Electrocardiographic Acute Myocardial
Criteria for Diagnosis of Infarction in Childhood
Jeffrey A. Towbin, MD, J. Timothy Bricker, MD, and Arthur Garson, Jr., MD
Myocardial infarction (Ml), a common occurrence in adults, is generally considered to be rare in children. Electrocardiographic criteria for diagnosis of MI in adults are well known and accepted, but no general criteria exist for children. We report 37 autopsy-proved cases of transmural MI and electrocardiographic evidence of MI in 30 of these cases. A variety of conditions previously reported to produce “pseudo-infarction” are included in these cases of MI, ineluding myocarditis, hypertrophic cardiomyopathy, and the cardiomyopathy of Duchenne’s muscular dystrophy. Compilation of the electrocardiographic data in all patients allowed for the development of criteria for this diagnosis of MI in chiidhood, and inelude wide Q waves (>35 me) with or without Q-wave notching, ST-segment elevation (>2 mm), and prolonged QT interval corrected for heart rate (QTc >440 ms) with accompanying Q-wave abnormalities. With use of these electrocardiographic criteria, an additional 3 patlents were subsequently diagnosed prospectively with MI and confirmed on autopsy. Pathologic evaluation confirmed the location of infarction predicted by the electrocardiograms in all 3 cases. (Am J Cardioll662369:164!5-1648)
yocardial infarction (MI) is among the most prevalent conditions in the United States, accounting for significant mortality and morbidity in adults. Diagnostic criteria for MI in adults have been established for electrocardiography, echocardiography, serum enzymes and radiopharmaceutical scans,‘3 but these criteria have either not been evaluated extensively in children or are not considereduseful. No diagnostic electrocardiographic criteria have been establishedfor MI in children. Fujiwara et al3 described the electrocardiographic findings of MI in Kawasaki diseasewith giant coronary artery aneurysms.Deep Q wavesor new-onsetQ wavesin the limb leads were considered indicators of MI and have subsequently been confirmed.4-6However, these findings appear to differ from that seen in childhood MI becauseof etiologies other than Kawasaki disease.The width of the Q wave, and not its depth, has been consideredto be the important diagnostic parameter in these disorders.4*7-10 QRS or Q-wave notching has been described in adults11-15 but is rarely noted in children.16 Notching has been shownto be both predictive of MI and the eventual outcomein adults,’ i but no definitive conclusionsregarding the value of Q-wave notching in the diagnosesof childhood MI have been formulated. The purpose of this study was to develop diagnostic electrocardiographic criteria for MI in childhood, including those secondary to congenital or acquired diseases.
M
METHODS
From the Department of Pediitrics, Lillie Frank Abercrombie Section of Cardiology, and Institute for Molecular Genetics,Baylor College of Medicine, Houston, Texas. Manuscript receivedJune 4,1991; revised manuscript receivedand acceptedFebruary 24,1992. Addressfor reprints: Jeffrey A. Towbin, MD, Department of Pediatrics, Pediatric Cardiology, Texas Children’s Hospital, 6621 Fannin, Houston, Texas 77030.
All autopsyspecimensfrom Texas Children’s Hospital (1952 to 1987) demonstrating transmural MI in patients aged 440 ms). 5. ST segment (Table II): Twenty-five tracings had leads with ST segment elevations >2 mm; 22 of these children had acute MI, whereas only 3 had nonacute MI. The lead most frequently abnormal was lead I (mean 4 mm). The elevation exceeded2 mm (and was therefore abnormal) in 12 of 37 patients (32%). Only lead III had ST segmentabnormalities (14 of 37, 37%). Theseelectrocardiographic criteria were usedto prospectively diagnose acute transmural MI in 6 patients (1 with critical aortic stenosis, 1 with anomalous left coronary artery, 1 with postoperativetransplant, 2 with myocarditis, 1 with pulmonary atresia-intact ventricular septum) who were later confirmed by autopsy to have MI. In addition, 30 tracings were reviewed from patients with each comparable diagnosis but without pathologic evidence of MI, except for anomalous left coronary artery in which only 10 cases without MI could be found. No abnormal Q wavesoccurred in comparable patients with anomalousleft coronary artery or Kawasaki diseasehaving