RS-T Elevation Research Articles

Worst lead ST deviation and resolution of ST elevation at one hour for prediction of myocardial salvage, infarct size, and microvascular obstruction in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

BackgroundECG changes after revascularization predicts improved outcome for patients with ST‐elevation myocardial infarction (STEMI). Worst lead residual (WLR) ST deviation and resolution of worst lead ST elevation (rST elevation) are simple measures that can be obtained early after PCI. The objective of the current study was to investigate whether simple ECG measures, obtained one hour following PCI, could predict cardiac magnetic resonance (CMR)‐derived myocardial salvage index (MSI), infarct size (IS), and microvascular obstruction (MVO) in patients with STEMI included in the MITOCARE trial.MethodsThe MITOCARE trial included 165 patients with a first‐time STEMI presenting within six hours of symptom onset. The current analysis included patients that had an ECG recorded at baseline and one hour after PCI and underwent CMR imaging after 3–5 days. Independent core laboratories determined WLR ST deviation, rST elevation, and the CMR variables (MSI, IS, and MVO).Results83 patients with a mean age of 61 years were included. 83.1% were males and 41% had anterior infarctions. In logistic regression models, WLR ST deviation was a statistically significant predictor of IS (OR 2.2, 95% CI 1.3–3.8) and MVO (OR 2.8, 95% CI 1.5–5.2), but not of MSI (OR 0.8, 95% CI 0.5–1.2). rST elevation showed a trend toward a significant association with IS (OR 0.3, 95% CI 0.1–1.0), but not with the other CMR variables.ConclusionWLR ST deviation one hour after PCI was a predictor of IS and MVO. WLR ST deviation, a measure easily obtained from ECGs following PCI, may provide important prognostic information in patients with STEMI.

Monophasic action potential-like electrocardiogram simulating acute myocardial infarction.

Monophasic action potential-like electrocardiogram simulating acute myocardial infarction has been reported in patients with hyperkalemia. We report two cases presenting marked diffuse RS-T elevation resembling monophasic action potential. They had abnormal electrolyte levels, including hyperkalemia and hypocalcemia in case 1 and hypokalemia and hypocalcemia in case 2. The ECG abnormality returned to baseline after correction of potassium and calcium. We conclude that monophasic action potential-like electrocardiogram is caused by electrolyte disturbance other than acute myocardial infarction.

Effect of isoproterenol on the “early repolarization” syndrome

A study has been carried out on a group of subjects with RS-T segment elevation, a normal variant of early repolarization. Following isoproterenol administration, the RS-T segment became isoelectric. In most cases this was accompanied by shorter QT and longer QT c intervals. The same effects were observed after physical exertion but not after atropine or amyl-nitrite. Propranolol administration exaggerated RS-T elevation. Considering the mechanism with which isoproterenol acts and some analogies with the electrocardiographic picture experimentally obtained by means of the unilateral stimulation of the stellate ganglions, the hypothesis is advanced that the normal variant of early repolarization is related to an enhanced activity of the right sympathetic nerves.

Long-term evaluation of early repolarization syndrome (normal variant RS-T segment elevation)

The electrocardiograms of 65 patients with the “early repolarization syndrome” (normal variant of RS-T elevation) were analyzed to delineate the features and evaluate the natural history of this electrocardiographic entity. Maximal follow-up was 26 years. The syndrome was characterized by (1) an upward concave elevation of the RS-T segment with distinct or “embryonic” J waves, slurred downstroke of R waves or distinct J points or both; (2) RS-T segment elevation commonly encountered in the precordiaj leads and more distinct in these leads; (3) rapid QRS transition in the precordial leads with counterclockwise rotation; and (4) persistence of these characteristics for many years although some intraindividual changes were common. Less commonly found were (5) tall R and T waves in the precordial leads; (6) “labile” or “juvenile” T wave patterns; (7) “pseudo-R′” waves; and (8) “isolated T negativity syndrome.” These changes commonly simulate pericarditis, myocardial ischemia, left ventricular hypertrophy and right bundle branch block.

