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Background Over the past 2 decades, the 12-lead electrocardiogram has attained special significance for the diag-
nosis and triage of patients with chest pain because timely detection of myocardial injury and a rapid assessment of
myocardium at risk proved pivotal to implementing effective reperfusion therapies during acute myocardial infarction. How-
ever, this wealth of information could still be underutilized by clinicians who may restrict their diagnostic quest in patients
with chest pain to the more classic electrocardiographic signs.
Methods The medical literature on electrocardiographic manifestations of acute myocardial infarction was extensively
reviewed.
Results The widespread utilization of both coronary angiography and methods to determine myocardial function and
metabolism in patients with acute myocardial infarction over the last 10 years has provided the means for rigorous compar-
isons with electrocardiographic information. We summarize these electrocardiographic signs and patterns in terms of their
relevance to the clinician to help reduce the incidence of “nondiagnostic electrocardiograms” and improve timely decision-
making.
Conclusions The electrocardiogram continues to be an invaluable tool in the initial evaluation of patients with chest
pain. The plethora of data currently available on electrocardiographic changes correlating with myocardial injury allows
clinicians to make faster and better decisions than ever before. (Am Heart J 2001;141:507-17.)
In comparison with other cardiac noninvasive diagnos- tractility, and myocardial metabolic state. Such contribu-
tic techniques, electrocardiography has evolved rather tions have considerably improved our ability to diag-
slowly over the past 40 to 50 years. Perhaps the most sig- nose acute myocardial infarction (AMI) and are summa-
nificant advance has been the introduction of computer- rized in this article in terms of their relevance to the
ized electrocardiographic interpretation. Although health clinician reviewing electrocardiograms.
professionals have increasingly relied on this feature,
automated reports are not optimal and should always be
overseen by an experienced, well-informed physician Normal anatomic references
with electrocardiography training.1,2 This is crucial when Several anatomic caveats are pertinent to the assess-
expeditious diagnoses may be life-saving, as in acute coro- ment of new fascicular blocks or axis changes and to
nary syndromes. Henry Marriott3 wrote that the electro- the assessment of infarct location.
cardiogram is “the single most often used, most cost- The heart lies horizontally with the atria at its base
effective, and most diagnostic test in cardiology” and also and the ventricles at its apex.4 Because the heart is
“the most frequently misinterpreted.” rotated over its long axis, the right atrium and ventricle
Many observations made over the past decade from are more anterior than the left chambers, and the right
both multicenter and small, prospective studies have and left sides of the heart are not aligned with the same
systematically correlated the electrocardiographic sides of the body. Thus the interventricular septum is
changes of myocardial injury to biochemical markers, almost parallel with the frontal—not the sagittal—plane,
early coronary angiographic findings, ventricular con- and the left ventricular free wall (usually considered a
lateral structure) includes nearly 300 degrees of the left
From the aSection of Cardiology, Rush-Presbyterian Medical Center, Chicago, Ill; ventricular circumference and faces superiorly, posteri-
and the bDepartment of Cardiology, Rabin Medical Center, Beilinson Campus, orly, and inferiorly.2,4 In addition, the heart position rel-
Petah-Tiqva, Israel.
Submitted August 16, 2000; accepted December 12, 2000.
ative to the electrocardiographic electrodes is highly
Reprint requests: Elena B. Sgarbossa, MD, Cardiology, Rush Presbyterian-St Luke’s variable; this results in a wide range of normalcy for the
Medical Center, 1750 W Harrison St, Chicago, IL 60612. cardiac long axis.5
E-mail: esgarbos@rush.edu
The conventional 12-lead system is unfortunately sub-
Copyright © 2001 by Mosby, Inc.
