Infarto agudo al miocardio: 5 patrones ECG no clásicos de alto riesgo
Resumen
Introducción: La principal causa de muerte en la población adulta chilena, son las enfermedades cardiovasculares. Entre ellas, el infarto agudo al miocardio (IAM) corresponde a la primera causa de muerte. En estos pacientes el electrocardiograma (ECG) sigue siendo el pilar fundamental en el diagnóstico. Clásicamente se presenta con un supra-desnivel del segmento ST (SDST) a nivel del punto J en al menos 2 derivadas contiguas anatómicamente. Sin embargo, aproximadamente la mitad de los IAM no se presentan con este patrón clásico.
Cuerpo de la revisión: Existen otros 5 patrones no-clásicos de presentación de un IAM. Estos patrones se observan como infarto de pared posterior del ventrículo izquierdo, síndrome de Wellens, signo de Winter (estos últimos 2 como oclusión proximal de la arteria descendente anterior izquierda (LAD)), oclusión de la primera rama diagonal de la LAD y oclusión de la arteria coronaria izquierda.
Discusión: Cada uno con elementos al ECG característicos, siendo equivalentes a un IAM con SDST, con oclusión de una arteria coronaria epicárdica, con irrigación ventricular significativa y por lo tanto, con malos resultados si no son reconocidos y tratados a tiempo.
Palabras clave:
síndrome coronario agudo, infarto agudo miocardio, electrocardiograma, supra-desnivel segmento STReferencias
(1) A Eugene Braunwald, Elliott M Antman, John W Beasley. report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Col Cardiol. 2000; 36: 970-1062.
(2) Kontos MC, Diercks DB, Kirk JD. Emergency Department and Office-Based Evaluation of Patients With Chest Pain. Mayo Clinic Proceedings. 2010; 85(3): 284-299. doi:10.4065/mcp.2009.0560.
(3) Durant, E., Singh, A. Acute first diagonal artery occlusion: a characteristic pattern of ST elevation in noncontiguous leads.. Am J Emerg Med. 2015; 33: 1326.e3 1326.e5.
(4) Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, CushmanM, et al. Heart Disease and Stroke Statistics. 2015 Update: a report from the American Heart Association. Circulation 2014; 131: e29-322.
(5) Deshpande A, Birnbaum Y. ST-segment elevation: Distinguishing ST elevation myocardial infarction from ST elevation secondary to nonischemic etiologies. World Journal of Cardiology 2014, 6(10), 1067–1079.
(6) Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR,White HD. Third universal definition of myocardial infarction. Clin Biochem 2013; 46: 1–4 [375].
(7) Brady, William J et al. The nondiagnostic ECG in the chest pain patient: Normal and nonspecific initial ECG presentations of acute MI. The American Journal of Emergency Medicine 1999 Jul; 17(4): 394-7.
(8) Yan, A.T., Yan, R.T., Kennelly, B.M., Anderson, F.A. Jr., Budaj, A., Lopez-Sendon, J. et al, Relationship of ST elevation in lead AVR with angiographic findings and outcome in non–ST elevation acute coronary syndromes. Am Heart J. 2007; 154: 71–78.
(9) Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. Am J Emerg Med 1998; 16: 409–13.
(10) Lawner BJ, Nable JV, Mattu A. Novel patterns of ischemia and STEMI equivalents. Cardiol Clin 2012; 30: 5919.
(11) Macias M, et al, The electrocardiogram in the ACS patient: high-risk electrocardiographic presentations lacking anatomically oriented ST-segment elevation, Am J Emerg Med 2016; 34: 611-7.
(12) De Zwaan C, Bär 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: 730–6.
(13) De Zwann 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: 65765.
(14) Kannan L, Figueredo VM. Wellens’ syndrome. N Engl J Med 2015; 372 (1): 66.
(15) De Zwaan C, Bär FW, Janssen JH, Cheriex EC, Dassen WRM, Brugada P, 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: 657–65.
(16) Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20: 638–43.
(17) Pellizzón O et all. Síndrome de Wellens. Alto riesgo electrocardiográfico de infarto agudo de miocardio. Rev Fed Arg Cardiol. 2015; 44(2): 114-115.
(18) Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD 367 Q3 occlusion. N Engl J Med 2008; 359: 2071–3.
