Goss Lucas, Meyers H Pendell, Friedman Brandon, Bracey Alexander, Smith Stephen W
Department of Emergency Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, United States of America; Department of Pulmonary and Critical Care Medicine, Emory University, Atlanta, GA, United States of America.
Department of Emergency Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, United States of America.
J Electrocardiol. 2025 Jul-Aug;91:153931. doi: 10.1016/j.jelectrocard.2025.153931. Epub 2025 Apr 20.
We sought to describe and evaluate an ECG pattern of left anterior descending (LAD) occlusion for which we have coined the term "precordial swirl." In this pattern the ECG manifests abnormal ST elevation (STE) and/or hyperacute T waves in V1-V2, with reciprocal STD and/or TWI in V5-V6, creating a clockwise "swirl" pattern in the ST-T shifts of the precordial leads.
After deriving the characteristics of the precordial swirl pattern from 17 patients with proven acute LAD occlusion, the pattern was evaluated retrospectively using a high-risk population of ED patients with possible ACS symptoms. The primary outcome measures were positive predictive value and specificity for Occlusion MI for each of the developed criteria for precordial swirl sign.
Several criteria were derived based on observations and measurements of the derivation cohort. The validation cohort consisted of 808 patients, of whom 265 had Occlusion MI. Precordial swirl pattern, defined as normal QRS (narrow QRS without LVH) with STD in V5 and/or V6 plus any STE in V1 and/or V2, yielded PPV 42 %, sensitivity 11 %, (95 % CI 8-15 %), and specificity 92 % (95 % CI 90-95 %) for Occlusion MI. When defined as a narrow QRS plus STD in V5/V6 plus T wave to S wave amplitude ratio > 0.40 in V2, precordial swirl pattern yielded PPV 70 %, sensitivity 9 %, specificity 98 %. Of the 23 Occlusion MI patients correctly identified by precordial swirl sign, 19 (83 %) had LAD culprit lesions, and 16 (70 %) were missed by STEMI criteria.
Among high-risk ACS patients in the ED, precordial swirl sign had clinically relevant PPV and specificity for LAD Occlusion MI, including a significant number of patients who are missed by the current STEMI criteria. Further study should be done to validate these findings and improve detection of acute coronary occlusion myocardial infarction.
我们试图描述和评估一种左前降支（LAD）闭塞的心电图模式，我们将其命名为“胸前区漩涡”。在这种模式下，心电图表现为V1-V2导联出现异常ST段抬高（STE）和/或超急性T波，V5-V6导联出现对应性ST段压低（STD）和/或T波倒置（TWI），在胸前导联的ST-T改变中形成顺时针“漩涡”模式。
从17例确诊为急性LAD闭塞的患者中得出胸前区漩涡模式的特征后，使用有急性冠状动脉综合征（ACS）症状可能性的急诊科高危患者群体进行回顾性评估。主要结局指标是胸前区漩涡征各制定标准对闭塞性心肌梗死（Occlusion MI）的阳性预测值和特异性。
基于推导队列的观察和测量得出了几个标准。验证队列由808例患者组成，其中265例患有闭塞性心肌梗死。胸前区漩涡模式定义为正常QRS波群（无左心室肥厚的窄QRS波群）伴V5和/或V6导联ST段压低以及V1和/或V2导联任何ST段抬高，对闭塞性心肌梗死的阳性预测值为42%，敏感性为11%（95%置信区间8%-15%），特异性为92%（95%置信区间90%-95%）。当定义为窄QRS波群加V5/V6导联ST段压低加V2导联T波与S波振幅比>0.40时，胸前区漩涡模式的阳性预测值为70%，敏感性为9%，特异性为98%。在通过胸前区漩涡征正确识别的23例闭塞性心肌梗死患者中，19例（83%）有LAD罪犯病变，16例（70%）被ST段抬高型心肌梗死（STEMI）标准漏诊。
在急诊科高危ACS患者中，胸前区漩涡征对LAD闭塞性心肌梗死具有临床相关的阳性预测值和特异性，包括大量被当前STEMI标准漏诊的患者。应进一步研究以验证这些发现并改善急性冠状动脉闭塞性心肌梗死的检测。
