Chronic stable angina electrocardiography

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.; Aysha Anwar, M.B.B.S [3]

Overview

A resting 12-lead ECG is performed and recorded in all patients with suspected angina pectoris. However, a normal resting ECG does not exclude the diagnosis of ischemia. Abnormalites commonly observed on resting ECG include: ST-segment changes, left ventricular hypertrophy (LVH), left branch bundle blockage (LBBB), signs of coronary artery disease (CAD) such as previous myocardial infarction (MI) or abnormal repolarization patterns.^[1] An ECG recorded during pain helps to identify an underlying vasospasm.

Electrocardiography

Indication

As a testing modality, electrocardiography (ECG) is critical not only to add support to the clinical suspicion of CAD but also to provide prognostic information based on the pattern and magnitude of the abnormalities.

Diagnostic Criteria

In approximately half of all patients with chronic stable angina without a history of previous myocardial infarction, ECG values may be within normal range. In others, a variety of ECG findings may be present and be suggestive of an ischemic heart disease.

Q waves may suggest prior myocardial infarction, but in the absence of a clinical history of previous myocardial infarction or CAD,

Q waves may also be caused by other conditions, including hypertrophic cardiomyopathy, left ventricular hypertrophy, dilated non ischemic cardiomyopathy and accessory conduction pathways.
Isolated Q waves in lead III or QS pattern in V1 and V2 are nonspecific for diagnosis.

The occurrence of ST segment depression and T wave inversion in the resting ECG, and signs of left ventricular hypertrophy, left bundle branch block (LBBB) and left anterior hemiblock LAH are compatible with, and favors to, but are not specifically indicative of CAD.

A physician should consider these abnormal ECG findings as indications for further evaluation.
Giant T-wave inversion in precordial leads can be an important indicator of severe Left Anterior Descending (LAD) artery stenosis.

ST segment changes in angina can be seen as downsloping, upsloping or horizontal ST segment depression.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)^[2]

Noninvasive Testing-ECG (DO NOT EDIT)^[2]

Resting electrocardiography to assess risk

Class I
“1. A resting ECG is recommended in patients without an obvious, noncardiac cause of chest pain. (Level of Evidence: B)”

ESC Guidelines- Resting ECG for Initial Diagnostic Assessment of Angina (DO NOT EDIT)^[3]

Class I
“1. Resting ECG while pain free. (Level of Evidence: C)”
“1. Resting ECG during episode of angina. (Level of Evidence: B)”

ESC Guidelines- Resting ECG for Routine Reassessment in Patients with Chronic Stable Angina (DO NOT EDIT)^[3]

Class IIb
“1. Routine periodic ECG in the absence of clinical change. (Level of Evidence: C)”

References

↑ Kléber AG (2000) ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia. Cardiovasc Res 45 (1):111-8. PMID: 10728321
↑ ^2.0 ^2.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons”. Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
↑ ^3.0 ^3.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). “Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology”. Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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[pmid10728321-1] Kléber AG (2000) ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia. Cardiovasc Res 45 (1):111-8. PMID: 10728321

[pmid23166210-2] 2.0 ^2.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons”. Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.

[pmid16735367-3] 3.0 ^3.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). “Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology”. Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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