The Surface Electrocardiography in Ischemic Heart Disease: Clinical and Imaging Correlations and Prognostic Implications

349 Pages·2008·19.38 MB·English

by  Antonio Bayes de Luna

BLUK094-Bayes September11,2007 7:39
The Surface
Electrocardiography
in Ischaemic Heart
Disease
i
BLUK094-Bayes September11,2007 7:39
The Surface
Electrocardiography
in Ischaemic Heart
Disease
CLINICAL AND IMAGING
CORRELATIONS AND
PROGNOSTIC IMPLICATIONS
A. Bayés de Luna,
MD, FESC, FACC
DirectorofCardiacDep.HospitalQuiron,Barcelona
ProfessorofMedicine,UniversidadAutonomaBarcelona
DirectorofInstitutCataladeCardiologia
HospitalSantaCreuISantPau
St.AntoniM.Claret167
ES-08025
Barcelona
Spain
M. Fiol-Sala,
MD
ChiefoftheIntensiveCoronaryCareUnit
IntensiveCoronaryCareUnit
HospitalSonDureta
Palma
Mallorca
Spain
With the collaboration of A. Carrillo†, D. Goldwasser*, J. Cino*,
A. Kotzeva*, M. Riera†, J. Guindo* and R. Baranowski*
∗FromtheInstitutCataladeCardiologica,HospitalSantaCreuISantPau,Barcelona,Spain
†FromtheIntensiveCoronaryCareUnit,HospitalSonDureta,Palma,Mallorca,Spain
iii
BLUK094-Bayes September11,2007 7:39
(cid:3)
C 2008A.Baye´sdeLunaandM.Fiol-Sala
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Firstpublished2008
1 2008
ISBN:978-1-4051-7362-9
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Baye´sdeLuna,Antonio.
Thesurfaceelectrocardiographyinischemicheartdisease:clinicalandimaging
correlationsandprognosticimplications/A.Baye´sdeLuna,M.Fiol-Sala.
p. ; cm.
Includesbibliographicalreferencesandindex.
ISBN978-1-4051-7362-9
1.Coronaryheartdisease–Diagnosis. 2.Electrocardiography.I.Fiol-Sala,M.(Miguel)
II.Title.
[DNLM: 1.MyocardialIschemia–diagnosis. 2.Electrocardiography–methods.WG300B357s2007]
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iv
BLUK094-Bayes September11,2007 7:39
Contents
ForewordbyGu¨nterBreihardt, vi 7 Patientswithacutechestpain:roleofthe
ECGanditscorrelations, 199
ForewordbyElliottM.Antman, vii
8 Acutecoronarysyndrome:unstableangina
Introduction, ix
andacutemyocardialinfarction, 209
PartI TheECGindifferentclinical 9 MyocardialinfarctionwithQwave, 275
settingsofischaemicheartdisease:
10 MyocardialinfarctionwithoutQwaves
correlationsandprognostic
orequivalent:acuteandchronicphase, 289
implications, 1
11 Clinicalsettingswithanginalpain,outside
1 Anatomyoftheheart:theimportance
theACS, 297
ofimagingtechniquescorrelations, 3
12 Silentischaemia, 302
2 Electrocardiographicchangessecondaryto
myocardialischaemia, 19 13 UsefulnessandlimitationsoftheECGinchronic
ischaemicheartdisease, 304
3 Electrocardiographicpatternofischaemia:
T-waveabnormalities, 30 14 TheECGasapredictorofischaemic
heartdisease, 308
4 Electrocardiographicpatternofinjury:
ST-segmentabnormalities, 55 References, 310
5 Electrocardiographicpatternofnecrosis: Index, 325
abnormalQwave, 128
Colourplate,facingpage12
PartII TheECGindifferentclinical
settingsofischaemicheartdisease:
correlationsandprognostic
implications, 195
6 Acuteandchronicischaemicheartdisease:
definitionofconceptsandclassification, 197
v
BLUK094-Bayes September11,2007 7:39
Foreword by Gu¨nter Breihardt
Itisagreatpleasureandhonourformetopresent ofstillusedclassificationsandcorrelationsbutthey
thisforewordtothisnewandexcitingbook. alsopresentsolutionstotheseproblemsbasedon
Untilrecently,correlationsbetweentheECGand recentanatomic–electrocardiographiccorrelations.