no pathologic evidenceof MI. In patients with hypertrophied ventricles but no pathologic evidenceof MI (aortic stenosis,hypertrophic cardiomyopathy, or pulmonary atresia with intact ventricular septum), only deep Q waves were seen.No patient with comparable diagnosis but without pathologic evidence of MI had wide Q waves. DISCUSSION MI may occur in children with a wide variety of congenital and acquired cardiac diseases(Table III). These include congenital cardiac disorders with coronary artery abnormalities as well as those causing ventricular hypertrophy. In the latter, the areas of necrosis are thought to occur in those with the most severehypertrophy.*“,20-22The electrocardiographic and patho-
TABLE III Reported Causes of Myocardial Infarction Children: Classified by Pathophysiologic Mechanisms
in
Coronary artery occlusion Artentis Kawasaki disease* Coronary artery vasculitis Rheumatic carditis Systemic lupus erythematosus* Takayasu’s disease Periarteritis nodosa Transplant rejection* Coronary vasospasm Cocaine abuse Glue sniffing Migraine headache Thrombi/emboli to coronary artery Coronary artery thrombosis Intrauterine coronary artery embolism Mitral valve prolapse Lymphoma* Ventricular tumor Sickle cell disease Umbilical cord hematoma Thromboembolism from umbilical vein Thromboembolism from ductus venosus Thromboembolism from intrauterine renal vein thrombosis Infective endocarditis Hemophilia treated with unactivated prothrombin complex concentrates Coronary mural thickening with metabolic diseases or intimal proliferation disease Progeria Pseudoxanthoma elasticum Mucopolysaccharidosis Fabry’s disease Alkaptonuria Hurler syndrome Birth control pills/pregnancy Premature atherosclerotic heart disease Transplant coronary heart disease* Hyperbetalipoproteinemia Other Idiopathic calcification of the coronary arteries Blunt chest trauma Coronary artery stenosis/single coronary artery Surgical trauma Postoperative arterial switch (Jatene) procedure Disseminated intravascular coagulation Coronary hypopetfusion Congenital coronary artery anomalies Anomalous origin of the left coronary artery* Transposition of the great vessels Myocardial oxygen supply-demand mismatch Perinatal asphyxia* Cardiomyopathy* Critical congenital aortic stenosis* Myocarditis* Pulmonary atresia with intact ventricular septum* Supravalvar aortic stenosis: Williams syndrome Coarctation of the aorta with/without Turner’s syndrome Hypoplastlc left heart syndrome Aortic thrombosis Erythroblastosis CongenItal cardiac disease Total anomalous pulmonary venous connection Congenital pulmonary stenosis (severe) Truncus alteriosus ‘Disorders associated with myocardial infarction in this report
ACUTE MYOCARDIAL INFARCTION IN CHILDHOOD
1547
logic correlates in our patients support this hypothesis; REFERENCES 1. Pasternak RC, Braunwald E, Soble BE. Acute myocardial infarction, In: when hypertrophy was in evidence,the infarcted region Braunwald E, ed. Heart disease:A Textbook of Cardiovascular Medicine. Philawas found in that hypertrophied ventricle. delphia: WB Saunders,1988:1222-l3 13. The electrocardiographicdata compiled in this study 2. Almve S, Gilpin E, MadsenEB, Froelicher V, Henning H, RossJ Jr. Prognosimportanceof QTc interval at dischargeafter acute myocardial infarction: a demonstratethat the finding most specific for childhood tic multicenter study of 865 patients. Am Ifeorr J 1984;108:395-400. MI is wide Q waves(transmural MI), >35 ms in dura- 3. Fujiwara H, Chen C, Fujiwara T, Nishioka K, Kawai C, Hamashima Y. tion, especially when this is a new finding, and suggest Clinicopathologicstudy of abnormal Q wavesin Kawasaki disease.Am J Cardiol that the diagnosisof acute transmural MI should not be 4.1980;45:797-804. Nakanishi T, Takao A, Kondoh C, Nakamwa M, Hiroe M, Matsumot Y. made in the absenceof Q-wave abnormalities on elec- ECG findings after myocardial infarction in children after Kawasaki disease.Am trocardiography. Q-wave notching occurred in a high Heart J 1988;116:1028-1033. 