Electrocardiographic Predictors of Primary Ventricular Fibrillation and 30-Day Mortality in Patients Presenting with ST-Segment Elevation Myocardial Infarction

Abstract

Primary ventricular fibrillation (PVF) may occur in the early phase of ST-elevation myocardial infarction (STEMI) prior to primary percutaneous coronary intervention (PCI). Multiple electrocardiographic STEMI patterns are associated with PVF and short-term mortality including the tombstone, Lambda, and triangular QRS-ST-T waveform (TW). We aimed to compare the predictive value of different electrocardiographic STEMI patterns for PVF and 30-day mortality. We included a consecutive cohort of 407 STEMI patients (75% males, median age 66 years) presenting within 12 h of symptoms onset. At first medical contact, 14 (3%) showed the TW or Lambda ECG patterns, which were combined in a single group (TW-Lambda pattern) characterized by giant R-wave and downsloping ST-segment. PVF prior to primary PCI occurred in 39 (10%) patients, significantly more often in patients with the TW-Lambda pattern than those without (50% vs. 8%, p < 0.001). For the multivariable analysis, Killip class ≥3 (OR 6.19, 95% CI 2.37–16.1, p < 0.001) and TW-Lambda pattern (OR 9.64, 95% CI 2.99–31.0, p < 0.001) remained as independent predictors of PVF. Thirty-day mortality was also higher in patients with the TW-Lambda pattern than in those without (43% vs. 6%, p < 0.001). However, only LVEF (OR 0.86, 95% CI 0.82–0.90, p < 0.001) and PVF (OR 4.61, 95% CI 1.49–14.3, p = 0.042) remained independent predictors of mortality. A mediation analysis showed that the effect of TW-Lambda pattern on mortality was mediated mainly via the reduced LVEF. In conclusion, among patients presenting with STEMI, the electrocardiographic TW-Lambda pattern was associated with both PVF before PCI and 30-day mortality. Therefore, this ECG pattern may be useful for early risk stratification of STEMI.

Hidden Fatal ECG Manifestations

“…As a reflection of transmural myocardial ischemia, the syndrome is closely associated with ventricular fibrillation and short-term mortality, highlighting the importance of timely diagnosis and effective management. [4][5][6] Severe myocardial ischemia with extensive myocardial injury can be followed by delayed depolarization and repolarization shifts in the ventricular myocardium. This phenomenon may be caused by increased permeability of the cell membrane to K + ions and outflow of K + ions, rendering the myocardium more susceptible to ventricular fibrillation.…”

“…Some studies have also identified it as the λ pattern or the triangular QRS-ST-T waveform based on distinct electrocardiogram characteristics. As a reflection of transmural myocardial ischemia, the syndrome is closely associated with ventricular fibrillation and short-term mortality, highlighting the importance of timely diagnosis and effective management …”

Myocardial Ischemia in Patients with COVID-19 Infection: Between Pathophysiological Mechanisms and Electrocardiographic Findings

“…The ST-segment elevation myocardial infarction (STEMI) is defined as new ST-elevation at the J point in two or more contiguous leads, ≥0.25 mV in men below the age of 40 years, ≥0.2 mV in men over the age of 40 years, or ≥0.15 mV in women in leads V2–V3, and/or ≥0.1 mV in other leads [ 86 , 99 , 100 ].…”

“…There was no specific localization of the myocardial infarction in COVID-19 patients as several studies have shown, some concluding that inferior myocardial infarction was the most frequent, while others showing that anterior myocardial injury was the most common type [ 75 , 94 , 100 ]. An important aspect to mention is that STEMI represented the first clinical manifestation of COVID-19 for most patients with myocardial infarction and only a few developed ST-segment elevation during hospitalization for COVID-19 [ 75 ].…”