Abstract
The standard 12-lead ECG gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST-elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: 1) ST-segment measurements; 2) T-wave configuration; 3) QRS changes; and 4) reperfusion arrhythmias. Complete and stable (≥70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30% to 70%) or no (<30%) ST-segment resolution. Early inversion of the T-waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude and width, R-wave amplitude and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes have not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST-segments and T-waves occur during reperfusion therapy and the days after. While changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes are less clear, and especially whether changes in the QRS-complex and T-wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and re-ischemia should be used for therapeutic decision-making in the clinical setting.
Similar content being viewed by others
References
Haider AW, Andreotti F, Hackett DR, Tousoulis D, Kluft C, Maseri A, Davies GJ. Early spontaneous intermittent myocardial reperfusion during acute myocardial infarction is associated with augmented thrombogenic activity and less myocardial damage. J Am Coll Cardiol 1995;26:662-7.
Klootwijk P, Cobbaert C, Fioretti P, Kint PP, Simoons ML. Noninvasive assessment of reperfusion and reocclusion after thrombolysis in acute myocardial infarction. Am J Cardiol 1993;72:75G-84G.
Krucoff MW, Croll MA, Pope JE, Granger CB, O'Connor CM, Sigmon KN, Wagner BL, Ryan JA, Lee KL, Kereiakes DJ, et al. Continuous 12-lead ST-segment recovery analysis in the TAMI 7 study. Performance of a noninvasive method for real-time detection of failed myocardial reperfusion. Circulation 1993;88:437-46.
Kwon K, Freedman SB, Wilcox I, Allman K, Madden A, Carter GS, Harris PJ. The unstable ST segment early after thrombolysis for acute infarction and its usefulness as a marker of recurrent coronary occlusion. Am J Cardiol 1991;67:109-15.
Clemmensen P, Ohman EM, Sevilla DC, Peck S, Wagner NB, Quigley PS, Grande P, Lee KL, Wagner GS. Changes in standard electrocardiographic ST-segment elevation predictive of successful reperfusion in acute myocardial infarction. Am J Cardiol 1990;66:1407-11.
Saran RK, Been M, Furniss SS, Hawkins T, Reid DS. Reduction in ST segment elevation after thrombolysis predicts either coronary reperfusion or preservation of left ventricular function. Br Heart J 1990;64:113-7.
Hogg KJ, Hornung RS, Howie CA, Hockings N, Dunn FG, Hillis WS. Electrocardiographic prediction of coronary artery patency after thrombolytic treatment in acute myocardial infarction: use of the ST segment as a non-invasive marker. Br Heart J 1988;60:275-80.
Nicolau JC, Lorga AM, Garzon SA, Jacob JL, Machado NC, Bellini AJ, Greco OT, Marques LA, Braile DM. Clinical and laboratory signs of reperfusion: are they reliable? Int J Cardiol 1989;25:313-20.
Barbash GI, Roth A, Hod H, Miller HI, Rath S, Har-Zahav Y, Modan M, Seligsohn U, Battler A, Kaplinsky E, et al. Rapid resolution of ST elevation and prediction of clinical outcome in patients undergoing thrombolysis with alteplase (recombinant tissue-type plasminogen activator): results of the Israeli Study of Early Intervention in Myocardial Infarction. Br Heart J 1990;64:241-7.
Mauri F, Maggioni AP, Franzosi MG, de Vita C, Santoro E, Santoro L, Giannuzzi P, Tognoni G. A simple electrocardiographic predictor of the outcome ECG in Acute Myocardial Infarction 11 of patients with acute myocardial infarction treated with a thrombolytic agent. A Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-Derived Analysis. J Am Coll Cardiol 1994;24:600-7.
Hohnloser SH, Zabel M, Kasper W, Meinertz T, Just H. Assessment of coronary artery patency after thrombolytic therapy: accurate prediction utilizing the combined analysis of three noninvasive markers. J Am Coll Cardiol 1991;18:44-9.
Shah PK, Cercek B, Lew AS, Ganz W. Angiographic validation of bedside markers of reperfusion. J Am Coll Cardiol 1993;21:55-61.
