Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
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Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : OC05 - OC09 Full Version

Correlation of Standard ECG with 2D-Echo and Serum Troponin I in Locating the Site of Myocardial Infarction and its Extent- An Observational Study

Published: March 1, 2022 | DOI:
AC Sanjay Reddy, TR Pandiyan, Srinivasa Rao, YJ Visweswara Reddy, PE Dhananjaya

1. Assistant Professor, Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. 2. Senior Resident, Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. 3. Professor, Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. 4. Professor, Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India. 5. Professor, Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India.

Correspondence Address :
Dr. Tr Pandiyan,
Flat No. 408, Hill View, PES Medical College, Kuppam-517425, Andhra Pradesh, India.


Introduction: Cardiovascular diseases are the leading causes of death in developed countries, and its incidence is on the rise in developing countries. Electrocardiogram (ECG), 2 Dimensional Echocardiography (2D-Echo) and myocardial injury biomarkers help in the diagnosis, prognostification of Myocardial Infarction (MI).

Aim: To correlate the findings of ECG, 2D-Echo and Troponin I levels in locating the site and extent of MI.

Materials and Methods: This observational study was conducted in the Cardiology Intensive Care Unit (ICU)/ward, PES Hospital, Kuppam, Andhra Pradesh, India, from January 2019 to June 2020. A total of 99 patients of acute MI were studied at baseline, and repeat 12 lead ECG, 2D-Echo and serum troponin I levels were recorded. Ejection Fraction (EF) was estimated from the QRS score by means of a formula, and Echocardiographic correlation was obtained on the same day with ECG-QRS scoring by direct estimation of EF in ‘Q’ wave infarction. High sensitivity cardiac Troponin – I was measured at the time of hospitalisation and repeated at six hours if required, and its levels were correlated to the extent of MI i.e., Left Ventricular Ejection Fraction (LVEF). The categorical data were analysed using Chi-square test and p<0.05 was considered as statistically significant. Regression analysis was done for associated factors.

Results: There was better correlation between EF calculated from ECG-QRS scoring system and 2D-Echo (r=0.78, p-value <0.001). There was poor correlation between serum Troponin I levels at admission, and extent of MI i.e., LVEF as estimated by ECG and 2D-Echo (r=-237.13, p=0.334 and r=-120.78, p=0.585). There was a significant correlation between serum Troponin I levels at 72 hours of chest pain or peak values and extent of MI i.e., LVEF as estimated by ECG and 2D-Echo (r=-1446.14, p<0.001 and r=-1354.42, p<0.001).

Conclusion: The location of MI, seen on ECG, correlated broadly with those seen on 2D-Echo. 2D-Echo was able to elaborate regional wall motion abnormalities in detail when compared to the ECG. LVEF can be calculated from ECG at bedside in Q wave infarction, which correlated fairly with 2D-Echo findings.


Electrocardiogram QRS scoring system, Left ventricular ejection fraction, Q wave infarction, Regional wall motion abnormalities

Ischaemic Heart Disease (IHD) is the cause of 25-30% of deaths in most industrialised countries (1). Various methods such as ECG and wall motion abnormality by 2D-Echo and myocardial injury biomarkers help in the diagnosis, prognostification of MI. These investigations are non invasive and can be done at less advanced centres (2). In 12 lead ECG, the site of MI can be localised depending upon the leads showing typical changes of infarction. Massive anterior infarction is shown by the typical changes of infarction in the chest leads from V1-V6 and/or in leads I and augmented Vector Left (aVL). Anteroseptal infarction is shown by changes in V1 to V3 while apical infarction is shown in V4-V6. Inferior MI is evident by Q wave in standard leads II and augmented Vector Foot (aVF), which persist after deep inspiration. Anterolateral infarction is present when typical changes are present in standard leads I and avL as well as in chest leads V5 and V6. Posterior or posterolateral wall infarction induces changes in leads placed over the back of the heart, such as leads V7 to V9 (3).

2D-Echo is an excellent technique for detecting the early changes in function, which occurs with Acute Myocardial Infarction (AMI) (4). One of the principle ways of detecting ischaemic muscle is that its motion is altered almost immediately after ischaemic (5). The major determinants of the immediate and long term outcome of AMI are the size of the infarct, and the functional status of the residual myocardium. The value of the ECG in diagnosis and localisation of an AMI is well established (6),(7),(8).

