ST-Segment Elevation Interpretation on Electrocardiogram

To Cath or Not to Cath?

Ali Pourdjabbar, MD1; Martin S. Green, MD1; Pablo B. Nery, MD1
JAMA Intern Med. Published online August 17, 2015. doi:10.1001/jamainternmed.2015.3989.
[+]Author Affiliations
The 12-lead electrocardiogram (ECG) is a diagnostic tool in cardiology and similar to other
diagnostic tests is also susceptible to misinterpretation. Understanding the principles of ECG
acquisition is essential to accurate interpretation. The reported cases highlight the importance of
applying these principles to challenging scenarios in which the ECG is the most important
investigation conducted to guide clinical decision-making.
Case 1
A woman in her 50s with no cardiac risk factors was assessed in an outpatient cardiology clinic for
paroxysmal atrial fibrillation and atypical chest pain. Her initial ECG is shown in Figure 1A.

Figure 1.

12-Lead Electrocardiograms (ECGs) From Patients 1 and 2

Question: Is the ST-segment elevation compatible with acute myocardial infarction (MI)?
The tracing in Figure 1A shows ST-segment elevation in the inferior leads with reciprocal changes
suggestive of an inferior ST-segment elevation MI (STEMI). A repeated ECG 30 minutes later
demonstrated resolution of ST-segment abnormalities (Figure 1B). Given the transient ST-segment
elevation, the patient was referred to our institution for urgent coronary angiography. This
demonstrated normal coronary arteries, and the patient was admitted with a presumptive
diagnosis of vasospasm. While some cardiologists believed the changes were real, others were

convinced that they were due to artifact. Subsequent ECGs and troponin I level (<0.04 ng/mL)
were normal. The patient was discharged home after 48 hours of observation.
Case 2
A woman in her 70s was assessed in the same outpatient clinic for a cardiac murmur. Her initial
ECG demonstrated ST-segment elevation (Figure 1C), which resolved after 10 minutes (Figure 1D).
She was transferred to our facility for coronary angiography. Given the pattern of ECG findings, it
was concluded that ECG abnormalities were artifactual. Therefore, she did not undergo invasive
testing. The patient was observed for 8 hours with normal serial ECG results, negative biomarkers,
and normal wall motion on echocardiogram.
Suspecting equipment malfunction, we arranged for the ECG machine to be examined by our
biomedical engineering department. Careful examination of the device identified an intermittent,
unexpectedly high impedance in the left leg (LL) lead cable. This confirmed that cable
microfracture was the cause of the ECG abnormalities shown in Figures 1A and C.
Discussion
Electrocardiographic artifacts are common. They can cause confusion and result in misdiagnosis.
Herein, we present 2 cases in which a lead microfracture resulted in ST-segment abnormalities
that were misinterpreted as acute ischemia. Both tracings depicted not only ST-segment elevation
but also reciprocal ST-segment deviation, a finding reported to increase the sensitivity of MI
detection on ECG. 1 The differential diagnosis for ST-segment elevation is broad, and includes
pulmonary embolism, pericarditis, myocarditis, hyperkalemia, acute aortic dissection, pancreatitis,
Brugada syndrome, gallbladder disease, antidepressant drug overdose, cardiac tumors, recent
electrical cardioversion, or implantable cardioverter defibrillator shocks. 2 It is imperative to
correlate the patients clinical presentation with ECG findings when evaluating patients with chest
pain or acute ST-segment abnormalities suggestive of acute ischemic ensure accurate diagnosis. A
few clues suggest the diagnosis of artifact in both tracings: (1) the pattern of ST-segment elevation
showing an unusual, abrupt return to baseline, (2) the presence of high-frequency noise in leads II
(Figure 1A), aVR, and V1 through V4 (Figure 1C), and (3) ST-segment changes affecting all ECG leads
except lead I. The latter is suggestive of an abnormality affecting the electrode connected to the
LL.
A standard 12-lead ECG is composed of 3 true bipolar leads (I, II, and III) that have 2 exploring
electrodes and 9 modified bipolar leads (aVR, aVL, aVF, and V1 through V6). 2 Although the latter
are also referred as unipolar leads, this terminology is controversial. In fact, they represent widely
spaced bipolar signals using a reference electrodethe Wilson Central Terminal (WCT). 3 The WCT
is a virtual (also called indifferent) electrode generated by the sum of the 3 signals from the left
arm, right arm, and LL (Figure 2). 4 5 Hence, the LL lead is involved in all leads except for lead I,
either directly or indirectly via the WCT. Normally, the theoretical summed current at WCT is zero.
ECG tracings are composed of a series of waveforms of varying frequencies and amplitude. To
generate good-quality tracings, signals have to be amplified equally. The electrical difference of
each lead is amplified by an instrumentation amplifier using common-mode rejection ratio
(CMRR). 3 Balancing the inputs involves maintaining similar impedances between each input and
circuit ground. Any imbalance, such as the high impedance identified in the LL cable, will lead to a

