De Winter et al. in 2008 described a new electrocardiographic sign of proximal LAD occlusion, that consists of ST segment upsloping depression at the J point in leads V1 to V6 that continued into tall, positive symmetrical T waves, that has been associated with the occlusion of the proximal left anterior descending artery (LAD).
This pattern was recognised in 2% of the patients with anterior myocardial infraction, and it was persisting from the first ECG obtained until the preprocedural ECGs, in contrast to hyperacute T waves that have been recognized as a transient early feature that changes into ST elevation. On coronary angiography, the culprit lesion was the proximal LAD artery, and a ‘wraparound’ LAD artery was present in approximately 50% of patients.
The electrophysiological explanation of this ECG pattern remains unclear. Hypothetically an anatomical variant of the Purkinje fibers, with endocardial conduction delay, could be present. An alternative explanation is that the absence of ST elevation may be related to the lack of activation of sarcolemmal ATP-sensitive potassium channels by ischemic ATP depletion.
2. De Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A New ECG Sign of Proximal LAD Occlusion. N Engl J Med 2008;359(19):2071–3.
3. De Winter RW, Adams R, Verouden NJW, de Winter RJ. Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalence. J Electrocardiol 2016;49(1):76–80.
4. Montero Cabezas JM, Karalis I, Schalij MJ. De Winter Electrocardiographic Pattern Related with a Non-Left Anterior Descending Coronary Artery Occlusion. Ann Noninvasive Electrocardiol 2016;21(5):526–8.
Cabrera sign is defined as the presence of a prominent, shelf-like or downward notching, of >0.04 second duration, at the ascending limb of the S wave.
Cabrera and Friedland in 1953 found that late notching of the up-slope of the S wave, occurring aſter 0.04 ms in leads V3–V5, is highly sensitive and specific for the diagnosis of old MI in LBBB. This electrocardiographic marker is a well-described sign of anteroseptal MI in the setting of LBBB and Wackers et al. estimated its sensitivity to 47% and a specificity to 87%. Hands et al. in 1989 determined the sensitivity and specificity of Cabrera’s sign to be 29% and 91% respectively. Furthermore, Barold et al. have reported that Cabrera’s sign, is the most useful single ECG criterion for the diagnosis of an old anterior, or anteroseptal MI during RV pacing with sensitivity 23–50% depending on the size of the MI, and specificity 97–100% if the notching is properly defined, findings, that are in accordance with many other studies.
Specific Cabrera cariants:
Small, narrow r wave deforming the terminal QRS
Series of tiny notches giving a serrated appearance along the ascending S wave
Series of late notches on QRS during epicardial pacing
False Cabrera’s sign
Slight notching of the ascending S wave in V leads is normal during RV apical pacing. It is usually confined to 1 lead, shows a sharp upward direction on the S wave and has a duration typically
Ventricular fusion beats
Early retrograde P waves deforming the late portion of the QRS complex masquerading as an intrinsic component of the QRS complex
Table reproduced from Herweg B, Marcus MB, Barold SS. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschrittmachertherapie + Elektrophysiologie 2016;27(3):307–22.
1. CABRERA E, FRIEDLAND C. Wave of ventricular activation in left branch block with infarct; new electrocardiographic sign. Arch Inst Cardiol Mex 1953;23(4):441–60.
2. Herweg B, Marcus MB, Barold SS. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschrittmachertherapie + Elektrophysiologie 2016;27(3):307–22.
3. Barold SS, Herweg B. Electrocardiographic diagnosis of myocardial infarction during left bundle branch block. Cardiol Clin 2006;24:377–385
4. Wackers FJ. The diagnosis of myocardial infarction in the presence of left bundle branch block. Cardiol Clin 1987;5:393–401
5. Hands MECE, Stone PH et al. Electrocardiographic diagnosis of myocardial infarction in thepresence of complete left bundle branch block. AmHeart J 1998;116:23–31
6. Kochiadakis GE, Kaleboubas MD, Igoumenidis NE et al. Electrocardiographic appearance of old myocardial infarction in paced patients. Pacing Clin Electrophysiol 2002;25:1061–1065.
7. Tzeis S, Andrikopoulos G, Asbach S, et al. Electrocardiographic identification of prior myocardial infarction during right ventricular pacing – Effect of septal versus apical pacing. Int J Cardiol 2014;177(3):977–81.
El-Sherif Sign is an rsR’ complex, or its variants (rSr’ or rSR’), in the left anterior precordial leads that is observed in patients with apical ventricular aneurysm. The rsR’ pattern in V6 with prolonged QRS was mentioned in the ’50s by many researchers that tried to relate it with ventricular aneurysms. In 1970 Nabil El-Sherif described this pattern in 18 patients with normal or prolonged QRS duration. 17 of them had left ventricular aneurysm (LVA).
El-Sherif suggested that the rsR’ pattern in the left precordial leads was due to extensive confluent scarring of the left ventricular cone. Fragmentation of the QRS has also been suggested as a marker of LVA and myocardial scar formation in computer models.
Reddy CV et al. tried to estimate the sensitivity, specificity as well as predictive values of fragmented left sided QRS (RSR’ pattern or its variant RSr’, rSR’, or rSr’) without evidence of left bundle branch block. The sensitivity of those patterns was 50% whereas the specificity was 94.6%. The positive predictive value (PPV) of fragmented QRS for LVA was 83.3% and the negative predictive value (NPV) was 79.2%. In postmyocardial infarction population, the PPV of El-Sherif sign for LVA after infarction was 29–53% and the NPV was 95–98%, as they estimated. Besides chronic apical aneurysms in coronary artery disease patients, El-Sherif sign has also been reported and found to be useful in apical aneurysms in hypertrophic cardiomyopathy (HCM) patients.
