Selvester QRS Score Research Articles

Value of modified selvester QRS score in prediction of successful reperfusion in patients with acute myocardial infarction

Background Reperfusion therapy basically aims to restore full antegrade flow in the infarct-related epicardial coronary artery. The modified Selvester QRS score, basically developed to estimate infarct size, was used with good predictive value to predict ST-resolution in acute myocardial infarction (AMI) treated with fibrinolysis. However, little data are available about its role in predicting reperfusion in ST-segment myocardial infarction (STEMI) patients undergoing primary percutaneous coronary interventions (PCI). Objectives Was to examine the value of modified Selvester QRS score in predicting ST-segment resolution in patients with first acute STEMI after thrombolytic therapy or primary PCI. Methods Sixty patients with acute STEMI were enrolled in the study, 56 males and 4 females; and their mean age was 56.4 ± 8.4 years. We excluded patients with bundle branch block, paced rhythm, left fascicle block, ECG signs of ventricular hypertrophy, cardiogenic shock and prior STEMI. All patients were submitted to full history taken and clinical examination, admission 12-leads electrocardiography (ECG) with estimation of modified Selvester QRS score and sum of ST-elevation, another ECG after 90 minutes of thrombolysis with estimation of the sum of ST-elevation and ST-resolution, cardiac enzymes, thrombolysis for 45 patients and primary PCI for 15 patients, echocardiographic assessment with measuring of left ventricular ejection fraction (EF) and wall motion score index (WMSI), and coronary angiography. Results Population characteristics and risk factors for coronary artery disease (CAD) were comparable between the two groups. In patients with QRS score > 4, time to admission was significantly higher, EF was significantly lower, WMSI was significantly higher, number of patients with no ST-segment resolution was significantly lower, number of patients with myocardial blush grade (MBG) 1 was significantly higher, number of patients with MBG 3 was significantly lower, and number of patients with three-vessel disease was significantly higher. Sensitivity of QRS score ⩽ 4 in predicting ST-segment resolution ⩾ 50% was 59.3%, specificity was 100%, positive predictive value was 62.1%, negative predictive value was 86%, and overall accuracy was 75.6%. There was a highly significant negative correlation between ST-segment resolution and QRS score (r = −0.483, p = 0.00078). Conclusion Selvester QRS scoring system is regaining its clinical value in patients with first STEMI. It can provide valuable information as regard area of myocardium at risk, prediction of residual left ventricular function, making treatment decisions. Though somewhat difficult, it is worthy to calculate QRS score from admission ECG in every patient presenting with STEMI. In patients who are controversial as regard thrombolytic therapy, QRS score could help in determining those who will get benefit from such therapy.

CRT-119 Prediction of Myocardial Salvage by Modified Selvester QRS Score in Patients with ST-Segment Elevation Myocardial Infarction After Primary PCI

QRS scores correlate well with the final infarct size and post MI left ventricular function .Tc99m-Sistamibi scan, despite the radiation hazard , is the gold standard for assessing the infarction size before and after reperfusion and it is considered a reliable method for assess myocardial salvage

Impact of ostium secundum atrial septal defect closure on the resolution of falsely positive electrocardiographic criteria for myocardial scarring

BackgroundElectrocardiographic (ECG) Selvester QRS score criteria with false indication of anteroseptal scarring consistent with myocardial infarction have been found in patients with ostium secundum atrial septal defect (OS-ASD). The objective of this study was to evaluate ECGs pre and post percutaneous transcatheter OS-ASD closure to test the hypothesis that the falsely positive criteria for anteroseptal scar decline 1 day post procedure. MethodsPatients (n=34, mean age 48 ±17 years, 79% female) that underwent OS-ASD closure and had undergone pre procedure cardiac magnetic resonance imaging showing no left ventricular (LV) scarring were included in this study. ECGs pre and 1 day post procedure were assessed according to the QRS Selvester scoring system and compared. ResultsMean Selvester score in anteroseptal regions pre procedure was 6.6 (0.0–6.8) % LV scar and decreased to 4.3 (0.0–6.0) % LV scar one day after the procedure (p=0.01). Mean Selvester score in lateral regions pre procedure was 3.7 (0.0–3.0) %LV scar and decreased to 2.8 (0.0–0.0) % LV scar one day post procedure (p=0.25). DiscussionOS-ASD patients with falsely positive anteroseptal scar criteria by the Selvester QRS score pre procedure have a significant decrease in anteroseptal Selvester score 1 day post procedure. The falsely positive anteroseptal scar criteria did not completely resolve 1 day post procedure. Further studies are needed to investigate the relationship between ECG criteria for anteroseptal scar and right ventricular volume overload in late follow up.

