Which Ecg Reading Looks Like a Tombstone
Curr Cardiol Rev. 2009 Nov; 5(4): 273–278.
Tombstoning ST-Elevation Myocardial Infarction
Received 2009 Feb 23; Revised 2009 Mar xviii; Accepted 2009 Mar 31.
Abstruse
Tombstoning ST top myocardial infarction can exist described as a STEMI characterized by tombstoning ST-segment summit. This myocardial infarction is associated with extensive myocardial damage, reduced left ventricle function, serious infirmary complications and poor prognosis. Tombstoning ECG pattern is a notion across morphological departure and is associated with more serious clinical results.
Despite the presence of a few reports on tombstoning ST pinnacle, at that place is no report which reviews STEMI demonstrating this electrocardiographic pattern.
Key words: Tombstoning, myocardial infarction, ST segment elevation
INTRODUCTION
Electrocardiography (ECG) is a complementary method in diagnosis and provides the risk stratification of people suspected of having myocardial infarction. It is vital in the classification of myocardial infarction [1]. Currently, myocardial infarction is classified in 2 groups: ST-elevation myocardial infarction (STEMI) and non-STEMI. STEMI is non a homogenous group in itself. Instead, differences are observed betwixt patients in terms of various parameters such as the amplitude and morphology of ST-segment acme, T-wave variations, the presence or absence of Q-wave, and clinical class and prognosis. Tombstoning ST-segment elevation is a type of ST-segment elevation with a specific morphology which is observed in the early period of acute myocardial infarction [2-7]. This ECG appearance is a notion beyond morphological difference and is associated with more serious clinical results. While at that place are a few reports on tombstoning ST elevation, there is no study which reviews STEMI displaying such ECG blueprint. The aim of this report was to outline the contour of Tombstoning ST-superlative myocardial infarction (TOMB-STEMI) by reviewing the ECG, clinical, laboratory, and angiographic characteristics in detail.
ECG CHARACTERISTICS
An ST-segment elevation with a specific design is the principal element of TOMB-STEMI. ST-segment elevation is often the primeval detected sign of acute MI. Initially, the ST segment may straighten, with loss of the ST-T moving ridge angle. Then the T wave becomes broader and the ST segment elevates, losing its normal concavity. Equally farther summit occurs, the ST segment tends to become convex upwards [8]. As ST-segment elevation can be minimal, in some cases, it may surpass the summit level of the R wave. Thus, ST-segment elevation surpassing the R wave exhibits such a morphological appearance that it reminds a tombstone. Ii electrophysiological mechanisms play a part in the germination of a tombstone advent: delayed transmural conduction and intramyocardial conduction cake [9]. The presence of tombstoning ECG in pericarditis and hypothermia suggests that it is not an infarction-specific event and that electrophysiological mechanisms may be involved in the germination of similar morphologies [10,eleven].
Wilmalaratna was the first to term this characteristic equally tombstone-like and convex ST segment elevation in MI patients every bit tombstoning [2]. Later on, Guo et al. modified the tombstoning criteria [3]. The criteria of tombstoning ST-segment elevation are equally follows: a) Absent R wave or an R wave duration <0.04 s with minimal amplitude, b) convex upward ST segment merging with the descending R or the ascending QS/QR, c) the peak of the ST segment is higher than the R wave and d) the ST segment merges with the T moving ridge.
It is very piece of cake to recognize and discriminate tombstoning ECG from others (Figs. 1 and ii ). The magnitude of ST elevation is adamant fundamentally by the severity of epicardial harm. Nevertheless, amplitude of the ST elevation is afflicted by myocardial zone, chest structure, and distance of the electrode to the myocardial zone [14-xvi]. Tombstoning ECG in STEMI is non a rare event and observed amidst 10-26.one% of the patients [2-5]. While this kind of infarction is more commonly seen in anterior localization (39.eight%), information technology may also be observed in junior localization (ten.vi%) [6].