thestructuralchangesofthehearthavereliedonex- Theirpresentationisbasedontherecentpioneering
perimentalstudiesandonstudiesdoneatautopsy, work,initiatedbyAntoniBaye´sdeLuna,ontheuse
and only to a limited degree on modern imaging ofmagneticresonanceimaginganditscorrelations
techniques. When invasive coronary angiography withtheECG.
came into broad use, the general interest shifted Thisbookdeservestheattentionofallthosewho
awayfromthesimpletooloftheECGthatwascon- takecareoftheever-increasingnumberofpatients
sideredaslowtechnology,leadingtoagradualde- with ischaemic heart disease. It is a treasure and
cline in interest in and knowledge of the ECG in a must for everyone who is involved in manag-
ischaemicheartdisease.Thisisincontrasttowhat ing patients with ischaemic heart disease, be it as
has happened over many years in the field of ar- practitioner, internist, cardiologist or as intensive
rhythmiaswheretherehasbeenacontinuinglearn- care physician or interventionalist, as teacher or
ingprocesswithincreasinglybetterinterpretation as student – all will benefit from the vast experi-
ofarrhythmiasbasedonmoreandmoresophisti- enceoftheauthorsandfromtheinformationfrom
catedinvasiveelectrophysiologicalstudies. theirownstudiesandtheliteraturethattheyhave
Fortunately,someprominentandexpertclinical assembled.
researchershavekepttheirinterestintheECGalive. The reader and eager student of this book will
AmongthemisAntoniBaye´sdeLunawho,jointly appreciatethatthemostimportantmessagesofeach
with Miquel Fiol Sala, now can be congratulated chapteraresummarisedinaboxthatemphasisesthe
forthepresentbookonclinicalandimagingcorre- didacticclaimofthiswork.
lationsandtheprognosticimplicationsofthesur- Thisbookhasthepotentialtobecomethe‘bible’
faceECGinischaemicheartdisease.Bothauthors in this field for generations to come, hopefully
rightlystatethattheyareauthorsandnoteditorsof worldwide.
amulti-authorbook.Lookattheresult:Thisbook
hasaquitehomogenousandunifiedpresentation Gu¨nterBreithardt,MD,FESC,FACC,FHRS
which can only be achieved if there is a common ProfessorofMedicine(Cardiology)
geniusbehindit. HeadoftheDepartmentofCardiology
The aim of this book is to present better cor- andAngiology;and
relations between the structure of the heart, its HeadoftheDepartmentof
variouswalls,especiallythoseoftheleftventricle, MolecularCardiologyofthe
andtheirrelationshipwiththetorso.Thiswillhelp Leibniz-InstituteforArteriosclerosisResearch,
to eliminate much of the confusion in the inter- WestphalianWilhelms–UniversityofMu¨nster,
pretation of the ECG and the terms used, which Mu¨nster,Germany
hasarisenoverseveraldecadesandstillcontinues
today.Theauthorsnotonlypointtothelimitations May2007
Mu¨nster,Germany
vi
BLUK094-Bayes September11,2007 7:39
Foreword by Elliott M. Antman
Medicaldecision-makingconsistsofafive-steppro- binationwithEinthovensthreelimbleads,thesix
cess including obtaining a medical history from precordialleads,andtheaugmentedunipolarleads
the patient, selecting the appropriate diagnostic formthe12-leadelectrocardiogramrecordingpat-
tests,interpretingtheresultsofthediagnostictests, ternasweknowittoday.
