Wall motion abnormalities and electrocardiographic changes in acute transmural myocardial infarction: Implications of reciprocal ST segment depression

doi:10.1016/0002-8703(83)90644-0

American Heart Journal

Volume 106, Issue 5, Part 1, November 1983, Pages 1003-1009

https://doi.org/10.1016/0002-8703(83)90644-0 Get rights and content

Abstract

Left ventricular ejection fraction and regional wall motion were assessed by multigated equilibrium radionuclide ventriculography within 24 hours of onset of first acute transmural myocardial infarction (MI) in 32 patients. Abnormal left ventricular wall motion was noted in all 16 patients with anterior infarction and in 14 of 16 (87.5%) patients with inferior infarction. Regional wall motion abnormalities frequently included areas adjacent to and remote from those predicted by the ECG location of ST elevation and pathologic Q waves. Such remote wall motion abnormalities were associated with reciprocal ST segment depression in 17 of 18 (94%) patients, and conversely reciprocal ST segment depressions were associated with remote wall motion abnormalities in 17 of 24 (71%) patients. The left ventricular ejection fraction was lower in patients with a reciprocal ST segment depression compared to those without (anterior MI 0.29 ± 0.07 vs 0.43 ± 0.08, p < 0.01; inferior MI 0.45 ± 0.11 vs 0.63 ± 0.06, p < 0.001). In addition, the peak MB-CK levels were higher in patients with compared to those without reciprocal ST segment depression (anterior MI 268 ± 183 vs 102 ± 60, p < 0.05; inferior MI 186 ± 120 vs 67 ± 20, p < 0.05). Thirteen of 18 (72%) patients with reciprocal ST segment depression compared to 4 of 13 (31%) patients without reciprocal ST segment depression had a complicated clinical course during their hospital stay. These observation suggest that global left ventricular dysfunction in first acute transmural MI is greater when reciprocal ST segment depression is present on the 12-lead ECG. Such reciprocal changes are frequently associated with enzymatic evidence of larger infarction, regional left ventricular dystunction extending to segments remote from the ECG predicted site of transmural infarction, and an unfavorable clinical course.

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Cited by (40)