Ventricular Conduction Delay and Arrhythmias during Regional Hyperkalemia in the Dog

Coronary arterial potassium (K + ) infusion induces RS-T elevation and ventricular arrhythmias. To explore electrical and metabolic events in this model, which simulates ischemia-induced injury currents and rhythm disturbances, isotonic KCl was infused at 0.5-2.0 ml/min into the left anterior descending or the left circumflex coronary artery of 37 intact anesthetized dogs. Conduction was monitored with His and left bundle branch recording catheters and with bipolar electrodes at endocardial and epicardial levels in the perfused zone. RS-T segments rose progressively in the perfused region despite normal coronary blood flow ( 85 Kr) some dogs progressed rapidly to multifocal ventricular extrasystoles and ventricular fibrillation (group 1), but others continued for 20 minutes without developing fibrillation (group 2). His-Q and bundle branch conduction times were not altered by regional perfusion, but the QRS complex was locally prolonged. Ventricular extrasystoles were frequently coupled and left bundle branch depolarizations never preceded them, suggesting origin within the myocardium. Intramural electrodes showed increasing delay in the perfused region; epicardial depression was uniformly more profound and preceded significant arrhythmias, often with 2:1 or higher intramural block and slowing sufficient to allow reentry. Epicardial activation preceding endocardial activation was observed during extrasystoles in the perfused zone, further indicating origin within the myocardium. These phenomena were associated with tissue concentrations of K + in the outer wall significantly higher than those in the inner wall; and sodium was also significantly elevated. Therefore, it was postulated that reentry from depressed epicardial layers into more normal surrounding tissue constitutes a possible basis for the arrythmias in this model.

Exercise-Induced RS-T Elevation

In 4 patients in which an exercise test induced an elevation of the RS-T segment and an increase of the R-wave, coronary angiography showed a localized, subocclusive stenosis of the single major coron

Psychic origin of a concave RS-T elevation in a patient with actual neurosis.

On the basis of clinical experiences, psychic origin of a concave RS-T elevation was previously indicated by the author. In one of the preceding reports, an appearance of a concave RS-T elevation was demonstrated in a 30-year-old male and its disappearance in a 31-year-old female. This paper demonstrates the processes of appearance and disappearance of the concave RS-T elevation in one 36-year-old male. The patient had to live for some 40 days with his cousin suffer-ing from postoperative gastric cancer in the same hospital. Until the entry into the hospital the patient had affiliated himself with the structure-improving committee. He resigned his post because of his annoying subjective symptoms such as precordial discomfort, insomnia, anorexia and so on. The electrocardiogram which was normal on admission showed a concave RS-T elevation in left pre-cordial leads with a tapering, heightened T wave when his cousin was most serious. The concave RS-T elevation returned to normal some 70 days after the death of his cousin when the patient regained self-confidence and was completely asymptomatic.

Two extremes of classically normal electrocardiograms, a concave RS-T elevation with a TU fusion and a gently-sloped ST-T segment with an accentuated U wave, disclosed by reaction patterns in a five-minute postural test.

Two extremes of classically normal electrocardiograms, a concave RS-T elevation with a TU fusion and a gently-sloped ST-T segment with an accentuated U wave, disclosed by reaction patterns in a five-minute postural test.

The Cornell Medical Index in patients with a concave RS-T elevation in Mid-and left precordial leads and new questionnaires specially designed for actual neurosis. I. The Cornell Medical Index in patients with a concave RS-T elevation in mid-and left precordial leads.

As reported previously a concave RS-T elevation in mid-and left precordial leads is produced by conscious persistent mental stress in a period of more than 1 to 2 months and can be normalized by minor psychotherapy with or without minor tranquilizers in certain cases. In order to confirm the psychosomatic significance or psychogenesis of the concave RS-T elevation in mid- and left precordial leads, mental state of patients with this concave RS-T elevation was investigated by the use of the Cornell Medical Index.

