Acute Inferior ST-segment Elevation Research Articles

Electrocardiographic Distinction of Culprit Artery in Patients with Acute Inferior ST Segment Elevation Myocardial Infarction and Multivessel Disease

Electrocardiographic Distinction of Culprit Artery in Patients with Acute Inferior ST Segment Elevation Myocardial Infarction and Multivessel Disease

Echocardiographic and Angiographic Assessment of Right Ventricular Function and Right Coronary Artery Stenosis in Acute Inferior Wall Myocardial Infarction.

Cardiovascular diseases (CVDs) are a global concern. CVD remains a primary cause of death despite reduced coronary heart disease death rates. Acute coronary syndrome (ACS) involves myocardial infarction (MI) and unstable angina, sharing mechanisms such as plaque instability. Our study assesses the right ventricular (RV) function's predictive value in acute inferior wall MI (IWMI) to identify high-risk patients with an elevated likelihood of experiencing severe cardiac complications, hemodynamic instability, or a higher mortality risk following an acute IWMI. The research was conductedin the Department of Cardiology at theRajendra Institute of Medical Sciences (RIMS), Ranchi, from July 2021 to June 2022, following the necessary ethical approval. A cohort of 140 patients with IWMI, carefully chosen according to rigorous criteria, clearly understood the study's objectives before providing informed consent. The evaluations were conducted in the following order: clinical assessments, followed by blood testing, then echocardiography, and finally, coronary angiography. Furthermore, the study examined risk factors and utilized statistical methods to elucidate the associations between qualities and results. The study included 140 participants, with 61% being male and 39% female. Among the participants, 14% were aged 30-45, 50% were aged 46-60, and 30% were over 60. Age shows significant proportions in different categories. Diabetes, dyslipidemia, hypertension, and smoking/tobacco addiction did not differ among stenosis groups. Proximal right coronary artery (RCA) stenosis patients had elevated jugular venous pressure (JVP). The echocardiograms were performed within 48 hours of post-percutaneous coronary intervention, and significant differences between groups were observed. Participants with proximal stenosis had lower tricuspid annular plane systolic excursion (TAPSE) and right ventricular fractional area change (RVFAC), which showedcompromised RV systolic function. Proximal stenosis patients had reduced systolic motion velocity (Sm), indicating impaired myocardial contraction. Echocardiographic parameters such as early diastolic velocity (Em), atrial contraction velocity (Am), Em/Am ratio (a marker of diastolic function), isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET) between groups were different, indicating distinct cardiac functions. Proximal stenosis increased the myocardial performance index (MPI), indicating cardiac impairment. The left ventricular ejection fraction (LVEF) was comparable in the two stenosis groups, indicating similar left ventricular performance. Echocardiography showed significant RV function differences in acute inferior wall ST-segment elevation myocardial infarction (STEMI) patients with proximal and distal RCA lesions. RV dysfunction is linked to right ventricle myocardial infarction (RVMI), and echocardiographic markers can provide valuable insights. Results emphasizethat acute inferior wall STEMI is diagnosed by electrocardiogram (ECG) criteria, particularly ST-segment elevation. However, these markers emphasize the importance of RV assessment in RCA involvement assessment. These findings suggest that RV function can help diagnose acute inferior wall STEMI RCA involvement. In acute inferior STEMIs, RV function echocardiography is essential for RCA lesion location.

RV Function by cardiac magnetic resonance and its relationship to RV longitudinal strain and neutrophil/lymphocyte ratio in patients with acute inferior ST-segment elevation myocardial infarction undergoing primary percutaneous intervention

Background: Although acute inferior myocardial infarction (MI) is usually regarded as being lower risk compared with acute anterior MI, right ventricular (RV) myocardial involvement (RVMI) may show an increased risk of cardiovascular (CV) morbidity and mortality in patients with inferior MI. CMR is ideal for assessing the RV because it allows comprehensive evaluation of cardiovascular morphology and physiology without most limitations that hinder alternative imaging modalities. Objectives: To evaluate the sensitivity of strain and strain rate of the RV using 2D speckle tracking echo and the neutrophil/ lymphocyte ratio (NLR) compared to cardiac MRI (CMR) as the gold standard among patients with inferior STEMI undergoing primary percutaneous coronary intervention (PCI). Methodology: 40 Patients with inferior MI who had primary PCI were included in the study; they were divided into two groups according to the RVEF using CMR. NLR was done in comparison to RVEF. Results: out of the 40 patients, 18 (45%) patients had RV dysfunction. 2D echocardiography was done for all patients, where fractional area change (FAC) in the RV dysfunction group appeared to be significantly reduced compared to the group without RV dysfunction (p value = 0.03). In addition, RV longitudinal strain (LS) by speckle tracking echo was reduced with an average of 19.5 ± 3.9% in the RV dysfunction group. Both CMR- derived RV SV, and EF were lower among the RV dysfunction group, (26.8 ± 15.8) ml and (35.4 ± 6.9)% respectively, with large RV systolic volume, with a highly statistically significant difference in comparison to the other group (p value = 0.000). Complications, heart block was significantly higher in patients with RV dysfunction (p value = 0.008) as it occurred in 5 (27.8%) patients. N/L ratio for predicting RV dysfunction by CMR had a cut-off value of > 7.7 with low sensitivity (38.8%) and high specificity (77.3 %). In contrast, LS for predicting RV dysfunction by CMR had high sensitivity (83.3%) and high specificity (63.6%) with p value = 0.005. Conclusion: Our results showed that RV dysfunction in inferior MI is better detected using cardiac magnetic resonance imaging. In inferior STEMI patients who underwent primary PCI, NLR has low sensitivity but high specificity for predicting RVD when measured by cardiac MRI.