1. Sherif NE. The rsR` pattern in left surface leads in ventricular aneurysm. Br Heart J 1970;32:440–448.
2. Dubnow, M. H., Burchell, H. B., and Titus, J. L. (I965). Postinfarction ventricular aneurysm. A clinico-morphologic and electrocardiographic study of 8o cases. American Heart Journal, 70, 753.
3. Goldberger, E., and Schwartz, S. P. (1948). ECG patterns of ventricular aneurysm. AmericanJournal of Medicine, 4, 243.
4. Lesh MD, Spear JF, Simon MB. A computer model of electrogram: What causes fractionation? J Electrocardiol 1988;21:S69–S73.
5. Flowers NC, Horan LG, Tolleson WJ, et al. Localization of the site of myocardial scarring in man by high-frequency components. Circulation 1969;40(6):927–934.
6. Reddy CVR, Cheriparambill K, Saul B, et al. Fragmented left sided QRS in absence of bundle branch block: Sign of left ventricular aneurysm. Ann Noninvasive Electrocardiol 2006;11(2):132–8.
7. Aras D, Ozeke O, Cay S, Ozcan F, Konte HC, Topaloglu S. El-Sherif sign and lateral ST segment elevation in hypertrophic cardiomyopathy associated with apical aneurysm. Int. J. Cardiol. 2016 Mar 15;207:80-3.
A few years ago Littmann et al. described a new electrocardiographic sign characterized by a dome-and-spike patterned apparent ST segment elevation, where the upward shift of the baseline started beforeand ended after the QRS complex.
It was named “Spiked Helmet” sign because of the resemblance to the “Pickelhaube”, a German military spiked helmet introduced in 1842 by Friedrich Wilhelm IV, the King of Prussia. This ECG sign was observed in a number of hospitalized critically ill patients that had ST segment elevation in their ECG but didn’t have STEMI. The presence of this ECG pattern was associated with critical illness and very high risk of in-hospital death.
In the original article and in subsequent publications, numerous cases were presented with this ECG pattern and with myocardial infarction ruled out. Acute abdominal events such as ileus, bowel perforation, gastric obstruction were associated with spiked helmet pattern in the inferior leads whereas acute thoracic events such as aortic dissection, pneumothorax and mechanical ventilation were associated with spiked helmet pattern in the chest leads.
The exact mechanism of this electrocardiographic sign remains uncertain. The observations of Littmann et al. and Tomcsányi et al. suggest that the pseudo-ST elevation is probably due to repetitive epidermal stretch that occurs in concert with the cardiac cycle due to an acute rise in intrathoracic or intraabdominal pressure.
1. Littmann L, Monroe MH. Tombstone ST elevation without myocardial infarction: A variant of the “Spiked Helmet” sign? The American Journal of Medicine 2013;126(8):e9–10.
2. Littmann L, Monroe MH. The “Spiked Helmet” sign: A new Electrocardiographic marker of critical illness and high risk of death. Mayo Clinic Proceedings 2011;86(12):1245–6.
3. Agarwal A, Janz T, Garikipati N. Spiked helmet sign: An under-recognized electrocardiogram finding in critically ill patients. Indian Journal of Critical Care Medicine 2014;18(4):238.
4. Hibbs J, Orlandi Q, Olivari MT, Dickey W, Sharkey SW. Giant J waves and sT-segment elevation associated with acute gastric distension. Circulation 2016;133(11):1132–4.
5. Littmann L. Letter by Littmann regarding article, “Giant J waves and sT-segment elevation associated with acute gastric Distension.” Circulation 2016;134(8):e109–10.
6. Littmann L, Proctor P. Real time recognition of the electrocardiographic “spiked helmet” sign in a critically ill patient with pneumothorax. International Journal of Cardiology 2014;173(3):e51–2.
7. Tomcsányi J, Frész T, Proctor P, Littmann L. Emergence and resolution of the electrocardiographic spiked helmet sign in acute noncardiac conditions. The American Journal of Emergency Medicine 2015;33(1):127.e5–127.e7.
The crochetage sign is an electrocardiographic pattern often observed in patients with atrial septal defect (ASD). It consists of a notch of the R wave in inferior limb leads. This early notch of the R wave in inferior leads was first observed 59 years before in a small group of patients with ostium secondum defect.
Heller et al. first studied this ECG pattern in ASD patients. Crochetage sign had sensitivity and specificity for ASD diagnosis, respectively, 73.1% and 92.6% if present in a single inferior lead, 58.1% and 97.2% if present in two leads and 27.8% and 100% if present in three inferior leads. The crochetage sign is independent of the frequency of incomplete right bundle branch block (iRBBB), but the association of iRBBB and crochetage sign increases the specificity of ASD diagnosis. Even more, the presence of crochetage pattern correlates with shunt severity, even in the presence of pulmonary hypertension but the underlying pathophysiology still remains unknown.
1. Toscano Barboza E, Brandenburg RO, Swan HJC. Atrial seplal defect. The electrocardiogram and its hemodynamic correlation in 100 proved cases. Am J Cardiol 1958;22:698-713.
2. Heller J, Hagège A, Besse B, Desnos M, Marie F, Guerot C. “Crochetage” (Notch) on R wave in inferior limb leads: A new independent electrocardiographic sign of atrial septal defect. Journal of the American College of Cardiology 1996;27(4):877-882.
3. McNamara DWu R. Not Just Another Notch. Circulation 2016;134(14):1054-1056.
4. Bhattacharyya P. ‘Crochetage’ sign on ECG in secundum ASD: clinical significance. BMJ Case Reports 2016;:bcr2016217817.