Clinical Significance of Reciprocal ST-segment Changes in Patients With STEMI: A Cardiac Magnetic Resonance Imaging Study
2019, Revista Espanola de Cardiologia
Se trató de determinar la asociación de los cambios recíprocos en el segmento ST con el daño miocardio evaluado mediante imagen con resonancia magnética cardiaca (RMC) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) que recibieron intervención coronaria percutánea (ICP).
Se realizó estudio de imagen con RMC a 244 pacientes tratados con ICP primaria durante el primer IAMCEST. El estudio con RMC se realizó de media 3 días después de la ICP primaria. Se analizó el primer electrocardiograma y los pacientes se estratificaron de acuerdo a la presencia de cambios recíprocos. El objetivo primario fue el tamaño del infarto medido por RMC y los secundarios el área en riesgo y el índice de miocardio rescatado.
Los pacientes con cambios recíprocos (133 pacientes, 54,5%) tuvieron una menor incidencia de infarto de miocardio anterior (27,8 frente al 71,2%; p < 0,001) y un tiempo más corto desde el inicio de los síntomas hasta la restauración del flujo coronario (221,5 ± 169,8 frente a 289,7 ± 337,3 min; p = 0,042). Usando un modelo de regresión lineal múltiple, se encontró que los pacientes con cambios recíprocos tuvieron una mayor área en riesgo (p = 0,002) y un mayor índice de miocardio rescatado (p = 0,04) comparado con los pacientes sin cambios recíprocos. Consecuentemente, el tamaño del infarto de miocardio no fue significantemente diferente entre los 2 grupos (p = 0,14). La tasa de eventos adversos cardiovasculares mayores, incluyendo muerte por todas las causas, infarto de miocardio, y nueva revascularización coronaria, fue similar entre los 2 grupos después de 2 años de seguimiento (p = 0,92).
Los cambios recíprocos del segmento ST se asociaron a una mayor extensión de miocardio isquémico en riesgo y a un mayor índice de miocardio rescatado, pero no a un mayor tamaño del infarto o eventos clínicos adversos en pacientes con IAMCEST tratados con ICP primaria.
We sought to determine the association of reciprocal change in the ST-segment with myocardial injury assessed by cardiac magnetic resonance (CMR) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
We performed CMR imaging in 244 patients who underwent primary PCI for their first STEMI; CMR was performed a median 3 days after primary PCI. The first electrocardiogram was analyzed, and patients were stratified according to the presence of reciprocal change. The primary outcome was infarct size measured by CMR. Secondary outcomes were area at risk and myocardial salvage index.
Patients with reciprocal change (n = 133, 54.5%) had a lower incidence of anterior infarction (27.8% vs 71.2%, P < .001) and shorter symptom onset to balloon time (221.5 ± 169.8 vs 289.7 ± 337.3 min, P = .042). Using a multiple linear regression model, we found that patients with reciprocal change had a larger area at risk (P = .002) and a greater myocardial salvage index (P = .04) than patients without reciprocal change. Consequently, myocardial infarct size was not significantly different between the 2 groups (P = .14). The rate of major adverse cardiovascular events, including all-cause death, myocardial infarction, and repeat coronary revascularization, was similar between the 2 groups after 2 years of follow-up (P = .92).
Reciprocal ST-segment change was associated with larger extent of ischemic myocardium at risk and more myocardial salvage but not with final infarct size or adverse clinical outcomes in STEMI patients undergoing primary PCI.
Full English text available from: www.revespcardiol.org/en
Mechanism and diagnostic potential of reciprocal ECG changes induced by acute coronary artery occlusion in pigs
2013, Heart Rhythm
Citation Excerpt :
Reciprocal ECG changes permitted a more accurate diagnostic prediction of the site of coronary occlusion. Following the observations by Wolferth et al,4 depression of the ST segment in ECG leads overlying the nonischemic area emerged as a well-recognized reciprocal ECG pattern in patients with acute transmural myocardial infarction.5,6 Two mechanisms have been proposed to explain the reciprocal ST-segment depression7: (1) distant reflection of the ST-segment elevation generated in the ischemic region and (2) true ST-segment deviation caused by added local subendocardial ischemia.
Reciprocal ST-segment depression simulating additional subendocardial ischemia is commonly observed in ST-segment elevation myocardial infarction.
To study the mechanism and characterization of the whole reciprocal electrocardiogram (ECG) patterns induced by acute coronary artery occlusion at different locations in the absence of additional subendocardial ischemia in pigs.
Conventional 12-lead ECG and/or local extracellular epicardial, mid-myocardial, and endocardial electrograms were recorded during the acute occlusion of right coronary (RC) and left anterior descending (LAD) coronary arteries in the in situ (n = 9) or in the isolated perfused (n = 5) pig hearts.
Mid-RC occlusion induced reciprocal ST-segment depression (−0.43±0.14 mV; P<.01) and S-wave deepening (−0.74±0.23 mV; P<.01) in anterior ECG leads. Mid-LAD occlusion induced reciprocal S-wave deepening (−0.43±0.37 mV; P = .02) but not ST-segment depression in inferior leads. Proximal LAD induced reciprocal ST-segment depression (−0.21±0.20 mV; P = .03) and S-wave deepening (−0.56±0.58 mV; P = .04) in inferior leads. Reciprocal QRS widening was observed only during proximal LAD occlusion. Local extracellular recordings did not show significant reciprocal QRS and ST-segment changes.
In the absence of additional subendocardial ischemia, acute coronary artery occlusion induces reciprocal ST-segment and S-wave changes in the 12-lead ECG that allow better differentiation between proximal and mid-LAD occlusion. Reciprocal ECG changes depend on conventional lead system design and not on the transmission of injury currents from the ischemic border zone to distant normal myocardium.
Prognostic significance of reciprocal ST-segment depression in patients with acute STEMI undergoing immediate invasive intervention
2012, American Journal of Emergency Medicine
Citation Excerpt :
