Interpretation of the ECG during Exercise and Recovery

2018 ◽  
pp. 160-198 ◽  
Author(s):  
Gregory S. Thomas ◽  
Sonia R. Samtani ◽  
Myrvin H. Ellestad
Keyword(s):  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Exercise Testing ◽  
Exercise Test ◽  
P Wave ◽  
St Depression ◽  
St Segment ◽  
Electrocardiographic Changes ◽  
St Elevation ◽  
Ecg Leads

The chapter Interpretation of the ECG During Stress Testing reviews the electrocardiographic changes of ischemia during exercise testing. Normal ECG changes during exercise are reviewed and include the Ta wave of atrial repolarization which is directed in the opposite direction of the P wave. Its duration extends into the ST segment, resulting in a false positive exercise test in some patients. The type, severity and duration of ST depression predicts CAD severity and outcome. Downsloping ST depression is more ominous than horizontal which is worse than upsloping. As Ellestad has long posited, an abnormal ST segment response is >1 mm of downsloping and horizontal and >1.5 mm of upsloping ST depression. The 12 lead ECG leads most predictive of myocardial ischemia are leads V4-6, I, and aVR. ST elevation in leads without Q waves occurs secondary to transmural ischemia and localizes to the stenotic coronary artery.

scholarly journals Electrocardiographic Effects of Propofol versus Etomidate in Patients with Brugada Syndrome

2020 ◽  
Vol 132 (3) ◽  
pp. 440-451 ◽  
Author(s):  
Panagiotis Flamée ◽  
Varnavas Varnavas ◽  
Wendy Dewals ◽  
Hugo Carvalho ◽  
Wilfried Cools ◽  
...  
Keyword(s):  
Brugada Syndrome ◽  
St Segment Elevation ◽  
St Depression ◽  
St Segment ◽  
Qrs Prolongation ◽  
Significant Difference ◽  
Electrocardiographic Changes ◽  
St Elevation ◽  
The Right ◽  
Double Blinded

Abstract Background Brugada Syndrome is an inherited arrhythmogenic disease, characterized by the typical coved type ST-segment elevation in the right precordial leads from V1 through V3. The BrugadaDrugs.org Advisory Board recommends avoiding administration of propofol in patients with Brugada Syndrome. Since prospective studies are lacking, it was the purpose of this study to assess the electrocardiographic effects of propofol and etomidate on the ST- and QRS-segments. In this trial, it was hypothesized that administration of propofol or etomidate in bolus for induction of anesthesia, in patients with Brugada Syndrome, do not clinically affect the ST- and QRS-segments and do not induce arrhythmias. Methods In this prospective, double-blinded trial, 98 patients with established Brugada syndrome were randomized to receive propofol (2 to 3 mg/kg-1) or etomidate (0.2 to 0.3 mg/kg-1) for induction of anesthesia. The primary endpoints were the changes of the ST- and QRS-segment, and the occurrence of new arrhythmias upon induction of anesthesia. Results The analysis included 80 patients: 43 were administered propofol and 37 etomidate. None of the patients had a ST elevation greater than or equal to 0.2 mV, one in each group had a ST elevation of 0.15 mV. An ST depression up to −0.15mV was observed eleven times with propofol and five with etomidate. A QRS-prolongation of 25% upon induction was seen in one patient with propofol and three with etomidate. This trial failed to establish any evidence to suggest that changes in either group differed, with most percentiles being zero (median [25th, 75th], 0 [0, 0] vs. 0 [0, 0]). Finally, no new arrhythmias occurred perioperatively in both groups. Conclusions In this trial, there does not appear to be a significant difference in electrocardiographic changes in patients with Brugada syndrome when propofol versus etomidate were administered for induction of anesthesia. This study did not investigate electrocardiographic changes related to propofol used as an infusion for maintenance of anesthesia, so future studies would be warranted before conclusions about safety of propofol infusions in patients with Brugada syndrome can be determined. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals Microfistulas Causing Diverse Regional Ischemia: Consecutive Inferior and Lateral ST-Elevation Myocardial Infarction

2020 ◽  
Vol 23 (10) ◽  
pp. 704-706
Author(s):  
Tufan Çınar ◽  
Yavuz Karabağ ◽  
İbrahim Rencuzogullari ◽  
Metin Cağdaş
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
St Elevation Myocardial Infarction ◽  
Type I ◽  
St Segment Elevation ◽  
St Segment ◽  
Coronary Artery Fistulas ◽  
Clinical Consequences ◽  
Electrocardiographic Changes ◽  
St Elevation

