VKG-vid akuta koronara syndromDocent Sven V ErikssonDocent Sven V Eriksson

E-mail:E-mail: sven@sjukhus.orgsven@sjukhus.orgHemsidaHemsida: : www.sjukhus.orgwww.sjukhus.org

Docent Sven V ErikssonDocent Sven V Eriksson

Åre 1999

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History 1History 1

ECG - (Waller 1887, Einthoven 1893)ECG - (Waller 1887, Einthoven 1893)

ST-elevation MI - (Smith 1918)ST-elevation MI - (Smith 1918)

Monocardiogram Monocardiogram - (Mann 1920)- (Mann 1920)

AHA V1-6, 1938AHA V1-6, 1938

12-lead ECG12-lead ECG, (Goldberger 1942), (Goldberger 1942)

VCG - (Schmitt 1955)VCG - (Schmitt 1955)

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History 2History 2

Standard VCG-leads (Frank 1956/60) Standard VCG-leads (Frank 1956/60)

VCG MI criteria (Hoffman 1964, Young VCG MI criteria (Hoffman 1964, Young

1968)1968)

Continuous VCG (cVCG) (Hodges 1974)Continuous VCG (cVCG) (Hodges 1974)

cVCG during acute MI (Sederholm 1984)cVCG during acute MI (Sederholm 1984)

On-line cVCG (Gröttum 1985)On-line cVCG (Gröttum 1985)

MIDAMIDA 1986 1986

EASI-MIDAEASI-MIDA 2001 2001

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Myter 1Myter 1

VKG används nästan bara i SverigeVKG används nästan bara i Sverige

Det krävs ingen genuin kunskap i fysiologi för att Det krävs ingen genuin kunskap i fysiologi för att lära sig VKGlära sig VKG

Det är enkelt att inkludera VKG-analyser i t.ex. Det är enkelt att inkludera VKG-analyser i t.ex. läkemedelsstudierläkemedelsstudier

Av multiavlednings-EKG-metoderna är bara VKG Av multiavlednings-EKG-metoderna är bara VKG utvärderade vid akut IHDutvärderade vid akut IHD

VKG används idag nästan bara i MIDA-systemenVKG används idag nästan bara i MIDA-systemen

Det krävs minst 8 avledningar för beräkning av VKGDet krävs minst 8 avledningar för beräkning av VKG

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Myter 2Myter 2

Icke-Q-vågs-infarkt = icke-transmural infarktIcke-Q-vågs-infarkt = icke-transmural infarkt

Icke-Q-vågsinfarkt har annan prognos än Q-vågs infarktIcke-Q-vågsinfarkt har annan prognos än Q-vågs infarkt

Icke-Q-vågs infarkt har icke ockluderat koronarkärl i Icke-Q-vågs infarkt har icke ockluderat koronarkärl i motsats till Q-våginfarkt (22% skillnad).motsats till Q-våginfarkt (22% skillnad).

Om cVKG är u.a. och pat. är smärtfri = ej MIOm cVKG är u.a. och pat. är smärtfri = ej MI

cVKG ger ingen information vid grenblock cVKG ger ingen information vid grenblock

Om cVKG/Holter visar ischemi = myokard-ischemiOm cVKG/Holter visar ischemi = myokard-ischemi

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Q Versus Non-QQ Versus Non-Q

Prinzmetal. Prinzmetal. Q-wave=Transmural MI.Q-wave=Transmural MI. Am J Med Am J Med 1954;16:469-88.1954;16:469-88.

Pipberger/Prinzmetal. Admitting errors of method ..”Pipberger/Prinzmetal. Admitting errors of method ..”there there was no reason to suppose that subendocardial infarcts was no reason to suppose that subendocardial infarcts could not generate Q-waves”could not generate Q-waves”. Am Heart J 1957;54:511-29.. Am Heart J 1957;54:511-29.