Some reports state that the reciprocal change in patients with ST-segment elevation MI (STEMI) is merely a benign electrical phenomenon rather than “ischemia at a distance” [2,3]. Conversely, other studies conclude that the reciprocal change is a surrogate marker of the severity of the disease; patients exhibiting this reciprocal change tend to have a larger infarction [4-6], poorer left ventricular systolic function [7,8], higher incidence of proximal left anterior descending artery (LAD) lesions [5,9], multivessel diseases [10-13], and worse prognosis [14,15]. Patients in the previously mentioned ECG studies usually received conservative or thrombolytic therapy, followed by coronary intervention.
Reciprocal changes are frequent in patients with acute ST-segment elevation myocardial infarction (STEMI). However, their prognostic significance is not clear in patients undergoing immediate invasive intervention.
We retrospectively examined 165 consecutive patients with STEMI receiving immediate invasive intervention. The first electrocardiography taken in the emergency department was analyzed. Patients were assigned to 2 groups: with a reciprocal change (group I, n = 100) and without a reciprocal change (group II, n = 65).
Electrocardiographs revealed that more anterolateral and inferior STEMI occurred in group I and more anterior STEMI occurred in group II. In the emergency department, group I had lower systolic and diastolic blood pressures, higher ventricular tachycardia and fibrillation rates, and higher cardiopulmonary resuscitation rates than did group II. Upon admission, peak troponin I levels were significantly higher in group I, and more group I patients required intra-aortic balloon pumping support. This unstable hemodynamic condition in group I patients was reflected by their higher in-hospital mortality rate. Multivariate analysis showed that age (odds ratio [OR], 1.103; 95% confidence interval [CI], 1.022-1.190; P = .012), Killip class (OR, 2.785; 95% CI, 1.049-7.400; P = .040), and reciprocal change (OR, 9.553; 95% CI, 1.146-79.608; P = .037) remained as independent predictors of in-hospital mortality. Actuarial freedom from all-cause mortality was worse in group I (P = .046).
The data suggest that patients with STEMI with reciprocal electrocardiographic changes have unstable hemodynamic status and poorer outcomes. Further prospective studies using a larger patient population are needed.
Detecting Posterior Wall Acute Myocardial Infarction by Electrocardiogram
2009, American Journal of Cardiology
Acute Ischemia: Electrocardiographic Patterns.
2008, Chou's Electrocardiography in Clinical Practice: Adult and Pediatric
Combination of electrocardiographic and angiographic markers of reperfusion in the prediction of infarct size in patients with ST-segment elevation myocardial infarction undergoing successful primary angioplasty
2007, International Journal of Cardiology
Citation Excerpt :
The accuracy of ST-segment resolution may be potentially affected by the fact that the presence of postprocedural ST-segment elevation, even though in the presence of complete resolution, may represent residual ischemia as a consequence of suboptimal reperfusion. Furthermore, despite the pathogenesis of concomitant ST-depression in patients with STEMI is still a matter of debate (“reciprocal” image of ST segment elevation in the infarct zone [19,20] or more extensive infarction [21,22] or additional ischemia beyond the infarct zone [23,24], several studies have shown its prognostic impact in patient with ST-segment elevation [25–27]. Thus, it is conceivable that the inclusion of ST-segment depression in the evaluation of myocardial perfusion would give more prognostic information in addition to only ST-segment elevation.
Optimal epicardial recanalization does not guarantee optimal myocardial perfusion. The aim of the current study was to evaluate angiographic and electrocardiographic markers of reperfusion in the prediction of infarct size in patients with STEMI undergoing successful primary angioplasty.
Our population is represented by 270 STEMI patients with ST successful primary angioplasty (postprocedural TIMI 3 flow and residual stenosis < 50%) with available corrected TIMI frame count (cTFC), myocardial blush grade (MBG), ST-segment resolution and enzymatic infarct size (peak CK-MB) analyses.
A significant linear relationship with enzymatic infarct size was observed for all markers of reperfusion, except for ST-segment resolution. These data were confirmed even when analyzed as continuous variables in case of cTFC (r = 0.13, p = 0.035), postprocedural residual cumulative ST-segment elevation (r = 0.41, p < 0.0001) and deviation (r = 0.45, p < 0.0001). At multivariate analysis applied to postprocedural angiographic and electrocardiographic markers of reperfusion, cumulative residual ST-segment deviation, myocardial blush grade, and corrected TIMI frame count were independent predictors of enzymatic infarct size.
This study showed that, among patients with STEMI treated by primary angioplasty, cTFC, MBG and cumulative residual ST-segment deviation are independent predictors of infarct size. Therefore, angiography and electrocardiography may provide complementary information in the evaluation of myocardial perfusion.

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¹: Supported by a Max Kade Postdoctoral Research Exchange Grant (Dr. Pichler) from Vienna, Austria.

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Wall motion abnormalities and electrocardiographic changes in acute transmural myocardial infarction: Implications of reciprocal ST segment depression

Abstract

Am Heart J

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am Heart J

Am J Cardiol

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Am J Cardiol

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Am J Cardiol

Am J Cardiol

Am J Cardiol

Nomenclature and criteria for diagnosis of diseases of the heart and great vessels

Correlation of postmortem anatomic findings with electrocardiographic changes in patients with myocardial infarction

Circulation

Quantitation of myocardial infarct size and location by electrocardiogram and vector cardiogram

Electrocardiographic, and cineangiographic correlations in assessment of the location, nature and extent of abnormal left ventricular segmental contraction in coronary artery disease

Circulation