Selvester QRS score: an automated algorithm for the quantification of myocardial scar

Selvester QRS score: an automated algorithm for the quantification of myocardial scar

Comparison of Different Electrocardiographic Scoring Systems for Detection of any Previous Myocardial Infarction as Assessed With Cardiovascular Magnetic Resonance Imaging

Although electrocardiography is frequently used as an initial test to detect or rule out previous myocardial infarction (MI), the diagnostic performance of commonly used electrocardiographic scoring systems is not well described. We aimed to determine the diagnostic accuracy of (1) the Universal Definition, (2) Minnesota ECG Code (MC), (3) Selvester QRS Score, and (4) assessment by cardiologists using late gadolinium enhancement cardiovascular magnetic resonance imaging as the reference standard. Additionally, the effect of electrocardiographic patterns and infarct characteristics on detecting previous MI was evaluated. The 3-month follow-up electrocardiograms of 78 patients with first-time reperfused ST elevation MI were pooled with electrocardiograms of 36 healthy controls. All 114 electrocardiograms were randomly analyzed, blinded to clinical and LGE-CMR data. The sensitivity of the Universal Definition, MC, Selvester QRS Score, and cardiologists todetect previous MI was 33%, 79%, 90%, and 67%, respectively; specificity 97%, 72%, 31%, and 89%, respectively; diagnostic accuracy 54%, 77%, 71%, and 74%, respectively. Probability of detecting MI by cardiologists increased with an increasing number (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.30 to 3.09), width (OR 1.02, 95% CI 1.01 to 1.03), and depth (OR 1.16, 95% CI 1.07 to 1.27) of Q waves as well as increasing infarct size (OR 1.15, 95% CI 1.06 to 1.25) and transmurality (OR 1.05, 95% CI 1.01 to 1.08; p <0.05 for all). The time-consuming MC and rapid visual assessment by cardiologists achieved the best and similar diagnostic accuracies to detect previous MI. The diagnostic performance of all 4 electrocardiographic scoring systems was modest and related to the number, depth, and width of Q waves as well as increasing infarct size and transmurality. In conclusion, the exclusion of a previous MI based solely on electrocardiographic findings should be done with caution. Future studies are needed to define which patients should be referred to additional diagnostic testing.

Localization of myocardial scar in patients with cardiomyopathy and left bundle branch block using electrocardiographic Selvester QRS scoring - comparison with cardiac magnetic resonance

Background The left ventricular (LV) lead in cardiac resynchronization therapy (CRT) can be placed on any non-septal LV wall, most commonly the lateral wall. Presence of myocardial scar adversely affects CRT outcome, particularly if it involves the LV pacing site. It is increasingly important to identify and localize myocardial scar in CRT candidates, the majority of whom have left bundle branch block (LBBB). We aimed to describe the diagnostic performance of electrocardiographic (ECG) criteria based on the Selvester QRS score in localizing myocardial scar into 5 LV wall segments and in detecting non-septal scar in patients with LBBB using Cardiac Magnetic Resonance as the gold standard. Methods In 39 cardiomyopathy patients with strictly defined LBBB (17 with scar, 22 without scar), late gadolinium enhancement cardiac magnetic resonance images (CMR-LGE) and 12-lead ECGs were analyzed for scar presence in 5 LV wall segments. Using stepwise regression analysis, multiple subsets of the Selvester QRS score ECG criteria were identified for each of the 5 individual segments and for the 4 non-septal segments together. The diagnostic performance of each of these subsets is displayed in the graph below. The one subset for each location that had the highest combination of sensitivity plus specificity was selected. Results The best identified subset of Selvester QRS score criteria for screening of non-septal scar had 75% (95% CI: 51-90%) sensitivity, 95% (78-99%) specificity, 92% (67-99%) positive predictive value and 84% (65-94%) negative predictive value. For each individual wall segment, 40-60% sensitivities and 77-100% specificities were found. Conclusions The 12-lead ECG can convey information about scar presence and location in patients with cardiomyopathy and LBBB. ECG screening criteria for scar in potential CRT LV pacing sites were identified. Further exploration is required to determine the clinical utility of the 12-lead ECG in combination with other imaging modalities to screen for scar in potential LV pacing sites in CRT candidates.