weighingtherisksandbenefitsofadditionaltesting Withthepassageoftime,manynewandhighly
or potential therapeutic interventions, and agree- sophisticated imaging and biochemical test have
ing on a plan of a therapeutic approach in con- beenintroducedintoclinicalmedicine.Somemight
junctionwiththepatientswishes.Adiagnostictest argue that the 12-lead electrocardiogram has lost
thatoptimizessensitivityandspecificityispartic- someitslusterbutamorepenetratinganalysisof
ularly attractive clinically, since it is used to am- thesituationshowsthatthisisnotthecase.Thenew
plify the prior probability that a particular diag- imagingandbiochemicaltestsamplifyandextend
nostic condition is present. Given the escalating our ability to interpret the 12-lead electrocardio-
cost of health care, a diagnostic test is especially graminwaysthatwedidnotrealizewerepossible
attractiveifitisinexpensive.Diagnosticteststhat inthepast.
contain these features and utilize equipment that One of the most important applications of the
isuniversallyavailablearemorelikelytostandthe surface electrocardiogram is in evaluation of pa-
test of time in clinical medicine. One such diag- tientswithischemicheartdisease.Thiseleganttext-
nostictest–theelectrocardiogram–standsoutas bookbyDrs.A.BayesdeLunaandM.Fiol-Salais
a shining example of a successful diagnostic test. a refreshing modernistic look at the surface elec-
It is a well accepted component of the diagnos- trocardiogram by two internationally recognized
tictoolboxofhealthcareprofessionalsaroundthe experts in the field. They provide the reader, in
world. a single volume, a richly illustrated resource that
Einthoven is often credited as the individual integratesclinicalfindings,contemporaryimaging
who introduced the electrocardiogram to clinical modalities, cutting edge biomarker findings with
medicine.Afterapplyingastringgalvanometerto a 100-year old diagnostic test – the 12-lead sur-
recordtheheartselectricalsignalsonthesurfaceof face electrocardiogram. The book is divided into
thebody,itwasin1895thatheintroducedthefive twoparts.First,electrocardiographicpatternsofis-
deflectionsP,Q,R,S,andT.WillemEinthovenwas chemia,injury,andinfarctionarediscussed.Polar
honored in 1924 for his invention of the electro- maps,vectorialillustrations,andsimplediagrams
cardiographbyreceivingtheNobelPrizeinPhys- illustrating the relationship between myocyte ac-
iology or Medicine. In 1934, Frank Wilson intro- tion potentials and the surface electrocardiogram
duced the concept of unipolar leads, and in 1938 areappealingforboththenoviceandexperienced
theAmericanHeartAssociationandCardiacSoci- reader. The second part of the book explores the
etyofGreatBritaindefinedthestandardpositions useofthesurfaceelectrocardiograminavarietyof
andwiringofthechestleadsV1–V6.In1942,Gold- clinicalsettingsofischemicheartdisease,touching
bergerintroducedthetechniqueforincreasingthe onthecorrelationswithcoronaryanatomyandthe
voltageofWilsonsunipolarleads,thuscreatingthe prognostic implications that can be gleaned from
augmentedlimbleadsaVR,aVL,andaVF.Incom- theECG.
vii
BLUK094-Bayes September11,2007 7:39
viii Foreword
ThistextbookbyBayesdeLunaandFiolSalais ElliottM.Antman
amarvelousexampleofwhatcanbeaccomplished SeniorInvestigator,TIMIStudyGroup
whenclinicianswhoarecomfortableatthepatient’s ProfessorofMedicine,HarvardMedicalSchool;and
bedside also have the visionary insight to incor- DirectoroftheSamuelA.LevineCardiacUnit
poratenewknowledgefromcontemporarycardiac attheBrigham&Women’sHospital
imaging procedures into a fresh view of an older, CardiovascularDivision
but still extremely useful, diagnostic test. As with Brigham&Women’sHospital
theclassical12-leadelectrocardiogramitself,read- Boston
ersofthistextbookwillfindthemselvesreturning USA
toitoverandoveragainbecauseofthedepthand
breadthofitsclinicalusefulness. May2007
Boston,USA
BLUK094-Bayes September11,2007 7:39
Introduction
The electrocardiogram (ECG), which was discov- helpstostratifytheriskand,consequently,totake
eredmorethan100yearsagoandhasjustcelebrated themostappropriatetherapeuticdecision.
