Clinical utility of electrocardiographic ST-segment area for predicting unsatisfactory outcomes following thrombolytic therapy
Background: The bedside surface 12-lead electrocardiogram is a mainstay in the early diagnostic evaluation of patients with suspected acute myocardial infarction. The presence of ST-segment elevation exceeding 1.0 mm in two or more anatomically associated leads is a reliable marker of myocardial injury and, when considered along with concomitant ST-segment depression, reflects the extent of myocardial injury. Mounting evidence also suggests that prolonged repolarization is a marker of injury and predicts the likelihood of malignant ventricular arrhythmias. We questioned whether a measure of both ST-segment duration and deviation (ST-deviation area) would offer additional prognostic information. Methods/Results: Admission electrocardiograms from 200 consecutive patients with ischemic chest pain accompanied by ST-segment elevation in whom thrombolytic therapy was given within 6 hours from symptom onset were analyzed. The sum of ST-segment elevation (2 ST elevation) and ST-segment deviation (2 ST deviation) were calculated, as was the sum of ST-segment deviation area (2 ST deviation area). All ST measurements were performed 60 msec after the J point. Computerized planimetry was used to calculate ST-segment area. ∑ ST deviation and ∑ ST deviation area remained constant over time. Patients with large deviations (∑ ST elevation >20 mm (odds ratio 2.14, p=0.02) and ∑ ST deviation area >150 (odds ratio 1.92, p=0.02) had a higher incidence of in-hospital unsatisfactory clinical outcome (defined as death, congestive heart failure, cardiogenic shock, recurrent myocardial infarction, or the need for coronary revascularization). These relationships were present for both inferior and anterior infarctions. ∑ ST deviation area correlated closely with ∑ ST elevation (r=0.92; p=0.0001) and significantly but much less strongly with the sum of Q waves (r=0.18; p=0.01). By univariate analysis, only site of infarction (p=0.01), ∑ ST deviation area (p=0.04), and the sum of Q waves (p=0.005) were identified as predictors of a poor clinical outcome. The sum of Q waves was identified by multivariate analysis as the best independent predictor of an unsatisfactory clinical outcome. Conclusions: A clinician's ability to provide optimal care is influenced strongly by the availability of diagnostic and prognostic information. In the evaluation of patients with acute myocardial infarction, ST-segment deviation area derived from the admission surface electrocardiogram can be used to risk-stratify patients. The full clinical potential of this measure is unknown and will require further evaluation. © 1995 Kluwer Academic Publishers.
Velury, VS; Ma, Y; Hurley, T; Hebert, JR; Becker, CF; Becker, RC
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