5. Kato H, IchinoseE, Kawasaki T. Myocardial infarction in Kawasaki disease: percentage of children with MI (16%) and in all in- clinical analysis in 195 cases.J Pediatr 1986;108:923-927. stancescorrectly predicted its location. In adults it has 6. Nakano H, Saito A, Ueda K, Nojima K. Clinical characteristicsof myocardial beensuggestedthat a poorer outcome occurs in patients infarction following Kawasaki disease:report of 11 cases. J Pediatr 1986;108: with notched Q wavesthan in patients without electro- 7.198-203. Garson A. The Electrocardiogram in Infants and Children. A Systematic cardiographic evidenceof notching.i1J2 The high inci- Approach. Philadelphia: Lea & Febiger, 1983. dence of Q-wave notching in our autopsy-provedcases 8. Bar FW, Brugada P, DassenWR, Vanderwerf T, Wellens HJJ. Prognostic of Q waves,R/S ratio, lassof R wavevoltage,ST-T segmentabnormalities, of childhood MI may also indicate that this is a poor value electrical axis, low voltage and notching. J Am Co/l Cardiol 1984;4:17-24. prognostic sign; however, this cannot be ascertaineddi- 9. Arkin BM, Hueter DC, Ryan TJ. Predictive value of electrocardiographic rectly from this study becauseonly autopsy specimens patterns in localizing left ventricular asynergy in coronary artery disease.Am J 1979;97:453-459. were used. Unlike adults with MI, deep Q waves were Heart 10. KangosJJ, Ferrer MI, Franc&i RA, Blanc WA, BlumenthalS. Electrocardiagnostic of MI only in children with Kawasaki disease diographicchangesassociatedwith papillary muscleinfarction in congenitalheart and giant coronary aneurysms. The data support the disease.Am J Cardiol 1969;23:801-809. 11. Langner PH Jr, Latter JA. The relative significance of high-frequency view that deep Q wavesshould be a criteria for MI only and low-frequency notching in the electrocardiogram.Am Heart J 1966;71:34in the presenceof known or suspectedhistory of Kawa- 42. 12. Langner PH Jr, De Mott T, Hussey M. High-fidelity electrocardiography: saki disease.The distribution of abnormal Q waves in effects of inducedlocalized myocardial injury in the dog. Am Hear? J 1966;71: Kawasaki disease was similar to that described by 190-796. Fujiwara3 and Nakanishi4 and their co-workers. Na- 13. Goldberaer AL, Bhiarnava V. Froelicher V. Cove11J. Effect of mvocardial on-high-frequencyQRS potentials. &rculation 1981;61:34142. kanishi et al4 showed that both Q-wave amplitude and infarction 14. France RJ, Formolo JM, PenneyDG. Value of notching and slurring of the duration is specific (97 to 100%)for diagnosing inferior resting. QRS complex in the detection of ischemic heart disease.C/in &rdio/ MI, but that only amplitude is sensitivefor the diagno- 1990;13:19&196. H, Anttonen V-M. Initial and terminal notchingof the QRS complex sis (86%) in patients with Kawasaki disease.In anterior in15.theRaunio convential electrocardiogram.Am Heart J 1972;83:717-719. and lateral infarctions, however, high sensitivity (85%) 16. Holcroft JS, Liebman J. Notching of the QRS complex in high frequency was seenonly when both amplitude and duration of Q electrocardiogramsof normal children and in children with rheumatic fever. J 1970;3: 133- 146. waves were abnormal. On serial tracings, new-onsetQ Electrocardiol 17. DavignonA, Rautahariu P, BoisselleE, SoumisF, MegelasM, ChoquetteA. wavesor increaseddepth of preexisting Q wavescorre- The normal ECG standardsfor infants andchildren. Pediatr Cardioll979; 1:123131. lated with new areas of necrosis. 18. Roman0 M, Clarizia M, Onofrio E, Caiazzo MR, AdinolIi L, Cutillo S, These accumulated electrocardiographic measure- Chiariello M, Condorelli M. Heart rate, PR, and QT intervals in normal children: ments therefore allow for establishment of electrocar- a 24hour Halter monitoring study. Chin Cardiol 1988;11:839-842. diographic criteria in the diagnosis of acute childhood 19. Bazett HC. An analysis of the time relations of electrocardiograms.Heart 1918;7:353-370. MI and include the following: (1) new appearanceof 20. Franciosi RA. Blanc WA. Myocardial infarcts in infants and children. I. A wide Q waves >35 ms in duration, (2) increasedampli- necronsvstudv in coneenital heart disease.J Pediafr 1968:73:309-319. 21. I&t&y JR, Oppeiheimer EH. Someaspectsof cardiac pathology in infancy tude or duration (>35 ms) of preexisting Q waves, (3) and childhood. IV. Myocardial and coronary lesionsin cardiac malformations. new-onsetQ wavesin serial tracings, (4) Q-wave notch- Pediatrics 1967;39:896-903. ing, and (5) ST segment elevation 12 mm and pro- 22. WesterlyJR, OppenheimerEH. Someaspectsof cardiac pathologyin infancy childhood: neonatal myocardial necrosis.Bull Johns Hopkins Hasp 1966; longed QTc >440 ms when associatedwith any other and 119:191-199. criterion. 