Electrocardiographic Diagnosis of
Electrocardiographic Diagnosis of
Electrocardiographic Diagnosis of
com
Electrocardiographic Diagnosis of
Life-Threatening STEMI Equivalents
Babken Asatryan Md Phd & Lukas
Vaisnora Md & Negar Manavifar Md
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JACC: CASE REPORTS VOL. 1, NO. 4, 2019
EDITORIAL COMMENT
Electrocardiographic Diagnosis of
Life-Threatening STEMI Equivalents
When Every Minute Counts*
F I G U R E 1 ECG Patterns Hinting for Potentially High-Risk Critical Coronary Artery Stenosis or Occlusion
(A) Conventional STEMI. (B to K) Potential STEMI equivalents. (I) Modification of the Sgarbossa criterion 3 by Smith et al. (7) improved the
test performance. According to the Smith-modified Sgarbossa rule, in the setting of a left bundle branch block or ventricular paced rhythm, a
cutoff value of $3 points with the 3 criteria (G to I) has 91% sensitivity and 90% specificity for STEMI. ECG ¼ electrocardiography; LVH ¼ left
ventricular hypertrophy; STEMI ¼ ST-segment elevation myocardial infarction.
668 Asatryan et al. JACC: CASE REPORTS, VOL. 1, NO. 4, 2019
treatment. Thus, due to this under-recognition and as not all ST-segment elevation patterns represent a
lack of timely management, they often experience a “true STEMI” (e.g., previous myocardial infarction,
worse clinical outcome and poor prognosis (9,10). left ventricular hypertrophy, Takotsubo cardiomy-
Although clinicians caring for patients presenting opathy), not all acute coronary occlusions needing
with chest pain rely upon ECG findings as the essen- primary PCI manifest the typical ST-segment eleva-
tial noninvasive test for identifying those who might tion. Fine-tuning our recognition of this wide range of
benefit from primary PCI, their awareness of these ECG patterns, hinting for potentially life-threatening
high-risk ECG patterns are pivotal in early recognition coronary stenosis or occlusion, may allow faster
to provide adequate treatment. However, currently, diagnosis, resulting in proper treatment and
the STEMI equivalents are neither adequately improved patient outcomes.
covered in teaching curricula nor properly addressed
by the current guidelines (11).
The authors certainly acknowledge that the ECG by ADDRESS FOR CORRESPONDENCE: Dr. Babken
itself is often insufficient to diagnose acute myocar- Asatryan, Department of Cardiology, Inselspital, Bern
dial ischemia or infarction and that all ECG findings University Hospital, Freiburgstrasse 10, 3010 Bern,
should be interpreted in the setting of clinical pre- Switzerland. E-mail: babken.asatryan@insel.ch.
sentation (12). However, it must be emphasized that, Twitter: @BabkenAsatryan.
REFERENCES
1. Benjamin EJ, Muntner P, Alonso A, et al. Heart myocardial infarction. Am Heart J 1982;103: TIMI 38 (Trial to Assess Improvement in Thera-
disease and stroke statistics-2019 update: a report 730–6. peutic Outcomes by Optimizing Platelet Inhibition
from the American Heart Association. Circulation With Prasugrel-Thrombolysis In Myocardial
6. Sgarbossa EB, Pinski SL, Barbagelata A, et al.
2019;139:e56–528. Infarction 38) substudy. J Am Coll Cardiol Intv
Electrocardiographic diagnosis of evolving acute
2010;3:806–11.
2. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 myocardial infarction in the presence of left
ACCF/AHA guideline for the management of bundle-branch block. GUSTO-1 (Global Utilization 10. Daly M, Finlay D, Guldenring D, et al. Detec-
ST-elevation myocardial infarction: executive of Streptokinase and Tissue Plasminogen Activator tion of acute coronary occlusion in patients with
summary: a report of the American College of for Occluded Coronary Arteries) investigators. acute coronary syndromes presenting with iso-
Cardiology Foundation/American Heart Associa- N Engl J Med 1996;334:481–7. lated ST-segment depression. Eur Heart J Acute
tion Task Force on Practice Guidelines. J Am Coll Cardiovasc Care 2012;1:128–35.
7. Smith SW, Dodd KW, Henry TD, Dvorak DM,
Cardiol 2013;61:485–510.
Pearce LA. Diagnosis of ST-elevation myocardial 11. Rokos IC, French WJ, Mattu A, et al. Appro-
3. Plane AF, Valette X, Blanchart K, Ardouin P, infarction in the presence of left bundle branch priate cardiac cath lab activation: optimizing
Beygui F, Roule V. Occluded or not? A subtle block with the ST-elevation to S-wave ratio in a electrocardiogram interpretation and clinical
Electrocardiographic answer. J Am Coll Cardiol modified Sgarbossa rule. Ann Emerg Med 2012; decision-making for acute ST-elevation myocardial
Case Rep 2019;1:663–5. 60:766–76. infarction. Am Heart J 2010;160:995–1003.
4. de Winter RJ, Verouden NJ, Wellens HJ, 8. Sgarbossa EB, Pinski SL, Gates KB, Wagner GS. 12. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth
Wilde AA. Interventional cardiology group of Early electrocardiographic diagnosis of acute universal definition of myocardial infarction
the Academic Medical C. A new ECG sign of myocardial infarction in the presence of ventricu- (2018). J Am Coll Cardiol 2018;72:2231–64.
proximal LAD occlusion. N Engl J Med 2008; lar paced rhythm. GUSTO-I investigators. Am J
359:2071–3. Cardiol 1996;77:423–4.
