cardiology. 1998;90:295–8.
Birnbaum Y, Bayes de Luna A, Fiol M, Nikus K, Macfarlane P, Gorgels A, Sionis A, Cinca J, Barrabes JA, Pahlm O, Sclarovsky S, Wellens H, Gettes L. Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report. J Electrocardiol. 2012;45:463–75.
Fiol M, Carrillo A, Rodriguez A, Pascual M, Bethencourt A, Bayes de Luna A. Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: differential diagnosis and clinical considerations. J Electrocardiol. 2012;45(5):487–90.
Wagner GS, Macfarlane P, Wellens H, Josephson M, Gorgels A, Mirvis DM, Pahlm O, Surawicz B, Kligfield P, Childers R, Gettes LS, Bailey JJ, Deal BJ, Gorgels A, Hancock EW, Kors JA, Mason JW, Okin P, Rautaharju PM, van Herpen G. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009;53:1003–11.
de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359:2071–3.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer-Verlag London
About this chapter
Cite this chapter
Birnbaum, Y., Wilson, J.M., Nikus, K. (2015). The Electrocardiogram in Coronary Artery Disease. In: Willerson, J., Holmes, Jr., D. (eds) Coronary Artery Disease. Cardiovascular Medicine. Springer, London. https://doi.org/10.1007/978-1-4471-2828-1_9
Download citation
DOI: https://doi.org/10.1007/978-1-4471-2828-1_9
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-2827-4
Online ISBN: 978-1-4471-2828-1
eBook Packages: MedicineMedicine (R0)