Comparison of different electrocardiographic criteria for the detection of previous myocardial infarction in relation to infarct characteristics as assessed with cardiovascular magnetic resonance imaging

The sensitivity of the universal definition, MC, Selvester QRS-score, and cardiologists was 33%, 79%, 88%, and 67%, specificity was 97%, 72%, 31%, and 89%, diagnostic accuracy was 54%, 77%, 70%, and 74%, respectively (Figure 1). Probability of detection of MI by cardiologists increased with an increasing number (odds ratio [OR] 2.00 (95% confidence interval [CI] 1.30-3.09)), width (OR 1.02 (95%CI 1.01-1.03)), and depth (OR 1,16 (95%CI 1.07-1.27)) of Q-waves in anterior MI and Q- or R-waves in non-anterior MI (p<0.01 for all). Increasing infarct size and transmurality also increased the likelihood of detecting previous MI (OR 1.15 (95%CI 1.06-1.25), p<0.01, and OR 1,05 (95%CI 1.01-1.08), p=0.01). Five infarctions (6%) were not detected by any of the ECGcriteria (infarct size and transmurality ranging from 1.5-8.5% and 32-86%, respectively). Conclusions For detecting previous MI, the time-consuming MC and visual assessment by cardiologists achieved the best and similar diagnostic accuracies. The likelihood of detecting previous MI increased with an increasing number, depth, and width of Q-waves in anterior MI and Q- or

Comparison of Selvester QRS score with magnetic resonance imaging measured infarct size in patients with ST elevation myocardial infarction

Background and PurposeRecent studies have shown that the Selvester QRS score is significantly correlated with delayed enhancement-magnetic resonance imaging (DE-MRI) measured myocardial infarct (MI) size in reperfused ST elevation MI (STEMI). This study further tests the hypothesis that Selvester QRS score correlates well with MI size determined by DE-MRI in reperfused STEMI. Methods and ResultsThe relationship was evaluated retrospectively in 55 first-time STEMI patients 3 months after receiving primary percutaneous coronary intervention. Selvester QRS score and DE-MRI MI size were significantly correlated, r = 0.41 (P < .01). The difference between the Selvester QRS score and DE-MRI was 5.8% MI of the left ventricle (95% confidence interval, 2.9%-8.6%). Furthermore, increasing difference between Selvester QRS score and DE-MRI was observed with increasing MI size. ConclusionSelvester QRS score correlated only moderately with DE-MRI MI size. Selvester QRS score overestimated MI size.

A detailed guide for quantification of myocardial scar with the Selvester QRS score in the presence of electrocardiogram confounders

The Selvester QRS score translates subtle changes in ventricular depolarization measured by the electrocardiogram into information about myocardial scar location and size. This estimated scar has been shown to have a high degree of correlation with autopsy-measured myocardial infarct size. In addition, multiple studies have demonstrated the value of the QRS score in post–myocardial infarct patients to provide prognostic information. Recent studies have demonstrated that increasing QRS score is predictive of increased implantable defibrillator shocks for ventricular tachycardia and fibrillation as well as decreased response to cardiac resynchronization therapy. Although QRS scoring has never achieved widespread clinical use, increased interest in patient selection and risk-stratification techniques for implantable defibrillators and cardiac resynchronization therapy has led to renewed interest in QRS scoring and its potential to identify which patients will benefit from device therapy. The QRS score criteria were updated in 2009 to expand their use to a broader population by accounting for the different ventricular depolarization sequences in patients with bundle-branch/fascicular blocks or ventricular hypertrophy. However, these changes also introduced additional complexity and nuance to the scoring procedure. This article provides detailed instructions and examples on how to apply the QRS score criteria in the presence of confounding conduction types to facilitate understanding and enable development and application of automated QRS scoring.