Approximately 50 % of all subendocardial infarcts are Approximately 50 % of all subendocardial infarcts are accompanied by Q-waves. Circulation 1958;18:600-11, accompanied by Q-waves. Circulation 1958;18:600-11, Circulation 1958;18:612-22.Circulation 1958;18:612-22.

Review of prognosis in non-Q versus Q in 9 studies. No Review of prognosis in non-Q versus Q in 9 studies. No difference!difference! Table 1. JACC 1999;33:576-82. Table 1. JACC 1999;33:576-82.

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Frank X-, Y- and Z-leads

Y

Z

X Z

X

Y

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ST-Vector Magnitude- ST-VM

X

Y

Z

S Tx

S Ty

S Tz–ST –ST –ST–x –y –z

–= –+ –+–2 –2 –2–ST-VM

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ST-Vector

Y

X

Z

S T -v e c to rS Ty

S Tz

S Tx

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ST Change Vector Magnitude STC-VM

P re s e n t S T-ve c to rY

X

Z

Initia l ST-ve ctor

STC-VM

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QRS-Vector Difference QRS-VD

A

QRS VD A A Ax y z 2 2 2

X

Y

Z

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Why use more/other than 12-lead Why use more/other than 12-lead ECG?ECG?

Matetzky S et al. Significance of ST Segment Elevations Matetzky S et al. Significance of ST Segment Elevations in Posterior Chest Leads (V7 to V9) in Patients with Acute in Posterior Chest Leads (V7 to V9) in Patients with Acute Inferior Myocardial Infarction: JACC 1998;31:506-11.Inferior Myocardial Infarction: JACC 1998;31:506-11.

Jai B et al. Importance of posterior chest leads in patients Jai B et al. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram. Am J Cardiol routine 12-lead electrocardiogram. Am J Cardiol 1999;83:323-6.1999;83:323-6.

Addition of right precordial leads to standard exercise Addition of right precordial leads to standard exercise electrocardiography improves sensitivity. electrocardiography improves sensitivity. N Engl J Med 1999;340:340-383.N Engl J Med 1999;340:340-383.

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Limits:Limits:

QRS-VD >15 uVsQRS-VD >15 uVs

ST-VM > 0.05 mVST-VM > 0.05 mV

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QRS-VD känslig för:QRS-VD känslig för:

Ändrat kroppsläge (ofta typisk bild)Ändrat kroppsläge (ofta typisk bild)

IschemiIschemi

Ändring i volymÄndring i volym

LedningshinderLedningshinder

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ST-VM känslig för:ST-VM känslig för:

Ischemi (relativt spec./män)Ischemi (relativt spec./män)

DigitalisDigitalis

FrekvensFrekvens

VänsterkammarhypertrofiVänsterkammarhypertrofi

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ECG/VCG difficult in patients with:ECG/VCG difficult in patients with:

Bundle branch block?Bundle branch block?

Ventricular pacingVentricular pacing

Left ventricular hypertrophy?Left ventricular hypertrophy?

Atrial fibrillation?Atrial fibrillation?

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VCG can give information VCG can give information regarding: regarding:

Ischemia (predischarge exercise test)Ischemia (predischarge exercise test)

Prognosis (MI/Unstable angina) Prognosis (MI/Unstable angina)

ReperfusionReperfusion

ReocclusionReocclusion

Diagnosis (bundle branch block)Diagnosis (bundle branch block)

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Value of clinical and VCG data for Value of clinical and VCG data for prediction of ST depression at exercise prediction of ST depression at exercise testtest

X2 value P value

STC-VM episodes 31.5 <0.001

ST-X maximum depression 16.2 <0.001

ST-Z value elevation 9.4 <0.01

Rest pain episodes 5.5 <0.05

Lundin P, Eriksson SV et al. J of Electrocardiol 1995;28:277-85

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Prognostic informationPrognostic information

Lundin P, Eriksson SV, Strandberg L, Rehnqvist N. Prognostic Information from on-line vectorcardiography in acute myocardial infarction. Am J Cardiol, 1994;74:1103-1108.

