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Transient Q waves: An anamnestic response of an old myocardial infarction
LETTERS TO THE EDITOR
TRANSIENT
0
OF AN
WAVES: OLD
AN
ANAMNESTIC
MYOCARDIAL
RESPONSE
INFARCTION
As Meller et al.’ indicate, the transient Q waves in Prinzmetal’s angina may reflect a severe ischemia of a localized area of myocardium, and electrical death is not synonymous with biologic death. We have recently proposed a new concept2J: Transient Q waves may reveal an old myocardial infarction. Thus, patterns of an old myocardial infarction, that had long ago disappeared, may reappear in the electrocardiogram during an acute ischemic episode. In these cases, it is likely that the transient reappearance of Q waves is due to transitory ischemia of the superficial myocardial layer that surrounds the old infarcted area. During ischemia, this layer becomes electrically silent; the formerly infarcted area then appears “under” the electrodes, and a QS or QR pattern is recorded; when the superficial layer has recovered, the infarcted area is no more “in contact” with the electrodes, and R waves reappear.4 Recent works support our view: Transient Q waves have been described during ischemia induced by atrial pacing5 or isoproterenol provocation6 in patients with a prior acute myocardial infarction. Knowledge that transient Q waves may appear as a temporary proof of an old and sometimes undiagnosed myocardial infarction is of importance since these waves are usually recorded during a new and severe ischemic episode with angina1 pain and patients with them are usually referred with the wrong diagnosis: recent acute myocardial infarction. Paul Chiche, MD, FACC Rober Haiat, MD, FACC Hopital Tenon Paris, France References
REPLY
I fully agree that transient Q waves reflect electrical silence without biologic death in certain cases. This would explain, as we discussed it, the momentary appearance in our Case 2 of a pattern of anteroseptal myocardial infarction during the episodes of anterior wall ischemia. Their speculation that transient Q waves may reveal an old myocardial infarction can apply only to our Case 1, in which a transient pattern of inferior wall myocardial infarction appeared during every episode of anterior wall myocardial ischemia. But, in contrast to the view that old myocardial infarction is unmasked because of new ischemia to the opposite wall, it was proposed by Bassan et al.’ that new Q waves seen in patients after coronary bypass might be due to improved coronary perfusion to ischemit areas opposite to the area of infarction. Such improvement thus relieved ischemia that had been canceling the loss of opposing forces of an old infarcted area. Both theories may be correct in different situations because the electrocardiogram is only the final expression of the balance of the electrical
October 1976
myocardial ischemia of myocardial perfu-
Jose Melter, MD Division of Cardiology Department of Medicine Mount Sinai School of Medicine of the City University of New York New York, N. Y. Reference 1. BassanMM,Oatfield
R, Hoffman I, et al: New Q waves after aortocoronary Engl J Med 290:349-353. 1974
“HOLOSYSTOLIC
EJECTION
bypass. N
MURMUR”
I was puzzled by the “grade 3/6 holosystolic ejection murmur that was heard at both the apex and the base” in Case 1 of Hirschfeld and Emilson’ for aortic ejection murmurs do not extend up to the aortic component of the second heart sound to justify the term “holosystolic.” 2 The patient might have a holosystolic murmur, presumably due to mitral regurgitation, or an aortic ejection murmur or, most likely, two separate murmurs (one holosystolic and one ejection) loud enough to be audible at both the apex and the base of the heart; but the use of the term “holosystolic ejection” to describe a murmur leads to confusion. Incidentally, in the echocardiogram of the same patient (Fig. 2B) the space behind the aorta labeled the right atrium (RA) in reality is the left atrium.:< Miltiadis A. Stefadouros, MD, FACC Department of Medicine/Cardiology Medical College of Georgia Augusta, Georgia References
1. Meller J. Conde CA. Donow E. et al: Transient Q waves in Prinzmetal’s anaina. Am J Cardiol i5:691-695; 1975 2. Chiche P, Berkman M, Haiat R: Ondes 0 transitoires et B eclipse au cows de I’insuffisance cwonarienne aique. Arch f&l Coeur 64:657-659. 1971 3. Haiat R, Chiche P: Tr&ient abnormal Q waves in the course of ischemic heart disease. Chest 65140-144, 1974 4. Cahen L: Explorations fonctionnelles cardiovasculaires. Paris, Maloine Edit, 1970, p 103 5. De La Fuente DJ, Gambetta M, Goldbarg AN: The significance of transient 0 waves (abstr). Circulation 45.46:Suppl ll:ll-153. 1972 6. Benaim R, Botteri L, Rennerf R, et al: Le test B I’isoprot&Cnol dans le diagnostic de I’insuffisance cwonarienne. In, Symposium de pharmacologic clinique des antiangineux (Boissier J. Chiche P, ed). Paris. Sandoz Edit, 1974
544
potentials, which are modified during and probably also after improvement sion.
