Electrocardiogram in the diagnosis of myocardial ischemia and infarction
- Ary L Goldberger, MD
Ary L Goldberger, MD
- Section Editor — Electrocardiography
- Professor of Medicine
- Harvard Medical School
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
- Section Editors
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis , Netherlands
- David M Mirvis, MD
David M Mirvis, MD
- Section Editor — Electrocardiography
- Professor of Medicine
- University of Tennessee College of Medicine
The electrocardiogram (ECG) is an important diagnostic test for patients with possible or established myocardial ischemia or infarction. Abnormalities are manifest in the ST-segment, T wave, and QRS complex. However, the ECG may be normal or nonspecific in these patients.
In addition, findings thought typical of acute myocardial infarction (MI) may occur in other conditions, such as myocarditis. (See "Clinical manifestations and diagnosis of myocarditis in adults".)
The use of the ECG in patients with suspected or proven myocardial ischemia or MI will be reviewed here. Other relevant topics include:
- Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012; 126:2020.
- Mirvis D, Goldberger AL. Electrocardiography. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th ed, Mann DL. (Ed), Elsevier/Saunders, Philadelphia 2014.
- Moon JC, De Arenaza DP, Elkington AG, et al. The pathologic basis of Q-wave and non-Q-wave myocardial infarction: a cardiovascular magnetic resonance study. J Am Coll Cardiol 2004; 44:554.
- Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28:2525.
- Zeymer U, Schröder R, Tebbe U, et al. Non-invasive detection of early infarct vessel patency by resolution of ST-segment elevation in patients with thrombolysis for acute myocardial infarction; results of the angiographic substudy of the Hirudin for Improvement of Thrombolysis (HIT)-4 trial. Eur Heart J 2001; 22:769.
- Schröder K, Wegscheider K, Zeymer U, et al. Extent of ST-segment deviation in a single electrocardiogram lead 90 min after thrombolysis as a predictor of medium-term mortality in acute myocardial infarction. Lancet 2001; 358:1479.
- Zeymer U, Schröder K, Wegscheider K, et al. ST resolution in a single electrocardiographic lead: a simple and accurate predictor of cardiac mortality in patients with fibrinolytic therapy for acute ST-elevation myocardial infarction. Am Heart J 2005; 149:91.
- Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med 2002; 113:37.
- Shalev Y, Fogelman R, Oettinger M, Caspi A. Does the electrocardiographic pattern of "anteroseptal" myocardial infarction correlate with the anatomic location of myocardial injury? Am J Cardiol 1995; 75:763.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Casas RE, Marriott HJ, Glancy DL. Value of leads V7-V9 in diagnosing posterior wall acute myocardial infarction and other causes of tall R waves in V1-V2. Am J Cardiol 1997; 80:508.
- Kulkarni AU, Brown R, Ayoubi M, Banka VS. Clinical use of posterior electrocardiographic leads: a prospective electrocardiographic analysis during coronary occlusion. Am Heart J 1996; 131:736.
- Kontos MC, Desai PV, Jesse RL, Ornato JP. Usefulness of the admission electrocardiogram for identifying the infarct-related artery in inferior wall acute myocardial infarction. Am J Cardiol 1997; 79:182.
- Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003; 348:933.
- Zimetbaum PJ, Krishnan S, Gold A, et al. Usefulness of ST-segment elevation in lead III exceeding that of lead II for identifying the location of the totally occluded coronary artery in inferior wall myocardial infarction. Am J Cardiol 1998; 81:918.
- Verouden NJ, Barwari K, Koch KT, et al. Distinguishing the right coronary artery from the left circumflex coronary artery as the infarct-related artery in patients undergoing primary percutaneous coronary intervention for acute inferior myocardial infarction. Europace 2009; 11:1517.
- Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211.
- Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981.
- Herz I, Assali AR, Adler Y, et al. New electrocardiographic criteria for predicting either the right or left circumflex artery as the culprit coronary artery in inferior wall acute myocardial infarction. Am J Cardiol 1997; 80:1343.
- Engelen DJ, Gorgels AP, Cheriex EC, et al. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. J Am Coll Cardiol 1999; 34:389.
- Arbane M, Goy JJ. Prediction of the site of total occlusion in the left anterior descending coronary artery using admission electrocardiogram in anterior wall acute myocardial infarction. Am J Cardiol 2000; 85:487.
- Haines DE, Raabe DS, Gundel WD, Wackers FJ. Anatomic and prognostic significance of new T-wave inversion in unstable angina. Am J Cardiol 1983; 52:14.
- de Zwaan C, Bär FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989; 117:657.
- Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20:638.
