Electrocardiogram in the prognosis of myocardial infarction or unstable angina
- Ary L Goldberger, MD
Ary L Goldberger, MD
- Section Editor — Electrocardiography
- Professor of Medicine
- Harvard Medical School
- Section Editor
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
The electrocardiogram (ECG) is a mainstay in the diagnosis of acute and chronic syndromes due to coronary artery disease. The findings depend upon several key factors including the duration (hyperacute/acute versus evolving/chronic), extent (Q wave versus non-Q wave), and localization (anterior versus inferior-posterior and the size of the ischemic or infarcted region) of ischemia or infarction, as well as the presence of other underlying abnormalities . The ECG also provides information on prognosis.
The use of the ECG for prognosis in myocardial infarction or unstable angina will be reviewed here. Use of the ECG for diagnosis is discussed separately. (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction".)
In addition to the findings on the ECG, a number of other parameters are of prognostic importance in patients with myocardial infarction or unstable angina. Among the poor prognostic factors are cardiogenic shock, a reduced left ventricular ejection fraction, and certain types of arrhythmias.
Clinicians need to be aware that the ECG findings due to atherosclerotic-related ischemia, including ST-T deviations and even Q waves, may be exactly simulated by those associated with acute “stress” (takotsubo) cardiomyopathy, as discussed separately. (See "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy".)
GENERAL ISSUES OF RISK STRATIFICATION
The process of risk stratification in a patient who has had an acute myocardial infarction (MI) has several components:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Mirvis D, Goldberger AL. Electrocardiography. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th ed, Mann DL. (Ed), Elsevier/Saunders, Philadelphia 2014.
- Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Circulation 1993; 87:38.
- Kerensky RA, Wade M, Deedwania P, et al. Revisiting the culprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol 2002; 39:1456.
- Wong GC, Morrow DA, Murphy S, et al. Elevations in troponin T and I are associated with abnormal tissue level perfusion: a TACTICS-TIMI 18 substudy. Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction. Circulation 2002; 106:202.
- Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. Circulation 1998; 98:1860.
- Hathaway WR, Peterson ED, Wagner GS, et al. Prognostic significance of the initial electrocardiogram in patients with acute myocardial infarction. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries. JAMA 1998; 279:387.
- Mauri F, Franzosi MG, Maggioni AP, et al. Clinical value of 12-lead electrocardiography to predict the long-term prognosis of GISSI-1 patients. J Am Coll Cardiol 2002; 39:1594.
- Stone PH, Raabe DS, Jaffe AS, et al. Prognostic significance of location and type of myocardial infarction: independent adverse outcome associated with anterior location. J Am Coll Cardiol 1988; 11:453.
- Haim M, Hod H, Reisin L, et al. Comparison of short- and long-term prognosis in patients with anterior wall versus inferior or lateral wall non-Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group. Am J Cardiol 1997; 79:717.
- Becker RC, Burns M, Gore JM, et al. Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants. Am Heart J 1998; 135:786.
- Califf RM, Pieper KS, Lee KL, et al. Prediction of 1-year survival after thrombolysis for acute myocardial infarction in the global utilization of streptokinase and TPA for occluded coronary arteries trial. Circulation 2000; 101:2231.
- Fresco C, Carinci F, Maggioni AP, et al. Very early assessment of risk for in-hospital death among 11,483 patients with acute myocardial infarction. GISSI investigators. Am Heart J 1999; 138:1058.
- Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000; 102:2031.
- Morrow DA, Antman EM, Parsons L, et al. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA 2001; 286:1356.
- Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835.
- Peterson ED, Hathaway WR, Zabel KM, et al. Prognostic significance of precordial ST segment depression during inferior myocardial infarction in the thrombolytic era: results in 16,521 patients. J Am Coll Cardiol 1996; 28:305.
- Birnbaum Y, Wagner GS, Barbash GI, et al. Correlation of angiographic findings and right (V1 to V3) versus left (V4 to V6) precordial ST-segment depression in inferior wall acute myocardial infarction. Am J Cardiol 1999; 83:143.
- Evans MA, Clements IP, Christian TF, Gibbons RJ. Association between anterior ST depression and increased myocardial salvage following reperfusion therapy in patients with inferior myocardial infarction. Am J Med 1998; 104:5.
- Birnbaum Y, Kloner RA, Sclarovsky S, et al. 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.
- Huey BL, Gheorghiade M, Crampton RS, et al. Acute non-Q wave myocardial infarction associated with early ST segment elevation: evidence for spontaneous coronary reperfusion and implications for thrombolytic trials. J Am Coll Cardiol 1987; 9:18.
- Armstrong PW, Fu Y, Westerhout CM, et al. Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2009; 53:1503.
- Barbagelata A, Califf RM, Sgarbossa EB, et al. Thrombolysis and Q wave versus non-Q wave first acute myocardial infarction: a GUSTO-I substudy. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries Investigators. J Am Coll Cardiol 1997; 29:770.
- Goodman SG, Langer A, Ross AM, et al. Non-Q-wave versus Q-wave myocardial infarction after thrombolytic therapy: angiographic and prognostic insights from the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries-I angiographic substudy. GUSTO-I Angiographic Investigators. Circulation 1998; 97:444.
- Lockwood E, Fu Y, Wong B, et al. Does 24-hour ST-segment resolution postfibrinolysis add prognostic value to a Q wave? An ASSENT 2 electrocardiographic substudy. Am Heart J 2003; 146:640.