The American Journal of CARDIOLOGY
1
Hirschfeld DS, Emilson BB: Echocardiogram in calcified mitral annulus. Am J Cardiol 36:354, 1975 2. Leatham A: Auscultation of the heart. Lancet 2:757, 1956 3. Fefgenbaum H: Echocardiography. Philadelphia, Lea 8 Febiger. 1972, p 146
REPLY
The term “holosystolic ejection” was meant to be descriptive rather than to imply a functional basis for the murmur. We have, in fact, utilized a simple noninvasive screening test for calcification of the mitral anulus: Patients are examined by two medical students; those patients who have a murmur described by one student as ejection in quality and by the other as holosystolic in timing are likely to have a calcified mitral ring. Ventricular septal defects also produce murmurs that may be described as both pansystolic and ejection in qua1ity.l The left atrium in the echocardiogram of our first patient was, as noted, incorrectly labeled. David S. Hirschfeld, MD Los Gatos, California Reference 1. Travel ME:
Clinical Phonocardiography Book Medical Publishers, 1972. p 120
TEMPORARY
TRANSVENOUS VALVE
and External Pulse Recording. Chicago, Year
PACING
AFTER
MITRAL
SURGERY
In connection with the recent article of Ritchie et al.’ we recently saw a patient with class III symptoms of congestive heart failure, 3+ mitral regurgitation and normal coronary
Volume 36
TRANSIENT
0
OF AN
WAVES: OLD
AN
ANAMNESTIC
MYOCARDIAL
RESPONSE
INFARCTION
As Meller et al.’ indicate, the transient Q waves in Prinzmetal’s angina may reflect a severe ischemia of a localized area of myocardium, and electrical death is not synonymous with biologic death. We have recently proposed a new concept2J: Transient Q waves may reveal an old myocardial infarction. Thus, patterns of an old myocardial infarction, that had long ago disappeared, may reappear in the electrocardiogram during an acute ischemic episode. In these cases, it is likely that the transient reappearance of Q waves is due to transitory ischemia of the superficial myocardial layer that surrounds the old infarcted area. During ischemia, this layer becomes electrically silent; the formerly infarcted area then appears “under” the electrodes, and a QS or QR pattern is recorded; when the superficial layer has recovered, the infarcted area is no more “in contact” with the electrodes, and R waves reappear.4 Recent works support our view: Transient Q waves have been described during ischemia induced by atrial pacing5 or isoproterenol provocation6 in patients with a prior acute myocardial infarction. Knowledge that transient Q waves may appear as a temporary proof of an old and sometimes undiagnosed myocardial infarction is of importance since these waves are usually recorded during a new and severe ischemic episode with angina1 pain and patients with them are usually referred with the wrong diagnosis: recent acute myocardial infarction. Paul Chiche, MD, FACC Rober Haiat, MD, FACC Hopital Tenon Paris, France References
REPLY
I fully agree that transient Q waves reflect electrical silence without biologic death in certain cases. This would explain, as we discussed it, the momentary appearance in our Case 2 of a pattern of anteroseptal myocardial infarction during the episodes of anterior wall ischemia. Their speculation that transient Q waves may reveal an old myocardial infarction can apply only to our Case 1, in which a transient pattern of inferior wall myocardial infarction appeared during every episode of anterior wall myocardial ischemia. But, in contrast to the view that old myocardial infarction is unmasked because of new ischemia to the opposite wall, it was proposed by Bassan et al.’ that new Q waves seen in patients after coronary bypass might be due to improved coronary perfusion to ischemit areas opposite to the area of infarction. Such improvement thus relieved ischemia that had been canceling the loss of opposing forces of an old infarcted area. Both theories may be correct in different situations because the electrocardiogram is only the final expression of the balance of the electrical