Lundin P, Eriksson SV, Fredriksson M, Rehnqvist N. Prognostic information from on-line vectorcardiography in patients with unstable angina pectoris. Cardiology, 1995;86:60-66.

Andersen K, Eriksson P, Dellborg M. Ischaemia detected by continuous on-line vectorcardiographic monitoring predicts unfavourable outcome in patients admitted with probable unstable coronary disease. Coron Artery Dis 1996;7:753-760.

Andersen K, Eriksson P, Dellborg M. Non-invasive risk stratification within 48 h of hospital admission in patients with unstable coronary disease. Eur Heart J 1997;18:780-788.

Holmvang L et al. Relative contributions of a single-admission 12-lead electrocardiogram and early 24-hour continuous electrocardiographic monitoring for early risk stratification in patients with unstable coronary artery disease. Am J Cardiol 1999;83:667-674.

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Comparison between 167 survivors and 36 Comparison between 167 survivors and 36 non-survivorsnon-survivors

VariableVariable AgeAge Performed ex-testPerformed ex-test VF during VF during

hospitalizationhospitalization STC-VM episodesSTC-VM episodes QRS-end valueQRS-end value VCG sign of VCG sign of

reperfusionreperfusion

Dead (n=36)Dead (n=36) Alive Alive (n=167)(n=167)

7373++77 6363++10**10** 42%42% 92%**92%** 19%19% 4%**4%** 3(2-5)3(2-5) 0(0-2)**0(0-2)** 25(17-36)25(17-36) 19(15-19(15-

30)*30)* 22%22% 46%*46%*

Lundin P, Eriksson SV et al. Am J Cardiol 1995;74:1103-08

*p<0.05, **p<0.01*p<0.05, **p<0.01

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Markers of reperfusion

35-50% of patients have multiple periods of both ST recovery and reelevation, reflecting cyclic variations in infarct artery

flow

Symptoms ECG

Relief of pain

a 5 point reduction

on a 1 to 10 scale

Abrupt increase of

Troponin-T/I

CK-MB

Myoglobin

Combination

Serum markers

A “snapshot” > 50%

reduction of of ST elevation

On-line VCG/ECG

% ST recovery

Accuracy 80%

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Signs of Signs of reperfusion:reperfusion:

> 50% reduction of ST-VM within 90 min> 50% reduction of ST-VM within 90 min

Early “plateau” of QRS-VDEarly “plateau” of QRS-VD

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Chest pain + Thrombolytic drugOn-line VCG 90 min (n=96)

“Open” by VCG (n=65)

Actually open (n=12)

5 + collateral1 - collaterals

Actually Closed(n=19)

12 - collaterals

7 + collateral's

Closed by VCG (n=31)

Actually closed (n=7

)Actually open

(n=58)

VCG monitoring to assess early VCG monitoring to assess early vessel patencyvessel patency

Dellborg et al. Eur Heart J 1995;16:21-29

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Selected publications Selected publications Lundin P, Eriksson SV et al. Ischemia monitoring with on-line vectorcardiography

compared with results from a predischarge exercise test in patients with acute ischemic heart disease. J of Electrocardiol 1995;28:277-285

Lundin P, Eriksson SV et al. Ischemia monitoring with on-line vectorcardiography during dobutamine stress-echocardiography in patients with unstable coronary artery disease. J Int Med., 1998;244:61-70

Lundin P, Eriksson SV et al. Ischemia monitoring with on-line vectorcardiography during dobutamine stress-echocardiography in patients with unstable coronary artery disease. J Int Med., 1998;244:61-70

  Jensen J, Eriksson SV et al. Systolic deterioration in basal segments of the left ventricle is

related to myocardial ischemia during angioplasty: A tissue Doppler echocardiographic and vectorcardiographic study. Clinical Science 2001;100:137-143

Jensen J, Eriksson SV, Lindvall B, Lundin P. Sylvén C. Women react with more myocardial ischemia and angina pectoris during elective percutaneous transluminal coronary angioplasty. Cor Art Disease 2000:11;527-35.