0002-8703/2001/$35.00 + 0 4/1/113571 optimal. Whereas leads V1 through V6 adequately cap-
doi:10.1067/mhj.2001.113571 ture most electrical cardiac phenomena taking place in
American Heart Journal
508 Sgarbossa, Birnbaum, and Parrillo April 2001
Figure 2
Twelve-lead electrocardiogram showing sinus tachycardia and inferior wall injury. Presence of ST elevation in lead III > lead II, a V3/III
ratio approximately 0.3 mm, plus ST depression in aVL all suggest proximal RCA occlusion.
Figure 3
Inferior infarction including recording of lead “–aVR” (from Reference 34, with permission).
the obtuse marginal branch of the LCX, the posterolat- ical practice can be very helpful in discriminating
eral, and the LAD branches. Thus ST changes in leads infarct-related arteries during inferior injury. ST eleva-
V5 and V6 indicate rather posterolateral ischemia trig- tion in leads V7 through V9 and ST depression in V4R
gered by either RCA or LCX occlusion.30 When this ST probably are related to LCX occlusion.26,33 ST elevation
elevation is significant (>2 mm), it is probably a sign of in leads I to aVL or V5 to V6 is frequently accompanied
“mega-artery-related” (either the RCA or LCX) infarction by ST depression in lead aVR (or ST elevation in “–aVR”
with a large ischemic burden.30 at 30 degrees) (Figure 3).34 This sign is independent of
Precordial ST depression accompanying inferior ST depression in V1, and it indicates a larger infarct
injury is more likely to develop from LCX than RCA size. However, during routine electrocardiographic
occlusion. Horizontal ST depression with initially nega- interpretation, most physicians—even electrocardio-
tive, then upright T waves in leads V1 through V3/V4 is graphic experts—seem to ignore lead aVR6; medical
associated with posterior wall motion abnormalities.31 teaching should probably emphasize its value.
The degree of ST depression in lead V3 compared with
the degree of ST elevation in lead III (“V3/III ratio”) is Lateral and posterior infarctions (LCX occlusion)
highest (1.2 mm) when the occlusion is in the LCX and The vascular beds of the LCX have broad anatomic vari-
lowest (<0.5 mm) when it is in the proximal RCA (Fig- ability and supply a rather small ventricular area. This is
ure 2). Occlusions of the mid RCA produce V3/III inter- why the standard 12-lead electrocardiogram shows ST ele-
mediate ratios.32 The absence of ST depression in leads vation in less than half of cases of LCX occlusion. When
V1 to V2 rules out LCX occlusion, with a predictive present, ST elevation is more often seen in leads II, III,
value of >90%. and aVF, followed by leads V5, V6, and aVL.35
Some electrocardiographic leads underutilized in clin- One third of patients with chest pain secondary to
American Heart Journal
Volume 141, Number 4 Sgarbossa, Birnbaum, and Parrillo 511
Figure 4
Electrocardiogram from patient with chest pain and left main disease. ST depression is present in leads I, II, and
V4 through V6 (from Reference 41, with permission from Excerpta Medica Inc).
Figure 5
Anterior wall AMI in patient with RBBB. Precordial and lateral ST elevation as well as inferior ST depression are not obscured by con-
duction defect.
Figure 6
Unipolar VVI pacing in patient with AMI. ST elevation ≥5 mm is visible in leads V2 through V4.
otal manifestation of pericarditis (sensitivity, 100%; tained or when posterior and right precordial leads
specificity, 77%).75 are recorded. A few hospitals around the world are
already using the 15- or 16-lead electrocardiogram for
Miscellaneous routine admission workups. Cardiologists and emer-
Other conditions that may mimic AMI are severe gency physicians in the United States should make an
hyperkalemia, primary and secondary cardiac tumors, effort to incorporate these leads in both teaching and
acute pulmonary embolism, ventricular aneurysm, left clinical practice and should request electrocardio-
ventricular hypertrophy, hypothermia with J waves, graphic machine vendors that electrocardiographers
and exercise-induced ST elevation in patients with pre- be set to provide a panoramic display of the frontal
vious AMI.2 In vagotonic persons, marked negative T plane leads including a “–aVR.” Finally, electrocardio-
waves—like those observed after AMI—may be nor- graphic technology would be more helpful if auto-
mally present in leads V6R through V2. mated diagnoses were provided along with their prob-
abilities in each case as well as with the clinical value
of the electrocardiographic signs incorporated in
Nondiagnostic electrocardiograms them.
