Holmvang et al evaluated changes in the admission electrocardiogram in patients with a non-ST segment elevation acute coronary syndrome. This can help identify patients who may benefit from more aggressive management. The patients were enrolled in the FRISC-II study and the authors are from Copenhagen (Denmark), Uppsala (Sweden) and Durham (USA).


Patient selection - chest pain within previous 48 hours with one or more of the following:

(1) elevation of cardiac markers (troponin)

(2) ST depression

(3) T wave inversion


Exclusion: ST-segment elevation


Outcome events: acute myocardial infarction and/or death within 1 year


Invasive treatment strategy:

(1) percutaneous coronary intervention (PCI) with 1 or 2 target lesions, not involving the left main coronary artery

(2) CABG if 3 vessel disease or involvement of the left main coronary artery



(1) presence of confounding factor that precludes ECG analysis

(2) total sum of ST segment deviation (absolute value of depression) in 11 leads (standard 12 leads except aVR)

(3) number of the same 11 leads with individual deviation >= 0.5 mm


Confounding factors (from Appendix A):

(1) left and/or right bundle branch block

(2) left anterior and/or posterior hemiblock

(3) left and/or right ventricular hypertrophy

(4) Wolf-Parkinson-White syndrome


Patients with a confounding factor:

(1) did about the same with either an invasive or noninvasive treatment strategy

(2) tended to have worse outcomes than patients without the confounding factors

Patients Who Benefit from an Invasive Management Strategy


total sum of deviations

> 2.5 mm

number of leads >= 0.5 mm

>= 5 leads


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