ST segment meridian meeting the criteria for tombstoning ECG.
ST segment elevation not meeting the criteria for tombstoning ECG.
ANGIOGRAPHIC CHARACTERISTICS
Regarding the coronary angiography findings of patients with TOMB-STEMI, the results of the studies are not consistent (Table 1 ). Tomcyanyi et al. reported coronary illness incidence (two or 3 vessel disease; 48% vs 54%; p=0.6311) and LAD involvement (LAD segment; one.35 vs 1.five; p=0.44) in patients with tombstoning STEMI as like to those of patients with STEMI who practise non demonstrate this pattern [6]. However, Guo et al. suggested that patients with tombstoning have severe apoplexy of the LAD artery (Total/partial occlusion of LAD; 100% vs 44%; p<0.0001) and commonly involving either left circumflex or right coronary artery (iii vessel disease; 54.i% vs 22%; p=0.001) but more often both [3]. These different results in epicardial coronary anatomy might stem from the specific methodologies used by the studies. The fact that tombstoning is more than commonly found in anterior than non-inductive STEMI may explain the higher rates of LAD disease in patients with tombstoning. Moreover, college TIMI frame count and lower TIMI myocardial perfusion form in the first one indicates the presence of a more severe ischemia in TOMB-STEMI cases [6].
Table 1
Angiographic Characteristics of TOMB-STEMI
| Parameters | Guo et al. [iii] | Tomcsanyi et al. [6] |
|---|---|---|
| Total/partial occlusion of LAD, % | 100 vs 44, p<0.0001 | |
| LAD =100% occlusion,% | 50 vs 20.5, p=0.02 | |
| LAD< 50% occlusion ,% | 0 vs 15.9, p=0.039 | |
| Proximal occlusion of LAD, % | 92 vs 65, p=0.017 | |
| three vessel disease,% | 54.1 vs 22, p=0.001 | |
| 2 or three vessel affliction,% | 48 vs 54, p=0.6311 | |
| LAD segment | 1.35 vs ane.5, p=0.44 | |
| Open up culprit artery,% | 26 vs 34, p=0.284 | |
| TIMI frame count | 28 vs 17.ii, p=0.0001 | |
| TIMI myocardial perfusion grade | 1.ii vs ane.8, p=0.043 | |
| Unsuccessful PCI, % | 22 vs six, p=0.05 |
CLINICAL CHARACTERISTICS
Clinical and laboratory characteristics of patients with TOMB-STEMI are shown in Tabular array 2 , whereas clinical profiles are shown in Table iii . Coronary run a risk factors are similar in patients with and without the tombstoning design. Chest pain durations are similar. Nevertheless, the incidence of preinfarct angina (39 vs. 64, p<0.03) is significantly lower [4]. Creatinine kinase (i.e.: 397 vs. 290, p<0.02) and brain natriuretic peptid (v times higher) levels are elevated, and left ventricle ejection fraction (i.due east.: 42 vs. 51, p<0.03) is reduced [4-6]. In other words, infarction size is larger and left ventricle function is worse in these patients.
