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Variations in the electrocardiograms of young adults: are revised criteria for thrombolysis needed?
J E Hollander1, M Lozano, E Goldstein
1Department of Emergency Medicine, SUNY Health Sciences Center, Stony Brook, 11794-7400, USA
Insights
Early repolarization variants are common in young adults and can mimic cocaine-induced myocardial ischemia on electrocardiograms. Differentiating these normal variants from acute ischemia is crucial for accurate diagnosis in chest pain evaluations.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Electrocardiography
Background:
- Cocaine use can induce myocardial ischemia, presenting diagnostic challenges in young adults with chest pain.
- Electrocardiograms (ECGs) in cocaine users often show abnormalities, frequently due to normal variants like early repolarization.
- Distinguishing these normal variants from acute ischemic changes is critical for appropriate patient management.
Purpose of the Study:
- To determine the frequency of normal electrocardiographic variants, specifically early repolarization, in a young adult population.
- To assess the potential for these normal variants to be misdiagnosed as acute ischemia.
- To evaluate the diagnostic agreement between physicians regarding ECG findings in young adults.
Main Methods:
- A prospective study enrolled 414 subjects aged 18-35 without known heart disease.
- Standard 12-lead electrocardiographic tracings were obtained and interpreted by two physicians blinded to patient history.
- Disagreements in ECG interpretation were resolved by a third physician adjudicator.
Main Results:
- Of 414 subjects, 37% had normal ECGs, 59% had abnormal but non-ischemic findings, and 4% showed ischemia.
- Repolarization abnormalities varied significantly by race: blacks (32-51%), Hispanics (26-35%), and Caucasians (17-27%).
- A substantial overlap existed between interpretations of ischemic and repolarization abnormalities, highlighting diagnostic ambiguity.
Conclusions:
- Early repolarization variants are prevalent in young adults and can be mistaken for acute ischemia.
- Race is a significant factor in the prevalence of these ECG variants.
- Careful interpretation of ECGs is necessary to avoid misdiagnosis of cocaine-induced myocardial ischemia in young adults presenting with chest pain.
Objective:
The evaluation of chest pain in young adults has changed with the recognition of cocaine-induced myocardial ischemia. The high frequency of abnormal electrocardiograms (56-84%) in the cocaine-user population is largely due to "normal" electrocardiographic variants (early repolarization). The authors sought to determine the frequency of these "normal" variants in a young population, and whether these findings can be confused with acute ischemia.
Methods:
A prospective convenience sample of subjects aged 18 to 35 without known heart disease was interviewed and had 12-lead electrocardiographic tracings performed. An emergency physician (physician 1) and a cardiologist (physician 2) read the tracings while blinded to patient history, age, and race. When the physicians disagreed, another physician adjudicated the diagnosis.
Results:
Four hundred fourteen subjects (127 black, 175 Hispanic, and 112 Caucasian) were enrolled. Overall, 154 tracings (37%) were normal, 245 (59%) were abnormal but nondiagnostic for ischemia, and 15 (4%) were consistent with ischemia. Frequencies of repolarization "abnormalities" as determined by physicians 1 and 2, respectively, were: blacks, 32%, 51%; Hispanics, 26%, 35%; Caucasians, 17%, 27%; chi-squared, p = 0.02 and 0.0004. Patients with ischemic electrocardiograms according to physician 1 had a high frequency of repolarization "abnormalities" according to physician 2, and vice versa (100%, 61%). Electrocardiographic criteria for thrombolytic use per physician 2 were present in 31 patients (7%): blacks, 9%; Hispanics, 10%; and Caucasians, 2%; chi-squared, p = 0.03.