Evaluation of serial QRS changes during acute inferior myocardial infarction using a QRS scoring system

doi:10.1016/0002-9149(83)90117-0

The American Journal of Cardiology

Volume 52, Issue 3, August 1983, Pages 252-256

https://doi.org/10.1016/0002-9149(83)90117-0 Get rights and content

Abstract

The evolution of changes in the QRS complex during the initial 3 days after the onset of an initial inferior myocardial infarction (MI) was studied in 82 consecutive patients. Each patient's standard 12-lead electrocardiogram was assigned points (a QRS score) according to the absolute duration of the Q and R waves and the amplitude ratios of R-to-Q and R-to-S waves. This QRS score has been demonstrated to correlate (r = 0.74) with the anatomic extent of single inferior MI. By this sytem, 43 patients (53% of the study group) had an initial electrocardiogram that registered a score of 0 and developed QRS points only after admission. The QRS scores of 18 additional patients (22% of the study group) changed after admission. Forty-nine score changes were noted on Day 2 and 18 on Day 3. All of these changes resulted in an increased QRS score.

Alteration of the QRS complex during initial inferior MI evolves over 2 to 3 days in many patients. There is a distinct pattern to this evolution, which results in sequential increases in a QRS score based upon electrocardiographic indicators of the extent of myocardial necrosis. This QRS scoring system might be applied to evaluate clinically interventions aimed at limiting the extent of necrosis in patients with initial acute inferior MI.

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Cited by (22)

