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Vol. 61. Issue 6.
Pages 657 (June 2008)
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DOI: 10.1016/S1885-5857(08)60197-8
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Antonio Bayés de Lunaa
a Institut Català Ciències Cardiovasculars (ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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To the Editor:

May I express my thanks to Dr Alarcón-Duque and his co-authors.

I would like to make it clear that the electrocardiographic criteria for Q wave myocardial infarction refer to patients with STEACS who, in the chronic phase, present tall Q or R waves in V1. Thanks to the correlation with magnetic resonance, our study shows that in these patients the presence of Q waves of necrosis or equivalent images (R in V1 with R/S >1, and/or R 340 ms in duration) enables us to locate the infarction. In Alarcón-Duque et al's example, R duration is <4 ms and the R/S relation is around 0.5. I seem to recall that an R/S relation 31 is the value which has 100% specificity for lateral infarction.

What we want to illustrate is that in a patient with myocardial infarction following STEACS, a tall R in V1—above all if the R/S relation is ≥1 and R duration ≥40 ms—necrosis must be lateral and not posterior. It cannot be posterior because: a) the posterior wall (now segment 4 of the Cerqueira classification: inferobasal) often does not exist because segment 4 does not curve upwards; b) even if it existed, necrosis would not give a tall R in V1, the mirror-image of the Q-wave of the leads on the back, because it is depolarized after 30-40 ms when the normal R wave has begun to register, meaning there cannot be Q on the back; and c) because, in any case, even if the necrosis vector existed, it would be directed towards V3-V4 not V1-V2 due to the oblique position of the heart in the chest.

Naturally, with a tall R wave in V1, we need to rule out Wolf-Parkinson-White syndrome, right bundle branch block, and right ventricular growth. In their absence, never in normal individuals, duration of R is ≥40 ms and the R/S relation is >1. The ECG presented by Alarcón-Duque et al presents neither R ≥40 ms nor R/S ≥1.

I thank Alarcón-Duque et al for stating the need always to correlate the ECG with the symptoms. Furthermore, I would like to add that more information on these data can be found in some of our other studies,1-4 in addition to those they quote.

Bibliography
[1]
Bayés de Luna A, Cino JM, Pujadas S, Cygankiewicz I, Carreras F, Garcia-Moll X, et al..
Concordance of electrocardiograhic patterns and healed myocardial infarction location detected by cardiovascular magnetic resonance..
Am J Cardiol, 97 (2006), pp. 443-51
[2]
Cino JM, Pujadas S, Carreras F, Cygankiewicz I, Leta R, Noguero M, et al..
Utility of contrast-enhanced cardiovascular magnetic resonance (CE-CMR) to assess how likely is an infarct to produce a typical ECG pattern..
J Cardiovasc Magn Reson, 8 (2006), pp. 335-44
[3]
Bayés de Luna A..
Location of Q-wave myocardial infarction in the era of cardiac magnetic resonance imaging techniques: an update..
J Electrocardiol, 39 (2006), pp. S79
[4]
Electrocardiography in ischemic heart disease. Oxford: Blackwell; 2008.
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Revista Española de Cardiología (English Edition)

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