Fifteen percent to 18% of patients with AMI do not
show changes in the initial electrocardiogram, and an
additional 25% show nonspecific changes.2 Although
References
1. Willems JL, Amaud P, van Bemmel JH, et al. Assessment of the per-
nondiagnostic electrocardiograms in patients with
formance of electrocardiographic computer programs with the use
chest pain are often associated with lesions in branch of a reference database. Circulation 1985;71:523-34.
vessels, the probability of detecting AMI does increase 2. Sgarbossa EB, Wagner GS. Electrocardiography. In: Topol EJ, edi-
by recording serial electrocardiograms.76 However, tor. Textbook of cardiovascular medicine. Philadelphia (Pa): Lippin-
because reperfusion therapies are more effective when cott-Raven Publishers; 1997. p. 1545-89.
administered early, it is ideal to maximize the informa- 3. Marriot HL, editor. Practical electrocardiography. Baltimore (Md):
tion provided by the admission electrocardiogram. Non- Williams & Wilkins; 1988.
diagnostic electrocardiograms are usually 12-lead 4. Grant RP. The relationship between the anatomic position of the
recordings; approximately 8% of patients with cardiac heart and the electrocardiogram: a criticism of “unipolar” electro-
chest pain will display ST elevation only in posterior cardiography. Circulation 1953;7:890-902.
5. Hoekema R, Uijen GJ, van Erning L, et al. Interindividual variability
(V7 through V9) or right precordial (V3R through V6R)
of multilead electrocardiographic recordings: influence of heart
leads.77 These patients may not be offered reperfusion
position. J Electrocardiol 1999;32:137-148.
if only the 12-lead electrocardiogram is used for deci- 6. Pahlm US, Pahlm O, Wagner GS. The standard 11-lead ECG:
sion-making. Systematically recording leads V4R, V8, neglect of lead aVR in the classical limb lead display. J Electrocar-
and V9 (ie, a 15-lead electrocardiogram) increases the diol 1996;29:270-4.
probability of detecting ST elevation from 47% to 59%, 7. Anderson ST, Pahlm O, Selvester RH, et al. Panoramic display of
with no decrease in specificity.77 It is also reasonable to the orderly sequenced 12-lead ECG. J Electrocardiol 1994;27:
assume that a systematic examination of lead aVR may 347-52.
increase sensitivity for acute infarction.34 8. Roberts WC, Gardin JM. Location of myocardial infarcts: a confu-
sion of terms and definitions. Am J Cardiol 1978;42:868-72.
9. Parker AB, Waller BF, Gering LE. Usefulness of the 12-lead ECG in
Conclusions and recommendations detection of myocardial infarction: electrocardiographic-anatomic
correlation, part II. Clin Cardiol 1996;19:141-8.
Relative to other diagnostic methods in cardiology, 10. Bough EW, Boden WE, Korr KS, et al. Left ventricular asynergy in
electrocardiographic technology has lagged behind. electrocardiographic “posterior” myocardial infarction. J Am Coll
Experts in electrocardiography have called for a con- Cardiol 1984;4:209-15.
certed effort to incorporate modern features to the bed- 11. Sharkey SW, Berger CR, Brunette DD, et al. Impact of the electro-
side diagnosis such as high-resolution, additional leads cardiogram on the delivery of thrombolytic therapy for acute myo-
and 3D vectrocardiography imaging.78 These additions cardial infarction. Am J Cardiol 1994;73:550-3.
would improve our ability to diagnose AMI. 12. Menown IB, Mackenzie G, Adgey AA. Optimizing the initial 12-
In the meantime, however, the plethora of data cur- lead electrocardiographic diagnosis of acute myocardial infarction.
rently available on electrocardiographic changes Eur Heart J 2000;21:275-83.