Table 2
Clinical and Laboratory Characteristics of TOMB-STEMI
| Parameters | Balci et al. [iv] | Kukla et al. [five] | Tomcsanyi et al. [six] |
|---|---|---|---|
| TC,mg/dl | 197 vs 194, p=0.seventy | ||
| LDL,mg/dl | 135 vs 126, p=0.30 | ||
| HDL,mg/dl | 34 vs 37, p=0.thirty | ||
| DM, % | 25 vs 18, p=0.37 | 22.iv vs fourteen.6, NS | 26 vs 18, p=0.55 |
| HT, % | 34 vs 26, p=0.26 | 53 vs 48, p=0.81 | |
| Smoker, % | 62 vs 61, p=0.91 | ||
| Chest Pain, hours | 4,7 vs four.ix, NS | ||
| Preinfarct angina , % | 39 vs 64, p<0.03 | ||
| SBP, mmHg | 101 vs 116,p0.05 | ||
| DBP, mmHg | 64 vs 73, p=0.06 | ||
| CK-MB, IU/L | 397 vs 290, p<0.02 | ||
| Peak CK, IU/50 | 1598.9 vs 1575, NS | ||
| EF, % | 42 vs 51, p<0.03 | 40.9 vs 48.6, p=0.001 | 42 vs 45, p=0.2 |
| Death, % | 26 vs 2, p<0.01 | 38.two vs nine.9, p=0.001 | 13 vs 6, p=0.37 |
| Cardiogenic shock, % | 22 vs ii, p<0.02 | 21.eight vs 12.3, NS | 9 vs 3, p=0.26 |
| Center failure, % | 45.half dozen vs 28.three, p=0.026 | 22 vs 14, p=0.50 | |
| Pulmonary oedema, % | 14.5 vs ix.6, p= NS | ||
| Ventricular tachycardia, % | 17 vs 2, p<0.01 | ||
| sVT/VF, % | nine vs half-dozen, p=0.65 | ||
| Ventricular fibrillation, % | 30 vs five, p<0.02 | 18.i vs 6.4, p=0.016 | |
| Atrial fibrillation, % | 4 vs two, p=0.52 | ||
| AV block, % | 13 vs 10, p=0.44 |
Table 3
Clinical Profile of TOMB-STEMI Compared with Non-TOMB-STEMI
| Coronary gamble factors | Similar |
|---|---|
| Symptom | Similar angina pectoris but less frequent preinfarction angina |
| Laboratory | Higher CK, college BNP which ways larger infarction area. |
| Echocardiography | Lower left ventricle EF which means a heavier left ventricle dysfunction |
| Angiography | Similar epicardial coronary anatomy or more extensive. Higher TIMI frame count and lower TIMI myocardial perfusion grade which means more than severe ischemia |
| Complication | More complications and poor prognosis |
| Reperfusion | Less efficient reperfusion therapy |
PROGNOSIS
Wilmanaratma associated tombstoning ECG pattern with the following complications. Six patients with tombstoning ECG pattern experienced ≥3 complications and 4 patients died within 7 days.2 Huang et al. reported reduced LV function and high mortality in patients with tombstoning ECG pattern [vii]. Mortality in TOMB-STEMI is 26-38.ii% [iv,5]. As atrial arrhythmias are like, life-threatening ventricular arrhythmias occur in a larger percentage of patients with TOMB-STEMI. This suggests the presence of variations in the ventricular arrhythmogenic substrate among TOMB-STEMI. Higher bloodshed rates may be explained with reduced pump part, life-threatening ventricular arrhythmias, and less reperfusion benefit.
Since it was defined, tombstoning ST-segment pinnacle has been associated with poor prognosis, but the reasons are still non fully understood. A few complementary hypotheses have been proposed. Several of the proposed mechanisms are every bit follows: extremely rapid myocardial harm, poor collateral flow and/or lengthened coronary artery affliction, inadequate myocardial protection effect of preinfarct angina, and peak of wall tension [three-6]. These hypotheses are based on astringent ischemia, unprepared myocardium and resultant extensive myocardial damage. Preinfarct angina is associated with coronary collateral development and ischemic preconditioning [12]. Poor collateral flow or ischemic preconditioning in TOMB-STEMI supports the notion of unprepared myocardium. In other words, an unprepared, large myocardial area is exposed to severe ischemia, which leads to infarction displaying this ECG blueprint.
