Korean Circ J.  2013 Jun;43(6):370-376. 10.4070/kcj.2013.43.6.370.

Etiologies and Predictors of ST-Segment Elevation Myocardial Infarction

• Bae MH
• Cheon SS
• Song JH
• Jang SY
• Choi WS
• Kim KH
• Park SH
• Lee JH
• Yang DH
• Park HS
• Cho Y
• Chae SC

• KMID: 2224897
• DOI: http://doi.org/10.4070/kcj.2013.43.6.370

Abstract

BACKGROUND AND OBJECTIVES
Rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is essential for the appropriate management of patients. We investigated the prevalence, etiologies and predictors of false-positive diagnosis of STEMI and subsequent inappropriate catheterization laboratory activation in patients with presumptive diagnosis of STEMI.
SUBJECTS AND METHODS
Four hundred fifty-five consecutive patients (62+/-13 years, 345 males) with presumptive diagnosis of STEMI between August 2008 and November 2010 were included.
RESULTS
A false-positive diagnosis of STEMI was made in 34 patients (7.5%) with no indication of coronary artery lesion. Common causes for the false-positive diagnosis were coronary spasm in 10 patients, left ventricular hypertrophy in 5 patients, myocarditis in 4 patients, early repolarization in 3 patients, and previous myocardial infarction and stress-induced cardiomyopathy in 2 patients each. In multivariate logistic regression analysis, symptom-to-door time >12 hours {odds ratio (OR) 4.995, 95% confidence interval (CI) 1.384-18.030, p=0.014}, presenting symptom other than chest pain (OR 7.709, 95% CI 1.255-39.922, p=0.027), absence of Q wave (OR 9.082, CI 2.631-31.351, p<0.001) and absence of reciprocal changes on electrocardiography (ECG) (OR 17.987, CI 5.295-61.106, p<0.001) were independent predictors of false-positive diagnosis of STEMI.
CONCLUSION
In patients whom STEMI was planned for primary coronary intervention, the false-positive diagnosis of STEMI was not rare. Correct interpretation of ECGs and consideration of ST-segment elevation in conditions other than STEMI may reduce inappropriate catheterization laboratory activation.

Keyword

Myocardial infarction; False positive reactions

MeSH Terms

Cardiomyopathies
Catheterization
Catheters
Chest Pain
Coronary Vessels
Electrocardiography
False Positive Reactions
Humans
Hypertrophy, Left Ventricular
Logistic Models
Myocardial Infarction
Myocarditis
Prevalence
Spasm

Reference

1. Watanabe K, Nagao K, Watanabe I, Kanmatsuse K. Relationship between the door-to-TIMI-3 flow time and the infarct size in patients suffering from acute myocardial infarction: analysis based on the fibrinolysis and subsequent transluminal (FAST-3) trial. Circ J. 2004; 68:280–285.

2. Brodie BR, Hansen C, Stuckey TD, et al. Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms. J Am Coll Cardiol. 2006; 47:289–295.

3. Nakayama N, Kimura K, Endo T, et al. Current status of emergency care for ST-elevation myocardial infarction in an urban setting in Japan. Circ J. 2009; 73:484–489.

4. Yan RT, Yan AT, Allegrone J, et al. Differences between local hospital and core laboratory interpretation of the admission electrocardiogram in patients with acute coronary syndromes and their relation to outcome. Am J Cardiol. 2007; 100:169–174.

5. Turnipseed SD, Bair AE, Kirk JD, Diercks DB, Tabar P, Amsterdam EA. Electrocardiogram differentiation of benign early repolarization versus acute myocardial infarction by emergency physicians and cardiologists. Acad Emerg Med. 2006; 13:961–966.

6. Surawicz B, Parikh SR. Prevalence of male and female patterns of early ventricular repolarization in the normal ECG of males and females from childhood to old age. J Am Coll Cardiol. 2002; 40:1870–1876.

7. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996; 334:481–487.

8. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004; 351:2195–2202.

9. Miller DH, Kligfield P, Schreiber TL, Borer JS. Relationship of prior myocardial infarction to false-positive electrocardiographic diagnosis of acute injury in patients with chest pain. Arch Intern Med. 1987; 147:257–261.

10. Ahmar W, Lefkovits J. Acute ST elevation myocardial infarction with angiographically normal coronary arteries: causes and outcomes. Int J Cardiol. 2008; 128:131–133.

11. Takagi M, Yokoyama Y, Aonuma K, Aihara N, Hiraoka M. Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) Investigators. Clinical characteristics and risk stratification in symptomatic and asymptomatic patients with brugada syndrome: multicenter study in Japan. J Cardiovasc Electrophysiol. 2007; 18:1244–1251.

12. Prasad A. Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation. 2007; 115:e56–e59.

13. Klinceva M, Widimský P, Pesl L, et al. Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction. Int J Cardiol. 2007; 120:411–413.

14. Gu YL, Svilaas T, van der, Zijlstra F. Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention. Neth Heart J. 2008; 16:325–331.

15. Kim PJ, Seung KB, Kim DB, et al. Clinical and angiographic characteristics of acute myocardial infarction caused by vasospastic angina without organic coronary heart disease. Circ J. 2007; 71:1383–1386.

16. Kang WY, Jeong MH, Ahn YK, et al. Are patients with angiographically near-normal coronary arteries who present as acute myocardial infarction actually safe? Int J Cardiol. 2011; 146:207–212.

17. Larson DM, Menssen KM, Sharkey SW, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007; 298:2754–2760.

18. Prasad SB, Richards DA, Sadick N, Ong AT, Kovoor P. Clinical and electrocardiographic correlates of normal coronary angiography in patients referred for primary percutaneous coronary intervention. Am J Cardiol. 2008; 102:155–159.

19. Al-Faleh H, Fu Y, Wagner G, et al. Unraveling the spectrum of left bundle branch block in acute myocardial infarction: insights from the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT 2 and 3) trials. Am Heart J. 2006; 151:10–15.

20. Sasaki K, Yotsukura M, Sakata K, Yoshino H, Ishikawa K. Relation of ST-segment changes in inferior leads during anterior wall acute myocardial infarction to length and occlusion site of the left anterior descending coronary artery. Am J Cardiol. 2001; 87:1340–1345.

21. Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000; 343:1388–1398.

22. Lee JW, Kim JY, Youn YJ, et al. Clinical characteristics and prognostic factors of stress-induced cardiomyopathy. Korean Circ J. 2010; 40:277–282.

23. Hung MJ, Cheng CW, Yang NI, Hung MY, Cherng WJ. Coronary vasospasm-induced acute coronary syndrome complicated by life-threatening cardiac arrhythmias in patients without hemodynamically significant coronary artery disease. Int J Cardiol. 2007; 117:37–44.

24. Antikainen RL, Grodzicki T, Palmer AJ, et al. Left ventricular hypertrophy determined by Sokolow-Lyon criteria: a different predictor in women than in men? J Hum Hypertens. 2006; 20:451–459.

25. Das MK, Khan B, Jacob S, Kumar A, Mahenthiran J. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation. 2006; 113:2495–2501.

26. Peterson ED, Hathaway WR, Zabel KM, et al. Prognostic significance of precordial ST segment depression during inferior myocardial infarction in the thrombolytic era: results in 16,521 patients. J Am Coll Cardiol. 1996; 28:305–312.

27. Tsuka Y, Sugiura T, Hatada K, Abe Y, Takahashi N, Iwasaka T. Clinical characteristics of ST-segment elevation in lead V6 in patients with Q-wave acute inferior wall myocardial infarction. Coron Artery Dis. 1999; 10:465–469.