Coronary artery fistulas (CAFs) are described as abnormal communications between a coronary artery and cardiac chambers, or other vascular structures. The two types of CAFs are defined as type I (singular fistula) and type II (microfistulas). Even though various electrocardiographic changes have been previously described in CAF patients, coronary-artery microfistulas causing ST-segment elevation in diverse locations have not been reported. We describe a case report of an adult patient who presented with acute inferior myocardial infarction due to coronary-artery microfistulas. During the hospital stay, the patient re-experienced chest pain, and control electrocardiography revealed ST-segment elevation in the I and AVL leads along with reciprocal ST-segment depression in the inferior precordial leads. Although CAFs are clinically rare, they can have important clinical consequences. Microfistulas should be kept in mind as a cause of ST elevation myocardial infarction in some patients.

scholarly journals Clinical Paradox: Anterior Wall Myocardial Infarction with Predominant Inferior ST Elevation and No Variation in Coronary Anatomy in a PAI-1 Homozygote

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Marko Perčić ◽  
Tea Friščić ◽  
Jasna Čerkez Habek ◽  
Dean Strinić ◽  
Ninoslav Rudman ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Anterior Wall ◽  
St Depression ◽  
St Segment ◽  
Electrocardiographic Changes ◽  
St Elevation ◽  
Anterior Wall Myocardial Infarction ◽  
Distal Occlusion ◽  
Pai 1

Changes of the ST segment are commonly used as predictors of the culprit vessel during an acute myocardial infarction. In case of combined ST elevation in both inferior and anterior leads, these changes can be due to a distal occlusion of a “wrapped” left anterior descending artery (LAD) or a two-vessel disease. Our case of anterior wall myocardial infarction with inferior ST elevation and anterior ST depression shows that electrocardiographic changes during acute myocardial infarction cannot always be explained by logical sequelae of the injury current, vessel anatomy, and their irrigation territory.

scholarly journals Total Occlusion of the Left Descending and circumflex Coronary Artery without ST Elevation: the De Winter electrocardiographic pattern

2020 ◽  
Vol 19 (3) ◽  
pp. 159-161
Author(s):  
Asim Kalkan ◽  
◽  
Bora Cekmen ◽  
Behlul Bas ◽  
Mehmet Taylan Kocer ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Myocardial Infarctions ◽  
Circumflex Coronary Artery ◽  
Total Occlusion ◽  
Mortality And Morbidity ◽  
St Segment Elevation ◽  
Sharp Waves ◽  
St Depression ◽  
St Segment ◽  
St Elevation

de Winter syndrome, or anterior ST segment elevation myocardial infarction (STEMI), constitutes 2% of acute myocardial infarctions. In contrast to classic ST segment elevation as seen with STEMI, it involves ST depression with precordial derivations and sharp waves. de Winter syndrome indicates critical narrowing of the left ascending coronary artery (LAD). Recognizing this presentation is important in terms of both mortality and morbidity. We present the case of a 71-year old patient presenting at the Emergency Department with chest pain, who had findings of de Winter syndrome on their ECG. Coronary angiography confirmed occlusions in the LAD and circumflex (CX) coronary arteries.

scholarly journals Electrocardiographic changes in awassi diarrheic suckling lambs in Iraq

2019 ◽  
Vol 43 (1) ◽  
pp. 26-33
Author(s):  
Islam Jawad . Alkhafaji
Keyword(s):  
P Wave ◽  
Qrs Complex ◽  
Sinus Arrhythmia ◽  
T Wave ◽  
St Depression ◽  
St Segment ◽  
Electrocardiographic Changes ◽  
Qrs Duration ◽  
Awassi Lambs ◽  
T Waves