ECG IN Take a chance STRATIFICATION
Many studies have investigated application of 12-lead ECG for hazard stratification. Various ECG variables have been studied such equally terminal QRS (east.g.: Sclarovsky-Bimbaum score), ST segment (e.chiliad.: ∑ST), T wave (e.g.: T moving ridge inversion), and initial QRS developing during ischemia (e.g.: Selvester QRS score) [13-17]. Distortion of the last portion of QRS complex (class 3 ischemia) is ane of the ECG signs that are used to decide patients under high risk. Principal criteria applied for terminal QRS distortion include disappearance of Due south moving ridge in leads with RS morphology and a J point elevated above the lower half of R wave in leads with QR morphology. Equally patients with grade III ischemia demonstrate poor prognosis and larger last infarct size, they benefit less from thrombolytic handling and primary angioplasty [13,xiv]. Form Three ischemia and TOMB-STEMI brandish similarities with respect to poor prognosis and less efficient reperfusion therapy.
Morphological changes occurring in the ECG are also included in the hazard stratification analysis. Regardless of the total amplitude of the ST-segment height, tombstoning pattern has been proposed to exist associated with college mortality and ST tiptop design has been reported to be a more important gene than quantitative changes (e.g: ∑ST) in chance stratification [5]. Pattern of the ST pinnacle has been shown to exist a strong prediction cistron in astute MI. While concave ST summit is associated with perfect LV function, convex ST elevation is associated with poor LV function [18]. Along with the quantitative changes in ST segment elevation, inclusion of morphologic alteration in risk stratification may contribute in obtaining more consistent results.
CONCLUSIONS
Information technology appears that a sudden occlusion of a coronary artery supplying a big area of unprepared myocardium; i.e. myocardium non protected past collaterals or ischemic preconditioning, results in complete transmural injury rapidly progressing to complete infarction, resulting in this characteristic ECG blueprint. The extensive nature of the myocardial infarction and the resultant left ventricular damage and dysfunction may explain the higher take chances of complications and mortality associated with this finding. The higher BNP levels on presentation in patients with tombstone STEMI seem to support the all-encompassing nature of the myocardial harm associated with this ECG finding.
What needs to be further defined? Information technology is non well divers nonetheless whether most of these patients progress to rapid and irreversible Q wave formation on the ECG, compared to patients without this ST pinnacle design. If the damage is rapid and all-encompassing, it is unclear whether early on percutaneous revascularization results in adequate myocardial salvage of patients with tombstoning, when compared to patients without this finding. Follow-up studies of these patients after revascularization should aid answer such a question. Tissue edema, microvascular plugging and inflammation that follow such extensive and rapid necrosis may explain the slower TIMI frame count, poor TIMI myocardial perfusion grade and the higher incidence of unsuccessful PCI. If myocardial recovery, despite revascularization, is shown to be express in these patients, then additional intracoronary pharmacological measures; i.eastward. intracoronary adenosine, GP IIb/IIIa inhibitors and/or postconditioning measures (serial 1 min balloon occlusion of the coronary avenue during PCI followed by reperfusion by balloon deflation) may exist necessary to improve outcome in these patients. Since approximately 25% of patients with anterior STEMI have this finding on the ECG, a improve definition of the significance of tombstoning STEMI is urgently needed and may event in more aggressive measures that aim myocardial salve in these patients.
Further studies are required to reveal the machinery of tombstoning ST-segment elevation, its relations with complications and its furnishings on long-term prognosis as well every bit optimization of medical or invasive treatments for TOMB-STEMI. Because this myocardial infarction is more than a mere ECG blueprint with a specific morphological advent, evaluating information technology as a dissimilar entity seems to be appropriate.
