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What is important is the truth
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Journal of Electrocardiology 44 (2011) 58 – 59 www.jecgonline.com
Letter to the Editor What is important is the truth
What you and I think is not important, what is important is the truth. W. Einthoven1
We have read Egle Kalinauskiene's letter,2 and we are surprised that he considers it necessary to retain the name “posterior MI” in case of myocardial infarction (MI) that originates R wave in V1. Let us state the following regarding this question. (1) The results from our and other groups,3-10 as well as previous studies performed some decades ago by pathologic11 and isotopic12 methods, demonstrate that R wave in V1 is caused by MI located in the lateral wall.
However, the prominence of the author and the renown of the journal that published this article,13 which wrongly states that strictly posterior MI is responsible for the presence of the dominant R wave in V1, together with human reluctance to change any dogma, may allow this mistake to go uncorrected for decades. We believe that nobody, after all this evidence, is against this statement. (2) The other question is if, after all this evidence, we still have to remain calling posterior MI when R wave is present in V1 only because this term is used for decades. Therefore, we consider that the answer is “no" for the following reasons: (a) the classical posterior wall is, in reality, the inferobasal part of inferior wall.5-7 As we clearly demonstrated using new imaging technology,7 the posterior wall generally does not exist because in only 25% of cases, the inferobasal part of inferior wall bends upward,
Fig. 1. Cardiovascular magnetic resonance in subjects with different body builds. A, An obese patient. B, A very lean patient. The apex points to V3 to V4 in both cases, and therefore, the infarction of the inferobasal (formerly “posterior”) wall faces V3 to V4 and not V1 in cases where an infarction vector is found (necrosis extended beyond the basal area). Thus, the prominent R wave in V1 may not be due to MI of inferior wall. 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Letter to the Editor / Journal of Electrocardiology 44 (2011) 58–59
and in only 5% of cases, in very lean people, there is a clear posterior position of the diaphragmatic (inferior) wall. However, even when it is found, the necrosis vector will point to V3 to V5, not V1 (Fig. 1). No necrosis vector is likely to exist when only the inferobasal part of the inferior wall (the classical posterior wall) presents an infarction because we know, thanks to Durrer et al,14 that the depolarization of this area occurs after 40 milliseconds and is expressed in the electrocardiogram by fractioned QRS instead of a Q wave (R in V1 as a mirror image). (b) It is clear that when a name is changed, a transitional period occurs and may induce some confusion, but what is really important, to quote W. Einthoven,1 is the truth. As a conclusion, we would like to reinforce the idea that this is not a change of name (we now call lateral wall what before was named posterior wall), but it is a change of location. It is necessary to remember that the R wave in V1 is not due to so-called posterior infarction (segment 4 [inferobasal] of the Cerqueira classification),15 but in fact to an infarction of the lateral wall (Segments 5, 6, 11, and 12 of the Cerqueira classification). Finally, this change is not only of academic interest but also of clinical relevance, especially from a prognostic point of view. The danger of papillary muscle dysfunction and the risk of sudden death are different in cases of infarction of the inferior wall generally due to right coronary artery occlusion, when compared with MI of the lateral wall due to left circumflex artery occlusion.16,17 Antonio Bayés de Luna, PhD Universidad Autónoma de Barcelona E-mail address: [email protected] Diego Goldwasser, MD Universidad Autónoma de Barcelona doi:10.1016/j.jelectrocard.2010.09.011
References 1. Burch G, DePasquale NP. A History of Electrocardiography. Chicago: Year Book Medical; 1964. p. 14.