23. PinskyWW, Gillette PC, Duff DF, WondermanN, Morriss JH, Mullins CE, McNamara DG. Anomalousorigin of left coronary artery from the pulmonary In 30 of 37 retrospective cases,1 or more of these artery with ventricular septal defect, Circularion 1978;57:1026-1030. criteria was associatedwith the autopsy-proved diag- 24. Bland EF, White PD. Garland J. Congenital anomaliesof coronary arteries: nosis of MI. Three patients prospectively evaluated report of an unusual case associatedwith cardiac hypertrophy. Am Heart J 1933;8:787-801. with electrocardiogramsmeeting these diagnostic crite- 25. Burch GE. Shewey LL. Viral coronary arteritis and myocardial infarction. ria subsequentlyhad infarctions confvmed by autopsy. Am Heart J 1976;92:11-14. We conclude that electrocardiography is useful in 26. CwtanzeNordin MR, O’Connell JB, SubramanianR, RobinsonJA, ScanIon PJ. Myocarditis confirmed by biopsy presentingas acute myocardial infarcthe diagnosis of acute transmural MI in children and tion. Br Hearf J 1985;53:25-29. that the electrocardiographiccriteria outlined in this re- 27. Vaisrub S. Hypertrophic cardiomyopathyand myocardial infarction. JAMA 1980;243(15):1554. port are sensitive for this diagnosis. These criteria ap- 28. Fiorista F, Brambilla G, Saviotti M, Disco T, Morpurgo M. Myocardial pear lessuseful for the diagnosesof nonacute MI in the infarction in a child aged ten with Duchennemuscular dystrophy. 2 Kardiol 1981;70:784-788. pediatric population.
1548
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
JUNE 15, 1992
Criteria for Diagnosis of Infarction in Childhood
Jeffrey A. Towbin, MD, J. Timothy Bricker, MD, and Arthur Garson, Jr., MD
Myocardial infarction (Ml), a common occurrence in adults, is generally considered to be rare in children. Electrocardiographic criteria for diagnosis of MI in adults are well known and accepted, but no general criteria exist for children. We report 37 autopsy-proved cases of transmural MI and electrocardiographic evidence of MI in 30 of these cases. A variety of conditions previously reported to produce “pseudo-infarction” are included in these cases of MI, ineluding myocarditis, hypertrophic cardiomyopathy, and the cardiomyopathy of Duchenne’s muscular dystrophy. Compilation of the electrocardiographic data in all patients allowed for the development of criteria for this diagnosis of MI in chiidhood, and inelude wide Q waves (>35 me) with or without Q-wave notching, ST-segment elevation (>2 mm), and prolonged QT interval corrected for heart rate (QTc >440 ms) with accompanying Q-wave abnormalities. With use of these electrocardiographic criteria, an additional 3 patlents were subsequently diagnosed prospectively with MI and confirmed on autopsy. Pathologic evaluation confirmed the location of infarction predicted by the electrocardiograms in all 3 cases. (Am J Cardioll662369:164!5-1648)
yocardial infarction (MI) is among the most prevalent conditions in the United States, accounting for significant mortality and morbidity in adults. Diagnostic criteria for MI in adults have been established for electrocardiography, echocardiography, serum enzymes and radiopharmaceutical scans,‘3 but these criteria have either not been evaluated extensively in children or are not considereduseful. No diagnostic electrocardiographic criteria have been establishedfor MI in children. Fujiwara et al3 described the electrocardiographic findings of MI in Kawasaki diseasewith giant coronary artery aneurysms.Deep Q wavesor new-onsetQ wavesin the limb leads were considered indicators of MI and have subsequently been confirmed.4-6However, these findings appear to differ from that seen in childhood MI becauseof etiologies other than Kawasaki disease.The width of the Q wave, and not its depth, has been consideredto be the important diagnostic parameter in these disorders.4*7-10 QRS or Q-wave notching has been described in adults11-15 but is rarely noted in children.16 Notching has been shownto be both predictive of MI and the eventual outcomein adults,’ i but no definitive conclusionsregarding the value of Q-wave notching in the diagnosesof childhood MI have been formulated. The purpose of this study was to develop diagnostic electrocardiographic criteria for MI in childhood, including those secondary to congenital or acquired diseases.
