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

References 

  1. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009;53:1003
  2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:E1
  3. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes. The task force for the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes of the European Society of Cardiology. Eur Heart J. 2007;28:1598
  4. Waxman S. Characterization of the unstable lesion by angiography, angioscopy, and intravascular ultrasound. Cardiol Clin. 1999;17:295
  5. Abela GS, Eisenberg JD, Mittelman MA, et al. Detecting and differentiating white from red coronary thrombus by angiography in angina pectoris and in acute myocardial infarction. Am J Cardiol. 1999;83:94
  6. Johnstone E, Friedl SE, Maheshwari A. Distinguishing characteristics of erythrocyte-rich and platelet-rich thrombus by intravascular ultrasound catheter system. J Thromb Thrombolysis. 2007;24:233
  7. Kleiman NS, White HD. The declining prevalence of ST elevation myocardial infarction in patients presenting with acute coronary syndromes. Heart. 2005;91:1121
  8. The Joint European Society of Cardiology/American College of Cardiology Committee . Myocardial infarction redefined—a consensus document of the joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction. Eur Heart J. 2000;21:1502
  9. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee on the management of patients with unstable angina). J Am Coll Cardiol. 2002;40:1366
  10. Montalescot G, Dallongeville J, Van Belle E, et al. STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Heart J. 2007;28:1409
  11. Roe MT, Parsons LS, Pollack CV, et al. Quality of care by classification of myocardial infarction: treatment patterns for ST-segment elevation vs. non–ST-segment elevation myocardial infarction. Arch Intern Med. 2005;165:1630
  12. Lamfers EJ, Hooghoudt TE, Hertzberger DP, et al. Abortion of acute ST segment elevation myocardial infarction after reperfusion: incidence, patients' characteristics, and prognosis. Heart. 2003;89:496
  13. Sclarovsky S. Electrocardiography of acute myocardial ischaemic syndromes. London, UK: Martin Dunitz Ltd.; 1999;
  14. In:  Wellens HJJ,  Gorgels APM,  Doevendans PA editor. The ECG in acute myocardial infarction and unstable angina. 1st ed. Norwell, Massachusetts, USA: Kluwer Academic Publishers; 2003;
  15. Bayés De Luna A, Fiol-Sala M. Electrocardiography in ischemic heart disease: clinical and imaging correlations and prognostic implications. Blackwell Publishing; 2007;
  16. Jacobs AK. Regional systems of care for patients with ST-elevation myocardial infarction: being at the right place at the right time. Circulation. 2007;116:689
  17. Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: a report of the ACC/AHA/ACP-ASIM task force on clinical competence (ACC/AHA committee to develop a clinical competence statement on electrocardiography and ambulatory electrocardiography) endorsed by the International Society for Holter and Noninvasive Electrocardiology. Circulation. 2001;104:3169
  18. Fayn J, Rubel P, Pahlm O, et al. Improvement of the detection of myocardial ischemia thanks to information technologies. Int J Cardiol. 2006;
  19. Eppinger H, Rothberger CJ. Zur analyse der electrokardiogramms. Wien klin Wchnschr. 1909;22:1091
  20. James TN, Geoghegan T. Sequential electrocardiographic changes following auricular injury. Am Heart J. 1953;46:830
  21. Sivertssen E, Hoel B, Bay G, et al. Electrocardiographic atrial complex and acute atrial myocardial infarction. Am J Cardiol. 1973;31:450
  22. Cinca J, Janse MJ, Morena H, et al. Mechanism and time course of the early electrical changes during acute coronary artery occlusion. An attempt to correlate the early ECG changes in man to the cellular electrophysiology in the pig. Chest. 1980;77:499
  23. Wagner NB, Sevilla DC, Krucoff MW, et al. Transient alterations of the QRS complex and ST segment during percutaneous transluminal balloon angioplasty of the left anterior descending coronary artery. Am J Cardiol. 1988;62:1038
