The Use of the Electrocardiogram to Identify Epicardial Coronary and Tissue Reperfusion in Acute Myocardial Infarction

The standard 12-lead ECG gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST-elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: 1) ST-segment measurements; 2) T-wave configuration; 3) QRS changes; and 4) reperfusion arrhythmias. Complete and stable (≥70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30% to 70%) or no (<30%) ST-segment resolution. Early inversion of the T-waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude and width, R-wave amplitude and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes have not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST-segments and T-waves occur during reperfusion therapy and the days after. While changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes are less clear, and especially whether changes in the QRS-complex and T-wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and re-ischemia should be used for therapeutic decision-making in the clinical setting.