13. Blanke H, Cohen M, Schlueter GU, et al. Electrocardiographic and
accompanying chest pain should allow clinicians to
coronary correlations during acute myocardial infarction. Am J Car-
make faster and better decisions than ever before. For
diol 1984;54:249-55.
example, it is now clear that isolated ST depression in 14. Aldrich HR, Hindman NB, Hinoara T, et al. Identification of optimal
leads V1 through V3 may indicate LCX occlusion and electrocardiographic leads for detecting acute epicardial injury in
potential benefit from thrombolysis. Entirely nondiag- acute myocardial infarction. Am J Cardiol 1987;59:20-3.
nostic electrocardiograms may become diagnostic 15. Birnbaum Y, Sclarovsky S, Solodky A, et al. Prediction of the level
when serial or previous electrocardiograms are ob- of left anterior descending coronary artery obstruction during ante-
American Heart Journal
516 Sgarbossa, Birnbaum, and Parrillo April 2001
rior wall acute myocardial infarction by the admission electrocar- 32. Kosuge M, Kimura K, Ishikawa T, et al. New electrocardiographic
diogram. Am J Cardiol 1993;72:823-6. criteria for predicting the site of coronary artery occlusion in inferior
16. Tamura A, Kataoka H, Mikuriya Y, et al. Inferior ST-segment depres- wall acute myocardial infarction. Am J Cardiol 1998;82:1318-22.
sion as a useful marker for identifying proximal left anterior descend- 33. Matetzky S, Freimark D, Chouraqui P, et al. Significance of ST seg-
ing coronary artery occlusion during acute myocardial infarction. Eur ment elevations in posterior chest leads (V7 to V9) in patients with
Heart J 1995;16:1795-9. acute inferior myocardial infarction: application for thrombolytic
17. Yotsukura M, Toyofuku M, Tajino K, et al. Clinical significance of therapy. J Am Coll Cardiol 1998;31:506-11.
the disappearance of septal Q waves after the onset of myocardial 34. Menown IBA, Adgey AAJ. Improving the ECG classification of infe-
infarction: correlation with location of responsible coronary lesions. rior and lateral myocardial infarction by inversion of lead aVR.
J Electrocardiol 1999;32:15-20. Heart 2000;83:657-60.
18. Tamura A, Kataoka H, Mikuriya Y. Electrocardiographic findings in 35. Huey BL, Beller GA, Kaiser DL, et al. A comprehensive analysis of
a patient with pure septal infarction. Br Heart J 1991;65:166-7. myocardial infarction due to left circumflex artery occlusion: compari-
19. Engelen DJ, Gorgels AP, Cheriex EC, et al. Value of the electrocar- son with infarction due to right coronary artery and left posterior
diogram in localizing the occlusion site in the left anterior descend- descending artery occlusion. J Am Coll Cardiol 1988;12:1156-66.
ing coronary artery in acute myocardial infarction. J Am Coll Car- 36. Boden WE, Kleiger RE, Gibson RS, et al, and the Diltiazem Reinfarc-
diol 1999;34:389-95. tion Study Group. Electrocardiographic evolution of posterior myo-
20. Selvester RH, Wagner NB, Wagner GS. Ventricular excitation dur- cardial infarction: importance of early precordial ST-depression. Am
ing percutaneous transluminal angioplasty of the left anterior J Cardiol 1987;59:782-7.
descending coronary artery. Am J Cardiol 1988;62:1116-21. 37. Sapin PM, Musselman DR, Dehmer GJ, et al. Implications of inferior
21. Ben-Gal T, Sclarovsky S, Herz I, et al. Importance of the conal ST-segment elevation accompanying anterior wall acute myocardial
branch of the right coronary artery in patients with acute anterior infarction for the angiographic morphology of the left anterior de-
wall myocardial infarction: electrocardiographic and angiographic scending coronary artery morphology and site of occlusion. Am J
correlation. J Am Coll Cardiol 1997;29:506-11. Cardiol 1992;69:860-5.