significant deleterious effect on CMRR. 3 This can impair the bidirectional filtering process
commonly used in ECG machines. These filtering abnormalities are called phase shifts and are
known to result in distortions that can affect the ST-segment. This critically timed phenomenon
can be observed after high-amplitude signals (eg, the QRS complex) generating artifact that
predominantly affects the ST-segment. 6 Alternatively, the abnormality noted could be explained
by saturation of the amplifier in the setting of cable microfracture, occurring after the QRS
complex given its high amplitude. In either scenario, the informed clinician is able to infer that the
abnormalities are due to artifact and that the LL electrode/cable interface is involved.

Figure 2.

Wilson Central Terminal (WCT)

A, Schematic representation of Einthovens triangle demonstrating the location of the 3 standard
limb electrodesright arm (RA), left arm (LA), and left leg (LL)input signals and vectors of the 6
limb leads of a 12-lead electrocardiogram and the WCT. B, Combination of input signals and
vectors of precordial leads. Modified from Braunwalds Heart Disease, 9th edition. Reproduced
with permission from Elsevier Ltd, Oxford, England, 2015.
The presented cases highlight how lead microfracture can result in artifact simulating acute
infarction on ECG. Misinterpretation of these findings can lead to incorrect diagnosis and
unnecessary investigations. Therefore, artifact should be included in the differential diagnosis of
ECG patterns that can mimic acute MI.
Take-Home Points

It is imperative that clinicians carefully evaluate history; physical examination; and

investigations, including biomarkers, before making clinical decisions in patients with STsegment elevation on ECG. Awareness of potential ECG patterns simulating MI is critical.

Potential causes of ST-segment elevation simulating acute MI include pulmonary

embolism, pericarditis, myocarditis, hyperkalemia, acute aortic dissection, pancreatitis,
Brugada syndrome, gallbladder disease, antidepressant drug overdose, and cardiac

tumors. ST-segment elevation can also be observed after electrical cardioversion or

following implantable cardioverter-defibrillator shocks.

Artifact can mimic ST-segment elevation in a pattern suggestive of acute MI.

Identification of artifact as a potential cause of ST-segment elevation can prevent

misinterpretation of ECG findings and avoid unnecessary investigations.

Article Information
Corresponding Author: Pablo B. Nery, MD, Division of Cardiology, Department of Medicine,
University of Ottawa Heart Institute, 40 Ruskin St, Room H1285, Ottawa, ON K1Y 4W7, Canada
(PNery@ottawaheart.ca).
Published Online: August 17, 2015. doi:10.1001/jamainternmed.2015.3989.
Conflict of Interest Disclosures: None reported.
Additional Contributions: Mark Cleland, BMET, CTech, an employee of the Department
Biomedical Engineering, University of Ottawa Heart Institute, assisted with the examination of the
ECG equipment; he did not receive additional reimbursement for his work other than his salary.
Section Editors: Zachary D. Goldberger, MD, MS; Nora Goldschlager, MD; Gregory M. Marcus, MD;
Elsayed Z. Soliman, MD, MSc, MS.
References
1
Martin TN, Groenning BA, Murray HM, et al. ST-segment deviation analysis of the admission 12lead electrocardiogram as an aid to early diagnosis of acute myocardial infarction with a cardiac
magnetic resonance imaging gold standard. J Am Coll Cardiol. 2007;50(11):1021-1028.
PubMed
2
Surawicz B, Knilans TK. Chous Electrocardiography in Clinical Practice. 6th ed. USA: Saunders;
2008.
3
Venkatachalam KL, Herbrandson JE, Asirvatham SJ. Signals and signal processing for the
electrophysiologist: part II: signal processing and artifact. Circ Arrhythm Electrophysiol.
2011;4(6):974-981.
PubMed
4
Gertsch M. The ECG Manual: An Evidence-Based Approach. London, England: Springer; 2009.
5

Miyamoto N, Shimizu Y, Nishiyama G, Mashima S, Okamoto Y. The absolute voltage and the lead
vector of Wilsons central terminal. Jpn Heart J. 1996;37(2):203-214.
PubMed
6
Tayler D, Hitt A, Jolley B, Sanders G, Chamberlain D. Phase shift in transmitted electrocardiograms:
a cautionary tale of distorted signals. Resuscitation. 2009;80(8):859-862.
PubMed