Journal of Electrocardiology
Volume 43, Issue 2 , Pages 91-103, March 2010

Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology☆

  • Kjell Nikus, MD

      Affiliations

    • Department of Cardiology, Heart Center, Tampere University Hospital, Biokatu 6, Tampere, Finland
    • Corresponding Author InformationCorresponding author. Department of Cardiology, Heart Center, Tampere University Hospital, Biokatu 6, 33520 Tampere, Finland.
    • ,
  • Olle Pahlm, MD

      Affiliations

    • Department of Clinical Physiology, Lund University Hospital, Lund, Sweden
    • ,
  • Galen Wagner, MD

      Affiliations

    • Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
    • ,
  • Yochai Birnbaum, MD

      Affiliations

    • Baylor College of Medicine, Houston, Texas, USA
    • ,
  • Juan Cinca, MD

      Affiliations

    • Cardiology Service-Institut Català de Ciencies Cardiovasculars, Hospital Santa Creu i Sant Pau, Barcelona, Spain
    • ,
  • Peter Clemmensen, MD

      Affiliations

    • Department of Cardiology B, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
    • ,
  • Markku Eskola, MD

      Affiliations

    • Department of Cardiology, Heart Center, Tampere University Hospital, Biokatu 6, Tampere, Finland
    • ,
  • Miquel Fiol, MD

      Affiliations

    • Hospital Son Dureta, Palma de Mallorca, Spain
    • ,
  • Diego Goldwasser, MD

      Affiliations

    • Cardiology Service-Institut Català de Ciencies Cardiovasculars, Hospital Santa Creu i Sant Pau, Barcelona, Spain
    • ,
  • Anton Gorgels, MD

      Affiliations

    • Department of Cardiology, University Hospital Maastricht, The Netherlands
    • ,
  • Samuel Sclarovsky, MD

      Affiliations

    • Procardia Medical Center, Tel Aviv, Israel
    • ,
  • Shlomo Stern, MD

      Affiliations

    • Hebrew University of Jerusalem, Jerusalem, Israel
    • ,
  • Hein Wellens, MD

      Affiliations

    • Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
    • ,
  • Wojciech Zareba, MD

      Affiliations

    • Cardiology Division of the Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
    • ,
  • Antoni Bayés de Luna, MD

      Affiliations

    • Institut Català Ciències Cardiovasculars, Barcelona, Spain

Received 1 November 2008 published online 16 November 2009.

Abstract 

The electrocardiogram (ECG) remains the most immediately accessible and widely used diagnostic tool for guiding emergency treatment strategies. The ECG recorded during acute myocardial ischemia is of diagnostic, therapeutic, and prognostic significance. In patients with myocardial ischemia as a result of decreased blood supply, the initial 12-lead ECG typically shows (1) predominant ST-segment elevation (STE) as part of STE acute coronary syndrome (STE-ACS), or (2) no predominant STE, that is, non–STE ACS (NSTE-ACS). Patients with predominant STE are classified as having either aborted myocardial infarction (MI) or ST-elevation MI (STEMI) based on the absence or presence of biomarkers of myocardial necrosis. The MI may be aborted either by spontaneous or therapeutic reperfusion of the ischemic myocardium before development of myocardial cell necrosis. NSTE-ACS patients are classified as having either unstable angina or NSTE-MI, based also on the absence or presence of biomarkers of mycardial necrosis.

The information obtained from the 12-lead ECG at presentation should be complemented by repeated ECGs especially during symptoms indicative of ischemia and, if applicable, by comparing the findings with reference ECGs. Also, continuous ECG recording in a coronary care setting, including the comparison of ECGs with and without pain, adds to the information gained at patient presentation.

In this article, mechanisms of ischemic ECG changes and the ECG patterns recorded in both STE-ACS and NSTE-ACS are described. ECG patterns of NSTE-ACS, which include ST depression, negative T wave, and even normal ECG, need to be better defined in future studies to correlate them with the severity and extent of ischemia and to explore to what extent they are explained by acute active ischemia or represent consequences of ischemia. One of the aims of this article is to propose a classification of the ECG patterns encountered in different clinical scenarios of ACS. How these patterns will aid in guiding the diagnostic and therapeutic process is discussed.

Keywords: Electrocardiogram, Acute coronary syndromes

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☆ Dr Clemmensen has research contracts and serves as consultant to Medtronic Inc. Dr Wagner has research grants or contracts from Medtronic Inc and Welch Allyn.

PII: S0022-0736(09)00282-9

doi:10.1016/j.jelectrocard.2009.07.009

Journal of Electrocardiology
Volume 43, Issue 2 , Pages 91-103, March 2010

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