October 1976
myocardial ischemia of myocardial perfu-
Jose Melter, MD Division of Cardiology Department of Medicine Mount Sinai School of Medicine of the City University of New York New York, N. Y. Reference 1. BassanMM,Oatfield
R, Hoffman I, et al: New Q waves after aortocoronary Engl J Med 290:349-353. 1974
“HOLOSYSTOLIC
EJECTION
bypass. N
MURMUR”
I was puzzled by the “grade 3/6 holosystolic ejection murmur that was heard at both the apex and the base” in Case 1 of Hirschfeld and Emilson’ for aortic ejection murmurs do not extend up to the aortic component of the second heart sound to justify the term “holosystolic.” 2 The patient might have a holosystolic murmur, presumably due to mitral regurgitation, or an aortic ejection murmur or, most likely, two separate murmurs (one holosystolic and one ejection) loud enough to be audible at both the apex and the base of the heart; but the use of the term “holosystolic ejection” to describe a murmur leads to confusion. Incidentally, in the echocardiogram of the same patient (Fig. 2B) the space behind the aorta labeled the right atrium (RA) in reality is the left atrium.:< Miltiadis A. Stefadouros, MD, FACC Department of Medicine/Cardiology Medical College of Georgia Augusta, Georgia References
1. Meller J. Conde CA. Donow E. et al: Transient Q waves in Prinzmetal’s anaina. Am J Cardiol i5:691-695; 1975 2. Chiche P, Berkman M, Haiat R: Ondes 0 transitoires et B eclipse au cows de I’insuffisance cwonarienne aique. Arch f&l Coeur 64:657-659. 1971 3. Haiat R, Chiche P: Tr&ient abnormal Q waves in the course of ischemic heart disease. Chest 65140-144, 1974 4. Cahen L: Explorations fonctionnelles cardiovasculaires. Paris, Maloine Edit, 1970, p 103 5. De La Fuente DJ, Gambetta M, Goldbarg AN: The significance of transient 0 waves (abstr). Circulation 45.46:Suppl ll:ll-153. 1972 6. Benaim R, Botteri L, Rennerf R, et al: Le test B I’isoprot&Cnol dans le diagnostic de I’insuffisance cwonarienne. In, Symposium de pharmacologic clinique des antiangineux (Boissier J. Chiche P, ed). Paris. Sandoz Edit, 1974
544
potentials, which are modified during and probably also after improvement sion.
The American Journal of CARDIOLOGY
1
Hirschfeld DS, Emilson BB: Echocardiogram in calcified mitral annulus. Am J Cardiol 36:354, 1975 2. Leatham A: Auscultation of the heart. Lancet 2:757, 1956 3. Fefgenbaum H: Echocardiography. Philadelphia, Lea 8 Febiger. 1972, p 146
REPLY
The term “holosystolic ejection” was meant to be descriptive rather than to imply a functional basis for the murmur. We have, in fact, utilized a simple noninvasive screening test for calcification of the mitral anulus: Patients are examined by two medical students; those patients who have a murmur described by one student as ejection in quality and by the other as holosystolic in timing are likely to have a calcified mitral ring. Ventricular septal defects also produce murmurs that may be described as both pansystolic and ejection in qua1ity.l The left atrium in the echocardiogram of our first patient was, as noted, incorrectly labeled. David S. Hirschfeld, MD Los Gatos, California Reference 1. Travel ME:
Clinical Phonocardiography Book Medical Publishers, 1972. p 120
TEMPORARY
TRANSVENOUS VALVE
and External Pulse Recording. Chicago, Year
PACING
AFTER
MITRAL
SURGERY
In connection with the recent article of Ritchie et al.’ we recently saw a patient with class III symptoms of congestive heart failure, 3+ mitral regurgitation and normal coronary
Volume 36