Usefulness of the QRS Score as a Strong Prognostic Marker in Patients Discharged After Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

The prognostic value of myocardial infarct size estimation by QRS scoring in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is unclear. The standard 32-point Selvester QRS score on the discharge electrocardiogram (each point approximately 3% left ventricular mass) was calculated in 4,113 patients with STEMI who underwent primary PCI and survived to hospital discharge in the APEX-AMI trial. QRS scores were divided into tertiles, i.e., < or =3 (<10% myocardium), 4 to 7 (10% to 21% myocardium), and > or =8 (>21% myocardium). Adjusted associations between QRS score and 90-day outcomes (death and composite of death/congestive heart failure (CHF)/shock) were examined. Higher QRS scores were associated with male gender, higher heart rate, worse Killip class, noninferior infarct location, greater ST-segment deviation, and longer times to reperfusion. Higher QRS scores were also associated with impaired culprit artery flow before and after PCI and more frequent multivessel disease. Adverse outcomes occurred more often in patients with higher QRS scores (90-day death: 1.9%, QRS score 0 to 3; 3.4%, 4 to 7; 4.9%, > or =8; 90-day death/shock/CHF: 4.5%, 0-3; 7.8%, 4 to 7; 12.1%, > or =8). After multivariable adjustment, patients with higher QRS scores remained more likely to develop an adverse outcome versus those with QRS scores < or =3 (score 4 to 7, hazard ratios [HR] for death 2.08, 95% confidence interval [CI] 1.26 to 3.41; HR for death/CHF/shock 2.00, 95% CI 1.26 to 3.17; score > or =8, HR for death 2.57, 95% CI 1.56 to 4.24, HR for death/CHF/shock 2.93, 95% CI 1.84 to 4.67). In conclusion, infarct size as estimated by QRS scoring at hospital discharge is an independent and prognostically relevant metric in patients with STEMI undergoing primary PCI.

Consideration of the Impact of Reperfusion Therapy on the Quantitative Relationship between the Selvester QRS Score and Infarct Size by Cardiac MRI

It has previously been shown that there is a good agreement between the Selvester QRS score and myocardial infarct (MI) size determined by postmortem histopathology in patients with nonreperfused MI. Currently, however, most patients with acute coronary thrombosis receive reperfusion therapy. Therefore, the aim of this study was to test the hypothesis that early reperfusion alters the quantitative relationship between Selvester QRS score and MI size. Twenty-seven patients with acute first-time reperfused MI were studied. Infarct size was determined by delayed contrast-enhanced magnetic resonance imaging (DE-MRI) and estimated with the 50-criteria/31-point Selvester QRS scoring system 1 week after admission. The findings in the present study were compared with previous postmortem studies exploring the quantitative relationship between Selvester QRS score and MI size in nonreperfused patients. The quantitative relationship between QRS score and MI size by DE-MRI in the present study of early reperfused MI was significantly different from previous postmortem histopathology studies of nonreperfused MI (P < 0.0001). In the present study, each QRS point represented approximately 2% of the left ventricle, compared to approximately 3% in previous postmortem histopathology studies of nonreperfused MI. When only considering small to moderate MI sizes, there was no significant difference in the quantitative relationship between QRS score and infarct size (P > 0.05). There is a different quantitative relationship between QRS score and MI size in early reperfused MI compared to nonreperfused MI, partly explained by differences in MI size. Thus, the Selvester QRS scoring system may not be linearly related to MI size.

The Selvester QRS Score is more accurate than Q waves and fragmented QRS complexes using the Mason-Likar configuration in estimating infarct volume in patients with ischemic cardiomyopathy

Infarct volume independently predicts cardiovascular events. Fragmented QRS complexes (fQRS) may complement Q waves for identifying infarction; however, their utility in advanced coronary disease is unknown. We tested whether fQRS could improve the electrocardiographic prediction of infarct volume by positron emission tomography in 138 patients with ischemic cardiomyopathy (ejection fraction, 0.27 ± 0.09). Indices of infarction (pathologic Q waves, fQRS, and Selvester QRS Score) were analyzed by blinded observers. In patients with QRS duration less than 120 milliseconds, number of leads with pathologic Q waves (mean, 1.6 ± 1.7) correlated weakly with infarct volume ( r = 0.30, P < .05). Adding fQRS increased the number of affected leads (3.6 ± 2.5), but the significant correlation with infarct volume was lost ( r = 0.02, P = .10). Selvester Score was the most accurate (mean, 5.9 ± 4.9 points; r = 0.49; P < .001). Fragmented QRS was not predictive of infarct size in patients with QRS duration of at least 120 milliseconds ( r = 0.02, P = .19). Thus, in ischemic cardiomyopathy, consideration of fQRS complexes does not improve Q wave prediction of infarct volume; but Selvester Score was more accurate.