itsfirstcentury,appearstobemorealivethanever. In the chronic phase of Q-wave infarction, the
Until recently its utility was especially important ECGisalsoveryuseful,sincetheidentificationof
foridentifyingdifferentECGmorphologicalabnor- differentECGpatternsofinfarctionpermitsusto
malities,includingarrhythmias,blocksatalllevels, haveareliableapproximationoftheinfarctedarea.
pre-excitation, acute coronary syndromes, as well Lastly, the ECG is of great importance, as the
as Q-wave acute myocardial infarction, for which number of patients with IHD is very large, and
ECGwasthe‘gold-standard’diagnostictechnique. thereforetherepercussiontoproperlyunderstand
Anauthenticre-evaluationofECGhasbeenevi- theECGchangesmayhaveanextraordinarysocial
dencedinthelastyearsasaresultofthegreatimpor- andeconomicimpact.
tanceitacquiredintheriskstratificationandprog- Nevertheless,inspiteofallabove-mentionedar-
nosisofdifferentheartdiseases.Everyyearthereis guments, there are few books that have dealt in a
moreandmoreinformationthatdemonstratesthat globalmannerwiththevalueofECGinIHD.Over
ECGprovidesnewandimportantdata,anditsap- 30yearsagoSchamrothandGoldbergerwrotetwo
plicationsaregrowingandwillbeexpandedinthe important works, dedicated more to the chronic
future.IthasbeenrecentlyconfirmedthatECGal- phaseofIHD,whichhaveinevitablybecomeout-
lowsustoapproachwithhighreliabilitythemolec- datedinmanyaspects.Morerecently,twogroups,
ularmechanismsthatexplainsomeheartdiseases, thoseofWellensandSclarovsky,whichhavepub-
suchaschanellopathies.Forexample,thecorrela- lishedpioneerstudiesontheimportanceoftheECG
tionbetweenECGchangesandthegenesinvolved intheacutephaseofIHD,havepublishedtwoexcel-
inlongQTsyndromeiswellknown. lentbooksthatbrilliantlydealwiththeECG’srole
AlthoughtheusefulnessofthesurfaceECGisim- intheacutephaseofthisdisease.Wenevertheless
portantinalltypesofheartdiseases,itstandsout consideredthatintheoverallcontextoftheECG’s
particularly in the case of ischaemic heart disease importance in IHD there remained a space to fill
(IHD),forvariousreasons.TheECGisthekeydi- inthisfield.Thatiswhatweintendtodowiththis
agnostictoolbothintheacutephaseofIHD(acute publication.
coronarysyndromes,ACSs)andinthechronicone One of the most important and new aspects of
(Q-waveinfarction).Furthermore,itiscrucialfor the book is the great number of correlations not
riskstratificationinpatientswithacuteischaemic onlywithcoronariographybutalsowithechocar-
pain.TheACSsarenowadaysdividedintotwotypes: diography,isotopicstudiesandnewimagingtech-
withorwithoutST-segmentelevation.Thisisex- niques, especially cardiovascular magnetic reso-
tremely important in the decision making to use nance(CMR),andalsoinsomecaseswithcoronary
fibrinolytic therapy. In the case of an ACS, espe- multidetector computer tomography (CMDCT).
ciallywithST-segmentelevation(STE-ACS),acare- Allthesecorrelationshavegivenusahugeamount
fulevaluationofST-segmentdeviationsindifferent ofimportantandnewinformation.
leadsallowsustoascertainnotonlytheoccluded WeexplaintheECGpatternofchronicQ-wave
artery but also the site of occlusion. Therefore, it myocardialinfarction(MI)basedonthecorrelation
ix
BLUK094-Bayes September11,2007 7:39
x Introduction
withtheVCGloops.WeconsiderthattheECG-VCG understandtheECGcurvesgeneratedduringacute
correlationisthemostdidacticwaytoexplainECG andchronicischaemia.
(BayesdeLuna1977,1999).However,weonlycom- In the second part we explain a detailed global
mentinthisbooktheECGcriteriafordiagnosisof approachthathastobedoneinpatientswithacute
chronic-QwaveMIbecausethereisnotagreement precordialpain,emphasisingontheimportanceof
supportingthattheVCGcriteriapresentbetterac- ECGchanges,firsttodiagnosetheischaemicorigin
curacythanECGcriteria(Hurd1981,Warner1982) andlatertostratifytheriskindifferenttypesofACS.