The importance of ECG for measuring the size of an infarct or for assessing left ventricular function has not been well defined. Palmeri ST et al., developed a QRS scoring system based on computer simulation of the sequence of ventricular activation. Their purpose was to evaluate the usefulness of the 12-lead ECG and a simplified version of the QRS scoring system for assessing left ventricular function after MI (9).

Cardiac Magnetic Resonance Imaging (MRI) with high spatial resolution, reproducibility, and the ability to detect small infarctions would have been an appropriate alternative for accurate quantification of infarct size and extent of MI. However, its use for routine assessment of infarct size in daily practice has been limited owing to high expenses and low availability and was not performed in the present study population (10).

The present study was conducted to correlate the ECG findings with 2D-Echo in locating the site of AMI and to correlate the ECG and 2D-Echo findings with the serum Troponin I levels in determining the extent of AMI.

Material and Methods

This observational study was conducted in Cardiology ICU/ward, PES Hospital, Kuppam, Andhra Pradesh, India, from January 2019 to June 2020. Institutional Ethical Committee (IEC) approval was obtained (No: PESIMSR/IHEC/15/2018) was obtained. The study was conducted on 99 patients admitted to Coronary Care Unit (CCU), in the Department of General Medicine, PESIMSR, Kuppam.

Sample size calculation: Sample size was calculated using the formula mentioned below:



Inclusion criteria:

Patients above 18 years of age and satisfying World Health Organisation (WHO) criteria for the diagnosis of acute MI were included (11).

Exclusion criteria:

a. Patients presenting with:
i. Previous history of MI.
ii. Left ventricular hypertrophy.
iii. Intraventricular conduction defects, hemi-block, bundle branch blocks and Complete AV block.
iv. Valvular heart disease.
v. Cardiomyopathy.
vi. Pericardial diseases.
vii. Congenital heart disease.
viii. Previous cardiac surgeries.
b. Patients having renal failure.

Study Procedure

Baseline and repeat 12 lead ECG, 2D-Echo, serum Troponin I was done. ECG was performed at the time of admission for diagnosis of MI. The criteria consisted of ST segment elevation of ≥2 mm, 0.08 second from J point in ≥2 related electric fields, with typical evolutionary changes or presence of new pathological Q waves (12). Continuous cardiac monitoring was done and patients were treated with generally accepted protocols of CCU. As soon as feasible, a 2D-Echo was performed by means of commercially available mechanical sector scanner. With the patient in left lateral decubitus position, multiple parasternal long axis views, short axis and apical views were taken to study regional wall motion abnormalities and for estimation of LVEF, in all 99 patients with AMI. ECG was recorded on a standard ECG machine at a paper speed of 25 mm/sec. Artifactual recordings were eliminated. ECG showing the presence of first Q wave in post MI were taken and the day of evolution of Q waves were noted. From such a reading the EF was estimated using the QRS scoring of Wagner GS et al., (13). The scoring was based primarily on the duration of the ‘Q’ and ‘R’ waves on a 12-lead ECG and secondarily on the magnitude of the R/Q and R/S with a maximum of 29 points possible. LVEF was estimated from the QRS score by means of a formula (14).

LVEF (%)=60-(3×QRS score)

Echocardiographic correlation was obtained on the same day of ECG QRS scoring, by direct estimation of EF in ‘Q’ wave infarction. High sensitivity cardiac Troponin- I was measured at the time of hospitalisation and repeated at six hours if required, and its levels were correlated to the extent of MI i.e., LVEF.

QRS-scoring system: The QRS scoring system was developed by Carey MG et al., (15), and then subsequently modified by Wagner GS et al., (13). The scoring system was simplified to include only aspects commonly employed clinically for identification of an infarct and it was modified to meet requirements for sensitivity and specificity. The point score was then calculated from the QRS complexes in 10 of the 12 standard leads (Table/Fig 1).

Statistical Analysis

The data was entered into MS excel 2007 version and further analysed using Statistical Package for the Social Sciences (SPSS) 20.0. For descriptive analysis, the categorical variable was analysed by using percentages and continuous variables were analysed by calculating mean±Standard Deviation (SD). The categorical data were analysed using Chi-square test and p<0.05 was considered as statistically significant. Regression analysis was performed for associated factors.