- Andrews J, French JK, Manda SO, White HD. New Q waves on the presenting electrocardiogram independently predict increased cardiac mortality following a first ST-elevation myocardial infarction. Eur Heart J 2000; 21:647.
- Askenazi J, Parisi AF, Cohn PF, et al. Value of the QRS complex in assessing left ventricular ejection fraction. Am J Cardiol 1978; 41:494.
- Palmeri ST, Harrison DG, Cobb FR, et al. A QRS scoring system for assessing left ventricular function after myocardial infarction. N Engl J Med 1982; 306:4.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 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:e362.
- de Lemos JA, Braunwald E. ST segment resolution as a tool for assessing the efficacy of reperfusion therapy. J Am Coll Cardiol 2001; 38:1283.
- Angeja BG, Gunda M, Murphy SA, et al. TIMI myocardial perfusion grade and ST segment resolution: association with infarct size as assessed by single photon emission computed tomography imaging. Circulation 2002; 105:282.
- 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.
- Shah A, Wagner GS, Califf RM, et al. Comparative prognostic significance of simultaneous versus independent resolution of ST segment depression relative to ST segment elevation during acute myocardial infarction. J Am Coll Cardiol 1997; 30:1478.
- Assali A, Sclarovsky S, Herz I, et al. Persistent ST segment depression in precordial leads V5-V6 after Q-wave anterior wall myocardial infarction is associated with restrictive physiology of the left ventricle. J Am Coll Cardiol 2000; 35:352.
- 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.
- Berger CJ, Murabito JM, Evans JC, et al. Prognosis after first myocardial infarction. Comparison of Q-wave and non-Q-wave myocardial infarction in the Framingham Heart Study. JAMA 1992; 268:1545.
- Furman MI, Dauerman HL, Goldberg RJ, et al. Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective. J Am Coll Cardiol 2001; 37:1571.
- Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999; 281:707.
- Cannon CP, McCabe CH, Stone PH, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol 1997; 30:133.
- Kaul P, Fu Y, Chang WC, et al. Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb. PARAGON-A and GUSTO IIb Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute Global Organization Network. J Am Coll Cardiol 2001; 38:64.
- Damman P, Holmvang L, Tijssen JG, et al. Usefulness of the admission electrocardiogram to predict long-term outcomes after non-ST-elevation acute coronary syndrome (from the FRISC II, ICTUS, and RITA-3 [FIR] Trials). Am J Cardiol 2012; 109:6.
- Savonitto S, Cohen MG, Politi A, et al. Extent of ST-segment depression and cardiac events in non-ST-segment elevation acute coronary syndromes. Eur Heart J 2005; 26:2106.
- Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344:1879.
- Diderholm E, Andrén B, Frostfeldt G, et al. ST depression in ECG at entry indicates severe coronary lesions and large benefits of an early invasive treatment strategy in unstable coronary artery disease; the FRISC II ECG substudy. The Fast Revascularisation during InStability in Coronary artery disease. Eur Heart J 2002; 23:41.
- Alexander JH, Harrington RA, Bhapkar M, et al. Prognostic importance of new small Q waves following non-ST-elevation acute coronary syndromes. Am J Med 2003; 115:613.
- Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179.
- Schechtman KB, Capone RJ, Kleiger RE, et al. Risk stratification of patients with non-Q wave myocardial infarction. The critical role of ST segment depression. The Diltiazem Reinfarction Study Research Group. Circulation 1989; 80:1148.
- Collinson J, Bakhai A, Taneja A, et al. Admission ECG predicts long-term outcome in acute coronary syndromes without ST elevation. QJM 2006; 99:601.
- Holmvang L, Lüscher MS, Clemmensen P, et al. Very early risk stratification using combined ECG and biochemical assessment in patients with unstable coronary artery disease (A thrombin inhibition in myocardial ischemia [TRIM] substudy). The TRIM Study Group. Circulation 1998; 98:2004.
- Barrabés JA, Figueras J, Moure C, et al. Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation. J Am Coll Cardiol 2000; 35:1813.
- Holmvang L, Clemmensen P, Lindahl B, et al. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. J Am Coll Cardiol 2003; 41:905.
- Haim M, Hod H, Kaplinsky E, et al. Frequency and prognostic significance of high-degree atrioventricular block in patients with a first non-Q-wave acute myocardial infarction. The SPRINT Study Group. Second Prevention Reinfarction Israeli Nifedipine Trial. Am J Cardiol 1997; 79:674.
- Gang UJ, Hvelplund A, Pedersen S, et al. High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the era of primary percutaneous coronary intervention. Europace 2012; 14:1639.
- Harikrishnan P, Gupta T, Palaniswamy C, et al. Complete heart block complicating ST-Segment elevation myocardial infarction: temporal trends and association with in-hospital outcomes. JACC Clin Electrophysiol 2015; 1:529.
- GENERAL ISSUES OF RISK STRATIFICATION
- STEMI VERSUS NSTEMI AND UNSTABLE ANGINA
- ECG FOR PROGNOSIS IN STEMI
- Extent of myocardial injury
- - Anterior MI
- - Inferior MI
- - QRS morphology
- Presence or absence of new Q waves
- R waves
- Resolution of ST and T wave changes
- - ST segment elevation
- - ST segment depression
- - T wave inversion
- Conduction abnormalities
- ECG FOR PROGNOSIS IN UA AND NSTEMI
- ST segment depression
- T wave inversion
- Extent of myocardial ischemia
- AV block
- New Q waves