Myocardium at risk assessed by electrocardiographic scores and cardiovascular magnetic resonance - a MITOCARE substudy
2017, Journal of Electrocardiology
The myocardium at risk (MaR) represents the quantitative ischemic area destined to myocardial infarction (MI) if no reperfusion therapy is initiated. Different ECG scores for MaR have been developed, but there is no consensus as to which should be preferred.
Comparisons of ECG scores and Cardiac Magnetic Resonance (CMR) for determining MaR.
MaR was determined by 3 different ECG scores, and by CMR in ST-segment elevation MI (STEMI) patients from the MITOCARE cardioprotection trial. The Aldrich score (AL) is based on the number of leads with ST-elevation for anterior MI and the sum of ST-segment elevation for inferior MI on the admission ECG. The van Hellemond score (VH) considers both the ischemic and infarcted component of the MaR by adding the AL and the QRS score, which is an estimate of final infarct size. The Hasche score is based on the maximal possible infarct size determined from the QRS score on the baseline ECG.
Ninety-eight patients (85% male, mean age 61 years) met STEMI criteria on their admission ECG and underwent CMR within 3–5 days after STEMI. Mean MaR by CMR was 41.2 ± 10.2 and 30.3 ± 7.2 for anterior and inferior infarcts, respectively. For both anterior and inferior infarcts the Aldrich (18.2 ± 5.1 and 18.6 ± 6.0) and Hasche (25.3 ± 9.8 and 26.4 ± 8.8) scores significantly underestimated MaR compared to MaR measured by CMR. In contrast, MaR by the van Hellemond score (37.0 ± 14.2 and 31.7 ± 12.8) was comparable to CMR.
We tested the performance of the electrocardiographic estimation of myocardium area at risk by Aldrich, Hasche and van Hellemond ECG scores in comparison to MaR measured by CMR in STEMI patients. MaR by the van Hellemond score and CMR were comparable, while Aldrich and Hasche underestimated MaR.
Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications
2017, Journal of Electrocardiology
Citation Excerpt :
With Dr. CR Roe, Galen was one of the first investigators to routinely obtain and quality-control assays of creatine phosphokinase (CPK) isoenzymes to more rapidly and accurately diagnose acute infarction [6,8,10,22,39,47,55,83,93,95] and non-coronary cardiac trauma [18]. In 1982, with Dr. Ron Selvester, he began work on the QRS scoring system for assessing left ventricular function following AMI with pathologic validation of infarct zone by computer modeling [56,57,65,70,79,84,91]. In the 1980s he authored five book chapters on myocardial infarction, one in “Current Diagnosis” [528] one in “Cardiac Emergencies” [531], one in “Progress in Cardiovascular Disease” [3], and two in the “Medical Clinics of North America” [38,77].
Inferior Q waves in apparently healthy subjects: Should we take a deep breath? An electrocardiographic, echocardiographic and cardiac magnetic resonance study
2016, Journal of Electrocardiology
To evaluate the diagnostic accuracy of electrocardiographic inferior Q waves persistence during inspiration and echocardiographic segmental wall motion abnormalities for the detection of previously unsuspected silent myocardial infarction, by using cardiac magnetic resonance as the gold standard.
We prospectively enrolled 50 apparently healthy subjects with inferior Q waves on routine electrocardiogram and high atherosclerotic risk profile. Patients underwent electrocardiogram during deep inspiration, standard transthoracic echocardiography, and cardiac magnetic resonance.
Inferior Q waves during deep inspiration persisted in 10 subjects (20%) and cardiac magnetic resonance was positive in 10 (20%). Between the 10 positive cardiac magnetic resonance subjects 8 showed persistence of inferior Q waves, giving a sensitivity of 80% (95%;CI 44.4–97.5%) and a specificity of 95% (95%;CI 83.1–99.4%). Segmental wall motion abnormalities were present overall in 10 subjects (20%), but only in 5 of the 10 positive cardiac magnetic resonance subjects, giving a sensitivity of 87.5% (95% CI 73.2–95.8) and specificity of 50% (95% CI 18.7–81.3).
Electrocardiographic inferior Q waves persistence during deep inspiration is a simple test with a high accuracy for diagnosis of silent myocardial infarction. Standard echocardiography resulted less accurate.
Consideration of QRS complex in addition to ST segment abnormalities in the estimation of the 'risk region' during acute inferior myocardial infarction
2013, Journal of Electrocardiology
Citation Excerpt :
The Aldrich Score has been compared with SPECT in several studies, and showed generally an underestimated total MaR.2,9 Indeed, any ST segment based method would be expected to underestimate the total MaR when the ST-segment deviation toward the ischemic component becomes replaced by QRS-complex deviation away from the infarcted component.2,10 Therefore, the Aldrich Score would be expected to underestimate the total MaR as infarction progressively develops; and an ECG method that considers both the ischemic and infarcted components should be more useful to estimate the total MaR.
The myocardial area at risk (MaR) has been estimated in patients with acute myocardial infarction (AMI) by using ST segment based ECG methods. However, as the process from ischemia to infarction progresses, the ST segment deviation is typically replaced by QRS abnormalities, causing a falsely low estimation of the total MaR if determined by using ST segment based methods. A previous study showed the value of the consideration of the abnormalities in the QRS complex, in addition to those in the ST segment estimating the total MaR for patients with anterior AMI. The purpose of this study was to investigate the same method for patients with inferior AMI.
