THE ECG IN ACUTE Mi AN EVIDENCE-BASED MANUAL OF REPERFUSION THERAPY Editor-in-Chief STEPHEN W. SMITH, M.D. Faculty Emergency Physician Hennepin County Medical Center Assistant Profesor of Clinical Emergency Medicine University of Minnesota School of Medicine ‘Minneapolis, Minnesota Senior Editor DEBORAH L. ZVOSEC, Ph.D. Research Associate Hennepin County Medical Center Investigator Minneapolis Medical Research Foundation Minneapolis, Minnesota Associate Editors SCOTT W. SHARKEY, M.D. Minneapolis Heart Institute Minneapolis, Minnesota TIMOTHY D. HENRY, M.D. Director, Interventional Cardiology Hennepin County Medical Center Associate Profesor of Medicine University of Minneapolis School of Medicine Minneapolis, Minnesota Mn LIPPINCOTT WILLIAMS & WILKINS ‘A Wolters Kluwer Company Philadelphia + Baltimore + New York + London Buenos Aires + Hong Kong + Sydney + TokyoAcquistion Fitor: Anne M. Sylae Developmental Edivr: Joanne Bersin ‘Production Editor: Erily Lerman “Mannfiesuring Maneger: Colin J, Warned (Cover Designer: Patica Gast onporiznrLippincote Willams & Wilkins Desktop Division Printer: Maple-Vil (© 2002 by LIPPINCOTT WILLIAMS & WILKINS 530 Walnue Street Philadelphia, PA 19106 USA LWWcom All sights reserved. This book is proceeted by copyright. No part of this book may be reproduced in any form or by any means including photocopying, or ulized by any information storage and revival system without written permission from the copyright ‘owner, except for brief quotations embodied in erccal articles and ceviews. Materials appearing in this book prepared by individuals at part oftheir oficial dares as U. ‘enment employees ze not covered hy the above-mentioned copyright Printed inthe USA Librasy of Congress Cataloging “The ECG in acute ME: an evidence-based manval of reperfusion therapy / editorinchi Stephen W. Smith : senior editor, Deborah L, Zvonee asvciate editors, Scott W. Sharkey, “Timothy D. Henry. em. Includes bibliographical references and inde. ISBN; 0-7817-2903-3 (lk. papes) 1. Myocardial infartion—Handbooks, manuals, et. 2, lectrocardiography— Handbooks, manuals, ete, 3, Myocardial reperfsion-—Handbools, manual, ec 1 Smith, Stephen W. (Stephen Walle) 1958- IDNLM: 1. Myocardial Infercrion—diagnoris. 2. Electrocaniography—methods 3. Evidence-Based Medicine. 4. Myocardial Infareion—therapy. 5. Myocardial Reperfusion—methods. WG 300 E17 2002], RC685.16 £295 2002 616.1°237—ded 2002016160, (Caras ben taken to confirm che accuracy of the infoemation presented and to descibe generally accepred practice. However, the authors editors, and publisher ae not responsible for erors or omisions or for any consequences fiom application of the information in this hole and make no warranty, expressed or implied, with espece tothe currency, compete- ness, or accuracy of the contents ofthe publication. Application ofthis information in particular situation remains the profesional responsibility of the practioner, ‘The authors, editors, and publisher have exered every effort ensue chat drug selec tion and dosage sec forth in this tex are in accordance with curent recommendations and practice at the ime of publication. However, in view of ongoing research, changes in gov- ‘emment regulations and the constant flow of information relating to deug therapy and ‘drug reactions, dhe readers urge to check the package inser foreach drug for any change in indications and dosage and for added wamings and precutions. This is paciclatly important when the recommended agent isa new ot infrequently employed dru. ‘Some drugs and medical devices presented in this publication have Food and Drog ‘Adminiscration (FDA) clearance for limited use in restricted research settings. Ite the responsibility of the health eae provider to ascertain the FDA staus ofeach drug or device planned for use in thie clinical practic. 987654321CONTENTS Contributing Authors vit Preface vith How to Use this Book iss Acknowledgments x PART I: ECG MORPHOLOGIES AND DIAGNOSIS OF AMI: GENERAL ISSUES Basic Principles and Electrophysiology 1 Terminology and ECG Types in Acute Coronary Syndromes 5 ‘The Role ofthe ECG in Reperfusion Therapy 9 ‘Anatomic Correlates of the ECG 17 Normal and Nonspecific ECGs 19 AMI and ST-Segment Elevation 28 Reciprocal ST Depression 38 ST Depression and T:Wave Inversion 47 Subtle EOG Abnormalities and Hyperacute T Waves 68 40. Serial ECG Comparison and Continuous ST-Segment Monitoring 82 11 QWaves 95 eovauruwne PART. (CG MORPHOLOGIES IN AMI 42 Anterior AMI 101 43 Inferior AMI 110 44 Lateral AMI 118 45. Right Ventricular AMI 128 416 Posterior AMI 137 PART Ill: CONDITIONS THAT OBSCURE THE DIAGNOSIS OF AMI 17 Right Bundle Branch Block and Fascicular Blocks 151 4B Left Bundle Branch Block 164 19 Antificial Ventricular Pacing 184