By Kim, Xiang, Yeo

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The electrocardiographic patterns of ischaemia, injury and necrosis are of greatest importance in the diagnosis and prognosis of IHD. They are recorded in different leads as direct patterns, according to the affected zone. On the other hand, they may also be recorded in opposite leads as ‘mirror patterns’ (a positive T wave instead of a negative T wave, STsegment depression instead of ST-segment elevation and a tall R wave instead of a Q wave). From the clinical point of view, these mirror patterns should not be considered only as a passive expression of something happening at a distance but, rather, as the indirect but evident sign that there exists an area of clinical ischaemia in some part of the heart distant from the exploring electrode that generates this pattern.

23). The negative T wave may be due to ‘active’ ischaemia, when the changes are dynamic and/or appear during angina pain. If the negative T wave is present in the absence of anginal pain, it may probably be considered a reperfusion pattern. However it is clear that we need to know more about the mechanism that explains the delay of repolarisation responsible for the presence of flattened or negative T wave during NSTE-ACS or in chronic state. 1B(1)). 38 PART I Electrocardiographic patterns of ischaemia, injury and infarction (b) As a part of clinical syndrome of STE-ACS, the negative T wave appears in the subacute phase of STE-ACS and may also correspond to an atypical pattern recorded in the dynamic process of STE-ACS.

In women it tends to be a little lower. The T wave may sometimes be very tall, without any pathological explanation, as occurs in cases of vagal overdrive or in very thin subjects (T wave in precordial leads of over 15 mm in height). Sometimes a positive T wave may have a low voltage, without any apparent explanation, which may have, according to some authors, prognostic implications in the long term. Epidemiological studies have demonstrated that a low-voltage T wave in lead I is a marker of poor prognosis in the follow-up (McFarlane and Coleman, 2004).

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