REFERENCES
1. Thygesen K, Alpert JS, White Hard disk. on behalf of the Joint ESC/ACCF/AHA/WHF Task Forcefulness for the Redefinition of Myocardial Infarction; Universal definition of myocardial infarction. Circulation. 2007;116:2634–53. [PubMed] [Google Scholar]
2. Wimalaratna HSK. Tombstoning of ST segment in acute myocardial infarction (letter) Lancet. 1993;342:96. [PubMed] [Google Scholar]
3. Guo XH, Yap YG, Chen LJ, Huang J, Camm AJ. Correlation of coronary angiography with tombstoning electrocardiographic pattern in patients with later on acute myocardial infarction. Clin Cardiol. 2000;23:347–52. [PMC gratis article] [PubMed] [Google Scholar]
4. Balci B, Yesildag O. Correlation betwixt clinical findings and the tombstoning electrocardiographic pattern in patients with anterior wall acute myocardial infarction. Am J Cardiol. 2003;92:1316–8. [PubMed] [Google Scholar]
5. Kukla P, Dudek D, Szczuka G. Tombstoning of ST segment in acute myocardial infarction-effect on clinical form. Kardiol Pol. 2006;64:275–fourscore. [PubMed] [Google Scholar]
6. Tomcsányi J, Marosi A, Bózsik B, et al. North-Terminal pro-encephalon natriuretic peptide and tombstoning ST-segment elevation in patients with anterior wall acute myocardial infarction. Am J Cardiol. 2005;96:1197–9. [PubMed] [Google Scholar]
7. Huang J, Redwood S, Poloniecki J, et al. Predicting death from tombstoning of the ST-segment in acute myocardial infarction. Circulation. 1994;ninety(suppl I):I-500. [Google Scholar]
8. Morris F, Brady WJ. ABC of clinical electrocardiography, Acute myocardial infarction-Part I. BMJ. 2002;324:831–4. [PMC free commodity] [PubMed] [Google Scholar]
9. Di Diego JM, Antzelevitch C. Cellular basis for ST-segment changes observed during ischemia. J Electrocardiol. 2003;36(suppl):ane–5. [PubMed] [Google Scholar]
x. Jain A. Tombstone anterior segment elevations secondary to acute pericarditis: the rol of two-dimensional echocardiogram. Clin Cardiol. 1997;20:404–6. [PMC free article] [PubMed] [Google Scholar]
11. Ansari E, Cook RJ. Profound hypothermia mimicking a Brugada type ECG. Clin Cardiol. 2003;36:257–60. [PubMed] [Google Scholar]
12. Ottani F, Galvani M, Ferrini D, et al. Prodromal angina limits infarct size: a role for ischemic preconditioning. Apportionment. 1995;91:291–7. [PubMed] [Google Scholar]
13. Birnbaum Y, Sclarovsky S. The grades of ischemia on the presenting electrocardiogram of patients with ST pinnacle acute myocardial infarction. J Electrocardiol. 2001;34(Suppl):17–26. [PubMed] [Google Scholar]
14. Atar S, Birnbaum Y. Ischemia-induced ST-segment tiptop: classication, prognosis, and therapy. J Electrocardiol. 2005;38:1–7. [PubMed] [Google Scholar]
xv. Yusuf South, Lopez R, Maddison A, et al. Value of electrocardiogram in predicting and estimating infarct size in human being. Br Centre J. 1979;42:286–93. [PMC free article] [PubMed] [Google Scholar]
16. Birnbaum Y, Criger DA, Wagner GS, et al. Prediction of the extent and severity of left ventricular dysfunction in inductive astute myocardial infarction by the admission electrocardiogram. Am Heart J. 2001;141:915–24. [PubMed] [Google Scholar]
17. Christian T, Gibbons R, Clements I, Berger BP, Selvester RH, Wagner GS. Estimates of myocardium at risk and collateral flow in astute myocardial infarction using electrocardiographic indexes with comparison to radionuclide and angiographic measures. J Am Coll Cardiol. 1995;26:388–93. [PubMed] [Google Scholar]
eighteen. Masami K, Kazuo Yard, Toshiyuki I, et al. Value of ST segment elevation pattern in predicting infarct size and left ventricular function at discharge in patients with reperfused acute anterior myocardial infarction. Am Heart J. 1999;137:522–7. [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842959/
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