TandtheuseofVCGismoretime-consumingand OtherelectrocardiographicfeaturesofACS,suchas
hasnotbecomepopularinclinicalpractice.Inorder coexisting arrhythmias, conduction disturbances,
tosetupitsrealimportancecouldbemandatoryin ECGchangesfollowingfibrinolytictreatmentand
the era of imaging techniques to perform a com- mechanicalcomplicationsandtheECGcharacter-
parative study of ECG and VCG criteria with the isticsofatypicalACSs,arealsopresented.Further-
standarsofcardiovascularmagneticresonance. more, we comment on the new, current concepts
When necessary, we also comment on the of MI with and without Q wave, the ECG mark-
role of other non-invasive electrocardiographic ersofpoorprognosisinchronicIHDandtheECG
techniques, especially exercise ECG and Holter characteristicsofotherclinicalsettingswithangi-
monitoring.Justafewremarksaregivenonother nalpainoutsidetheacutephaseofACSaschronic
non-invasive electrocardiological techniques. The stable angina, X syndrome, silent ischaemia, etc.
invasive electrophysiological techniques are usu- Finally, the capacity of ECG as marker of IHD is
ally not useful for risk stratification but are nec- alsodiscussed.
essaryincaseofresynchronisationandimplantable Theinformationgiveninthisbookmayhelpto
cardioverter-defibrillatorimplantationorablation perform the best diagnosis in patients with acute
procedures. thoracicpainandtotakedecisions,sometimesin
Wehavetwopartsinthisbook.Inthefirstone, anurgentmanner,forthebestapproachofmanage-
following comments on the most important as- mentinpatientswithacuteandchronicIHDs.We
pects of the heart’s anatomy related to IHD on wouldliketoemphasisethatwearenottheeditors,
thebasisofcoronariographicandimagingcorrela- buttheauthorsofthebook.Thisisimportant,be-
tions,wediscusstheconceptoftheECGpatternsof causealltheinformationisgiveninahomogeneous
ischaemia,injuryandinfarction,theelectrophysio- manner, without the presence of contradictory
logicalmechanismsthatexplainthemandthecor- opinionsthatoftenappearin‘edited’books.Also,
relation that exists between the presence of these thepresenceoffrequentcross-referenceswithinthe
patternsindifferentleadsandthemyocardialarea text makes the content of the book easier to fol-
involved. Correlations between ECG curves and low.Weareawarethatweareoftenrepetitive,es-
vectorcardiographicloopsconstitutethekeytoun- peciallywhenwecommentonthenewconceptsof
derstand the ECG morphologies. For this reason, ACSwithorwithoutSTEandthenewclassification
the two above-mentioned techniques of electrical of Q-wave MI based on CMR correlations. How-
activityrecordingareoftenrepresentedtogetherin ever,weconsiderthatthismaybehelpfulespecially
thisbook.Nevertheless,inclinicalpracticethesur- forthereaderswhoarenottoomuchinvolvedin
face ECG alone allows for making a correct diag- thetopicandalsoforconsultantsofsomespecific
nosis in most cases. Of particular interest is the topic.
possibility to locate the place of coronary occlu- WeexpressourgratitudetoE.Antman,pioneer
sion in patients with STE-ACS, thanks to the ap- in many aspects of IHD, who has written a gen-
plicationofsequentialalgorithms,andtoidentify erous Foreword to this book, for his support and
thetypicalandatypicalECGpatternsofSTE-ACS, collaboration. We have written together a mono-
andtodefineproperlytheclassificationofnon(N) graphrelatedtotheroleofsurfaceECGinpatients
STE-ACS.Alsoimportantisthenewclassificationof withacutethoracicpainandST-segmentelevation
infarctionincaseofQ-waveMIbasedonourex- MI,whichhasbeenmostlyincludedinthisbook,
perience with contrast-enhanced (CE)-CMR cor- andforthathemayalsobeconsideredco-authorof
relations. All this represents a new approach to thebook.AlsomythankstoGu¨nterBreithardt,an