Ischemia-induced ST-segment elevation: classification, prognosis, and therapy

The standard 12-lead electrocardiogram (ECG) remains the most useful tool for the diagnosis, early risk stratification, triage, and guidance of therapy in patients with acute coronary syndromes. However, the initial and the terminal part of the QRS complex, the ST segments, and the T waves are influenced by anatomical and metabolic factors such as the “myocardium at risk” and “severity” and “duration” of ischemia. Moreover, there are complex interactions between all these factors. The ECG can identify potential candidates for reperfusion therapy as well as the completeness and success of reperfusion, whereas it can also identify those patients who will have no benefit from reperfusion because of either late arrival or nonischemic etiologies of ECG changes. These patients may have a “pseudo” ST-elevation acute myocardial infarction (STEAMI) or “pseudo-pseudo” STEAMI. The presence of Q waves and additional ST-segment depression and T-wave inversion on the admission ECG in patients with STEAMI may provide us information regarding the potential myocardial reserves, and various ECG scoring systems are in current use for that purpose. The pattern and timing of changes in Q waves, ST segment, and T waves may all be markers of the patency status of the infarct-related artery. We review and discuss each of the dynamic ECG variables during ischemia and reperfusion: the initial QRS (Q and R waves), the terminal QRS (Sclarovsky-Birnbaum score), the ST segment, and the T waves.