  24. Birnbaum Y, Ware DL. Electrocardiogram of acute ST-elevation myocardial infarction: the significance of the various “scores”. J Electrocardiol. 2005;38:113
  25. Hurst JW. Interpreting electrocardiograms using basic principles and vector concepts. New York: Marcel Dekker; 2001;
  26. Pardee HEB. An electrocardiographic sign of coronary artery obstruction. Arch Intern Med. 1920;26:244
  27. Maseri A, Severi S, Nes MD, et al. Variant” angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol. 1978;42:1019
  28. In:  Katz AM editors. Physiology of the heart. 4th ed. Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2006;
  29. Baim DS, Grossman W. Grossman's cardiac catheterization, angiography and intervention. 6th ed.. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001;
  30. Visner MS, Arentzen CE, Parrish DG, et al. Effects of global ischemia on the diastolic properties of the left ventricle in the conscious dog. Circulation. 1985;71:610
  31. Aroesty JM, McKay RG, Heller GV, et al. Simultaneous assessment of left ventricular systolic and diastolic dysfunction during pacing-induced ischemia. Circulation. 1985;71:889
  32. Hlaing T, DiMino T, Kowey PR, et al. ECG repolarization waves: their genesis and clinical implications. Ann Noninvasive Electrocardiol. 2005;10:211
  33. Rautaharju PM, Surawicz B, Gettes LS, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009;53:982
  34. Kenigsberg DN, Khanal S, Kowalski M, et al. Prolongation of the QTc interval is seen uniformly during early transmural ischemia. J Am Coll Cardiol. 2007;49:1299
  35. Smith FM. The ligation of coronary arteries with electrocardiographic study. Arch Intern Med. 1918;22:8
  36. Somers MP, Brady WJ, Perron AD, et al. The prominent T wave: electrocardiographic differential diagnosis. Am J Emerg Med. 2002;20:243
  37. Bayes de Luna A, Carreras F, Cladellas M, et al. Holter ECG study of the electrocardiographic phenomena in Prinzmetal angina attacks with emphasis on the study of ventricular arrhythmias. J Electrocardiol. 1985;18:267
  38. Agetsuma H, Hirai M, Hirayama H, et al. Transient giant negative T wave in acute anterior myocardial infarction predicts R wave recovery and preservation of left ventricular function. Heart. 1996;75:229
  39. Herz I, Birnbaum Y, Zlotikamien B, et al. The prognostic implications of negative T waves in the leads with ST segment elevation on admission in acute myocardial infarction. Cardiology. 1999;92:121
  40. Doevendans PA, Gorgels AP, van der Zee R, et al. Electrocardiographic diagnosis of reperfusion during thrombolytic therapy in acute myocardial infarction. Am J Cardiol. 1995;75:1206
  41. Wasserburger RH, Corliss RJ. Prominent precordial T waves as an expression of coronary insufficiency. Am J Cardiol. 1965;16:195
  42. Zack PM, Aker UT, Kennedy HL. Pseudonormalization of T-waves during coronary angioplasty. Cathet Cardiovasc Diagn. 1987;13:191
  43. Noble RJ, Rothbaum DA, Knoebel SB, et al. Normalization of abnormal T waves in ischemia. Arch Intern Med. 1976;136:391
  44. Nikus KC, Eskola MJ, Virtanen VK, et al. ST-depression with negative T waves in leads V4-V5—a marker of severe coronary artery disease in non–ST elevation acute coronary syndrome: a prospective study of angina at rest, with troponin, clinical, electrocardiographic, and angiographic correlation. Ann Noninvasive Electrocardiol. 2004;9:207
  45. Hayden GE, Brady WJ, Perron AD, et al. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med. 2002;20:252
  46. Eskola MJ, Holmvang L, Nikus KC, et al. The electrocardiogram window of opportunity to treat vs. the different evolving stages of ST-elevation myocardial infarction: correlation with therapeutic approach, coronary anatomy, and outcome in the DANAMI-2 trial. Eur Heart J. 2007;28:2985
  47. Birnbaum Y, Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. Postgrad Med J. 2003;79:490
