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original article

Wien Klin Wochenschr (2016) 128:524–527

DOI 10.1007/s00508-016-1006-9

Horizontal ECG in acute anterolateral myocardial infarction

Okan Erdogan · Bahar Dalkilic · Alper Kepez

Received: 21 December 2015 / Accepted: 23 March 2016 / Published online: 7 June 2016
© Springer-Verlag Wien 2016

Summary Introduction
Background The present study aims to compare the
amount of ST segment changes recorded by horizon- Standard 12-lead surface ECG (sECG) is a useful tool
tal electrocardiography (hECG) with standard ECG in the differential diagnosis of severe chest pain. Early
(sECG) in patients with acute anterior and/or lateral detection of ST segment elevation is of paramount im-
ST segment elevation myocardial infarction (STEMI). portance for commencing revascularization therapy,
Methods Consecutive eligible patients (n = 58) who especially in patients with ST segment elevation my-
were diagnosed with acute anterior and/or lateral ocardial infarction (STEMI). However, the sensitivity
STEMI were included in the study. After recording of admission sECG for detecting STEMI is limited, par-
simultaneous sECG and hECG by placing precordial ticularly for high lateral and posterior wall myocardial
leads (V3–6) horizontally on the left 4th intercostal infarctions [1, 2]. Hence, the sensitivity of sECG for de-
space, ST segment changes were compared. tecting ST segment changes needs to be improved, ei-
Results The mean ST segment changes (mV) on hECG ther by increasing the number of surface ECG leads or
were significantly higher than sECG in V4 (0.27 ± 0.2 vs. using different recording methods. Body surface map-
0.21 ± 0.21, p = 0.001), V5 (0.21 ± 0.17 vs. 0.12 ± 0.16, ping was found to be superior to sECG for detecting
p < 0.001) and V6 (0.09 ± 0.1 vs. 0.04 ± 0.12, p < 0.001), ST segment changes [1–5]. However, its limited avail-
respectively. When hECG and sECG were compared ability renders it applicable only to certain clinical re-
in patients with BMI < 30 kg/m2, mean ST segment search projects. Besides this, it requires special ex-
changes (mV) on hECG were significantly higher than pertise for application and interpretation, which un-
sECG in V4 (0.29 ± 0.21 vs. 0.21 ± 0.24, p = 0.004), fortunately restricts its widespread use in emergency
V5 (0.22 ± 0.19 vs. 0.13 ± 0.17, p < 0.001) and V6 (0.11 ± rooms. We propose a much more practical and easily
0.11 vs. 0.04 ± 0.11, p < 0.001), respectively. applicable ECG recording method, termed horizontal
Conclusions Mean ST segment changes in patients ECG (hECG), which is performed by moving and plac-
with anterior and/or lateral STEMI were significantly ing standard precordial V3–6 leads horizontally higher
higher and easily detectable on hECG compared with on the left 4th intercostal space on the same line with
sECG. We suggest that hECG be used in conjunction V1–2. Although this method has not been clinically val-
with sECG to diagnose anterior and lateral wall STEMI idated previously by prospective studies, it might be
in cases of diagnostic doubt. an alternative solution for improving diagnostic capa-
bility of sECG in emergency settings. Therefore, the
Keywords ECG · ST segment elevation · Acute myocar- present clinical prospective study aimed to compare
dial infarction · Diagnosis · Body surface mapping the amount of ST segment changes recorded by this
novel hECG method with sECG in patients who came
in with suspected acute anterior and/or lateral STEMI.
O. Erdogan, Professor of Cardiology (!) · B. Dalkilic, MD ·
A. Kepez, MD
Department of Cardiology, Marmara University School of
Medicine, Istanbul, Turkey

524 Horizontal ECG in acute anterolateral myocardial infarction K

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Fig. 1 a and b denote

lead positions of standard
ECG (sECG) and horizontal
ECG (hECG), respectively.
c sECG seems to be normal
with no obvious ST segment
changes in precordial leads
(V3–6). d However, when the
leads (V3–6) are moved to
the 4th intercostal space,
named hECG, they demon-
strate 0.2 mV horizontal-
and convex-type ST seg-
ment elevations associated
with biphasic or negative
T waves. e sECG shows
ST segment depressions
in V3–6. f However, hECG
clearly demonstrates 0.2 mV
further ST segment eleva-
tions associated with de
novo pathologic q waves in

