Start learning now Clinical ECG Interpretation > Myocardial Ischemia & Infarction > ECG signs of myo, SECTION 3, CHAPTER 14 < > EGG signs of myocardial infarction: pathological Q- waves & pathological R-waves Pathological Q-waves are evidence of myocardial infarction Myocardial infarction — particularly if extensive in size — typically manifests with pathological Q-waves. These Q-waves are wider and deeper than normally occurring Q-waves, and they are referred to as pathological Q-waves. They typically emerge between 6 and 16 hours after symptom onset, but may occasionally develop earlier. Standard textbooks have traditionally taught that the pathological Q-wave is a permanent ECG manifestation and that it represents transmural infarction (STEMI. However, recent studies challenge these notions. Pathological Q-waves may resolve in up to 30% of patients with inferior infarction. The amplitude of Q-waves may also diminish over time. Moreover, magnetic resonance imaging has suggested that pathological Q-waves may also arise due to extensive subendocardial infarction (NSTEM)). Chapter content == If pathological Q-waves occur as a result of myocardial infarction, the infarction may be classified as Q-wave infarction (this has st art negligible clinical implication). Hence, Q-wave infarctions areStart learning now mostly the result of transmural infarction (STEMI) but may be caused by extensive subendocardial ischemia (NSTEMI). Q Establishing a diagnosis of Q-wave infarction requires that pathological Q-waves be present in at least two anatomically contiguous leads. In patients with STEMI, ST-segment elevations and pathological Q-waves occur in the same leads, which is why pathological Q-waves can be used to localize the infarct area. ECG criteria for pathological Q-waves (Q- wave infarction) Definition of pathological Lead Q-wave Normal variants V2- -20,02sorQS None V3 complex* All 20,03 s and 21__ Individuals with electrical other mmdeep (or _ axis 60-90" often display a leads QS complex) small q-wave in aVL. Leads VS— V6 often display a small q- wave (called septal q-wave, explained in this article). An isolated QS complex is allowed in lead V1 (due to missing r- wave or misplaced electrode). Lead Ill occasionally displays a large isolated Q-wave; this is called a respiratory Q-wave, because its amplitude varies with respiration. Lead Ill may also display small Q-waves (not related to respiration) in individuals with electrical axis -30° to 0°, *QS complex implies that the entire QRS complex is comprised of one negative deflection. The following figure shows pathological Q-waves in two patients with acute STEMI. StartCeasers el one) avL 1 + ave : Ww a fa eN, Tee ee 4 1 ave GHGS pH pee S L Fi. Rete pain ECG shows STsegment elevations, reciprocal ‘pressions and pathological waves, 60 year old male with retrsteral chest pain, ECG shows ST segment elevations in inferior leads, aVF andi, There are recipocal ST segment depressonsin aVL and There are ko pathologial @- waves inthe inferior ead > ST segment elevation > Pathological -waves > Reciprocal SF-seqment depresion Figure 1. Examples of STE-ACS (STEMI). Note that these patients presented with pathological Q-waves, which means that these ECGs were recorded several hours after symptom onset or those are signs of old infarction, Pathological R-waves also indicate previous | infarction myocar Current European (ESC) guidelines suggest that R-waves may also be used to diagnose previous myocardial infarction, Criteria for pathological R-waves: R-wave 20,04 s in VI-V2 and R/S ratio >1 with concordant positive T-wave in absence of conduction defect. R/S ratio > 1 implies that the R-wave is larger than the S- wave, Start learning now Start