- Shvilkin A, Ho KK, Rosen MR, Josephson ME. T-vector direction differentiates postpacing from ischemic T-wave inversion in precordial leads. Circulation 2005; 111:969.
- Sasaki K, Yotsukura M, Sakata K, et al. Relation of ST-segment changes in inferior leads during anterior wall acute myocardial infarction to length and occlusion site of the left anterior descending coronary artery. Am J Cardiol 2001; 87:1340.
- Wagner GS, Macfarlane P, Wellens H, et al. 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.
- Yamaji H, Iwasaki K, Kusachi S, et al. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1). J Am Coll Cardiol 2001; 38:1348.
- Assali AR, Sclarovsky S, Herz I, et al. Comparison of patients with inferior wall acute myocardial infarction with versus without ST-segment elevation in leads V5 and V6. Am J Cardiol 1998; 81:81.
- Mills JS, Mahaffey KW, Lokhnygina Y, et al. Prediction of enzymatic infarct size in ST-segment elevation myocardial infarction. Coron Artery Dis 2012; 23:118.
- Maeda S, Imai T, Kuboki K, et al. Pathologic implications of restored positive T waves and persistent negative T waves after Q wave myocardial infarction. J Am Coll Cardiol 1996; 28:1514.
- Bosimini E, Giannuzzi P, Temporelli PL, et al. Electrocardiographic evolutionary changes and left ventricular remodeling after acute myocardial infarction: results of the GISSI-3 Echo substudy. J Am Coll Cardiol 2000; 35:127.
- Nagase K, Tamura A, Mikuriya Y, Nasu M. Significance of Q-wave regression after anterior wall acute myocardial infarction. Eur Heart J 1998; 19:742.
- Parodi O, Uthurralt N, Severi S, et al. Transient reduction of regional myocardial perfusion during angina at rest with ST-segment depression or normalization of negative T waves. Circulation 1981; 63:1238.
- Antman, EM, Anbe, DT, Armstrong, PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on June 07, 2009).
- Pirwitz MJ, Lange RA, Landau C, et al. Utility of the 12-lead electrocardiogram in identifying underlying coronary artery disease in patients with depressed left ventricular systolic function. Am J Cardiol 1996; 77:1289.
- Ananthasubramaniam K, Chow BJ, Ruddy TD, et al. Does electrocardiographic Q wave burden predict the extent of scarring or hibernating myocardium as quantified by positron emission tomography? Can J Cardiol 2005; 21:51.
- Al-Mohammad A, Norton MY, Mahy IR, et al. Can the surface electrocardiogram be used to predict myocardial viability? Heart 1999; 82:663.
- Davidoff R, Goldman AP, Diamond TH, et al. The natural history of the Q wave in inferoposterior myocardial infarction. S Afr Med J 1982; 61:611.
- Richter A, Herlitz J, Hjalmarson A. QRS complex recovery during one year after acute myocardial infarction. Clin Cardiol 1987; 10:16.
- Voon WC, Chen YW, Hsu CC, et al. Q-wave regression after acute myocardial infarction assessed by Tl-201 myocardial perfusion SPECT. J Nucl Cardiol 2004; 11:165.
- Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996; 334:481.
- Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128.
- Angelini A, Calzolari V, Calabrese F, et al. Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis. Heart 2000; 84:245.
- Sarda L, Colin P, Boccara F, et al. Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms. J Am Coll Cardiol 2001; 37:786.
- Shvilkin A, Bojovic B, Vajdic B, et al. Vectorcardiographic determinants of cardiac memory during normal ventricular activation and continuous ventricular pacing. Heart Rhythm 2009; 6:943.
- Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36:959.
- ECG CRITERIA FOR MYOCARDIAL ISCHEMIA/INFARCT
- SIGNIFICANCE OF Q WAVES
- LOCATION OF ISCHEMIA OR INFARCTION
- Anterior, lateral, and apical MI
- Inferior and right ventricular MI
- Posterior wall MI
- Multiple regions
- IDENTIFICATION OF THE INFARCT-RELATED ARTERY
- Inferior MI on the ECG
- Anterior MI on the ECG
- Abnormal findings in lead aVR
- EXTENT OF THE INFARCT
- EVOLUTION OF THE ECG
- LESS COMMON ECG MANIFESTATIONS OF ISCHEMIA
- LAD-T wave inversion pattern
- Pseudonormalization of T waves
- UNEXPECTED ABSENCE OF DIAGNOSTIC FINDINGS
- Absence of Q waves
- Left bundle branch block
- DIFFERENTIAL DIAGNOSIS OF ECG ABNORMALITES
- Early repolarization
- ST-segment elevation or depression
- Abnormal T waves
- Q waves
- INFORMATION FOR PATIENTS