Materials and methods Statistical analysis was performed using SPSS for
Windows (version 15.0; SPSS Inc., Chicago, Illinois,
Our prospective clinical study included 58 consecu- USA). The distribution of data was assessed using a
tive eligible patients admitted to our coronary care one-sample Kolmogorov–Smirnov test. Ordinal vari-
unit with the diagnosis of anterior and/or lateral acute ables displaying normal distribution were expressed
STEMI after exclusion of the following ECG findings: as mean ±SD, and ordinal variables not displaying
artefacts, right and left bundle branch blocks, in- normal distribution were expressed as median (in-
traventricular conduction delay, preexcitation, pace- terquartile range). Differences regarding the amount
maker rhythm and left ventricular hypertrophy, in of ST segment elevation between sECG and hECG
addition to electrolyte disorders and digoxin use. All leads were evaluated by using paired-samples Stu-
patients underwent emergent percutaneous coronary dent t-tests for variables with normal distribution and
intervention according to updated guidelines. The Wilcoxon signed rank tests for variables without nor-
study complies with the declaration of Helsinki and mal distribution. A P-value less than 0.05 was consid-
was approved by the local ethics committee. All sub- ered significant.
jects gave written informed consent to participate in
the study. Results
In the emergency room, sECGs were obtained
from all subjects while supine at a paper speed of Among patients (n = 58; mean age 56.6 ± 13.3 years)
25 mm/sec and a calibration of 10 mm/mV. All ECG there were 46 men (mean age 54.1 ± 10.8 years) and
recordings were performed by the same investiga- 12 women (mean age 66.5 ± 13.4 years). Fifty-four pa-
tor using the same ECG recording machine (Nihon tients (93 %) were diagnosed with anterior STEMI and
Kohden ECG-9020 K, Tokyo, Japan). hECGs were 4 patients (7 %) with lateral STEMI. All patients in-
recorded by moving and placing the standard precor- cluded in the study demonstrated occluded left ante-
dial V3–6 leads horizontally higher on the left 4th in- rior descending (LAD) artery and/or diagonal branch
tercostal space on the same line with V1–2 (Fig. 1b). occlusion. Median time from chest pain to admission
Both sECG and hECG recordings were obtained at the was 4 h (1–24 h). Mean body mass index (BMI) of all
same time. After the study was completed, all ECG patients was 28.7 ± 3.4 kg/m2. Forty patients (69 %)
recordings were blindly evaluated by two experienced had BMI below 30 kg/m2, whereas 18 (31 %) patients
cardiologists. The amount of ST segment deviation had a BMI above 30 kg/m2. Surprisingly, 5 (8.6 %),
from the J point were measured and calculated using 9 (15.5 %), 12 (20.6 %) and 10 (17.2 %) patients who
a magnifying loop and callipers. had isoelectric ST segment on sECG demonstrated de
novo ST segment elevation (≥ 0.1 mV) on hECG in

K Horizontal ECG in acute anterolateral myocardial infarction 525

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Table 1 Number of patients with ST segment changes recorded by horizontal ECG (hECG)
hECG leads ST segment elevation ST segment depression Unchanged
n (%) n (%) n (%)
V3 29 (50) 19 (33) 10 (17)
V4 40 (69) 8 (14) 10 (17)
V5 44 (76) 8 (14) 6 (10)
V6 36 (62) 7 (12) 15 (26)

Table 2 Comparison of ST segment changes (mV) between standard ECG (sECG) and horizontal ECG (hECG)
Precordial leads sECG (mV) hECG (mV) P-value
All patients (n = 58)
V3 0.31 ± 0.26 0.33 ± 0.22 0.38
V4 0.21 ± 0.21 0.27 ± 0.2 0.001
V5 0.12 ± 0.16 0.21 ± 0.17 <0.001
V6 0.04 ± 0.12 0.09 ± 0.1 <0.001
Men (n = 46)
V3 0.32 ± 0.27 0.35 ± 0.23 0.216
V4 0.22 ± 0.22 0.30 ± 0.21 <0.001
V5 0.14 ± 0.17 0.22 ± 0.18 <0.001
V6 0.04 ± 0.13 0.1 ± 0.1 <0.001
Women (n = 12)
V3 0.28 ± 0.22 0.22 ± 0.13 0.29
V4 0.16 ± 0.17 0.18 ± 0.11 0.65
V5 0.07 ± 0.08 0.15 ± 0.09 0.014
V6 0.04 ± 0.06 0.07 ± 0.06 0.032
BMI < 30 kg/m2 (n = 40)
V3 0.31 ± 0.29 0.34 ± 0.24 0.439
V4 0.21 ± 0.24 0.29 ± 0.21 0.004
V5 0.13 ± 0.17 0.22 ± 0.19 <0.001
V6 0.04 ± 0.11 0.11 ± 0.11 <0.001
BMI ≥ 30 kg/m (n = 18)
V3 0.33 ± 0.19 0.29 ± 0.19 0.422
V4 0.20 ± 0.15 0.23 ± 0.16 0.538
V5 0.10 ± 0.11 0.16 ± 0.12 0.058
V6 0.04 ± 0.14 0.06 ± 0.07 0.538
BMIbody mass index, LAD left anterior descending

