Chronic stable angina electrocardiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

A resting 12-lead ECG is performed and recorded in all patients with suspected angina pectoris. However, a normal resting ECG does not exclude the diagnosis of ischemia. Abnormalites commonly observed on resting ECG include: ST-segment changes, left ventricular hypertrophy (LVH), left branch bundle blockage (LBBB), signs of coronary artery disease (CAD) such as previous myocardial infarction (MI) or abnormal repolarization patterns . An ECG recorded during pain helps to identify an underlying vasospasm.

Indication

As a testing modality, electrocardiography (ECG) is critical not only to add support to the clinical suspicion of CAD but also to provide prognostic information based on the pattern and magnitude of the abnormalities.

Diagnostic criteria

• In approximately half of all patients with chronic stable angina withou a history of previous myocardial infarction, ECG values may be within normal range. In others, a variety of ECG findings may be present and be suggestive of an ischemic heart disease.

• Q waves may suggest prior myocardial infarction, but in the absence of a clinical history of previous myocardial infarction or CAD,

• Q waves may also be caused by other conditions, including hypertrophic cardiomyopathy, left ventricular hypertrophy, dilated non ischemic cardiomyopathy and accessory conduction pathways.
• Isolated Q waves in lead III or QS pattern in V1 and V2 are nonspecific for diagnosis.

• The occurrence of ST segment depression and T wave inversion in the resting ECG, and signs of left ventricular hypertrophy, left bundle branch block (LBBB) and left anterior hemiblock LAH are compatible with, and favors to, but are not specifically indicative of CAD.

• A physician should consider these abnormal ECG findings as indications for further evaluation.
• Giant T-wave inversion in precordial leads can be an important indicator of severe Left Anterior Descending (LAD) artery stenosis.

• ST segment changes in angina can be seen as downsloping, upsloping or horizontal ST segment depression.

Myocardial Ischemia EKG examples

Shown below is an EKG that shows atrial fibrillation with wide spread ST depressions suggestive of ischemia or possibly non-Q myocardial infarction. In this case there were no enzyme changes suggestive of a myocardial infarction and the changes probably represent ischemia secondary to the ventricular tachycardia terminated by the lidocaine. It is also possible that the ST changes are purely a result of the tachycardia but in this case this would seem unlikely.

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ACC / AHA Guidelines- Resting ECG (DO NOT EDIT)

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Class I 1. Rest ECG in patients without an obvious noncardiac cause of chest pain. (Level of Evidence: B) 2. Rest ECG during an episode of chest pain. (Level of Evidence: B)

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ESC Guidelines- Resting ECG for Initial diagnostic assessment of angina (DO NOT EDIT)

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Class I (in all patients) 1. Resting ECG while pain free. (Level of Evidence: C) 2. Resting ECG during episode of angina. (Level of Evidence: B)

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ESC Guidelines- Resting ECG for Routine reassessment in patients with chronic stable angina (DO NOT EDIT)

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Class IIb 1. Routine periodic ECG in the absence of clinical change. (Level of Evidence: C)

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Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

References

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