Kircher BJ, Topol EJ, O'Neill WW, Pitt B. Prediction of infarct coronary artery recanalization after intravenous thrombolytic therapy. Am J Cardiol 1987;59:513-5.
Richardson SG, Morton P, Murtagh JG, Scott ME, O'Keeffe DB. Relation of coronary arterial patency and left ventricular function to electrocardiographic changes after streptokinase treatment during acute myocardial infarction. Am J Cardiol 1988;61:961-5.
Krucoff MW, Croll MA, Pope JE, Pieper KS, Kanani PM, Granger CB, Veldkamp RF, Wagner BL, Sawchak ST, Califf RM. Continuously updated 12-lead ST-segment recovery analysis for myocardial infarct artery patency assessment and its correlation with multiple simultaneous early angiographic observations. Am J Cardiol 1993;71:145-51.
Krucoff MW, Wagner NB, Pope JE, Mortara DM, Jackson YR, Bottner RK, Wagner GS, Kent KM. The portable programmable microprocessor-driven realtime 12-lead electrocardiographic monitor: a preliminary report of a new device for the noninvasive detection of successful reperfusion or silent coronary reocclusion. Am J Cardiol 1990;65:143-8.
Dellborg M, Topol EJ, Swedberg K. Dynamic QRS complex and ST segment vectorcardiographic monitoring can identify vessel patency in patients with acute myocardial infarction treated with reperfusion therapy. Am Heart J 1991;122:943-8.
Dellborg M, Steg PG, Simoons M, Dietz R, Sen S, van den Brand M, Lotze U, Hauck S, van den Wieken R, Himbert D, et al. Vectorcardiographic monitoring to assess early vessel patency after reperfusion therapy for acute myocardial infarction. Eur Heart J 1995;16:21-9.
Klootwijk P, Langer A, Meij S, Green C, Veldkamp RF, Ross AM, Armstrong PW, Simoons ML. Non-invasive prediction of reperfusion and coronary artery patency by continuous ST segment monitoring in the GUSTO-I trial. Eur Heart J 1996;17:689-98.
Schroder R, Zeymer U, Wegscheider K, Neuhaus KL. Comparison of the predictive value of ST segment elevation resolution at 90 and 180 min after start of streptokinase in acute myocardial infarction. A substudy of the hirudin for improvement of thrombolysis (HIT)-4 study. Eur Heart J 1999;20:1563-71.
van't Hof AW, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation 1998;97:2302-6.
Matetzky S, Freimark D, Chouraqui P, Novikov I, Agranat O, Rabinowitz B, Kaplinsky E, Hod H. The distinction between coronary and myocardial reperfusion after thrombolytic therapy by clinical markers of reperfusion. J Am Coll Cardiol 1998;32:1326-30.
Santoro GM, Valenti R, Buonamici P, Bolognese L, Cerisano G, Moschi G, Trapani M, Antoniucci D, Fazzini PF. Relation between ST-segment changes and myocardial perfusion evaluated by myocardial contrast echocardiography in patients with acute myocardial infarction treated with direct angioplasty. Am J Cardiol 1998;82:932-7.
van't Hof AW, Liem A, de Boer MJ, Zijlstra F. Clinical value of 12-lead electrocardiogram after successful reperfusion therapy for acute myocardial infarction. Zwolle Myocardial infarction Study Group. Lancet 1997;350:615-9.
Carlsson J, Kamp U, Hartel D, Brockmeier J, Meierhenrich R, Miketic S, Walter S, van de Werf F, Tebbe U. Resolution of ST-segment elevation in acute myocardial infarction-early prognostic significance after thrombolytic therapy. Results from the COBALT trial. Herz 1999;24:440-7.
Claeys MJ, Bosmans J, Veenstra L, Jorens P, De Raedt H, Vrints CJ. Determinants and prognostic implications of persistent ST-segment elevation after primary angioplasty for acute myocardial infarction: importance of microvascular reperfusion injury on clinical outcome. Circulation 1999;99:1972-7.