  48. Fiol M, Cygankiewicz I, Carrillo A, et al. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction. Am J Cardiol. 2004;94:709
  49. Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med. 2003;348:933
  50. Wellens HJ. The value of the right precordial leads of the electrocardiogram. N Engl J Med. 1999;340:381
  51. Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Eur Heart J. 2007;28:2525
  52. Perloff JK. The recognition of strictly posterior myocardial infarction by conventional scalar electrocardiography. Circulation. 1964;30:706
  53. Bayes de Luna A, Wagner G, Birnbaum Y, et al. A new terminology for left ventricular walls and location of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging: a statement for healthcare professionals from a committee appointed by the International Society for Holter and Noninvasive Electrocardiography. Circulation. 2006;114:1755
  54. Birnbaum Y, Herz I, Sclarovsky S, et al. Prognostic significance of precordial ST segment depression on admission electrocardiogram in patients with inferior wall myocardial infarction. J Am Coll Cardiol. 1996;28:313
  55. Agarwal JB, Khaw K, Aurignac F, et al. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram. Am J Cardiol. 1999;83:323
  56. Sclarovsky S, Topaz O, Rechavia E, et al. Ischemic ST segment depression in leads V2-V3 as the presenting electrocardiographic feature of posterolateral wall myocardial infarction. Am Heart J. 1987;113:1085
  57. Sclarovsky S, Mager A, Kusniec J, et al. Electrocardiographic classification of acute myocardial ischemia. Isr J Med Sci. 1990;26:525
  58. Birnbaum Y, Criger DA, Gates KB. Grade 3 ischemia on presentation with acute myocardial infarction predicts rapid progression of necrosis and less myocardial salvage with thrombolysis. J Am Coll Cardiol. 2001;37:115A
  59. Sagie A, Sclarovsky S, Strasberg B, et al. Acute anterior wall myocardial infarction presenting with positive T waves and without ST segment shift. electrocardiographic features and angiographic correlation. Chest. 1989;95:1211
  60. Pruitt RD, Klakeg CH, Chapin LE. Certain clinical states and pathologic changes associated with deeply inverted T waves in the precordial electrocardiogram. Circulation. 1955;11:517
  61. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730
  62. de Zwaan C, Bar FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989;117:657
  63. Renkin J, Wijns W, Ladha Z, et al. Reversal of segmental hypokinesis by coronary angioplasty in patients with unstable angina, persistent T wave inversion, and left anterior descending coronary artery stenosis. additional evidence for myocardial stunning in humans. Circulation. 1990;82:913
  64. Levine HD, Ford RV. Subendocardial infarction; report of six cases and critical survey of the literature. Circulation. 1950;1:246
  65. Sclarovsky S, Rechavia E, Strasberg B, et al. Unstable angina: ST segment depression with positive versus negative T wave deflections—clinical course, ECG evolution, and angiographic correlation. Am Heart J. 1988;116:933
  66. Atie J, Brugada P, Brugada J, et al. Clinical presentation and prognosis of left main coronary artery disease in the 1980s. Eur Heart J. 1991;12:495
  67. Nikus KC, Eskola MJ. The ECG in a mechanical obstruction of the ostium of the left main coronary artery. Int J Cardiol. 2002;86:327
  68. Shapira OM, Davidoff R. Images in cardiovascular medicine. functional left main coronary artery obstruction due to aortic dissection. Circulation. 1998;98:278
  69. Nikus KC. Acute total occlusion of the left main coronary artery with emphasis on electrocardiographic manifestations. TT Top Med Cardiovasc Dis. 2007;11:
  70. Master AM, Jaffe HL. Coronary insufficiency and myocardial necrosis due to acute hemorrhage. J Mt Sinai Hosp. 1940;7:26
  71. Kemball Price R, Janes LR. A case of subendocardial infarction. Br Heart J. 1943;5:134
  72. Bayley RH. The electrocardiographic effects of injury at the endocardial surface of the left ventricle. Am Heart J. 1946;31:677