M
METHODS
From the Department of Pediitrics, Lillie Frank Abercrombie Section of Cardiology, and Institute for Molecular Genetics,Baylor College of Medicine, Houston, Texas. Manuscript receivedJune 4,1991; revised manuscript receivedand acceptedFebruary 24,1992. Addressfor reprints: Jeffrey A. Towbin, MD, Department of Pediatrics, Pediatric Cardiology, Texas Children’s Hospital, 6621 Fannin, Houston, Texas 77030.
All autopsyspecimensfrom Texas Children’s Hospital (1952 to 1987) demonstrating transmural MI in patients aged 440 ms). 5. ST segment (Table II): Twenty-five tracings had leads with ST segment elevations >2 mm; 22 of these children had acute MI, whereas only 3 had nonacute MI. The lead most frequently abnormal was lead I (mean 4 mm). The elevation exceeded2 mm (and was therefore abnormal) in 12 of 37 patients (32%). Only lead III had ST segmentabnormalities (14 of 37, 37%). Theseelectrocardiographic criteria were usedto prospectively diagnose acute transmural MI in 6 patients (1 with critical aortic stenosis, 1 with anomalous left coronary artery, 1 with postoperativetransplant, 2 with myocarditis, 1 with pulmonary atresia-intact ventricular septum) who were later confirmed by autopsy to have MI. In addition, 30 tracings were reviewed from patients with each comparable diagnosis but without pathologic evidence of MI, except for anomalous left coronary artery in which only 10 cases without MI could be found. No abnormal Q wavesoccurred in comparable patients with anomalousleft coronary artery or Kawasaki diseasehaving no pathologic evidenceof MI. In patients with hypertrophied ventricles but no pathologic evidenceof MI (aortic stenosis,hypertrophic cardiomyopathy, or pulmonary atresia with intact ventricular septum), only deep Q waves were seen.No patient with comparable diagnosis but without pathologic evidence of MI had wide Q waves. DISCUSSION MI may occur in children with a wide variety of congenital and acquired cardiac diseases(Table III). These include congenital cardiac disorders with coronary artery abnormalities as well as those causing ventricular hypertrophy. In the latter, the areas of necrosis are thought to occur in those with the most severehypertrophy.*“,20-22The electrocardiographic and patho-
TABLE III Reported Causes of Myocardial Infarction Children: Classified by Pathophysiologic Mechanisms
in
Coronary artery occlusion Artentis Kawasaki disease* Coronary artery vasculitis Rheumatic carditis Systemic lupus erythematosus* Takayasu’s disease Periarteritis nodosa Transplant rejection* Coronary vasospasm Cocaine abuse Glue sniffing Migraine headache Thrombi/emboli to coronary artery Coronary artery thrombosis Intrauterine coronary artery embolism Mitral valve prolapse Lymphoma* Ventricular tumor Sickle cell disease Umbilical cord hematoma Thromboembolism from umbilical vein Thromboembolism from ductus venosus Thromboembolism from intrauterine renal vein thrombosis Infective endocarditis Hemophilia treated with unactivated prothrombin complex concentrates Coronary mural thickening with metabolic diseases or intimal proliferation disease Progeria Pseudoxanthoma elasticum Mucopolysaccharidosis Fabry’s disease Alkaptonuria Hurler syndrome Birth control pills/pregnancy Premature atherosclerotic heart disease Transplant coronary heart disease* Hyperbetalipoproteinemia Other Idiopathic calcification of the coronary arteries Blunt chest trauma Coronary artery stenosis/single coronary artery Surgical trauma Postoperative arterial switch (Jatene) procedure Disseminated intravascular coagulation Coronary hypopetfusion Congenital coronary artery anomalies Anomalous origin of the left coronary artery* Transposition of the great vessels Myocardial oxygen supply-demand mismatch Perinatal asphyxia* Cardiomyopathy* Critical congenital aortic stenosis* Myocarditis* Pulmonary atresia with intact ventricular septum* Supravalvar aortic stenosis: Williams syndrome Coarctation of the aorta with/without Turner’s syndrome Hypoplastlc left heart syndrome Aortic thrombosis Erythroblastosis CongenItal cardiac disease Total anomalous pulmonary venous connection Congenital pulmonary stenosis (severe) Truncus alteriosus ‘Disorders associated with myocardial infarction in this report