Matetzky S, Novikov M, Gruberg L, Freimark D, Feinberg M, Elian D, Novikov I, Di Segni E, Agranat O, Har-Zahav Y, Rabinowitz B, Kaplinsky E, Hod H. The significance of persistent ST elevation versus early resolution of ST segment elevation after primary PTCA. J Am Coll Cardiol 1999;34:1932-8.
de Lemos JA, Antman EM, Gibson CM, McCabe CH, Giugliano RP, Murphy SA, Coulter SA, Anderson K, Scherer J, Frey MJ, Van Der Wieken R, Van De Werf F, Braunwald E. Abciximab improves both epicardial flow and myocardial reperfusion in ST-elevation myocardial infarction. Observations from the TIMI 14 trial. Circulation 2000;101:239-43.
Dovendans PA, Gorgels AP, van-der-Zee R, Partouns J, Bar FW, Wellens HJJ. Electrocardiographic diagnosis of reperfusion during thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1995;75:1206-1210.
Matetzky S, Barabash GI, Shahar A, Rabinovitz B, Rath S, Har-Zahav Y, Agranat O, Kaplinsky E, Hod H. Early T wave inversion after thrombolytic therapy predicts better coronary perfusion: clinical and angiographic study. J Am Coll Cardiol 1994;24:378-383.
Corbalan R, Prieto JC, Chavez E, Nazzal C, Cumsille F, Krucoff M. Bedside markers of coronary artery patency and short-term prognosis of patients with acute myocardial infarction and thrombolysis. Am Heart J 1999;138:533-9.
Herz I, Birnbaum Y, Zlotikamien B, Strasberg B, Sclarovsky S, Chetrit A, Olmer L, Barbash. GI. The prognostic implications of negative T waves in the leads with ST segment elevation on admission in acute myocardial infarction. Cardiology 2000;92:121-127.
Wong CK, French JK, Aylward PE, Frey MJ, Adgey AA, White HD. Usefulness of the presenting electrocardiogram in predicting successful reperfusion with streptokinase in acute myocardial infarction. Am J Cardiol 1999;83:164-8.
Adler Y, N. Zafrir, Ben-Gal T, Ben-Lulu O, Maynard C, Sclarovsky S, Balicer R, Mager A, Strasberg B, Solodky A, Wagner GS, Birnbaum Y. Relation between evolutionary ST segment and T-wave direction and electrocardiographic prediction of myocardial infarct size and left ventricular function among patients with anterior wall Q-wave acute myocardial infarction that received reperfusion therapy. Am J Cardiol 2000;85:927-933.
Tamura A, Nagase K, Mikuriya Y, Nasu M. Significance of spontaneous normalization of negative T waves in infarct-related leads during healing of anterior wall acute myocardial infarction. Am J Cardiol 1999;84:1341-4.
Agetsuma H, Hirai M, Hirayama H, Suzuki A, Takanaka C, Yabe S, Inagaki H, Takatsu F, Hayashi H, Saito H. Transient giant negative T wave in acute anterior myocardial infarction predicts R wave recovery and preservation of left ventricular function. Heart 1996;75:229-34.
Dellborg M, Riha M, Swedberg K. Dynamic QRS and ST-segment changes in myocardial infarction monitored by continuous on-line vectorcardiography. J Electrocardiol 1990;23:11-9.
Dellborg M, Riha M, Swedberg K. Dynamic QRScomplex and ST-segment monitoring in acute myocardial infarction during recombinant tissue-type plasminogen activator therapy. The TEAHAT Study Group. Am J Cardiol 1991;67:343-9.
Dellborg M, Steg PG, Simoons M, Dietz R, Sen S, van den Brand M, Lotze U, Hauck S, Juliard JM, Swedberg K. Increased rate of evolution of QRS changes in patients with acute myocardial infarction. Results from the Vermut Study. J Electrocardiol 1993; 26:244-8.
Timmis G. Electrocardiographic effects of reperfusion. Cardiol Clin 1987;5:427-445.