59
2. Kalinauskiene E. Nine times measure, 10th cut away. J Electrocardiol 2010;43:220. 3. Bayés de Luna A, Cino J, Pujadas S, et al. Concordance of ECG patterns and myocardial location detected by cardiovascular magnetic resonance. Am J Cardiol 2006;97:443. 4. Cino JM, Pujadas S, Carreras F, et al. Utility of contrast-enhanced cardiovascular magnetic resonance (CE-CMR) to assess how likely is an infarct to produce a typical ECG pattern. J Cardiovasc Magn Reson 2006;8:335. 5. Bayés de Luna A, Wagner G, Birnbaum Y, et al. A new terminology for the left ventricular walls and for the locations of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging. A statement for healthcare professionals from a committee appointed by the International Society for Holter and Non invasive Electrocardiography. Circulation 2006;114:1755. 6. Wagner G. Triple Red Journal celebration of the 2007 New Year. Editorial. JECG 2007;40:1. 7. Bayés de Luna A, Fiol M. Electrocardiography in ischemic heart disease. Oxford: Blackwell-Futura; 2008. 8. Bayés de Luna. New heart wall terminology and new electrocardiographic classification of q-wave myocardial infarction based on correlations with magnetic resonance imaging. Rev Esp Cardiol 2007; 60:683. 9. Van der Weg K, Bekkers SCAM, Winkens B, et al, on behalf of MAST. The R in V1 in non-anterior wall infarction indicates lateral rather than posterior involvement. Results from ECG/MRI correlations. Eur H Journal 2009;30(Suppl):P2981K. 10. Rovai D, Di Bella G, Rossi G, et al. Q-wave prediction of myocardial infarct location, size and transmural extent at magnetic resonance imaging. Coron Artery Dis 2007;18:381. 11. Dunn W, Edwards J, Puitt R. The electrocardiogram in infarction of the lateral wall of the left ventricle: a clinicopathological study. Circulation 1956;14:540. 12. Bough E, Boden W, Kenneth K, Gandsman E. Left ventricular asynergy in electrocardiographic “posterior” myocardial infarction. J Am Coll Cardiol 1984;4:209. 13. Perloff JK. The recognition of strictly posterior myocardial infarction by conventional scalar electrocardiography. Circulation 1964;30:706. 14. Durrer D, Van Dam R, Freud G, Janse M, Meijler F. Total excitation of the isolated human heart. Circulation 1970;41:899. 15. Cerqueira MD, Weissman NJ, Disizian V. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002;105:539. 16. Pascale P, Schlaepfer J, Oddo M, Schaller MD, Vogt P, Fromer M. Ventricular arrhythmia in coronary artery disease: limits of a risk stratification strategy based on the ejection fraction alone and impact of infarct localization. Europace 2009;11:1639. 17. Gorgels A. Posterior or lateral involvement in nonanterior wall infarction. What's in a name). J Electrocardiol 2010;43:221.
Journal of Electrocardiology 44 (2011) 58 – 59 www.jecgonline.com
Letter to the Editor What is important is the truth
What you and I think is not important, what is important is the truth. W. Einthoven1
We have read Egle Kalinauskiene's letter,2 and we are surprised that he considers it necessary to retain the name “posterior MI” in case of myocardial infarction (MI) that originates R wave in V1. Let us state the following regarding this question. (1) The results from our and other groups,3-10 as well as previous studies performed some decades ago by pathologic11 and isotopic12 methods, demonstrate that R wave in V1 is caused by MI located in the lateral wall.
However, the prominence of the author and the renown of the journal that published this article,13 which wrongly states that strictly posterior MI is responsible for the presence of the dominant R wave in V1, together with human reluctance to change any dogma, may allow this mistake to go uncorrected for decades. We believe that nobody, after all this evidence, is against this statement. (2) The other question is if, after all this evidence, we still have to remain calling posterior MI when R wave is present in V1 only because this term is used for decades. Therefore, we consider that the answer is “no" for the following reasons: (a) the classical posterior wall is, in reality, the inferobasal part of inferior wall.5-7 As we clearly demonstrated using new imaging technology,7 the posterior wall generally does not exist because in only 25% of cases, the inferobasal part of inferior wall bends upward,
Fig. 1. Cardiovascular magnetic resonance in subjects with different body builds. A, An obese patient. B, A very lean patient. The apex points to V3 to V4 in both cases, and therefore, the infarction of the inferobasal (formerly “posterior”) wall faces V3 to V4 and not V1 in cases where an infarction vector is found (necrosis extended beyond the basal area). Thus, the prominent R wave in V1 may not be due to MI of inferior wall. 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Letter to the Editor / Journal of Electrocardiology 44 (2011) 58–59
