Correlation between ST-segment elevation and negative T waves in the precordial leads in acute pulmonary embolism: insights into serial electrocardiogram changes.

BACKGROUND: Acute pulmonary embolism (APE) is often misdiagnosed as acute coronary syndrome because of the similarity of the presenting symptoms and of the electrocardiogram (ECG) manifestations. In APE, ST-segment elevation (STE) in leads V1 to V3 /V4 , mimicking anteroseptal myocardial infarction, is not a rare phenomenon. Negative T waves (NTW) in the precordial leads mimicking the "Wellens' syndrome" is an important ECG manifestation of APE. The evolution of these ECG changes-STE and NTW-in APE has not been thoroughly studied. METHODS: We present two patient cases with APE and their evolving serial ECGs to analyze the correlation between STE and NTW. RESULTS: NTW developed later than STE in these two patient cases. CONCLUSIONS: NTW might represent a "postischemic" ECG pattern indicating a previous stage with transmural myocardial ischemia.

Electrocardiographic findings in accessory right precordial leads in adults and seniors with notched S waves in lead V1-a preliminary study.

BACKGROUND: Atypical right bundle branch block (RBBB) may present with an rS pattern and notched S wave in lead V1 . The notched S wave may represent slowed conduction or delayed activation of the right ventricular conduction system or ventricular myocardium. METHODS: We retrospectively analyzed the QRS patterns in accessory right precordial leads (from V3 R to V5 R) in 15 adults/senior individuals with notched S wave in lead V1 . RESULTS: In the right accessory precordial leads, 13 showed triphasic QRS pattern with final R' wave in their QRS complexes. This QRS pattern in association with notched S wave in lead V1 is suggestive of the presence of RBBB (incomplete or complete). CONCLUSIONS: A notched S wave in lead V1 and in the right precordial accessory leads associated with a final R' wave suggests the possibility of concealed RBBB (incomplete or complete).

Correlation between ECG presentation and cardiovascular magnetic resonance imaging in Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TTC) is characterized by acute and reversible ventricular dysfunction in the absence of significant coronary artery disease, typically triggered by acute emotional or physical stress. In the acute phase of TTC, the electrocardiogram (ECG) shows ST-segment elevation, which rapidly evolves into negative T waves and QT prolongation. However, different types of ventricular dysfunction may be associated with different patterns of ECG presentation. In this paper, we discuss the correlation between ECG presentation and cardiovascular magnetic resonance imaging in TTC.

ST-segment deviation pattern of takotsubo cardiomyopathy similar to acute pericarditis: diffuse ST-segment elevation.

BACKGROUND: Possible similarities or differences in the ST- and PR-segment deviations in the electrocardiogram of takotsubo cardiomyopathy (TTC) and acute pericarditis (AP) are not well defined. METHODS: We compared different parameters of the admission electrocardiogram in eight patients with TTC and eight patients with AP with ST-segment elevation in the acute phase. RESULTS: We found significant differences in the maximal magnitude of the T wave in the precordial leads, but not in the ST- and PR-segment deviation patterns between the two patient groups. All the patients in the two groups showed consistent ST-segment depression in lead aVR and absence of ST-segment elevation in lead V1. CONCLUSIONS: The ST- and PR-segment deviation patterns in TTC are similar to that of AP, namely diffuse ST-segment elevations with reciprocal changes in aVR and V1 and PR-segment elevation in aVR accompanied by PR-segment depression in the inferior leads, possibly indicating that TTC has ECG characteristics of circumferential subepicardial ischemia in the acute phase.

Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V3R, V1 or aVR: electrocardiographic and angiographic correlations.

BACKGROUND: The correlation between ST-segment elevation (ST upward arrow) in lead V(3)R (ST upward arrow(V3R)), lead V(1) (ST upward arrow(V1)), and lead aVR (ST upward arrow(aVR)) during anterior wall acute myocardial infarction (AMI) and the culprit lesion site in the left anterior descending (LAD) coronary artery and the nature of the conal branch of the right coronary artery has not been thoroughly described. METHODS: One hundred forty-two patients with first anterior wall AMI were included. The 15-lead electrocardiogram with the standard 12 leads plus leads V(3)R through V(5)R showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site in relation to the first septal perforator (S1) and the nature of the conal branch of the right coronary artery as determined by coronary angiography. RESULTS: ST-segment elevation in lead aVR, ST upward arrow(V1) of at least 2 mm, and ST upward arrow(V3R) of at least 1 mm were more prevalent among patients with occlusions proximal to S1 than patients with occlusions distal to S1 (41.7% vs 4.9%, P < .01; 30.0% vs 7.3%, P < .01; and 91.7% vs 4.9%, P < .01, respectively). Of the 60 patients with occlusions proximal to S1, 20 patients had a small conal branch (18 patients with ST upward arrow(aVR) and 15 patients with ST upward arrow(V1) >or=2 mm), and 24 patients had a large conal branch (all patients with non-ST upward arrow(aVR) and ST upward arrow(V1) <2 mm; P < .01). The sensitivity of ST upward arrow(V1) of more than 1 mm, of at least 2 mm, ST upward arrow(V3R) of at least 1.5 mm, and ST upward arrow(aVR) for detecting a small conal branch was 65.1%, 81.8%, 84.0%, and 90%, respectively; the specificity was 68.5%, 64%, 66.7%, and 64.9%, respectively. CONCLUSIONS: In patients with anterior wall AMI, ST upward arrow(V3R) of at least 1 mm combined with ST upward arrow in leads V(2) through V(4) were strongly predictive of LAD occlusion proximal to S1; furthermore, ST upward arrow(aVR) and ST upward arrow(V1) of at least 2 mm were found to be useful in identifying LAD occlusion proximal to S1. ST upward arrow(aVR), ST upward arrow(V3R) of at least 1.5 mm, and ST upward arrow(V1) of at least 2.0 mm were also associated with the presence of a small conal branch not reaching the intraventricular septum during anterior wall AMI.