5. de Zwaan C, Bar FW, Wellens HJ. Characteristic 9. Pride YB, Tung P, Mohanavelu S, et al. Angio- KEY WORDS acute coronary syndrome,
electrocardiographic pattern indicating a critical graphic and clinical outcomes among patients with electrocardiogram, myocardial infarction,
stenosis high in left anterior descending coronary acute coronary syndromes presenting with iso- myocardial ischemia, percutaneous coronary
artery in patients admitted because of impending lated anterior ST-segment depression: a TRITON- intervention
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swelled the heart of the wealthiest peer in the land. In a
savage spirit of discontent, Mytton cut a thick hunch of
bread from the loaf which Amy had spread ready for him,
and a slice from the piece of stale cheese. There was no
grace said before dinner by Mytton, indeed thanksgiving
would have keen a mockery from one who looked upon
himself as wronged, because he had been born in a station
as lowly as that which the Lord of Heaven, when He came
to visit earth, had chosen for His own.
And May ran out to look at it, either because any kind of
conveyance was a rarity in that place, or because the
presence of one stern irritable man made the cottage
uncomfortable.
"Can you tell me, little girl, if any one of the name of
Mytton lives in this neighbourhood?" said he, addressing
himself to May, who stood with her chubby finger in her
mouth, staring at instead of answering the stranger.
"That be my father," said Joe, grinning with wonder that
any one coming in a yellow chariot should wish to see him.
"Is any one wanting me?" asked Silas, rising and going
forth from his cottage, for in that quiet spot every word
spoken had been heard in the dwelling.
CHAPTER IV.
Earthly Hope.
THE sun's red rim had just sunk over the common;
evening would soon close in, nothing had been found, save
that one little scrap, which could possibly help even a keen
lawyer in finding a clue. The strangers rose to depart, sorry
to have had their trouble for nothing; the boys were
quaking at thoughts of what would follow after the
gentlemen had left; for a thunder cloud of gloom had
gathered on the face of their father, and the children could
read that face too well to expect to escape a storm.
May was standing close by Amy's chair, when, after a
severe fit of coughing, her sister bent down towards her and
whispered, "May, I have just thought of something; is not
my pillow stuffed with paper?"
"I will try not to bring you into trouble; but I think that
we ought to tell father," said Amy.
"I beg your pardon, genl'men, but not one bit of paper
shall go out of this cottage!" cried Mytton, to whom it
seemed as if the fortunes of himself and his family had all
been sewn up in that pillow. "Search here till doomsday, if
you like it, but I'll not have a scrap of that there heap taken
out of my sight."
CHAPTER V.
Heavenly Hope.
"Oh! Amy," sighed poor May, "I wish—I wish we'd never
heard of that Mytton estate, that those men in black coats
had never come near our cottage, or found these scraps in
your pillow! Looking for that inheritance, as father calls it,
has been plague and worry to us ever since, and if he don't
get it at last, 'twill drive him right out of his wits!"
"I don't know—I hope so; but one can't be quite sure
with anything earthly," said Amy.
May looked surprised at the doubt. "I'm sure that it will,
if father only gets the inheritance," she cried; "but 'tis so
very long a-coming, I'm afraid it will never be his."
"I believe that I shall enter into mine first," said Amy
very faintly, and her lips formed the words to which she had
hardly strength to give breath, "far better—far better—
undefiled and that fadeth not away!"
A SAINT
OR,
A CHRISTIAN IN CHARACTER.
CHAPTER I.
The Patient Restored.
"I'M glad that you'll have your husband back again to-
day, Mrs. Laver, and I hope that such a long time spent in
the hospital will have set him up for good," said Mrs.
Batten, the fishmonger's stout good-humoured wife, as she
took up the little parcel of snuff which she had just been
purchasing at Mrs. Laver's counter.
"I'm sure," she said, "that if any one knew the moiling
and toiling I've had, what with looking after the shop, and
keeping things tidy and respectable like, minding the child,
and—ah! You little brat!" exclaimed Mrs. Laver, interrupting
her complaint, to make a sudden dash at her little girl, a
child of about two years of age, who, having been placed by
her mother on the counter, had stretched out her hand to
the jar of snuff left upon it.
"If you go on whining like that, I'll give you to the black
man, I will, instead of taking you with me to Greenwich!"
The sweet little face of the child was again very pale,
with its habitual expression of patience and thought. Annie
did not look like a light-hearted child. One might have
fancied, as she sat with her large blue eyes fixed on the jars
and pipes and papers in the window, that a good deal was
passing through her infant mind, and that not of a cheerful
description.
Though Mrs. Laver was fond of her only child, there was
not much tenderness in her manner towards her. Mrs. Laver
would have been indignant had any one charged her with
cruelty, above all towards her daughter; but the harsh
word, the hasty slap, the angry threat with which Annie was
familiar, had much the same effect on the poor little girl
that a blight has on the tender green leaves of the spring.
Annie loved her mother, but scarcely as much as she feared
her. The little one wanted more of the sunshine of smiles.
She had pined wearily for her father, and the two first
nights after Martin Laver had gone to the hospital, his child
had cried herself to sleep, "'Cause Daddy's away, and I can't
have his bye-bye kiss," as she sobbed.
CHAPTER II.
Decision.
"Ah! Martin, is that you? I did not look for your coming
till the evening," cried Mrs. Laver, turning round, and then
giving her husband a welcome that was not unkindly,
though she shewed none of the rapturous delight of the
child, who clung to her father's neck, and buried her face on
his shoulder.