Goldberg S, Urban P, Greenspon A, Berger B, Walinsky P, Muza B, Kusiak V, Maroko PR. Limitation of infarct size with thrombolytic agents-electrocardiographic indexes. Circulation 1983;68(Suppl I):I-77-I-82.
Rechavia E, Blum A, Mager A, Birnbaum Y, Strasberg B, Sclarovsky S. Electrocardiographic Q-waves inconstancy during thrombolysis in acute anterior wall myocardial infarction. Cardiology 1992;80:392-398.
Raitt M, Maynard C, Wagner G, Cerqueira M, Selvester R, Weaver W. Appearance of abnormal Q waves early in the course of acute myocardial infarction: implications for efficacy of thrombolytic therapy. J Am Coll Cardiol 1995;25:1084-1088.
Raitt MH, Maynard C, Wagner GS, Cerqueira MD, Selvester RH, Weaver WD. Relation between symptom duration before thrombolytic therapy and final myocardial infarct size. Circulation 1996;93:48-53.
Bar FW, Vermeer F, de-Zwaan C, et al. Value of admission electrocardiogram in predicting outcome of thrombolytic therapy in acute myocardial infarction. A randomized trial conducted by The Netherlands Interuniversity Cardiology Institute. Am J Cardiol 1987;59:6-13.
Birnbaum Y, Chetrit A, Sclarovsky S, Zlotikamien B, Herz I, Olmer L, Barbash GI. Abnormal Q waves on the admission electrocardiogram of patients with first acute myocardial infarction: prognostic implications. Clin Cardiol 1997;20:477-81.
Birnbaum Y, Hale SL, Kloner RA. Changes in R wave amplitude: ECG differentiation between episodes of reocclusion and reperfusion associated with ST-segment elevation. J Electrocardiol 1997;30:211-6.
Birnbaum Y, Maynard C, Wolfe S, Mager A, Strasberg B, Rechavia E, Gates K, Wagner GS. Terminal QRS distortion on admission is better than ST-segment measurements in predicting final infarct size and assessing the Potential effect of thrombolytic therapy in anterior wall acute myocardial infarction. Am J Cardiol 1999;84:530-4.
Birnbaum Y, Herz I, Sclarovsky S, Zlotikamien B, Chetrit A, Olmer L, Barbash GI. Prognostic significance of the admission electrocardiogram in acute myocardial infarction. J Am Coll Cardiol 1996; 27:1128-32.
Birnbaum Y, Kloner RA, Sclarovsky S, Cannon CP, McCabe CH, Davis VG, Zaret BL, Wackers FJ, Braunwald E. Distortion of the terminal portion of the QRS on the admission electrocardiogram in acute myocardial infarction and correlation with infarct size and long-term prognosis (Thrombolysis in Myocardial Infarction 4 Trial). Am J Cardiol 1996;78:396-403.
Mager A, Sclarovsky S, Herz I, Zlotikamien B, Strasberg B, Birnbaum Y. QRS complex distortion predicts no reflow after emergency angioplasty in patients with anterior wall acute myocardial infarction. Coron Artery Dis 1998;9:199-205.
Selwyn AP, Ogunro E, Shillingford JP. Loss of electrically active myocardium during anterior infarction in man. Br Heart J 1977;39:1186-91.
von Essen R, Merx W, Doerr R, Effert S, Silny J, Rau G. QRS mapping in the evaluation of acute anterior myocardial infarction. Circulation 1980;62:266-76.
Kalbfleisch JM, Shadaksharappa KS, Conrad LL, Sarkar NK. Disappearance of the Q-deflection following myocardial infarction. Am Heart J 1968;76:193-8.
von Essen R, Schmidt W, Uebis R, Edelmann B, Effert S, Silny J, Rau G. Myocardial infarction and thrombolysis. Electrocardiographic short term and long term results using precordial mapping. Br Heart J 1985;54:6-10.
Kaplinsky E, Ogawa S, Michelson EL, Dreifus LS. Instantaneous and delayed ventricular arrhythmias after reperfusion of acutely ischemic myocardium: evidence for multiple mechanisms. Circulation 1981;63:333-40.