22. Geft IL, Shah PK, Rodriguez L, et al. ST elevations in leads V1 to V5 38. Mak KH, Chia BL, Tan AT, et al. Simultaneous ST-segment elevation in
may be caused by right coronary artery occlusion and acute right lead V1 and depression in lead V2: a discordant ECG pattern indicat-
ventricular infarction. Am J Cardiol 1984;53:991-6. ing right ventricular infarction. J Electrocardiol 1994;27:203-7.
23. Kim TY, Alturk N, Shaikh N, et al. An electrocardiographic algo- 39. Shalev Y, Fogelman R, Oettinger M, et al. Does the electrocardio-
rithm for the prediction of the culprit lesion site in acute anterior graphic pattern of “anteroseptal” myocardial infarction correlate
myocardial infarction. Clin Cardiol 1999;22:77-83. with the anatomic location of myocardial injury? Am J Cardiol
24. Sclarovsky S, Birnbaum Y, Solodky A, et al. Isolated midanterior 1995;75:763-6.
myocardial infarction: a special electrocardiographic sub-type of 40. Boden WE, Bough EW, Korr KS, et al. Inferoseptal myocardial
acute myocardial infarction consisting of ST-elevation in non- infarction: another cause of precordial ST-segment depression in
consecutive leads and two different morphologic types of ST- transmural inferior wall myocardial infarction? Am J Cardiol 1984;
depression. Int J Cardiol 1994;46:37-47. 54:1216-23.
25. Birnbaum Y, Hasdai D, Sclarovsky S, et al. Acute myocardial infarc- 41. Gorgels APM, Vos MA, Mulleneers R, et al. Value of the electrocar-
tion entailing ST segment elevation in lead aVL: electrocardio- diogram in diagnosing the number of severely narrowed coronary
graphic differentiation among occlusion of the left anterior descend- arteries in rest angina pectoris. Am J Cardiol 1993;72:999-1003.
ing, first diagonal, and first obtuse marginal coronary arteries. Am 42. Braat SH, de Zwaan C, Brugada P, et al. Right ventricular involve-
Heart J 1996;131:38-42. ment with acute inferior wall myocardial infarction identifies high
26. Braat SH, Brugada P, Den Dulk K, et al. Value of lead V4R for risk of developing atrioventricular nodal conduction disturbances.
recognition of the infarct coronary in acute inferior myocardial Am Heart J 1984;107:1183-7.
infarction. Am J Cardiol 1984;53:1538-41. 43. López-Sendon J, Coma-Canella I, Alcasena S, et al. Electrocardio-
27. Herz I, Assali AR, Adler Y, et al. New electrocardiographic criteria graphic findings in acute right ventricular infarction: sensitivity and
for predicting either the right or left circumflex artery as the culprit specificity of electrocardiographic alterations in right precordial
coronary artery in inferior wall acute myocardial infarction. Am J leads V4R, V3R, Vl, V2, and V3. J Am Coll Cardiol 1985;6:1273-9.
Cardiol 1997;80:1343-5. 44. Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction
28. Zimetbaum PJ, Krishnan S, Gold A, et al. Usefulness of ST-segment as an independent predictor of prognosis after acute inferior
elevation in lead III exceeding that of lead II for identifying the loca- myocardial infarction. N Engl J Med 1993;328:981-8.
tion of the totally occluded coronary artery in inferior wall myocar- 45. Kopelman HA, Forman MB, Wilson H, et al. Right ventricular
dial infarction. Am J Cardiol 1998;81:918-9. myocardial infarction in patients with chronic lung disease: possible
29. Hasdai D, Birnbaum Y, Herz I, et al. ST segment depression in lat- role of right ventricular hypertrophy. J Am Coll Cardiol 1985;5:
eral limb leads in inferior wall acute myocardial infarction: implica- 1302-7.
