ECG patterns for early recognition of cardiac rupture in STEMI

Cardiac rupture is a catastrophic complication of ST-segment elevation myocardial infarction (STEMI). Early recognition may be lifesaving and reduce mortality; however, electrocardiographic evidence for early diagnosis remains limited. We aimed to characterize the electrocardiographic features of cardiac rupture in patients presenting with STEMI. This retrospective multicenter cohort study included patients from four hospitals over a 17-year period. Electrocardiograms (ECGs) were obtained at emergency department presentation, performed daily during hospitalization, and repeated as clinically indicated. Dynamic ECG evolution after initial ST-segment resolution was analyzed, including new-onset or recurrent ST-segment elevation and dynamic depression in lead AVR, along with clinical presentation and imaging findings. Among the 30 patients diagnosed with cardiac rupture, 26 patients (87%) developed new-onset ST-segment elevation, an equal proportion exhibited recurrent elevation, and 17 (57%) showed dynamic ST-segment depression in lead AVR. Overall, 26 patients (87%) exhibited at least two features, and 13 (43%) demonstrated the full ECG pattern. The median number of leads demonstrating ST-segment elevation decreased from 6 at baseline to 4 prior to rupture, while the median total magnitude declined from 8 to 4 mm. Compared with the pre-rupture phase, the median number of involved leads increased to 8, and total ST-segment elevation to 13.5 mm, indicating more diffuse and pronounced abnormalities. In exploratory analyses, anterior infarction was associated with a greater extent of ST-segment elevation at baseline, reflected by more elevated leads and greater total elevation, but not at cardiac rupture. Cardiac rupture following STEMI is characterized by distinctive ECG evolution, including new-onset or recurrent ST-segment elevation with concomitant AVR depression. Recognition of these features should prompt echocardiographic evaluation to enable early diagnosis and timely intervention.