Penkoske PA, Sobel BE, Corr PB. Disparate electrophysiological alterations accompanying dysrhythmia due to coronary occlusion and reperfusion in the cat. Circulation 1978;58:1023-35.
Kerin NZ, Rubenfire M, Willens HJ, Rao P, Cascade PN. The mechanism of dysrhythmias in variant angina pectoris: occlusive versus reperfusion. Am Heart J 1983;106:1332-40.
Ganz W, Buchbinder N, Marcus H, Mondkar A, Maddahi J, Charuzi Y, O'Connor L, Shell W, Fishbein MC, Kass R, Miyamoto A, Swan HJ. Intracoronary thrombolysis in evolving myocardial infarction. Am Heart J 1981;101:4-13.
Markis JE, Malagold M, Parker JA, Silverman KJ, Barry WH, Als AV, Paulin S, Grossman W, Braunwald E. Myocardial salvage after intracoronary thrombolysis with streptokinase in acute myocardial infarction. N Engl J Med 1981;305:777-82.
Mathey DG, Kuck KH, Tilsner V, Krebber HJ, Bleifeld W. Non surgical coronary artery recanalization in acute transmural myocardial infarction. Circulation 1981;63:489-97.
Rentrop P, Blanke H, Karsch KR, Kaiser H, Kostering H, Leitz K. Selective intracoronary thrombolysis in acute myocardial infarction and unstable angina pectoris. Circulation 1981;63:307-17.
Goldberg S, Greenspon AJ, Urban PL, Muza B, Berger B, Walinsky P, Maroko PR. Reperfusion arrhythmia: a marker of restoration of antegrade flow during intracoronary thrombolysis for acute myocardial infarction. Am Heart J 1983;105:26-32.
Gore JM, Roberts R, Ball SP, Montero A, Goldberg RJ, Dalen JE. Peak creatine kinase as a measure of effectiveness of thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1987;59:1234-8.
Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B, Russell RO, Smith EE, 3rd, Weaver WD, Gibbons RJ, Alpert JS, Eagle KA, Gardner TJ, Garson A, Jr., Gregoratos G, Smith SC, Jr. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999;34:890-911.
Bossaert L, Conraads V, Pintens H. ST-segment analysis: a useful marker for reperfusion after thrombolysis with APSAC? The Belgian EMS Study Group. Eur Heart J 1991;12:357-362.
Dissmann R, Goerke M, von Ameln H, Rennhak U, Schroeder J, Linderer T, Schroder R. Detection of early reperfusion and prediction of left ventricular damage from the course of increased ST values in acute myocardial infarct with thrombolysis. Z Kardiol 1993;82:271-278.
Gressin V, Gorgels A, Louvard Y, Lardoux H, Bigelow R. ST-segment normalization time and ventricular arrhythmias as electrocardiographic markers of reperfusion during intravenous thrombolysis for acute myocardial infarction. Am J Cardiol 1993;71:1436-1439.
Fernandez AR, Sequeira RF, Chakko S, Correa LF, de Marchena EJ, Chahine RA, Franceour DA, Myerburg RJ. ST segment tracking for rapid determination of patency of the infarct-related artery in acute myocardial infarction. J Am Coll Cardiol 1995;26:675-683.
Buszman P, Szafranek A, Kalarus Z, Gasior M. Use of changes in ST segment elevation for prediction of infarct artery recanalization in acute myocardial infarction. Eur Heart J 1995;16:1207-1214.
Krucoff MW, Green CE, Satler LF, Miller FC, Pallas RS, Kent KM, Negro AD, Pearle DL, Fletcher RD, Rackley CE. Noninvasive detection of coronary artery patency using continuous ST-segment monitoring. Am J Cardiol 1986;57:916-922.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Vaturi, M., Birnbaum, Y. The Use of the Electrocardiogram to Identify Epicardial Coronary and Tissue Reperfusion in Acute Myocardial Infarction. J Thromb Thrombolysis 10, 5–14 (2000). https://doi.org/10.1023/A:1018794918584
Issue Date:
DOI: https://doi.org/10.1023/A:1018794918584