Assessment of ST segment changes on ECG in children: approaches to diagnosis and treatment

Introduction. ST segment changes can be observed both in completely healthy children and in children with organic myocardial pathology. Currently, there are no recommendations for the management of pediatric patients with documented ST segment changes on the ECG.

Aim: To analyze clinical data, identify causes of ST segment changes on the ECG and determine diagnostic algorithms for treatment tactics.

Material and Methods. The study included 22 patients with ST segment and T wave changes according to standard ECG. All patients underwent daily ECG monitoring, exercise stress test, standard Echo. Diagnostic laboratory screening included determination of lipid spectrum, electrolyte analysis (sodium, potassium, calcium), assessment of markers of myocardial damage and inflammation. In case of deviations, additionally MSCT coronary angiography, myocardial perfusion scintigraphy and stress echocardiography were performed.

Results. 22 patients with ST segment changes on the ECG were examined. In two cases, the cause of ST segment changes was undifferentiated cardiomyopathy. Both patients were asymptomatic, one of them was an athlete. In eight cases, ST segment and T wave changes on the ECG were assessed as manifestations of autonomic dysfunction against the background of concomitant pathology. Anomalies of the course and development of the coronary arteries, including muscular bridges (MB) and anomalies of the origin of the coronary vessels, were detected in 12 examined patients, including two patients with WolffParkinson-White (WPW) syndrome and phenomenon, in whom ST segment changes persisted after radiofrequency ablation (RFA) and in three sportsmen. Based on the examination, one patient with an identified anomaly of the coronary arteries underwent surgical correction. Five patients were prescribed drug therapy with β-blockers.

Conclusion. ST segment changes on the ECG require special attention. Standard ECG and echocardiography have limitations in diagnosing coronary artery anomalies. A mandatory method of additional examination is physical exercise tests. In case of suspicion of an ischemic nature of changes, it is extremely important to exclude coronary artery anomalies using additional examination methods, the most important of which is MSCT coronary angiography, invasive coronary angiography, myocardial perfusion scintigraphy, stress echocardiography are of auxiliary importance.

1. Paech C., Moser J., Dähnert I., Wagner F., Gebauer R.A., Kirsten T. et al. Different habitus but similar electrocardiogram: Cardiac repolarization parameters in children – Comparison of elite athletes to obese children. Ann. Pediatr. Cardiol. 2019;12(3):201–205. https://doi.org/10.4103/apc.APC_90_18

2. Gutheil H., Lindinger A. ECG in adolescents. M.: GAOTAR-Media; 2013:256; ISBN: 978-5-9704-1811-6 (In Russ.).

3. Chang S.M., Nabi F., Xu J., Raza U., Mahmarian J.J. Normal stressonly versus standard stress/rest myocardial perfusion imaging: similar patient mortality with reduced radiation exposure. J. Am. Coll. Cardiol. 2010;55:221–230. https://doi.org/10.1016/j.jacc.2009.09.022

4. Philip Saul J., Kanter R.J., Writing Committee; et al. PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease: Developed in partnership with the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Association for European Pediatric and Congenital Cardiology (AEPC). Heart Rhythm. 2016;13(6):e251– e289. https://doi.org/10.1016/j.hrthm.2016.02.009

5. Ghadri J.R., Wittstein I.S., Prasad A., Sharkey S., Dote K., Akashi Y.J. et al. International expert consensus document on takotsubo syndrome (Part II): Diagnostic workup, outcome, and management. Eur. Heart J. 2018;39(22):2047–2062. https://doi.org/10.1093/eurheartj/ehy077

6. Gao Y., Zhang Q., Sun Y., Du J. Congenital anomalous origin of coronary artery disease in children with syncope: A case series. Front. Pediatr. 2022;5:10:879753. https://doi.org/10.3389/fped.2022.879753

7. Sternheim D., Power D.A., Samtani R., Kini A., Fuster V., Sharma S. Myocardial bridging: Diagnosis, functional assessment, and management: JACC State-of-the-Art Review. J. Am. Coll. Cardiol. 2021;78(22):2196–2212. https://doi.org/10.1016/j.jacc.2021.09.859

8. Erol N. Challenges in evaluation and management of children with myocardial bridging. Cardiology. 2021;146(3):273–280. https://doi.org/10.1159/000513900

9. Hostiuc S., Negoi I., Rusu M.C., Hostiuc M. Myocardial bridging: A metaanalysis of prevalence. J. Forensic. Sci. 2018;63(4):1176–1185. https://doi.org/10.1111/1556-4029.13665

10. Andreev S.L., Shipulin V.M., Aleksandrova E.A., Gulya M.O. Myocardial muscular bridge: complications and treatment (clinical case). Siberian Medical Journal (Tomsk). 2014;29(3):98–101. (In Russ.) https://doi.org/10.29001/2073-8552-2014-29-3-98-101

11. Kim P.J., Hur G., Kim S.Y., Namgung J., Hong S.W., Kim Y.H. et al. Frequency of myocardial bridges and dynamic compression of epicardial coronary arteries: a comparison between computed tomography and invasive coronary angiography. Circulation. 2009;119(10):1408–1416. https://doi.org/10.1161/circulationaha.108.788901

12. Evbayekha E.O., Nwogwugwu E., Olawoye A., Bolaji K., Adeosun A.A., Ajibowo A.O. et al. A comprehensive review of myocardial bridging: Exploring diagnostic and treatment modalities. Cureus. 2023;8;15(8):e43132. https://doi.org/10.7759/cureus.43132

13. Maeda K., Schnittger I., Murphy D.J., Tremmel J.A., Boyd J.H., Peng L. et al. Surgical unroofing of hemodynamically significant myocardial bridges in a pediatric population. J. Thorac. Cardiovasc. Surg. 2018;156(4):1618–1626. https://doi.org/10.1016/j.jtcvs.2018.01.081

14. Gawor R., Kuśmierek J., Płachcińska A., Bieńkiewicz M., Drożdż J., Piotrowski G. et al. Myocardial perfusion GSPECT imaging in patients with myocardial bridging. J. Nucl. Cardiol. 2011;18(6):1059–1065. https://doi.org/10.1007/s12350-011-9406-8

15. Alessandri N., Dei Giudici A., De Angelis S., Urciuoli F., Garante M.C., Di Matteo A. Efficacy of calcium channel blockers in the treatment of the myocardial bridging: A pilot study. Eur. Rev. Med. Pharmacol. Sci. 2012;16(6):829–834. PMID: 22913217.

16. Fujita S., Kabata E., Mizutomi S., Usuda K., Chikata A., Futatani T. et al. A change in QT interval and ST-segment after radiofrequency catheter ablation in pediatric patients with Wolff – Parkinson – White syndrome. J. Electrocardiol. 2024;87:153814. https://doi.org/10.1016/j.jelectrocard.2024.153814

17. Kanwal A., Bustin K.M., Delasobera B.E., Shah A.B. Ischaemia during exercise stress testing in an athlete with Wolff – Parkinson – White pattern. BMJ Case Rep. 2020;13(4):e235055. https://doi.org/10.1136/bcr-2020-235055