The Cornell Medical Index in patients with concave RS-T elevation mid-and left precordial leads and new questionnaires specially designed for actual neurosis. II. New questionnaires specially designed for actual neurosis.

As discussed in Part I, the Cornell Medical Index is impertinent for a patient with actual neurosis who has the spirit of self-respect and is ashamed of exposing himself, bodily or mental, to others. However, in dealing with neuroses, what we physicians must search for is that obstacle which interferes with normal emotional discharge and not the products of reactions of the organism to this obstacle. For this reason, new questionnaires which have no column for the name of patients and consist of concrete questions asking the environment in which they live were specially designed for actual neurosis.

PSYCHOSOMATIC SIGNIFICANCE OF A CONCAVE RS-T ELEVATION IN CHEMICALLY NORMAL HEARTS.

An ST elevation in the left precordial leads is one of our five criteria for the pattern of actual peurosis (Boss). Further analytic and psychotherapeutic approaches were made to those patients with normal hearts which show a concave RS-T elevation in the left precordial leads. Examples of the life history of patients with a concave RS-T elevation were described. The development of a concave RS-T elevation by stress and its normalization by psychotherapy were demonstrated. The concave RS-T elevation similar to that found in patients with actual neurosis was found in patients treated by a long-term administration of glucocorticoids.

Some objective methods for electrocardiographic and vectorcardiographic diagnosis.

ECG and VCG diagnosis has still various difficulties. In order to overcome these difficulties, following studies were attempted : 1) Various combinations of height of the waves recorded by Frank's orthogonal leads were compared as index for left ventricular hypertrophy. RX/RY was most useful to differentiate LVH from normal and had larger positivity than some other criteria presented by various authors. On the one hand, RX+ SY + SZ was thought to be a better index for degree of LVH. 2) Differential curves of the second order of coronary T wave is considerably differed from that of usual negative T wave. Differences are also observed in the differential curve of the first order between the RS-T elevation in myocardial infarction and non-specific elevation. The differential curves are useful for objective recognition of shape of the waves. 3) Statistical diagnosis of disease by ECG findings was attempted by using Bayes' theorem without referring to other clinical data. Calculation with electronic computor showed fairly correct answers in various actual cases. Some of the results are indicated.

A long term study of concave RS-T elevation--a normal variant of the electrocardiogram.

A long term study of concave RS-T elevation--a normal variant of the electrocardiogram.

Myocardial Infarction, Its Diagnosis and Treatment: Literature Review

Myocardial infarction is a pathological process established by a compromise in the blood supply to an area of myocardium of such severity that even with prolonged rest adequate oxygen connot be obtained. In the United States there are approximately 600,000 to 800,000 persons each year suffering attacks from this disease.1 Even though in recent years greater facilitation in diagnosis and tremendous strides in therapy have reduced mortality during the first attack in private patients to 5 per cent or less,2 the overall annual mortality is 200,000.1 A large number of the deaths occur during the most productive years of life ; many of those who survive suffer disabling complications. The figures for mortality and disabling complications can be decreased by a careful differential diagnosis of patients presenting chest pains and other symptoms characteristic of myocardial infarction and by individualization of therapeutic procedures. Diagnosis The diagnosis of acute myocardial infarction is based on the history, the clinical findings, and an evaluation of the electrocardiographic changes. There are many nonspecific signs which may be used as adjuncts. A tentative diagnosis of myocardial infarction may be suggested in a patient presenting a severe, oppressive pain over the lower sternum or more extensively over the precordium or anterior chest which lasts for 30 minutes or longer and which is not relieved by rest or nitrites.3 Radiation of this pain to neck, shoulders, or arms confirms the likely origin in the heart. The pain builds up slowly and steadly to a plateau of maximal intensity. Anxiety and fear of impending doom mount rapidly as the pain continues. After several hours the pericardial inflammation resulting from ventricular necrosis may introduce a sharp, stabbing component to the pain. It is typically aggravated by respiration, emotion, swallowing, and may have a throbbing element synchronous with the heartbeat.4 Complications as shock and congestion of the lungs from acute left ventricular failure may increase the complexity of the symptoms ;4 however, a rapid fall in blood pressure within twenty-four hours or even a more gradual fall in the next few days is interpreted as an important confirmatory sign.1 Fever, leukocytosis, and elevation of the erythrocyte sedimentation rate are clinical signs which support the diagnosis. Serial changes in the electrocardiogram are of great value, but not essential, for the diagnosis.4 The electrocardiogram is considered characteristic of acute myocardial infarction when elevation of the RS-T segment and a deep Q wave are present in one or more leads, with progressive change from RS-T elevation to T-wave inversion in serial records.� At 45ubmitted in the 1957 Essay Contest of the American College of Chest Physicians.