Comparison of serial measurements of infarct size and left ventricular ejection fraction by contrast-enhanced cardiac magnetic resonance imaging and electrocardiographic QRS scoring in reperfused anterior ST-elevation myocardial infarction

Background Left ventricular ejection fraction (LVEF) is a powerful prognostic marker after acute myocardial infarction and is dependent on infarct magnitude. Contrast-enhanced cardiac magnetic resonance (ceCMR) represents the current criterion standard means of LVEF and infarct size measurement. Infarct size and LVEF can be estimated from the 12-lead electrocardiogram (ECG) using the Selvester QRS score. We examined for the first time the relationship between serial measures of LVEF and infarct size by ceCMR and ECG in patients with reperfused anterior ST-elevation myocardial infarction (STEMI) and depressed LVEF. Methods Thirty-four patients (mean ± SD age, 59 ± 11.8 years; 70.6% male) underwent ceCMR and simultaneous ECG at mean 93 hours after admission and at 12 and 24 weeks. The QRS score was calculated on each ECG, from which infarct size and LVEF were estimated and compared with the equivalent ceCMR measurements. Results Infarct size on ceCMR was higher than that by QRS score at each time-point ( P < .001) with modest correlation ( r = 0.56-0.78, P < .001). Left ventricular ejection fraction was consistently significantly higher on CMR than on ECG, with weak correlation ( r = 0.37-0.51, P < .05). We derived a novel equation relating QRS score to CMR-measured LVEF in the subacute phase of infarction: LVEF = 61 − (1.7 × QRS score) (%). Conclusions In patients with reperfused anterior ST-elevation myocardial infarction and depressed LVEF, ceCMR is moderately correlated with the QRS in the serial measurement of infarct size and LVEF. Infarct size (measured by ceCMR) and LVEF are consistently higher than those calculated on the QRS score in the acute and subacute phases of infarction.

Simpler Is Better

“It has long been an axiom of mine that the little things are infinitely the most important” — —Sherlock Holmes in “A Case of Identity” by Arthur Conan Doyle Cardiac resynchronization therapy (CRT) can have a profound therapeutic impact on appropriately selected patients. However, even when the current clinical guidelines for CRT1 are rigorously applied, the response rate is ≈70%. Nearly a third of patients who undergo implantation of a CRT device are clinical nonresponders and more may be “remodeling nonresponders.” An extensive body of literature reports on a wide variety of methods that can be better used to identify potential responders by measurement of mechanical dyssynchrony. Factors responsible for nonresponse include comorbid conditions, cardiac substrate, left ventricular (LV) lead location, and device programming. Comorbid conditions such as obstructive sleep apnea, right-sided heart failure, and type of intraventricular conduction delay should be considered at the preprocedural stage. Device programming may help minimize the number of nonresponders. Prediction of responders by invasive hemodynamic assessment is impractical for daily clinical practice. Cardiac magnetic resonance imaging is too expensive for routine use and is not an option for many patients who already have devices and need upgrades. The appeal of echocardiography for predicting responders by identifying mechanical dyssynchrony has been dampened by its limited reproducibility and poor predictive value.2 It is also impractical to perform echocardiography during implantations. The prolonged QRS duration (QRSd; electric dyssynchrony), as measured on a standard 12-lead ECG, remains the best method for identifying candidates for CRT. In an elegant and important study reported in this issue of Circulation , Sweeney and colleagues3 use the 12-lead ECG and show that, despite its apparent simplicity, analysis of the standard 12-lead ECG can yield both pitfalls and impressive rewards. Article see p 626 Current clinical guidelines specify a …

Consideration of the impact of reperfusion therapy on the quantitative relationship between the Selvester QRS score and infarct size by cardiac magnetic resonance

