Predictive Value of Serial ECGs in Patients with Suspected Myocardial Infarction.

Jonas Lehmacher,Tau Sarra Hartikainen,Tanja Zeller,Dirk Westermann,Stefan Blankenberg,Alina Goßling,Paul Michael Haller,Peter Clemmensen,Nils Arne Sörensen,Johannes Tobias Neumann

doi:10.3390/jcm9072303

Abstract

The electrocardiogram (ECG) is an important diagnostic tool for patients with suspected acute myocardial infarction (AMI). Current guidelines recommend serial ECGs in case of persisting symptoms. We aimed to analyze the predictive value of ischemic ECG-signs in patients with suspected AMI. Patients presenting to the emergency department with suspected AMI were included. All patients with ST-elevation AMI were excluded from analyses. Patients received 12-lead-ECG and high-sensitive Troponin T (hs-TnT)-measurement at admission and after 3 h. Four groups were defined: no ischemic signs in either ECG; new ischemic signs in the second ECG; resolved ischemic signs in the second ECG; and persistent ischemic signs in both ECGs. Patients were followed for 2 years to assess the composite endpoint of all-cause-mortality, AMI, and coronary revascularization. Using a 30-day landmark analysis, a Cox regression with ischemic signs as the variable of interest, adjusted by cardiovascular risk factors, was calculated. Of 1675 patients, 1321 showed no ischemic signs, in 25 new-, in 92 resolved- and in 237 patients, persistent ischemic signs were documented. Patients with persistent ischemic signs had significantly worse outcomes, compared to those without. Compared to no ischemic signs, adjusted hazard ratios for the combined endpoint were 0.81 (95% CI 0.20, 3.31; p-value = 0.77) for new-, 0.59 (95% CI 0.26, 1.34; p-value = 0.21) for resolved-, and 1.47 (95% CI 1.102, 2.13; p-value = 0.041) for persistent ischemic signs. In patients with suspected AMI, persistent ischemic ECG-signs are predictive of a higher rate of all-cause-mortality, AMI, and revascularization.

Highlights

The electrocardiogram (ECG) is a pivotal part of the diagnostic workup of patients with suspected acute myocardial infarction (AMI), being the first diagnostic test provided in an acute setting
For T-wave-inversion (TWI), previous study results have indicated that isolated TWI is not associated with poor outcomes, but occurring with segment deviation (STD) simultaneously, they seem to be an independent indicator for higher risk of adverse events [4,5,6,9,18]
We aimed to evaluate the predictive and prognostic value of ischemic signs and dynamic changes in short-term serial ECGs in patients with suspected AMI presenting to the emergency department

Summary

Introduction

The electrocardiogram (ECG) is a pivotal part of the diagnostic workup of patients with suspected acute myocardial infarction (AMI), being the first diagnostic test provided in an acute setting. The amplitude of STD, as well as the number of leads showing STD, are known to be associated with a higher rate of adverse events [10,12,13] These aspects already find consideration in several validated models for risk stratification [14,15,16,17]. Little is known about possible prognostic value of short-term serial ECGs in the emergency department in the first hours after presentation. Some studies regarding prognostic value of continuous ST-monitoring have shown that transient ischemic episodes predict a higher rate of short- and long term adverse cardiac events in patients with AMI [24,25,26]. We aimed to evaluate the predictive and prognostic value of ischemic signs and dynamic changes in short-term serial ECGs in patients with suspected AMI presenting to the emergency department

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