ACUTE MYOCARDIAL INFARCTION IN CHILDHOOD
1547
logic correlates in our patients support this hypothesis; REFERENCES 1. Pasternak RC, Braunwald E, Soble BE. Acute myocardial infarction, In: when hypertrophy was in evidence,the infarcted region Braunwald E, ed. Heart disease:A Textbook of Cardiovascular Medicine. Philawas found in that hypertrophied ventricle. delphia: WB Saunders,1988:1222-l3 13. The electrocardiographicdata compiled in this study 2. Almve S, Gilpin E, MadsenEB, Froelicher V, Henning H, RossJ Jr. Prognosimportanceof QTc interval at dischargeafter acute myocardial infarction: a demonstratethat the finding most specific for childhood tic multicenter study of 865 patients. Am Ifeorr J 1984;108:395-400. MI is wide Q waves(transmural MI), >35 ms in dura- 3. Fujiwara H, Chen C, Fujiwara T, Nishioka K, Kawai C, Hamashima Y. tion, especially when this is a new finding, and suggest Clinicopathologicstudy of abnormal Q wavesin Kawasaki disease.Am J Cardiol that the diagnosisof acute transmural MI should not be 4.1980;45:797-804. Nakanishi T, Takao A, Kondoh C, Nakamwa M, Hiroe M, Matsumot Y. made in the absenceof Q-wave abnormalities on elec- ECG findings after myocardial infarction in children after Kawasaki disease.Am trocardiography. Q-wave notching occurred in a high Heart J 1988;116:1028-1033. 5. Kato H, IchinoseE, Kawasaki T. Myocardial infarction in Kawasaki disease: percentage of children with MI (16%) and in all in- clinical analysis in 195 cases.J Pediatr 1986;108:923-927. stancescorrectly predicted its location. In adults it has 6. Nakano H, Saito A, Ueda K, Nojima K. Clinical characteristicsof myocardial beensuggestedthat a poorer outcome occurs in patients infarction following Kawasaki disease:report of 11 cases. J Pediatr 1986;108: with notched Q wavesthan in patients without electro- 7.198-203. Garson A. The Electrocardiogram in Infants and Children. A Systematic cardiographic evidenceof notching.i1J2 The high inci- Approach. Philadelphia: Lea & Febiger, 1983. dence of Q-wave notching in our autopsy-provedcases 8. Bar FW, Brugada P, DassenWR, Vanderwerf T, Wellens HJJ. Prognostic of Q waves,R/S ratio, lassof R wavevoltage,ST-T segmentabnormalities, of childhood MI may also indicate that this is a poor value electrical axis, low voltage and notching. J Am Co/l Cardiol 1984;4:17-24. prognostic sign; however, this cannot be ascertaineddi- 9. Arkin BM, Hueter DC, Ryan TJ. Predictive value of electrocardiographic rectly from this study becauseonly autopsy specimens patterns in localizing left ventricular asynergy in coronary artery disease.Am J 1979;97:453-459. were used. Unlike adults with MI, deep Q waves were Heart 10. KangosJJ, Ferrer MI, Franc&i RA, Blanc WA, BlumenthalS. Electrocardiagnostic of MI only in children with Kawasaki disease diographicchangesassociatedwith papillary muscleinfarction in congenitalheart and giant coronary aneurysms. The data support the disease.Am J Cardiol 1969;23:801-809. 11. Langner PH Jr, Latter JA. The relative significance of high-frequency view that deep Q wavesshould be a criteria for MI only and low-frequency notching in the electrocardiogram.Am Heart J 1966;71:34in the presenceof known or suspectedhistory of Kawa- 42. 