This study was done to investigate the electrocardiographic changes in 90 diarrheic nursed Awassi lambs, in comparison with 10 clinically healthy lambs of the same breed. Their ages were ranged from 5 days to 2 months, in Karbala City-Iraq, from November 2015 to April 2016. The  diarrheic lambs showed significant (P≤0.05) decreased duration of  P-wave (0.039±0.0000001 ms and shorter QRS wave amplitudes 0.6 0±0.042 mV with  duration 0.041±0.0008 ms  , higher T wave amplitude and   duration (  0.25±0.034 mV  and 0.070±0.002 ms)  , prolonged QT (0.21±0.004 ms) but  ST-segment  ( 0.17±0.004 ms) were its observed  sinus arrhythmia with tachycardia in  lead-II  in diarrheic lambs were recorded  compared with  non-diarrheic lambs group which their QRS duration and amplitude were it was (0.04±0.000001ms and 0.65±0.026 mV ) , T waves duration and amplitude were (  0.076±0.004 ms and 0.21±0.012 mV  )   QT interval (0.20±0.011 ms) and ST-segment (  0.16±0.011 ms) .The morphological abnormal of ECG changes in diarrheic suckling lambs characterized by a widening or flattening, bifid(mitral) and pulmonale (tall) shape  of P wave, increased P-R interval, increased duration of QRS complex and QT-prolongation, ST-depression or elevation .Inverted or board (slurring) tall, symmetric, peaked shape of T waves. These abnormal shapes appeared alternately   in lead I, II, III, aVR, aVL and aVF. Conclusively the diarrheic lambs showed serious abnormal changes of electrocardiography..

Reciprocal change, exercise-induced ST segment depression and coronary anatomy: Are they related in the post-infarct patient?

1988 ◽  
Vol 74 (6) ◽  
pp. 621-627 ◽  
Author(s):  
Donal P. Murray ◽  
Lip Bun Tan ◽  
Mahmood Salih ◽  
Peter Weissberg ◽  
R. Gordon Murray ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Exercise Test ◽  
Predictive Accuracy ◽  
Enzyme Release ◽  
Coronary Anatomy ◽  
St Depression ◽  
St Segment ◽  
Electrocardiographic Changes ◽  
Exercise Induced ◽  
Reciprocal Change

1. The relationship of reciprocal change on the electrocardiogram, at the time of acute myocardial infarction, to exercise-induced ST segment depression and coronary anatomy was studied in 125 post-infarct patients. 2. Eighty-three patients had reciprocal changes, 90 had exercise-induced ST depression and 72 had both of these findings. 3. Patients with reciprocal changes had larger myocardial infarctions, as assessed by peak enzyme release and ejection fraction, than patients without this finding. 4. Multi-vessel disease was significantly more common among patients with reciprocal changes and those with exercise-induced ST depression compared with patients without these findings. 5. The exercise test was more sensitive and had a higher predictive accuracy than reciprocal change when electrocardiographic changes were compared with findings at coronary angiography. 6. With both tests the antero-lateral leads were significantly more sensitive, but less specific, than the inferior leads in classifying patients. 7. Thus while both tests yielded information with regard to coronary anatomy in post-infarct patients, the exercise test was a better predictor of coronary anatomy than reciprocal change. 8. Therefore, reliance should not be placed on the presence or absence of reciprocal change alone when assessing patients for further investigation after myocardial infarction.

scholarly journals A case of left circumflex artery stenosis involving ST segment depression in multiple leads with ST elevation in lead augmented vector right

2019 ◽  
Vol 6 (7) ◽  
pp. 2598
Author(s):  
C. P. Karunadas ◽  
Cibu Mathew
Keyword(s):  
Beta Blockers ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Circumflex Artery ◽  
St Segment Elevation ◽  
Left Circumflex Artery ◽  
St Depression ◽  
St Segment ◽  
Lead Avr ◽  
St Elevation

Electrocardiography (ECG) patterns of ST-segment elevation in lead aVR with or without diffuse ST segment depression may predict either left main coronary artery or triple vessel stenosis. Here, we have presented the case of a 56-year-old female involving such an ECG pattern with ST-segment depression in more than eight leads and ST Segment elevation in lead aVR, however, showing stenosis of the mid-segment of the left circumflex artery (LCX). She was scheduled to undergo percutaneous coronary intervention with implantation of a drug-eluting stent with respect to mid LCX stenosis. The patient was asymptomatic post procedure and was discharged on beta blockers. To conclude, the ECG pattern of ST depression in multiple leads with ST-elevation in aVR lead can occur in LCX obstruction as well. 

Symptomatic and silent myocardial ischemia during exercise testing in coronary artery disease

1986 ◽  
Vol 58 (4) ◽  
pp. B43-B46 ◽  
Author(s):  
Ezra A. Amsterdam ◽  
Robert Martschinske ◽  
Lawrence J. Laslett ◽  
John C. Rutledge ◽  
Zakauddin Vera
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Exercise Testing ◽  
Silent Myocardial Ischemia ◽  
Artery Disease
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