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European Heart Journal 1989 10(10):880-886;
Copyright © 1989 by the European Society of Cardiology.
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© 1889 The European Society of Cardiology

Inaccuracy of various proposed electrocardiographic criteria in the diagnosis of apical myocardial infarction — a critical review

P. GIANNUZZI, A. IMPARATO, P. LUIGI TEMPORELLI, F. SANTORO and L. TAVAZZI

Division of Cardiology, Clinica del Lavoro Foundation, Institute of Care and Research, Medical Center of Rehabilitation Veruno, Italy

Received 12 August 1988; revised 1 March 1988; .

Address for reprints: Pantaleo Giannuzzi MD, Divisione di Cardiologia, Centra medico di Riabilitazione, 28010 Veruno (NO), Italy

Abstract

The diagnostic accuracy of the standard electrocardiogram (ECG) in apical myocardial infarction (MI) was evaluated in 112 consecutive patients with recent MI and wall-motion abnormalities limited to the left ventricular (LV) apex on two-dimensional echocardiography, performed at rest 21 to 84 days after MI.

The following patterns of abnormal (≥30 ms) Q waves were found: anteroseptal (Q V1–V4) in 44 patients (39.3%), anterolateral (Q V1–V6 and/or I, aVL) in 22 (19.6%), inferior (Q III, aVF or II, III, aVF) in five (4.5%), lateral (Q I, aVL and/or V5–V6) in five (4.5%), anteroinferior in six (5.3%); non-Q MI was present in 30 patients (26.8%).

By applying various proposed ECG criteria, the presence of apical MI was correctly identified in very few (24, 21%) patients.

LV apex was extensively asynergic in 85 patients (76%) and partially asynergic in 27 (24%). All the patients with Q waves in lateral leads and 47% of the patients with non-Q MI had partially asynergic LV apex, while in the other ECG patterns, extensively asynergic LV apex was predominant. The presence of both ≥ 30 ms Q waves and loss of R in left precordial leads and I strongly suggests extensive apical asynergy; normal QRS in the same leads, however, does not exclude extensive apical involvement.

Patients with extensively asynergic LV apex had higher end-diastolic volume (58±23 vs 46±15 mlm–2 P < 0.01), lower ejection fraction (52±5 vs 58±6%, P < 0.001) and a greater incidence of abnormal Q waves (3.2±1.8 vs 1.2±1.1, P<0.01) than patients with partially asynergic LV apex.

In conclusion; various proposed ECG criteria are insensitive (21% success rate) in detecting apical MI diagnosed by 2D ECHO; the most common ECG pattern is anterior Q waves, and the ECG may simulate a large infarction even when the asynergy is limited to the LV apex. However a greater infarct size on ECG is associated with greater apical involvement.

Key Words: Apical infarction • electrocardiogram • echocardiography


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