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Still Substantial Risk for MI Patients with Normal Initial ECG

The prognostic value of a normal initial ECG in patients with acute MI has not been appropriately examined. The authors of this observational study analyzed data on 391,208 patients enrolled in the National Registry of Myocardial Infarction who were diagnosed with acute MI by standard criteria between June 1994 and June 2000.

The initial ECG was normal in 30,759 patients (7.9 percent), nonspecific in 137,574 (35.2 percent), and diagnostic (ST-segment elevation or depression or left bundle-branch block) in 222,875 (57.0 percent). In-hospital mortality rates were 5.7 percent, 8.7 percent, and 11.5 percent, respectively. Within the normal ECG cohort, men younger than 65 had a mortality rate of only 1.5 percent. The combined rates of in-hospital mortality and life-threatening adverse events (ventricular tachycardia or fibrillation, development of pulmonary edema or cardiogenic shock, and/or hypotension requiring intervention) were 19.2 percent, 27.5 percent, and 34.9 percent, respectively.

Comment: These data indicate that among patients with acute MI, those with normal or nonspecific initial ECGs have a lower but still clinically significant chance of serious morbidity or death compared with those with diagnostic ECGs. The high rate of death and adverse events may be because patients with normal ECGs presented later after symptom onset and were less likely to present with chest pain than those with diagnostic ECGs.

— John A. Marx, MD, FACEP

Published in Journal Watch Emergency Medicine December 19, 2001

Citation(s):

Welch RD et al. Prognostic value of a normal or nonspecific initial electrocardiogram in acute myocardial infarction. JAMA 2001 Oct 24 286 1977-1984.

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