Eriksson SV. Vectorcardiography: a tool for the non-invasive detection of reperfusion and reocclusion? Thrombosis and Haemostasis 1999;82:64-67

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VCG-studies VCG-studies DS/HS/USA/GermanyDS/HS/USA/Germanywww.sjukhus.orgwww.sjukhus.org for more details for more details

VCG during acute MI 210 pat. DS, VCG during acute MI 210 pat. DS, Thesis 1995Thesis 1995

VCG in unstable angina 160 pat. DSVCG in unstable angina 160 pat. DS

PEGHIRUIDPEGHIRUID 210 pat. DS “ 210 pat. DS “core-lab”, Berlin, Germanycore-lab”, Berlin, Germany

VCG-registration during PTCA 209 pat. HS, VCG-registration during PTCA 209 pat. HS, Thesis 2000Thesis 2000

VCG during dialysis DSVCG during dialysis DS. 120 registrations. 120 registrations

VCG-in Chest pain unit, 1918 pat. Chattanooga, VCG-in Chest pain unit, 1918 pat. Chattanooga, USAUSA

EASI/Frank-MIDAEASI/Frank-MIDA during PTCA during PTCA 108108 pat. pat.

EASI/Frank-MIDA EASI/Frank-MIDA during thallium 90 pat.during thallium 90 pat.

The Erlanger/DS VCG-The Erlanger/DS VCG-studystudy

Assistant Professor, Francis M. Fesmire UT College of MedicineAssistant Professor, Sven V Eriksson, Danderyds Hospital, Karolinska Institutet

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1 918 pat.1 918 pat.

Patients in VCG-studyPatients in VCG-study

210 with BBB210 with BBB2 128 with VCG2 128 with VCG

2 206 consecutive pat 2 206 consecutive pat

Characteristics in patients with and without LVH on Characteristics in patients with and without LVH on ECGECG

With LVHWith LVH Without LVHWithout LVH N=196 N=196 N=N=1 7221 722

AgeAge 54.5 54.5 ++ 13.4 13.4 53.5 53.5 ++ 13.9 13.9

Male Male 99 (50.5%)99 (50.5%) 889 (51.6%)889 (51.6%)

RaceRaceCaucasianCaucasian 86 (43.9%)86 (43.9%)1326 (77.0%)***1326 (77.0%)***African AmericanAfrican American 107 (54.6%)107 (54.6%) 379 (22.0%)*** 379 (22.0%)***

OtherOther 3 (1.5%)3 (1.5%)17 (1.0%)17 (1.0%)

Previous MI Previous MI 65 (33.2%)65 (33.2%)496 (28.8%)496 (28.8%)

Previous PTCA/CABG Previous PTCA/CABG 47 (24.0%)47 (24.0%)410 (23.8%)410 (23.8%)

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Patients without LVHPatients without LVH

05

1015202530354045

0 25 50 75 100 125 150 175 200 225

Baseline ST-Vector Magnitude

+ L

ikel

ihoo

d R

atio

(A

MI)

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Patients with LVHPatients with LVH

0

1

2

3

4

5

6

7

0 50 100 150 200 250 300

Baseline ST-Vector Magnitude

+L

ikel

ihoo

d R

atio

(A

MI)

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Conclusions:Conclusions:– VCG registration improves VCG registration improves

identification of patients with high risk identification of patients with high risk of an acute MIof an acute MI

– The optimal cut-off value for patients The optimal cut-off value for patients without left ventricular hypertrophy is without left ventricular hypertrophy is 100 uV100 uV

– In pat. with LVH, VCG-monitoring has In pat. with LVH, VCG-monitoring has limited power for detection of acute MIlimited power for detection of acute MI