(19) Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T waves signify proximal left anterior descending artery occlusion. Heart 2009; 95: 1701–6.
(20) Goebel M, Orford J, Mattu L, Brady A, William J. et al. A new ST-segment elevation myocardial infarction equivalent pattern? Prominent T wave and J-point depression in the precordial leads associated with ST-segment elevation in lead aVr. The American Journal of Emergency Medicine 2014; 32(3): 287.
(21) Zhong-Qun Z, Nikus KC, Sclarovsky S. Prominent precordial T waves as a sign of acute anterior myocardial infarction: electrocardiographic and angiographic correlations. J Electrocardiol 2011; 44: 533–7.
(22) de Winter R, Verouden N, Wellens H, Wilde A. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008; 359: 2071-2073.
(23) Hennings, J.R., Fesmire, F.M. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30: 994–1000.
(24) Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Oude Ophuis AJ, Vainer J, 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: 389–95.
(25) Barrionuevo M, Córdoba J, Gallego J, Ramírez C, García J, Jiménez J. El patrón ST-T de Winter: un equivalente de Síndrome coronario agudo con elevación de ST. Med Intensiva. 2016; 40: 127-9.
(26) Tatli, E., Aktoz, M. Wellens' syndrome: the electrocardiographic finding that is seen as unimportant. Cardiol J. 2009; 16: 73–75.
(27) Levin DC, Harrington DP, Bettman MA, Garnic JD, Davidoff A, Lois J. Anatomic Variations of the coronary arteries supplying the antero-lateral aspect of the left ventricle (LV)—possible explanation for the “unexplained” anterior aneurysm. Invest Radiol 1982; 17: 420–7.
(28) Sclarovsky S, Birnbaum Y, Solodky A, Zafrirb N, Wurzela M, Rechavia E. Isolated midanterior myocardial infarction: a special electrocardiographic sub-type of acute myocardial infarction consisting of ST segment elevation in non-consecutive leads and two different morphologic types of ST segment depression. Int J Cardiol 1994; 46: 37–47.
(29) Birnbaum Y, Hasdai D, Sclarovsky S, Herz I, Strasberg B, Rechavia E. Acute myocardial infarction entailing ST-segment elevation in lead AVL: electrocardiographic differentiation among occlusion of the left anterior descending, first diagonal, and first obtuse marginal coronary arteries. Am Heart J 1996; 131: 38–42.
(30) Rostoff, PawelPawelec, Tomasz et al. Electrocardiographic prediction of acute left main coronary artery occlusion. The American Journal of Emergency Medicine 2001; 25: 852-7.
(31) Knotts RJ, Wilson J, Birnbaum Y. Diffuse ST depression with ST elevation in AVR: is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2012; 45: 698–9.
(32) Nikus KC, Eskola MJ. Electrocardiogram patterns in acute left main coronary artery 414 occlusion. J Electrocardiol 2008;41:626–9.
(33) Rostoff P, Piwowarska W, Gackowski A, Konduracka E, El Massri N, Latacz P. Electrocardiographic prediction of acute left main coronary artery occlusion. Am J Emerg Med 2007; 25: 852–5.
(34) Dassen W, Gorgels A, Mulleneers R, Latacz P, Els H, Talmon J. Development of ECG criteria to diagnose the number of narrowed coronary arteries in rest angina using new self-learning techniques. J Electrocardiol 1994; 27: 15660.
(35) Kosuge M, Kimura K, Ishikawa T, Ebina T, Shimizu T, Hibi K, 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: 1366–9.
(36) Taglieri N, Marzocchi A, Saia F, Marrozzini C, Palmerini T, Ortolani P, et al. Short- and long-term prognostic significance of ST-segment elevation in lead AVR in patients with non–ST-segment elevation acute coronary syndrome. Am J Cardiol 2011; 108: 21–8.
(37) Gorgels AP, Engelen DJ, Wellens HJ. Lead AVR, a mostly ignored but very valuable lead in clinical electrocardiography. J Am Coll Cardiol 2001; 38: 1355–6.
(38) Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Oude Ophuis AJ, Vainer J, 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: 389–95.
(39) Aqel RA, Hage FG, Ellipeddi P., Blackmon L, McElderry HT, Kay GN et al, Usefulness of three posterior chest leads for the detection of posterior wall acute myocardial infarction. Am J Cardiol. 2009; 103: 159–164.