Acute coronary insufficiency: its differential diagnosis and treatment.

Excerpt As the years pass, the known incidence of coronary disease continues to rise. Today, about one of every three men over the age of 35 and the vast majority of men over 50 have a significant ...

Remarks on the Graphic Diagnosis of Coronary Disease

I . Typical and Atypical Electrocardiograms in Myocardial Infarction Caused by Acute Coronaqj Occlusion and Coronary Insufficiency The electrocardiogram has been epic making in the diagnosis of coronary occlusion and is the main reason for the ever increasing frequency with which this disease is detected. The ordinary electrocardiographic diagnosis has become so well-recognized that i t is now well to talk, not only of the typical electrocardiogram, but of the atypical electrocardiogram in myocardial infarction. I t is time also to divide the study of myocardial infarction into two types, (1) the subendocardial type, secondary to coronary insufficiency, that is, without complete occlusion of a coronary artery, (2) the through-and-through type caused by coronary occlusion, that is, complete obstruction of a coronary artery. Coronary insufficiency is usually associated with coronary sclerosis but may be observed in a normal heart, for example, following hemorrhage. In coronary insufficiency the electrocardiogram shows RS-T depression, T-wave inversion, or RS-T depression and T-wave inversion combined, since the damage is localized in the subendocardial region. For the same reason, the outlobk is much better in coronary insufficiency. The electrocardiographic alterations are usually transient, lasting a day or two, or one or two weeks or months ; rarely they are permanent. The T-wave inversions are not usually as deep as those seen in coronary occlusion. There are no Q-waves or RS-T segment elevations because there is no through-and-through infarction. I t may take a few days for the electrocardiographic changes to develop; hence, if an acute coronary episode of any kind is suspected the electrocardiogram should be repeated several times. The type of electrocardiogram just described, that is, with RS-T depressions and T-wave inversions, but without deep Q-waves, is also seen in the premonitory phase of a coronary occlusion. Obviously there is a partial occlusion which causes coronary insufficiency. I believe that, once the artery is completely occluded, the clinical and electrocardiographic picture of coronary occlusion appears, that is, RS-T elevation is seen immediately. Within the first 12 to 24 hours the characteristic deep Q-wave is not seen but one can almost discern i t if he looks intently. After 12 to 24 hours i t is usually quite obvious. In anterior wall infarction the deep Q and RS-T elevations appear in leads I, aVL and in chest leads. In diaphragmatic or inferior wall infarction these alterations appear in leads 11, I11 and aVF. In true posterior infarction, tall R-waves appear on the right side of the chest, i. e., in V1 and 2. Q-waves may be seen in Va, s, 7 or Vs. Doctor Jaffe has been in the forefront in the description of atypical changes in coronary occlusion. For example, in serial electrocardiograms, temporary improvement may occur.