Thirty-two patients with acute inferior ST elevation myocardial infarction received ^99mTc-Sestamibi before percutaneous coronary intervention. SPECT was performed within 2 hours after treatment and was used as a gold standard for the estimation of the total MaR. The ECG recorded at admission in the hospital was used for the ECG estimates of the total MaR. This included a ST segment estimation of the ischemic component of the total MaR (Aldrich score) and an estimation of the infarcted component of the total MaR in the acute phase of AMI by QRS abnormalities (Selvester score). These scores were added for the combined ECG score.
The ischemic component of the total MaR estimated by the Aldrich score alone no statistically significant correlation with SPECT (r = 0.17, p = 0.36). The infarcted component of the total MaR estimated by the Selvester score showed a significant correlation with SPECT (r = 0.55, p = 0.001). When the Aldrich and Selvester scores were combined, the correlation with SPECT improved (r = 0.58, p < 0.001). Both the Aldrich and Selvester score alone underestimated the mean MaR measured by SPECT (respectively p = 0.007 and p < 0.0001). There was no statistically significant difference between the mean MaR estimated by the sum of Aldrich and Selvester and the MaR measured by SPECT (p = 0.636).
The estimation of the total MaR was more accurate by taking both ST deviation and QRS abnormalities in account than by using either method alone. A new ECG method to determine the total MaR during acute coronary occlusion should consider both its ischemic and infarcted components.
Consideration of QRS complex in addition to ST-segment abnormalities in the estimated "risk region" during acute anterior myocardial infarction
2011, Journal of Electrocardiology
Citation Excerpt :
Every point was developed to represent infarction of 3% of the total LV mass (% LV). In this study, the Selvester score is used to determine the component of the total MaR that is already infarcted in the period before the ECG recording immediately before initiating myocardial reperfusion therapy.10,21 The electronic GE Healthcare QRS waveform amplitude and duration measurements were used by 2 investigators (I.H. and S.B.) to apply the Selvester QRS scoring on the ECGs.
The myocardial area at risk (MaR) has been estimated in patients with acute myocardial infarction (AMI) by using ST segment–based electrocardiographic (ECG) methods. As the process from ischemia to infarction progresses, the ST-segment deviation is typically replaced by QRS abnormalities causing a falsely low estimated total MaR if determined by using ST segment–based methods. The purpose of this study was to investigate if consideration of the abnormalities in the QRS complex, in addition to those in the ST segment, provides a more accurate estimated total MaR during anterior AMI than by considering the ST segment alone.
Twenty-five patients with acute anterior ST elevation myocardial infarction (STEMI) received technetium Tc 99m–sestamibi before percutaneous coronary intervention. Single photon emission computed tomography (SPECT) was performed within 2 hours after treatment and was used as a criterion standard for the estimated total MaR. The ECG recorded at admission in the hospital was used for the ECG estimated total MaR. This included an ST-segment estimated ischemic component of the total MaR (Aldrich score) and an estimated infarcted component of the total MaR in the acute phase of AMI by QRS abnormalities (Selvester score). These scores were added for the combined ECG score.
The ischemic component of the total MaR estimated by the Aldrich score alone had no statistically significant correlation with SPECT (r = 0.21, P = .32). The infarcted component of the total MaR estimated by the Selvester score showed a significant correlation with SPECT (r = 0.49, P = .01). Each score gave a significant underestimated total MaR measured by SPECT (P < .01). When the Aldrich and Selvester scores were combined, the correlation with SPECT was r = 0.47, P = .02. The combined score still underestimated the total MaR by SPECT (P < .01), though the difference was smaller in comparison to either method alone (P < .01).
The ECG estimated total MaR was more accurate by taking both ST deviation and QRS abnormalities into account than by using either method alone. A new ECG method to determine the total MaR during acute coronary occlusion should consider both its ischemic and infarcted components.
Myocardial Infarction and Electrocardiographic Patterns Simulating Myocardial Infarction
2008, Chou's Electrocardiography in Clinical Practice: Adult and Pediatric

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^☆: This study was supported in part by Contract HRA-230-76-0300 from the National Center of Health Services Research; by Research Grants HL-17670 and HL-00546 from the National Heart, Lung, and Blood Institute, the National Institutes of Health, Bethesda, Maryland, and by grants from the Prudential Insurance Company of America and the Kaiser Family Foundation.

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Coronary heart diseaseEvaluation of serial QRS changes during acute inferior myocardial infarction using a QRS scoring system☆

Abstract

Am Heart J

Am J Med

Am J Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

An electrocardiographic sign of coronary artery obstruction

Arch Intern Med

QRS complex to assess interventions which modify the extent of myocardial necrosis following coronary artery occlusions

Circulation

Clinical Vectorcardiography and Electrocardiography

Electrocardiography and Vectorcardiography

Uses and limitations of electrocardiography in the diagnosis of acute coronary occlusion

Yale J Biol Med

Coronary heart disease
Evaluation of serial QRS changes during acute inferior myocardial infarction using a QRS scoring system☆