Out of 99 patients of MI, 44 had AMI (44.4%), 35 patients had inferior wall (35.3%), 15 had anteroseptal (15.1%), 2 had antero-inferior (2.1%), two had posterior wall (2.1%) and 1 had Right Ventricular Myocardial Infarction (RVMI) (1%). Chest pain was the most common presenting symptom, and excessive sweating was the most common associated symptom. Other symptoms noted were breathlessness, epigastric pain, palpitations, vomiting and syncope. The age of the patients ranged from 31 years to 89 years. The maximum numbers of patients (31.3%) were seen in the age group of 61-70 years. The minimum numbers of patients (10.1%) were seen in 31-40 years. Male to female ratio was 2.6:1. The association of age and sex-wise distribution was found to be statistically insignificant p>0.05 (Table/Fig 2).

An analysis of coronary risk factors among the 99 patients revealed, 52 patients were chronic smokers (52.5%), 42 patients with family history of IHD/Diabetes Mellitus (DM)/Hypertension (42.4%), 38 patients with DM (38.4%), 36 patients with obesity (36.4%), 34 patients with hypertension (34.4%), 31 patients were alcoholic (31.3%), and 48 patients out of 95 patients (for four patients lipid profile could not be done) showed hyperlipidemia (50.5%).

2D-Echo on the 44 patients with AMI on ECG further elaborated that additional regional areas of Left Ventricle (LV) were involved, 12 patients had extensive AMI, 11 patients had apical and anterior wall hypokinesia and rest as shown in the (Table/Fig 3).

2D-Echo of 35 patients with inferior wall MI on ECG showed that, 23 patients had basal inferior wall hypokinesia, eight patients had basal mid inferior, inferoseptal, inferolateral and inferoposterior wall hypokinesia and rest as shown in the (Table/Fig 4).

Of the 15 patients who had anteroseptal MI on ECG, 2D-Echo in these patients further revealed that 10 patients had apical and anteroseptal wall hypokinesia, four patients had anteroseptal wall hypokinesia and rest as shown in the (Table/Fig 5).

2D-Echo on two patients with posterior wall MI on ECG showed that one had inferoseptum, inferoposterior segment hypokinesia, while the other had posterior wall hypokinesia. 2D-Echo in the patient with RVMI further revealed that the patient had RV segment hypokinesia.

LVEF was dichotomised at 40% (>40% and <40%) this cut-off point has been shown to be of major prognostic importance after MI (16). LVEF by QRS scoring system showed EF <40% in 56/99 patients. Whereas, LVEF by 2D-Echo showed EF <40% in 51/99 patients.

There was a good correlation of EF calculated from ECG QRS scoring system and 2D-Echo in all sub-groups of MI. However, there was better correlation in anterior wall MI, anteroseptal MI and inferior wall MI as shown in the (Table/Fig 6).

There was a fair degree of correlation between EF calculated from ECG and 2D-Echo (r=0.78 and p-value <0.001) (Table/Fig 7).

There was poor correlation between serum Troponin I levels at admission and EF calculated from ECG QRS whereas serum Troponin I levels at 72 hours or peak level and EF calculated from ECG QRS correlated significantly (Table/Fig 8).

There was poor correlation between serum Troponin I levels at admission and EF calculated from 2D-Echo whereas serum Troponin I levels at 72 hours or peak level and EF calculated from 2D-Echo correlated significantly (Table/Fig 9).


Ninety nine patients were studied in the present study. The age ranged from 31-89 years. A total of 72 patients were males (72.7%) and 27 patients were females (27.3%). The maximum number of cases was noted in 61-70 years (33 cases). Less number of cases were noted in 31-40 years (10 cases). The male to female ratio was 2.6:1. Among risk factors, the present study shows that smoking was the commonest risk factor (52.5%), followed by hyperlipidaemia (50.5%), family history of IHD/DM/hypertension (42.4%), DM (38.4%), obesity (36.4%), hypertension (34.4%), alcoholic (31.3%).

