Available online at www.sciencedirect.com
ScienceDirect Journal of Electrocardiology xx (2015) xxx – xxx www.jecgonline.com
Electrocardiogram differentiating acute ST-segment elevation myocardial infarction from Takotsubo syndrome☆
To the Editor: The article by Vervaat et al [1], published online ahead of print on February 20, 2015 in the Journal, about a potential role of the electrocardiogram (ECG) to convincingly differentiate Takotsubo syndrome (TTS) from an acute anterior ST-segment elevation myocardial infarction (AASTEMI), is contributory to our quest to explore for a method enabling physicians to conclude that they are dealing with TTS, where conservative management is in order, or AASTEMI, where expeditious percutaneous coronary interventions, or thrombolysis are indicated. The authors appropriately contrasted their 37 patients with TTS (34 female) with 103 female patients with AASTEMI [1], considering the immense propensity of women to suffer TTS. Indeed the female gender and the postmenopausal state are 2 variables to be focusing upon, while the triage (first) ECG is being analyzed, and thus a serious consideration should be given to the diagnosis of TTS. The authors concluded that “the ECG criteria investigated”, “were insufficient to reliably distinguish patients with TTS from patients with an AASTEMI”, and thus “to definitely exclude the diagnosis of an AASTEMI coronary angiography”, which “remains the gold standard”, and “needs to be performed” [1]. One management approach is to consider the above conclusions definitive, and abandon any hope that the ECG could play a decisive role in teasing patients with TTS out of the bulk of patients with AASTEMI, so that coronary arteriography is promptly performed. Another way to consider is to practice as currently done, while in parallel we explore another “angle”. It has been reported recently that TTS is associated with ECG low voltage of the amplitude of the QRS complexes (LVQRS) on the admission ECG and/or a reduction of the voltage of the amplitude of QRS complexes (RVQRS), when the first ECG was compared with subsequently recorded ECGs [2]. However a more recent report found that LVQRS and RVQRS “are not reliable in differentiating acute coronary syndrome (not only AASTEMI) from TTS”, but that “QRS amplitude attenuation in TTS is transient, and is linearly associated with systolic function recovery and cardiac biomarkers normalization” [3]. Obviously ☆
Conflict of Interest: none.
0022-0736/© 2015 Elsevier Inc. All rights reserved.
this late differentiator is not useful in the early decision making, i.e. whether one needs to resort to prompt coronary arteriography. However 2 other sources of information needing exploration are: (1) possible RVQRS between the triage ECG and subsequent ECGs recorded during the time interval from admission to just prior to the start of coronary arteriography. Delays for recording additional to the original ECGs should be avoided, and preparations for coronary arteriography should have precedence; however if such ECG recordings could be accommodated unobtrusively, they may provide additional diagnostic insights. In terms of further burdening cardiologists with measurements and comparisons of serial ECGs, the ECG manufacturers can be induced to provide automated comparison of the amplitudes of QRS complexes for all leads or sets of leads [2]. (2) Possible RVQRS between the triage ECG and available ECGs recorded prior to the patients’ admission. The latter will be facilitated in the future by smart phone, smart devices, smart personal health data cards, and cloud computing [2]. What do the above add to the present practice with telemedicine and online ECG transmission to smart phones, iPADs etc, are the prospects of having an upgraded ECG of patients on their smart personal health data cards, take advantage of cloud computing to access old ECGs recorded anywhere on the planet, and having the benefits of yet to be created ECG algorithms for data comparisons from serial ECGs as standard features of commercial electrocardiographic equipment [2]. In the spirit of the above, it would be contributory if the authors of the present report [1], could provide data (if available) on: (1) LVQRS in the triage ECG of their 140 patients; (2) RVQRS between the triage ECGs and subsequently recorded ECGs until, or even after, the time of performance of coronary arteriography; and (3) RVQRS between the triage ECG and available ECGs recorded prior to the patients’ admission. John E. Madias MD, FACC, FAHA Icahn School of Medicine at Mount Sinai, New York, NY, USA Division of Cardiology, Elmhurst Hospital Center Elmhurst, NY, USA E-mail address: [email protected] http://dx.doi.org/10.1016/j.jelectrocard.2015.06.002
2
Electrocardiogram differentiating acute ST-segment elevation myocardial infarction from Takotsubo syndrome
References [1] Vervaat FE, Christensen TE, Smeijers L, Holmvang L, Hasbak P, Szabó BM, et al. Is it possible to differentiate between Takotsubo cardiomyopathy and acute anterior ST-elevation myocardial infarction? J Electrocardiol 2015. http://dx.doi.org/10.1016/j.jelectrocard.2015.02.008 [pii: S0022-0736(15) 00057-6, Epub ahead of print].
[2] Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28–36. [3] Guerra F, Giannini I, Pongetti G, Fabbrizioli A, Rrapaj E, Aschieri D, et al. Transient QRS amplitude attenuation is associated with clinical recovery in patients with takotsubo cardiomyopathy. Int J Cardiol 2015;187:198–205. http://dx.doi.org/10.1016/j.ijcard.2015.03.350 [Epub ahead of print].
