Diagnostic Accuracy of Fourth Universal Definition ECG Criteria for Identifying Prior Myocardial Infarction

Purpose To assess the diagnostic accuracy of 12-lead electrocardiography (ECG) in detecting, quantifying, and localizing prior myocardial infarction (pMIs) using cardiac MRI as the reference standard. Materials and Methods In this retrospective study, consecutive patients referred for cardiac MRI and their recorded digital ECGs were evaluated between January 2018 and August 2020. Patients underwent cardiac MRI assessment for coronary artery disease or cardiomyopathy. Late gadolinium enhancement was assessed across a 17-segment heart model for patients with and without ischemia. Two blinded cardiologists independently applied the fourth universal definition of myocardial infarction ECG criteria to identify pMIs. Diagnostic accuracy of ECG in detecting pMI was assessed by calculating accuracy, sensitivity, and specificity; χ² test was used to assess the independence of observed frequencies. Results Among 1038 patients (median age, 63 years; IQR, 52-75 years, 405 female patients), ECG detection accuracy for pMI was 78.6% (88.4% specificity and 39.4% sensitivity). Using ECG, 40.2% of all transmural pMIs and 12.3% of all subendocardial pMIs were detected. ECG did not detect pMIs in 126 of 208 (60.6%) patients, particularly in the lateral (69.3%) and inferior (52.3%) regions. ECG did not detect 72.6% and 48.0% of subendocardial and transmural pMIs, respectively. Detection rates decreased further in the presence of complete left or right bundle branch block. Nonspecific conduction disturbances were more common in patients with pMIs (5.3% vs 1.6%, P = .003), especially those with transmural pMIs (6.9% vs 1.6%, P = .002). Conclusion The Fourth Universal Definition of Myocardial Infarction ECG criteria provided high specificity but limited sensitivity for detecting pMI, particularly subendocardial and lateral infarcts. Keywords: Electrocardiogram, Cardiovascular Magnetic Resonance, Myocardial Infarction, Late Gadolinium Enhancement, Fourth Universal Definition of Myocardial Infarction Supplemental material is available for this article. © RSNA, 2025.