ECG and 2D-Echo correlation for site of MI: In present study, out of 99 patients, 44 patients had AMI, 15 patients had anteroseptal MI, 35 patients had inferior wall MI and two patients had anteroinferior MI, two patients had posterior wall MI and one patient had RVMI on ECG. 2D-Echo in these patients further elaborated site of infarction seen on ECG in great detail, thereby, lending credence to the fact, that, 2D-Echo delineates ischaemic changes more extensively.

The present study was in agreement with the findings of many researchers. It reiterates that electrocardiography and 2D-Echo have a good correlation in localising the site of infarction but 2D-Echo was able to elaborate the site of infarction in detail. Hence, clinically ECG can be used as a better tool in diagnosing and localising the site of MI in remote areas where 2D-Echo is not available (17),(18),(19).

Correlation of EF calculated from ECG 2D-Echo: In the present study, it was found that there was a good correlation of EF in anterior wall MI, anteroseptal MI and inferior wall MI (Table/Fig 6). There was a fair degree of correlation between EF calculated from ECG and 2D-Echo with r=0.78 and p-value <0.001 (Table/Fig 7). A study by Tateishi S et al., concluded that the QRS scoring system can be used as a simple and economical method for estimation of infarct size soon after reperfusion (20). Barbagelata A et al., concluded that in the reperfusion era, a 12-lead ECG provides a simple, economical means of risk stratification at discharge (21). Hence, estimation of infarct size soon after reperfusion by the QRS scoring system is simple and economical method. Though the relative inadequacies of this study (as given in limitation of study), relatively fair correlation was obtained between ECG QRS scoring and echocardiographic LV pump function. Hence, this can be used as an additional method of evaluating left ventricular function in ‘Q’ wave infarction.

Correlation of Serum Troponin I levels with the extent of MI by LV EF calculated from ECG QRS score and 2D-Echo: In the present study, serum high sensitivity troponin I levels at admission did not correlate with LVEF calculated from ECG QRS score and 2D-Echo (r=-237.07, p=0.334 and r=-120.78, p=0.585) (Table/Fig 8), (Table/Fig 9). But high sensitivity Troponin I levels at 72 hours of chest pain or peak values correlated with LVEF calculated from ECG QRS score and 2D-Echo (r=-1446.09, p<0.001 and r=-1354.42, p<0.001). Stanley C et al., found that the Troponin I levels, on admission, weakly correlated with LVEF with p-value <0.05, whereas peak Troponin I value correlated well with p<0.001 (135). The index study results were also similar (22). Ohlmann P et al., reported that cardiac Troponin I concentrations done at the time of admission did not correlate with LVEF, whereas Troponin I levels done from the 3rd to the 72nd hour following Percutaneous Intervention (PCI) correlated with LVEF (p<0.001; R: -0.42 to -0.50). Similar findings were there in the present study too (23). Hence, serum Troponin I cannot be used as good indicator of extent of MI.


However, better correlative values could not be obtained possibly because of certain limitations: Equipment and techniques used in estimation of EF will vary in different studies/Institutes. Standardisation of ECG is required for homogeneity. Ideally the ECG used for scoring should have been performed on the same day or nearest possible day of ECHO study to obtain the best correlation. EF by QRS scoring system cannot be superior to LVEF obtained by 2D-Echo or even used as a substitute because of the following limitations: It cannot estimate infarct size directly. It cannot be used in non Q-wave infarct and acute MI with conduction disturbance. Scoring system cannot be used to exclude diagnosis of a prior or AMI. Different equipment and techniques used in different Institutions may have limitations on the scoring system.


The location of MI seen on ECG correlated broadly with those seen on 2D-Echo. However, elaboration of regional wall motion abnormalities could be done in detail by 2D-Echo. LVEF calculated from ECG at bedside in Q wave infarction correlated fairly to 2D-Echo findings. Serum high sensitivity Troponin I levels at admission did not correlate with extent of MI calculated by LVEF. Serum high sensitivity Troponin I levels at 72 hours after onset of chest pain or peak levels documented during admission correlated with the extent of MI calculated by LVEF.


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DOI and Others

DOI: 10.7860/JCDR/2022/53075.16071

Date of Submission: Nov 02, 2021
Date of Peer Review: Dec 29, 2021
Date of Acceptance: Jan 28, 2022
Date of Publishing: Mar 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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