12. Langner PH Jr, De Mott T, Hussey M. High-fidelity electrocardiography: saki disease.The distribution of abnormal Q waves in effects of inducedlocalized myocardial injury in the dog. Am Hear? J 1966;71: Kawasaki disease was similar to that described by 190-796. Fujiwara3 and Nakanishi4 and their co-workers. Na- 13. Goldberaer AL, Bhiarnava V. Froelicher V. Cove11J. Effect of mvocardial on-high-frequencyQRS potentials. &rculation 1981;61:34142. kanishi et al4 showed that both Q-wave amplitude and infarction 14. France RJ, Formolo JM, PenneyDG. Value of notching and slurring of the duration is specific (97 to 100%)for diagnosing inferior resting. QRS complex in the detection of ischemic heart disease.C/in &rdio/ MI, but that only amplitude is sensitivefor the diagno- 1990;13:19&196. H, Anttonen V-M. Initial and terminal notchingof the QRS complex sis (86%) in patients with Kawasaki disease.In anterior in15.theRaunio convential electrocardiogram.Am Heart J 1972;83:717-719. and lateral infarctions, however, high sensitivity (85%) 16. Holcroft JS, Liebman J. Notching of the QRS complex in high frequency was seenonly when both amplitude and duration of Q electrocardiogramsof normal children and in children with rheumatic fever. J 1970;3: 133- 146. waves were abnormal. On serial tracings, new-onsetQ Electrocardiol 17. DavignonA, Rautahariu P, BoisselleE, SoumisF, MegelasM, ChoquetteA. wavesor increaseddepth of preexisting Q wavescorre- The normal ECG standardsfor infants andchildren. Pediatr Cardioll979; 1:123131. lated with new areas of necrosis. 18. Roman0 M, Clarizia M, Onofrio E, Caiazzo MR, AdinolIi L, Cutillo S, These accumulated electrocardiographic measure- Chiariello M, Condorelli M. Heart rate, PR, and QT intervals in normal children: ments therefore allow for establishment of electrocar- a 24hour Halter monitoring study. Chin Cardiol 1988;11:839-842. diographic criteria in the diagnosis of acute childhood 19. Bazett HC. An analysis of the time relations of electrocardiograms.Heart 1918;7:353-370. MI and include the following: (1) new appearanceof 20. Franciosi RA. Blanc WA. Myocardial infarcts in infants and children. I. A wide Q waves >35 ms in duration, (2) increasedampli- necronsvstudv in coneenital heart disease.J Pediafr 1968:73:309-319. 21. I&t&y JR, Oppeiheimer EH. Someaspectsof cardiac pathology in infancy tude or duration (>35 ms) of preexisting Q waves, (3) and childhood. IV. Myocardial and coronary lesionsin cardiac malformations. new-onsetQ wavesin serial tracings, (4) Q-wave notch- Pediatrics 1967;39:896-903. ing, and (5) ST segment elevation 12 mm and pro- 22. WesterlyJR, OppenheimerEH. Someaspectsof cardiac pathologyin infancy childhood: neonatal myocardial necrosis.Bull Johns Hopkins Hasp 1966; longed QTc >440 ms when associatedwith any other and 119:191-199. criterion. 23. PinskyWW, Gillette PC, Duff DF, WondermanN, Morriss JH, Mullins CE, McNamara DG. Anomalousorigin of left coronary artery from the pulmonary In 30 of 37 retrospective cases,1 or more of these artery with ventricular septal defect, Circularion 1978;57:1026-1030. criteria was associatedwith the autopsy-proved diag- 24. Bland EF, White PD. Garland J. Congenital anomaliesof coronary arteries: nosis of MI. Three patients prospectively evaluated report of an unusual case associatedwith cardiac hypertrophy. Am Heart J 1933;8:787-801. with electrocardiogramsmeeting these diagnostic crite- 25. Burch GE. Shewey LL. Viral coronary arteritis and myocardial infarction. ria subsequentlyhad infarctions confvmed by autopsy. Am Heart J 1976;92:11-14. We conclude that electrocardiography is useful in 26. CwtanzeNordin MR, O’Connell JB, SubramanianR, RobinsonJA, ScanIon PJ. Myocarditis confirmed by biopsy presentingas acute myocardial infarcthe diagnosis of acute transmural MI in children and tion. Br Hearf J 1985;53:25-29. that the electrocardiographiccriteria outlined in this re- 27. Vaisrub S. Hypertrophic cardiomyopathyand myocardial infarction. JAMA 1980;243(15):1554. port are sensitive for this diagnosis. These criteria ap- 28. Fiorista F, Brambilla G, Saviotti M, Disco T, Morpurgo M. Myocardial pear lessuseful for the diagnosesof nonacute MI in the infarction in a child aged ten with Duchennemuscular dystrophy. 2 Kardiol 1981;70:784-788. pediatric population.
1548
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
JUNE 15, 1992