  73. Cook RW, Edwards JE, Pruitt RD. Electrocardiographic changes in acute subendocardial infarction. I. Large subendocardial and large nontransmural infarcts. Circulation. 1958;18(4 Part 1):603
  74. Holmvang L, Clemmensen P, Lindahl B, et al. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. J Am Coll Cardiol. 2003;41:905
  75. Savonitto S, Cohen MG, Politi A, et al. Extent of ST-segment depression and cardiac events in non–ST-segment elevation acute coronary syndromes. Eur Heart J. 2005;26:2106
  76. Atar S, Fu Y, Wagner GS, et al. Usefulness of ST depression with T-wave inversion in leads V(4) to V(6) for predicting one-year mortality in non–ST-elevation acute coronary syndrome (from the electrocardiographic analysis of the global use of strategies to open occluded coronary arteries IIB trial). Am J Cardiol. 2007;99:934
  77. Gorgels AP, Vos MA, Mulleneers R, et al. Value of the electrocardiogram in diagnosing the number of severely narrowed coronary arteries in rest angina pectoris. Am J Cardiol. 1993;72:999
  78. Kosuge M, Kimura K, Ishikawa T, et al. Predictors of left main or three-vessel disease in patients who have acute coronary syndromes with non–ST-segment elevation. Am J Cardiol. 2005;95:1366
  79. Barrabes JA, Figueras J, Moure C, et al. Prognostic value of lead aVR in patients with a first non–ST-segment elevation acute myocardial infarction. Circulation. 2003;108:814
  80. Yamaji H, Iwasaki K, Kusachi S, et al. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1). J Am Coll Cardiol. 2001;38:1348
  81. Engelen DJ, Gorgels AP, Cheriex EC, et al. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. J Am Coll Cardiol. 1999;34:389
  82. Hasdai D, Yeshurun M, Birnbaum Y, et al. Inferior wall acute myocardial infarction with one-lead ST-segment elevation: electrocardiographic distinction between a benign and a malignant clinical course. Coron Artery Dis. 1995;6:875
  83. Blumgart HL, Zoll PM. Angina pectoris, coronary failure and myocardial infarction. The role of coronary occlusions and collateral circulation. JAMA. 1941;116:91
  84. Assali A, Sclarovsky S, Herz I, et al. Persistent ST segment depression in precordial leads V5-V6 after Q-wave anterior wall myocardial infarction is associated with restrictive physiology of the left ventricle. J Am Coll Cardiol. 2000;35:352
  85. Froelicher VF, Myers JN. Exercise and the heart. Philadelphia, PA: W.B. Saunders Co.; 2000;
  86. De Servi S, Specchia G, Angoli L. Coronary artery spasm of different degrees as cause of angina at rest with ST segment depression and elevation. Br Heart J. 1979;42:110
  87. Parodi O, Uthurralt N, Severi S, et al. Transient reduction of regional myocardial perfusion during angina at rest with ST-segment depression or normalization of negative T waves. Circulation. 1981;63:1238
  88. Porter A, Vaturi M, Adler Y, et al. Are there differences among patients with inferior acute myocardial infarction with ST depression in leads V2 and V3 and positive versus negative T waves in these leads on admission?. Cardiology. 1998;90:295
  89. Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:707
  90. Hyde TA, French JK, Wong CK, et al. Four-year survival of patients with acute coronary syndromes without ST-segment elevation and prognostic significance of 0.5-mm ST-segment depression. Am J Cardiol. 1999;84:379
  91. Gerson MC, McHenry PL. Resting U wave inversion as a marker of stenosis of the left anterior descending coronary artery. Am J Med. 1980;69:545
  92. Kishida H, Cole JS, Surawicz B. Negative U wave: a highly specific but poorly understood sign of heart disease. Am J Cardiol. 1982;49:2030
  93. Behar, S., et al. ACSIS 2004. Acute coronary syndromes—Israel 2004. 2005;242:13.
  94. Antman EM, McCabe CH, Gurfinkel EP, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. 1999;100:1593
  95. In:  Bayés de Luna A editors. Clinical electrocardiography: a textbook. Armonk, NY, USA: Futura Publishing Company, Inc.; 1998;

☆ 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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