Consideration of the impact of reperfusion therapy on the quantitative relationship between the Selvester QRS score and infarct size by cardiac magnetic resonance

ECG Quantification of Myocardial Scar Does Not Differ between Primary and Secondary Prevention ICD Recipients with Ischemic Heart Disease

Myocardial scar is an anatomic substrate for potentially lethal arrhythmias. Recent study showed that higher QRS-estimated scar size using the Selvester QRS score was associated with increased arrhythmogenesis during electrophysiologic testing. Therefore, QRS scoring might play a potential role in risk stratification before implantable cardioverter defibrillator (ICD) implantation. In this study, we tested the hypothesis that QRS scores among ICD recipients for secondary prevention are higher than QRS scores in primary prevention patients. From the hospital database, 100 consecutive patients with ischemic heart disease and prior ICD implantation were selected. Twelve-lead electrocardiograms (ECGs) had been obtained before implantation. ECGs were scored following the 32-points Selvester QRS scoring system and corrected for underlying conduction defects and/or hypertrophy. Ninety-three ECGs were suitable for scoring; seven ECGs were rejected because of noise, missing leads, excessive ventricular extrasystoles, or ventricular pacing. No statistically significant difference in QRS score was found between the primary [6.90 (standard deviation [SD] 3.94), n = 63] and secondary prevention group [6.17 (SD 4.50) (P = 0.260), n = 30]. Left ventricular ejection fraction (LVEF) was significantly higher in the secondary prevention group [31% (SD 13.5) vs 24% (SD 11.7) (P = 0.015)]. When patients with LVEF > or =35% were excluded, QRS scores were still comparable, namely 7.02 (SD 4.04) in the primary prevention group (n = 52) and 6.28 (SD 4.24) in the secondary (P = 0.510) (n = 18). We found no significant difference in QRS score between the ischemic primary and secondary prevention groups. Therefore, a role of the Selvester QRS score as a risk stratifier remains unlikely.

Comparison of the correlation of the Selvester QRS scoring system with cardiac contrast-enhanced magnetic resonance imaging–measured acute myocardial infarct size in patients with and without thrombolytic therapy

Background After an acute myocardial infarction (MI), it is important to define the infarct size because it is related to mortality and morbidity. The Selvester QRS Score is an electrocardiographic (ECG) method that has been developed for estimating MI size. It has been shown to correlate well with postmortem anatomically measured sizes of single MI in patients who did not receive thrombolytic therapy. The aim of this study was to test the hypothesis that correlation between Selvester QRS Score–estimated MI size and contrast-enhanced magnetic resonance imaging (ceMRI)–measured MI size is equivalent in patients who did vs those who did not receive thrombolytic therapy. Methods Thirty-six patients with MI (24 with thrombolytic therapy and 12 without) received ceMRI and ECG at admission and at 1 or 6 months after admission. Indeed, in 23 of the patients, the therapy was intravenous only. The Selvester QRS Score was calculated using the 1-month ECG or, if not available, the 6-month ECG. The correlation between the 2 measures of MI size was determined for all patients and for the 2 groups separately. Results The mean MI size in the group that did not receive thrombolytic therapy was 8.5% ± 6.4% estimated by the Selvester QRS Score and 11.7% ± 10.2% measured by ceMRI. For the group that received thrombolytic therapy, Selvester QRS Score was 13.9% ± 11.1% and ceMRI was 20.2% ± 11.3%. The mean MI size in both groups combined was 12.1% ± 10.0% estimated by the Selvester QRS Score and 17.3% ± 11.5% measured by ceMRI. The Spearman rank correlation coefficient between Selvester QRS Score and ceMRI was 0.74 ( P < .0001) for all patients, 0.74 ( P < .0001) for the group that received thrombolytic therapy, and 0.64 ( P = .024) for the group that did not receive thrombolytic therapy. Conclusions The associations between Selvester QRS Score and ceMRI-based MI were statistically significant and similar in both groups.