Typical and Atypical Electrocardiograms in Myocardial Infarction Caused by Acute Coronary Occlusion and Coronary Insufficiency

When an acute coronary episode occurs, if the initial electrocardiogram does not indicate a coronary occlusion, it may be difficult at first to determine the exact nature of the attack. The electrocardiogram may remain normal for a variable period or may indicate coronary insufficiency and myocardial ischemia. In the cases going on to coronary thrombosis and massive infarction, the electrocardiogram may show various rapidly changing patterns before the appearance of RS-T elevation and Q-waves. In coronary occlusion the electrocardiogram often shows involvement of more than one surface and variations of the typical patterns are frequent. The changes may be present in only a few of the 12 routine leads or only in special chest positions. In an acute coronary episode it is essential to keep the patient at rest until the extent of myocardial involvement has been determined. Not infrequently the electrocardiogram shows temporary improvement or actual return of RS-T and T to normal between the third and 10th days following myocardial infarction.

Constrictive pericarditis caused by solitary metastatic carcinosis of the pericardium and complicated by radiation fibrosis of the mediastinum

1. 1. A case of chronic constrictive pericarditis produced by diffuse metastatic carcinoma of the pericardium is presented. The pericardial carcinoma was the only metastasis from a primary breast carcinoma completely resected fourteen years previously. 2. 2. The etiology of constrictive pericarditis must include metastatic carcinoma as well ast uberculosis, nonspecific undetermined fibrosis, trauma, and pyogenic inflammation of the pericardium. 3. 3. Radiation contributed to the fibrosis but was not responsible for the constrictive pericarditis. The constrictive encasement of the heart was produced by the scirrhus stromal reaction to the tumor cells. 4. 4. The pulmonary and mediastinal fibrosis secondary to radiation therapy complicated and obscured the diagnosis. 5. 5. Jaundice may occur during the course of constrictive pericarditis and is secondary to chronic congestion of the liver. 6. 6. Electrocardiographic changes of acute pericardial injury (RS-T elevation and T-wave changes) occurring during the course of constrictive pericarditis may indicate either active tuberculosis or the presence of actively growing tumor tissue.

Cardiac aneurysm: Clinical and electrocardiographic analysis

1. 1. Twenty cases with autopsy or x-ray diagnoses of ventricular aneurysm have been reviewed. 2. 2. Electrocardiographic considerations based upon the Wilson concepts from 13 cases, in addition to 16 reported elsewhere, suggest that there is no pattern characteristic of ventricular aneurysm. 3. 3. Electrocardiographic changes, when present, are those of antecedent extensive myocardial infarction and do not differ from similar cases uncomplicated by ventricular aneurysm. 4. 4. Persistent RS-T elevation, frequently associated with ventricular aneurysm, correlates with large infarcts which are potential sites for aneurysm formation. RS-T elevation is due to: (a) hypertrophy of the opposite heart wall, and (b) lack of modifying potential from destroyed myocardium. 5. 5. Failure to verify presence of extensive myocardial infarction by electrocardiogram in the presence of abnormal bulges on the cardiac silhouette by roentgen study does not exclude, but should cast serious doubt, on the diagnosis of ventricular aneurysm.

The extremity and circumferential chest lead electrocardiogram in induced acute coronary insufficiency.

The extremity and circumferential chest lead electrocardiogram (twenty-two leads) was studied in 8 patients with generalized coronary insufficiency induced by exercise. Over the right chest, posteriorly and laterally, there was noted RS-T elevation similar to but less pronounced than that occurring in lead aV R . These leads probably represent true or mixed cavity potentials. Standard leads revealed more marked RS-T alterations after exercise than did aV leads. In the left anterior chest leads, the greatest RS-T depression occurred in the left unipolar precordial leads representing the maximal voltage of the R wave—usually V 4 or V 5 . The practical application of these findings is discussed in relation to routine two step exercise tests.