and in only 5% of cases, in very lean people, there is a clear posterior position of the diaphragmatic (inferior) wall. However, even when it is found, the necrosis vector will point to V3 to V5, not V1 (Fig. 1). No necrosis vector is likely to exist when only the inferobasal part of the inferior wall (the classical posterior wall) presents an infarction because we know, thanks to Durrer et al,14 that the depolarization of this area occurs after 40 milliseconds and is expressed in the electrocardiogram by fractioned QRS instead of a Q wave (R in V1 as a mirror image). (b) It is clear that when a name is changed, a transitional period occurs and may induce some confusion, but what is really important, to quote W. Einthoven,1 is the truth. As a conclusion, we would like to reinforce the idea that this is not a change of name (we now call lateral wall what before was named posterior wall), but it is a change of location. It is necessary to remember that the R wave in V1 is not due to so-called posterior infarction (segment 4 [inferobasal] of the Cerqueira classification),15 but in fact to an infarction of the lateral wall (Segments 5, 6, 11, and 12 of the Cerqueira classification). Finally, this change is not only of academic interest but also of clinical relevance, especially from a prognostic point of view. The danger of papillary muscle dysfunction and the risk of sudden death are different in cases of infarction of the inferior wall generally due to right coronary artery occlusion, when compared with MI of the lateral wall due to left circumflex artery occlusion.16,17 Antonio Bayés de Luna, PhD Universidad Autónoma de Barcelona E-mail address: [email protected] Diego Goldwasser, MD Universidad Autónoma de Barcelona doi:10.1016/j.jelectrocard.2010.09.011
References 1. Burch G, DePasquale NP. A History of Electrocardiography. Chicago: Year Book Medical; 1964. p. 14.
59
2. Kalinauskiene E. Nine times measure, 10th cut away. J Electrocardiol 2010;43:220. 3. Bayés de Luna A, Cino J, Pujadas S, et al. Concordance of ECG patterns and myocardial location detected by cardiovascular magnetic resonance. Am J Cardiol 2006;97:443. 4. Cino JM, Pujadas S, Carreras F, et al. Utility of contrast-enhanced cardiovascular magnetic resonance (CE-CMR) to assess how likely is an infarct to produce a typical ECG pattern. J Cardiovasc Magn Reson 2006;8:335. 5. Bayés de Luna A, Wagner G, Birnbaum Y, et al. A new terminology for the left ventricular walls and for the locations of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging. A statement for healthcare professionals from a committee appointed by the International Society for Holter and Non invasive Electrocardiography. Circulation 2006;114:1755. 6. Wagner G. Triple Red Journal celebration of the 2007 New Year. Editorial. JECG 2007;40:1. 7. Bayés de Luna A, Fiol M. Electrocardiography in ischemic heart disease. Oxford: Blackwell-Futura; 2008. 8. Bayés de Luna. New heart wall terminology and new electrocardiographic classification of q-wave myocardial infarction based on correlations with magnetic resonance imaging. Rev Esp Cardiol 2007; 60:683. 9. Van der Weg K, Bekkers SCAM, Winkens B, et al, on behalf of MAST. The R in V1 in non-anterior wall infarction indicates lateral rather than posterior involvement. Results from ECG/MRI correlations. Eur H Journal 2009;30(Suppl):P2981K. 10. Rovai D, Di Bella G, Rossi G, et al. Q-wave prediction of myocardial infarct location, size and transmural extent at magnetic resonance imaging. Coron Artery Dis 2007;18:381. 11. Dunn W, Edwards J, Puitt R. The electrocardiogram in infarction of the lateral wall of the left ventricle: a clinicopathological study. Circulation 1956;14:540. 12. Bough E, Boden W, Kenneth K, Gandsman E. Left ventricular asynergy in electrocardiographic “posterior” myocardial infarction. J Am Coll Cardiol 1984;4:209. 13. Perloff JK. The recognition of strictly posterior myocardial infarction by conventional scalar electrocardiography. Circulation 1964;30:706. 14. Durrer D, Van Dam R, Freud G, Janse M, Meijler F. Total excitation of the isolated human heart. Circulation 1970;41:899. 15. Cerqueira MD, Weissman NJ, Disizian V. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002;105:539. 16. Pascale P, Schlaepfer J, Oddo M, Schaller MD, Vogt P, Fromer M. Ventricular arrhythmia in coronary artery disease: limits of a risk stratification strategy based on the ejection fraction alone and impact of infarct localization. Europace 2009;11:1639. 17. Gorgels A. Posterior or lateral involvement in nonanterior wall infarction. What's in a name). J Electrocardiol 2010;43:221.