EASI-Derived vs standard 12-lead electrocardiogram for Selvester QRS score estimations of chronic myocardial infarct size, using cardiac magnetic resonance imaging as gold standard

Background The size of myocardial infarction (MI) is of significance for the prognosis. Selvester scores might be valuable for this estimation. Objective To compare the differences in Selvester scores for chronic MI provided from standard and EASI-derived 12-lead electrocardiograms (ECGs) and to compare these scores to the MI size measured by delayed-enhancement magnetic resonance imaging (DE-MRI). Methods Thirty-seven patients were studied. In connection with their DE-MRI scan follow-up after chest pain, body surface potential mapping was performed. Standard and EASI 12-lead ECGs were constructed from the maps. Two investigators manually performed the measurements required for scoring with the Selvester system using a quad-plot format of the ECGs. One of the investigators repeated this once for the standard leads. Results The differences between the 2 ECG estimations of MRI-measured MI size were not statistically significant. Neither the association nor the agreement between MRI and EASI-lead measurements or between MRI and standard-lead measurements were very strong. Conclusions The differences between ECG and MRI measurements of MI size indicate that both methods may need improvement.

ECG Quantification of Myocardial Scar in Cardiomyopathy Patients With or Without Conduction Defects

Background— Myocardial scarring from infarction or nonischemic fibrosis forms an arrhythmogenic substrate. The Selvester QRS score has been extensively validated for estimating myocardial infarction scar size in the absence of ECG confounders, but has not been tested to quantify scar in patients with hypertrophy, bundle branch/fascicular blocks, or nonischemic cardiomyopathy. We assessed the hypotheses that (1) QRS scores (modified for each ECG confounder) correctly identify and quantify scar in ischemic and nonischemic patients when compared with the reference standard of cardiac magnetic resonance using late-gadolinium enhancement, and (2) QRS-estimated scar size predicts inducible sustained monomorphic ventricular tachycardia during electrophysiological testing. Methods and Results— One hundred sixty-two patients with left ventricular ejection fraction ≤35% (95 ischemic, 67 nonischemic) received 12-lead ECG and cardiac magnetic resonance using late-gadolinium enhancement before implantable cardioverter defibrillator placement for primary prevention of sudden cardiac death. QRS scores correctly diagnosed cardiovascular magnetic resonance scar presence with receiver operating characteristics area under the curve of 0.91 and correlation for scar quantification of r =0.74 ( P &lt;0.0001) for all patients. Performance within hypertrophy, conduction defect, and nonischemic subgroups ranged from area under the curve of 0.81 to 0.94 and r =0.60 to 0.80 ( P &lt;0.001 for all). Among the 137 patients undergoing electrophysiological or device testing, each 3-point QRS-score increase (9% left ventricular scarring) was associated with an odds ratio for inducing monomorphic ventricular tachycardia of 2.2 (95% CI, 1.5 to 3.2; P &lt;0.001) for all patients, 1.7 (1.0 to 2.7, P =0.04) for ischemics, and 2.2 (1.0 to 5.0, P =0.05) for nonischemics. Conclusions— QRS scores identify and quantify scar in ischemic and nonischemic cardiomyopathy patients despite ECG confounders. Higher QRS-estimated scar size is associated with increased arrhythmogenesis and warrants further study as a risk-stratifying tool.

ST Resolution 1 Hour After Fibrinolysis for Prediction of Myocardial Infarct Size: Insights from ASSENT 3

Acute ST-segment elevation myocardial infarction requires prompt restoration of myocardial perfusion to salvage myocardium at risk of ischemic necrosis and improve clinical outcome. Early resolution of ST-segment elevation during the time after reperfusion has been associated with both these end points. From the ASsessment of the Safety and Efficacy of a New Thrombolytic regimen (ASSENT) 3 trial, 3,425 patients were analyzed to investigate whether the amount of ST-segment resolution, divided into 3 groups (complete, >70%; partial, 30% to 70%; and no resolution, <30%), in the first hour after initiation of therapy was a predictor of final infarct size, estimated by peak creatine kinase and Selvester QRS score on the discharge electrocardiogram. Complete compared with partial and no ST resolution resulted in significantly (p<0.001) smaller infarct sizes of 10.5%, 13.2%, and 15.0% of the left ventricle and significantly (p=0.001) fewer patients with peak creatine >5 times the upper reference level at 50.3%, 71.8%, and 76.3%, respectively. In conclusion, our findings supported previous smaller studies suggesting that early resolution of ST elevation, as a sign of early myocardial reperfusion, resulted in less myocardial damage and preservation of left ventricular function.