tions regarding the culprit artery and the site of obstruction. Eur 46. Camara EJN, Chandra N, Ouyang P, et al. Reciprocal ST change
Heart J 1995;16:1549-53. in acute myocardial infarction: assessment by electrocardiography
30. Assali AR, Sclarovsky S, Herz I, et al. Comparison of patients with and echocardiography. J Am Coll Cardiol 1983;2:251-7.
inferior wall acute myocardial infarction with versus without ST- 47. Tabbalat RA, Haft JI. Are reciprocal changes a consequence of
segment elevation in leads V5 and V6. Am J Cardiol 1998;81:81-3. “ischemia at a distance” or merely a benign electric phenomenon?
31. Porter A, Vaturi M, Adler Y, et al. Are there differences among A PTCA study. Am Heart J 1993;126:95-103.
patients with inferior acute myocardial infarction with ST depression 48. Lee HS, Cross SJ, Rawles JM, et al. Patients with suspected myo-
in leads V2 and V3 and positive versus negative T waves in these cardial infarction who present with ST depression. Lancet 1993;
leads on admission? Cardiology 1998;90:295-8. 342:1204-7.
American Heart Journal
Volume 141, Number 4 Sgarbossa, Birnbaum, and Parrillo 517
49. Birnbaum Y, Wagner GS, Barbash GI, et al. Correlation of angio- venous thrombolysis in patients with myocardial infarction who are
graphic findings and right (V1 to V3) versus left (V4 to V6) precor- older than 75 years. Circulation 2000;101:2239-46.
dial ST-segment depression in inferior wall acute myocardial infarc- 64. Berger AK, Radford MJ, Wang Y, et al. Thrombolytic therapy in
tion. Am J Cardiol 1999;15:83:143-8. older patients. J Am Coll Cardiol 2000;36:366-74.
50. O’Keefe JH, Sayed-Taha K, Gibson W, et al. Do patients with left 65. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic
circumflex coronary artery-related acute myocardial infarction with- diagnosis of evolving acute myocardial infarction in the presence of
out ST-segment elevation benefit from reperfusion therapy? Am J left bundle branch block. N Engl J Med 1996;334:481-7.
Cardiol 1995;75:718-20. 66. Sgarbossa EB. Value of the ECG in suspected acute myocardial
51. Sclarovsky S. Angina at rest and acute myocardial ischemia. In: infarction with left bundle branch block. J Electrocardiol 2000;
Electrocardiography of acute myocardial ischemic syndromes. Lon- 33(Suppl):87-92.
don (England): Marlin Dunitz Ltd; 1999. p. 1-30. 67. Sokolove PE, Sgarbossa EB, Amsterdam EA, et al. Interobserver
52. Cook RW, Edwards JE, Pruitt RD. Electrocardiographic changes in agreement in the ECG diagnosis of acute myocardial infarction in
acute subendocardial infarction, I: large subendocardial and large the presence of left bundle branch block. Ann Emerg Med 2000;
nontransmural infarcts. Circulation 1958;18:603-12. 36:566-71.
53. Shah A, Wagner GS, Green CL, et al. Electrocardiographic dif- 68. Edhouse JA, Sakr M, Angus J, et al. Suspected myocardial infarc-
ferentiation of the ST-segment depression of acute myocardial tion and left bundle branch block: electrocardiographic indicators
injury due to the left circumflex artery occlusion from that of myo- of acute ischaemia. J Accid Emerg Med 1999;16:331-5.
cardial ischemia of nonocclusive etiologies. Am J Cardiol 1997; 69. Kontos MC, McQueen RH, Jesse RL, et al. Can the ECG diagnose
80:512-3. acute myocardial infarction in emergency department patients with
54. Dabrowska B, Walczak E, Preis R, et al. Acute infarction of the left chest pain and left bundle branch block [abstract]? J Am Coll Car-
ventricular papillary muscle: electrocardiographic pattern and diol 1999;33:347A.