ScienceDirect Journal of Electrocardiology xx (2015) xxx – xxx www.jecgonline.com
Electrocardiogram differentiating acute ST-segment elevation myocardial infarction from Takotsubo syndrome☆
To the Editor: The article by Vervaat et al [1], published online ahead of print on February 20, 2015 in the Journal, about a potential role of the electrocardiogram (ECG) to convincingly differentiate Takotsubo syndrome (TTS) from an acute anterior ST-segment elevation myocardial infarction (AASTEMI), is contributory to our quest to explore for a method enabling physicians to conclude that they are dealing with TTS, where conservative management is in order, or AASTEMI, where expeditious percutaneous coronary interventions, or thrombolysis are indicated. The authors appropriately contrasted their 37 patients with TTS (34 female) with 103 female patients with AASTEMI [1], considering the immense propensity of women to suffer TTS. Indeed the female gender and the postmenopausal state are 2 variables to be focusing upon, while the triage (first) ECG is being analyzed, and thus a serious consideration should be given to the diagnosis of TTS. The authors concluded that “the ECG criteria investigated”, “were insufficient to reliably distinguish patients with TTS from patients with an AASTEMI”, and thus “to definitely exclude the diagnosis of an AASTEMI coronary angiography”, which “remains the gold standard”, and “needs to be performed” [1]. One management approach is to consider the above conclusions definitive, and abandon any hope that the ECG could play a decisive role in teasing patients with TTS out of the bulk of patients with AASTEMI, so that coronary arteriography is promptly performed. Another way to consider is to practice as currently done, while in parallel we explore another “angle”. It has been reported recently that TTS is associated with ECG low voltage of the amplitude of the QRS complexes (LVQRS) on the admission ECG and/or a reduction of the voltage of the amplitude of QRS complexes (RVQRS), when the first ECG was compared with subsequently recorded ECGs [2]. However a more recent report found that LVQRS and RVQRS “are not reliable in differentiating acute coronary syndrome (not only AASTEMI) from TTS”, but that “QRS amplitude attenuation in TTS is transient, and is linearly associated with systolic function recovery and cardiac biomarkers normalization” [3]. Obviously ☆
Conflict of Interest: none.
0022-0736/© 2015 Elsevier Inc. All rights reserved.
this late differentiator is not useful in the early decision making, i.e. whether one needs to resort to prompt coronary arteriography. However 2 other sources of information needing exploration are: (1) possible RVQRS between the triage ECG and subsequent ECGs recorded during the time interval from admission to just prior to the start of coronary arteriography. Delays for recording additional to the original ECGs should be avoided, and preparations for coronary arteriography should have precedence; however if such ECG recordings could be accommodated unobtrusively, they may provide additional diagnostic insights. In terms of further burdening cardiologists with measurements and comparisons of serial ECGs, the ECG manufacturers can be induced to provide automated comparison of the amplitudes of QRS complexes for all leads or sets of leads [2]. (2) Possible RVQRS between the triage ECG and available ECGs recorded prior to the patients’ admission. The latter will be facilitated in the future by smart phone, smart devices, smart personal health data cards, and cloud computing [2]. What do the above add to the present practice with telemedicine and online ECG transmission to smart phones, iPADs etc, are the prospects of having an upgraded ECG of patients on their smart personal health data cards, take advantage of cloud computing to access old ECGs recorded anywhere on the planet, and having the benefits of yet to be created ECG algorithms for data comparisons from serial ECGs as standard features of commercial electrocardiographic equipment [2]. In the spirit of the above, it would be contributory if the authors of the present report [1], could provide data (if available) on: (1) LVQRS in the triage ECG of their 140 patients; (2) RVQRS between the triage ECGs and subsequently recorded ECGs until, or even after, the time of performance of coronary arteriography; and (3) RVQRS between the triage ECG and available ECGs recorded prior to the patients’ admission. John E. Madias MD, FACC, FAHA Icahn School of Medicine at Mount Sinai, New York, NY, USA Division of Cardiology, Elmhurst Hospital Center Elmhurst, NY, USA E-mail address: [email protected] http://dx.doi.org/10.1016/j.jelectrocard.2015.06.002
2
Electrocardiogram differentiating acute ST-segment elevation myocardial infarction from Takotsubo syndrome
References [1] Vervaat FE, Christensen TE, Smeijers L, Holmvang L, Hasbak P, Szabó BM, et al. Is it possible to differentiate between Takotsubo cardiomyopathy and acute anterior ST-elevation myocardial infarction? J Electrocardiol 2015. http://dx.doi.org/10.1016/j.jelectrocard.2015.02.008 [pii: S0022-0736(15) 00057-6, Epub ahead of print].
[2] Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28–36. [3] Guerra F, Giannini I, Pongetti G, Fabbrizioli A, Rrapaj E, Aschieri D, et al. Transient QRS amplitude attenuation is associated with clinical recovery in patients with takotsubo cardiomyopathy. Int J Cardiol 2015;187:198–205. http://dx.doi.org/10.1016/j.ijcard.2015.03.350 [Epub ahead of print].