leads V3 to V6, respectively (Fig. 1c–f). Any additional related due to the small number of female patients
change of ST segment is demonstrated in Table 1, included in the study. According to BMI, patients with
namely depression or elevation observed on hECG < 30 kg/m2 unequivocally showed more pronounced
compared to sECG. During hECG recording, a sub- ST segment elevations during hECG compared to
stantial number of patients developed a significant sECG in all leads except V3.
de novo change of ST segment, mostly elevation,
especially in leads V4–6. The amount of ST segment Discussion
changes observed by hECG compared to sECG is
shown descriptively in Table 2. ST segments were The principle findings of our study are, firstly, that
significantly more elevated during hECG compared to hECG compared to sECG seems to display increased
sECG in all leads (V3–6). Amount of ST segment change amount of ST segment elevation in patients with an-
during hECG seemed to be evident for both genders; terolateral STEMI and secondly, the amount of change
however it was more likely to be pronounced in men. is more pronounced in men and patients with BMI
During hECG, men demonstrated significantly more < 30 kg/m2.
ST segment elevation in all precordial leads except V3, Because of limited sensitivity of sECG for diagnos-
whereas women showed significant ST segment ele- ing STEMI in some cases, previous studies empha-
vation only in leads V5 and V6. However, this less im- sized the need of more sensitive ECG mapping tech-
pressive change observed in women might be falsely niques by adding several nonstandard leads [1–5]. The

526 Horizontal ECG in acute anterolateral myocardial infarction K

original article

idea behind this body surface mapping relies on en- Conclusion

abling the detection of ischemic areas by placing sev-
eral leads at multiple locations all over the chest wall. A novel ECG recording method, named hECG, seems
Interestingly, standard precordial leads recorded by to be diagnostically more valuable than sECG for de-
sECG were originally derived from the heart bound- tecting ST segment changes in patients who present
aries seen on chest X-ray [5]. However, it is evident with suspected acute coronary syndrome. hECG can
that the middle and basal parts of the heart consist easily be applied in the emergency rooms and does
of more thickened myocardial muscle mass. Hence, it not need sophisticated tools. We would like to recom-
is wise to hypothesize that the leads placed above the mend that this reliable method be used in conjunction
basal part of the heart, such as in hECG, may inscribe with sECG to diagnose anterior and lateral wall STEMI
and record more definite ST segment shifts compared patients in case of diagnostic doubt; however large-
to sECG, in which leads are located in the apical my- base clinical studies including patients who present
ocardial area where a lesser amount of myocardial with non-STEMI are also needed and would support
muscle mass exists. In one recent study, Scott et al. the general applicability of this novel method.
[5] emphasized the diagnostic role of 80-lead body
surface ECG mapping in which horizontal leads on Compliance with ethical guidelines
the left 4th intercostal space in line with V1–2 showed Conflict of interest O. Erdogan, B. Dalkilic and A. Kepez state
superiority for detection of anterior and lateral my- that there are no conflicts of interest.
ocardial infarction compared with leads V3–6 on sECG.
The results of our prospective clinical study using only Ethical standards The study complies with the declaration
of Helsinki and was approved by the local ethics committee.
hECG leads instead of 80-lead body surface mapping
All subjects gave written informed consent to participate in
confirmed their results. Additionally, we also looked the study.
for the effect of gender and obesity on ST segment
changes recorded by hECG. Interestingly, we found
that the improved sensitivity of hECG compared to References
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map: primary results from the multicenter OCCULT MI
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in women. This highlights the importance of hECG
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able and clear sECG recording, especially for leads V5 4. Ornato JP, Menown IB, Peberdy MA, et al. Body surface
and V6. mapping vs 12-lead electrocardiography to detect ST-
One important limitation of our study may be the elevation myocardial infarction. Am J Emerg Med. 2009;
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Therefore, we would like to recommend that large 5. Scott PJ, Navarro C, Stevenson M, et al. Optimization of
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K Horizontal ECG in acute anterolateral myocardial infarction 527