what is “tombstone” ST segment elevation of MI ( Tombstoning ECG =grave prognosis)

Tombstoning ST elevation myocardial infarction can be described as a STEMI characterized by tombstoning ST-segment elevation. This myocardial infarction is associated with extensive myocardial damage, reduced left ventricle function, serious hospital complications and poor prognosis. Tombstoning ECG pattern is a notion beyond morphological difference and is associated with more serious clinical results.

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Angiographic Characteristics of TOMB-STEMI

Parameters	Guo et al. [3]	Tomcsanyi et al. [6]
Total/partial occlusion of LAD, %	100 vs 44, p<0.0001
LAD =100% occlusion,%	50 vs 20.5, p=0.02
LAD< 50% occlusion ,%	0 vs 15.9, p=0.039
Proximal occlusion of LAD, %	92 vs 65, p=0.017
3 vessel disease,%	54.1 vs 22, p=0.001
2 or 3 vessel disease,%	48 vs 54, p=0.6311
LAD segment	1.35 vs 1.5, p=0.44
Open culprit artery,%	26 vs 34, p=0.284
TIMI frame count	28 vs 17.2, p=0.0001
TIMI myocardial perfusion grade	1.2 vs 1.8, p=0.043
Unsuccessful PCI, %	22 vs 6, p=0.05

LAD=left anterior descending coronary artery; TIMI=thrombolysis in myocardial infarction; PCI=percutaneous coronary intervention.

It appears that a sudden occlusion of a coronary artery supplying a large area of unprepared myocardium; i.e. myocardium not protected by collaterals or ischemic preconditioning, results in complete transmural injury rapidly progressing to complete infarction, resulting in this characteristic ECG pattern. The extensive nature of the myocardial infarction and the resultant left ventricular damage and dysfunction may explain the higher risk of complications and mortality associated with this finding. The higher BNP levels on presentation in patients with tombstone STEMI seem to support the extensive nature of the myocardial damage associated with this ECG finding.