recognition of its location. Clin Cardiol 1996;19:404-7. 70. Sgarbossa EB, Pinski SL, Gates KB, et al, for the GUSTO-I Investiga-
55. Langer A, Goodman SG, Topol EJ, et al. Late assessment of throm- tors. Electrocardiographic diagnosis of acute myocardial infarction
bolytic efficacy (LATE) study: prognosis in patients with non-Q wave in the presence of ventricular paced rhythm. Am J Cardiol 1996;
myocardial infarction. J Am Coll Cardiol 1996;27:1327-32. 77:423-4.
56. Weiss P, Weiss I, Zuber M, et al. How many patients with acute dis- 71. Pinski SL, Sgarbossa EB, Wagner GS, for the GUSTO Investigators.
section of the thoracic aorta would erroneously receive thrombolytic Electrocardiographic manifestations of acute myocardial infarction
therapy based on the electrocardiographic findings on admission? in patients with Wolff-Parkinson-White syndrome. PACE Pacing Clin
Am J Cardiol 1993;72:1329-30. Electrophysiol 1995;18:1739.
57. Rogers WJ, Bowlby LJ, Chandra NC, et al. Treatment of myocardial 72. Spodick DH. Differential characteristics of the electrocardiogram in
infarction in the United States (1990 to 1993): observations from early repolarization and acute pericarditis. N Engl J Med 1976;
the National Registry of Myocardial Infarction. Circulation 1994; 295:523-6.
90:2103-14. 73. Kambara H, Phillips J. Long-term evaluation of early repolarization
58. Eriksson P, Gunnarsson G, Dellborg M. Diagnosis of acute myocar- syndrome (normal variant RS-T segment elevation). Am J Cardiol
dial infarction in patients with chronic right bundle-branch block 1976;38:157-61.
using standard 12-lead electrocardiogram compared with dynamic 74. Spodick DH. Differential characteristics of the electrocardiogram in
vectorcardiography. Cardiology 1998;90:58-62. early repolarization and acute pericarditis. N Engl J Med 1976;
59. Cannon A, Freedman B, Bailey BP, et al. ST-segment changes dur- 295:523-6.
ing transmural myocardial ischemia in chronic left bundle branch 75. Oliva PB, Hammill SC, Edwards WD. Electrocardiographic diagno-
block. Am J Cardiol 1989;64:1216-7. sis of postinfarction regional pericarditis: ancillary observations
60. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for regarding the effect of reperfusion on the rapidity and amplitude of
acute myocardial infarction in the United States: data from the T-wave inversion after acute myocardial infarction. Circulation
National Registry of Myocardial Infarction 2. Circulation 1998;97: 1993;88:896-904.
1150-6. 76. Gibler WB, Sayre MR, Levy RC, et al. Serial 12-lead electrocardio-
61. Berger AK, Radford MJ, Krumholz HM. Factors associated with graphic monitoring in patients presenting to the emergency depart-
delay in reperfusion therapy in elderly patients with acute myocar- ment with chest pain. J Electrocardiol 1993;26(suppl):238-43.
dial infarction: analysis of the cooperative cardiovascular project. 77. Zalenski RI, Rydman RI, Sloan EP, et al. Value of posterior and right
Am Heart J 2000;139:985-92. ventricular leads in comparison to the standard 12-lead electrocar-
62. Shlipak MG, Lyons WL, Go AS, et al. Should the electrocardiogram diogram in evaluation of ST-segment elevation in suspected acute
be used to guide therapy for patients with left bundle-branch block myocardial infarction. Am J Cardiol 1997;79:1579-85.
and suspected myocardial infarction? JAMA 1999;281:714-9. 78. Selvester RHS. A call to concerted action for change. J Electrocar-
63. Thiemann DR, Coresh J, Schulman SP, et al. Lack of benefit for intra- diol 1998;31:367-70.