9A
Old Myocardial Infarction
Synopsis
Significance
Old myocardial infarction (MI) by ECG criteria
has been used as evidence for coronary heart
disease (CHD) in epidemiological studies for
comparing cross-sectional MI prevalence and for
risk evaluation in contrasting populations. Myo-
cardial infarction by ECG is the only manifesta-
tion of past silent MI.
Mechanism
Coronary arteries are endarteries. Obstruction of
an artery in the coronary bed results in acute isch-
emic injury, and if not resolved, a subsequent loss
of electrical activity and death of damaged myo-
cardial cells. Abnormal QS or Q waves usually
appear following or concomitant with ST devia-
tions in acute phase and evolving ST-T changes.
Dead or fibrosed myocardial tissue alters excita-
tion pathways around the damaged region causing
other QRS changes, and occasionally blocking
conduction in major conduction pathways of the
His–Purkinje system.
Risk Factors
These include CHD risk factors in general:
cigarette smoking, age, male gender, serum cho-
lesterol and improper lipoprotein balance, hyper-
tension, impaired glucose tolerance, and heredity.
Elevated homocysteine, C-reactive protein, fibrin-
ogen, and other factors promoting plaque forma-
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tion in coronary arteries have been identified as
newer risk factors for MI.
Classification Problems
Abnormal Q waves in survivors of acute MI may
not develop and when present, they tend to dimin-
ish or even disappear with time. In older studies
using ventriculography as a standard, the sensi-
tivity of Minnesota Code 1.1–1.3 Q waves in
detecting wall motion abnormalities was reported
as 51% at a specificity of 84%. Equally low sensi-
tivity has been reported in autopsy studies or
using ECG-independent evidence in the acute
phase as a standard. Low specificity reduces the
utility of some more sensitive ECG criteria such
as poor R wave progression in anterior MI. Up to
a quarter to a third of MIs by ECG criteria have
been found to be unrecognized, one-half of them
without any reported symptoms. The limited clas-
sification accuracy of ECG criteria based solely on
ECG evidence reduces the utility of comparative
evaluation of MI prevalence in contrasting
populations.
Prevalence
The reported prevalence of Minnesota Code 1.1–
1.3 Q waves in community-based populations at
age 40–59 years ranges from less than 1% to 6.6%
in men and from 1% to 4.5% in women. In CHD-
free cohorts of 40- to 59-year-old men, the preva-
lence ranges from 1.6 to 2.1%. Definite old MI
prevalence by strict Q-wave criteria is low at age
40–59 years, even in countries with high CHD
Introduction
mortality like Finland (1.3% in men and 0.5% in
women).
Mortality Risk
Independent short-term risk for CHD mortality
for MI by the Minnesota Code 1.1–1.3 combina-
tion varies in contrasting populations from
nonsignificant to over fourfold risk increase.
Long-term risk is not significant. Short-term
excess mortality risk for large Q waves in CHD-
free and in total male cohorts has been 13- to
nearly 20-fold in some studies. For strict MI cri-
teria combining major Q waves and major ST-T
codes, the reported multivariable-adjusted short-
term risk for CHD mortality ranges from seven-
fold up to 19-fold, and also the reported long-term
risk is over threefold. Prevalence of MI by such
stricter criteria is low, reducing the corresponding
utility in identifying high-risk subgroups. In most
studies, mortality risk has been similar for non-
recognized and recognized MI in men. Mortality
risk in women has been reported to be marginally
lower for unrecognized than for recognized MI.
Abbreviations and Acronyms
BARI – Bypass Angioplasty Revascularization
Investigation
CABG – coronary artery bypass grafting
CAD – coronary artery disease
CHD – coronary heart disease
CVD – cardiovascular disease
LAD – left anterior descending (coronary artery)
LCX – left circumferential (coronary artery)
LBBB – left bundle branch block
LVH – left ventricular hypertrophy
LPD – left posterior descending (coronary
artery)
MI – myocardial infarction
RCA – right coronary artery
9A.1 Introduction
Objective coding of ECG abnormalities associated
with coronary heart disease (CHD), particularly
old myocardial infarction (MI), has been one of
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the primary requirements in cardiovascular
epidemiological studies. Acute MI, of primary
concern in clinical applications, is rarely encoun-
tered in community health surveys. The sequels
of myocardial damage following the acute MI
phase, the residual abnormal Q waves and re-
polarization abnormalities, provide primary evi-
dence for an old MI. Abnormal Q waves do not
develop in a certain fraction of patients, and when
they do, they tend to become smaller or even dis-
appear with time because of cardiac remodeling
in the healing and adaptation phase following
acute MI. While ST elevation is the primary
marker of acute ischemic injury, negative or “flat”
T waves, often with borderline-abnormal Q waves,
remain as chronic manifestations of old ischemic
injury. Some degree of residual ST elevation is
often retained particularly in old anterior MI. Sus-
tained ST depression may indicate the presence of
a chronic ischemic state.
There are several other clinical conditions that
may induce secondary repolarization abnormali-
ties, including in particular left ventricular con-
duction defects and left ventricular hypertrophy
(LVH). In CHD, repolarization abnormalities may
be secondary, due to altered sequence of ventricu-
lar excitation with scar formation and fibrosis
(often combined with compensatory LVH in post-
MI states), or they can be primary signs of derailed
ionic channel function in ischemic regions. Clini-
cally so-called non-Q-wave MI in the acute phase
may occur particularly in smaller MIs when clearly
abnormal Q waves do not develop. Repolarization
abnormalities evolve characteristically in the
acute phase in Q-wave and in non-Q-wave MI.
This chapter covers ECG abnormalities that are
most directly associated with an old MI. Various
studies have used quite diverse definitions for MI
and ischemic abnormalities. In the Minnesota
Code, abnormal Q waves are covered under Code
1. Abnormalities in ST and T waves are coded
under Codes 4 and 5. In the Minnesota Code in
general, various categories are coded as indepen-
dent entities without a clear hierarchy in relation
to other coding categories. Many newer studies
have used various combinations of Q wave and
ST-T codes to identify an old MI. At times left
bundle branch block (Code 7.1) is included with
Q wave and ST-T codes in a pooled category char-
acterized as “ischemic abnormalities”.