The electrocardiographic "triangular QRS-ST-T waveform" pattern in patients with ST-segment elevation myocardial infarction: Incidence, pathophysiology and clinical implications

Background: A specific ECG pattern of presentation of ST-segment elevation acute myocardial infarction (STEMI), characterized by "triangular QRS-ST-T waveform" (TW), has been associated with poor in-hospital prognosis but longitudinal data on its incidence and clinical impact are lacking. We prospectively evaluated the incidence and prognostic meaning of the TW pattern in a cohort of consecutive STEMI patients. Methods: All STEMI patients who presented within 12 h of symptoms onset and showed no complete bundle branch block or paced ventricular rhythm were included. The TW pattern was defined as a unique, giant wave (amplitude >= 1 mV) resulting from the fusion of the QRS complex, the ST-segment and the T-wave and showing a "triangular" morphology with a positive polarity in the leads exploring the ischemic region. Results: Among 428 consecutive STEMI patients, 367 fulfilled the enrollment criteria. The TW pattern was identified in 5 of 367 patients (1.4%) on the admission ECG. This subset of STEMI patients with TW pattern significantly more often showed a left main coronary artery involvement (2/4, 50% vs 2/322, 0.6%; p < 0.001), experienced ventricular fibrillation (5/5, 100% vs 35/362, 9.6% p < 0.001), had cardiogenic shock (4/5, 80% vs. 14/362, 3.8%, p < 0.001) and died during hospitalization (2/5, 40% vs 15/362, 4.1% p = 0.02), compared with those with other ST-segment elevation ECG patterns. Conclusions: The TW pattern is an uncommon ECG finding, which reflects the presence of a large area of transmural myocardial ischemia and predicts cardiogenic shock accounting for high in hospital mortality. When present, this ECG pattern should prompt aggressive therapeutic strategies, including mechanical support of circulation. (C) 2017 Elsevier Inc. All rights reserved.