Coronary Artery Spasm–Induced Cardiac Arrest Precipitated by Iodine Contrast Load in Unknown Pre-Existing Graves’ Disease

A 51-year-old female active smoker with no cardiac history presented with jaw pain and acute inferior ST-segment elevation electrocardiography (ECG) changes. Emergency coronary angiography revealed a culprit thrombotic occlusion of the mid right coronary artery, which was successfully recanalized

Extremely Late In-Stent Thrombosis 12 Years After Implantation of a Drug-Eluting Stent

Stent thrombosis is one of the most feared complications of percutaneous coronary intervention. Most commonly it occurs within the first few days after the deployment of the stent. Once the stent is completely endothelialized, this complication becomes extremely rare. Few cases of very late stent thrombosis were reported in the literature with the longest interval being around 11 years after the initial intervention. We report here the case of a 78-year-old male patient who presented with acute onset chest pain found to have acute inferior ST-segment elevation myocardial infarction due to thrombotic occlusion of a prior paclitaxel drug-eluting stent placed 12 years prior. This is, to our knowledge, the first case of stent thrombosis occurring after this long duration since stent implantation.

Mismatch Between Cardiac Magnetic Resonance Imaging and Invasive Physiology

A 74-year-old man returned to the clinic for follow-up of residual nonculprit lesions after reperfused acute inferior ST-segment elevation myocardial infarction. Stress cardiac magnetic resonance perfusion imaging demonstrated a severe perfusion defect in the anterior wall. Surprisingly, subsequent invasive assessment did not reveal hemodynamically significant obstruction in the nonculprit vessels. (Level of Difficulty: Beginners.)

Single Coronary Artery Anomaly in a Woman With Acute ST-Segment Elevation Myocardial Infarction

A 65-year-old woman presented with an acute inferior ST-segment elevation myocardial infarction and was found to have a rare single coronary artery anomaly on coronary angiography. A complete occlusion at the mid right coronary artery was identified as the culprit lesion and underwent successful percutaneous revascularization with stenting. (Level of Difficulty: Beginner.)

HIGHER ST-SEGMENT ELEVATION IN LEAD III THAN LEAD II IN ACUTE INFERIOR MYOCARDIAL INFARCTION CAN BE A PREDICTOR OF SHORT-TERM MORBIDITY AND MORTALITY

Background:The incidence of mortality and complications are high in patients with acute inferior wall ST-segment elevation myocardial infarction with right ventricular involvement, which has been reported to be an independent predictor of significant complications and in-hospital mortality. Objective:To investigate the feasibility of using electrocardiographic changes in inferior myocardial infarction represented by ST-segment elevation ratio in lead II and III as a predictor of right ventricular infarction and in-hospital morbidity and mortality. Methods:Ninety-nine patients were studied in this prospective study, their ages ranged from 19-90 years, average 58.12 (±12.7 SD). They were presented to the Coronary Care Unit of Basrah General Hospital with acute inferior ST-segment elevation myocardial infarction. The 12 leads plus right-sided precordial electrocardiograms were done to all patients within 12 hours of the onset of symptoms, and ST-segment elevation was measured. ST-segment elevation in lead III exceeding lead II was defined as a ratio of elevation in lead III: II>1. Patients grouped according to ST-segment elevation III:II ratio into either >1 or ≤1. In-hospital morbidity and mortality were studied in both groups. Results:ST-segment elevation ratio > 1was detected in 68 patients (68.7%) with acute inferior myocardial infarction at time of admission. Right ventricular infarction was diagnosed in 33 (33.3%) patients, with the majority (32 patients) have ST-elevation ratio > 1. Thirty-Six patients had at least one of the in-hospital complications with significantly higher incidence (51.4%) in patients with higher ST elevation ratio. The mortality was statistically higher when ST segment elevation level in the lead III > than that in the lead II. Conclusion:In patients with inferior STEMI, ST-segment elevation in the lead III more than lead II can be a potential marker of the presence of right ventricular infarction in association with inferior myocardial infarction. Short-term prognosis is possibly worse in the presence of a higher ratio between lead III and II ST-segment elevation. However, further studies are needed to validate this conclusion. Keywords:Inferior MI, right ventricular infarction, ST-segment changes Citation:Al-Mansouri LA, Al-Obaidi FR, Al-Humrani AH. Higher ST-Segment elevation in lead III than lead II in acute inferior myocardial infarction can be a predictor of short-term morbidity and mortality. Iraqi JMS. 2019; 17(3&4): 168-174. doi: 10.22578/IJMS.17.3&4.2

Comparison of ST segment Changes in Lead aVR with in-Hospital Outcomes in Patients with First attack of Acute Inferior ST Segment Elevation Myocardial Infarction

Background: Inferior wall ST segment elevation myocardial infarction is considered to be at lower risk than anterior wall STEMI except in some cases. The aim of our study was to evaluate the relationships between on admission ST segment changes in lead aVR and short term in-hospital outcomes in acute isolated inferior myocardial infarction undergoing thrombolysis.
 Methods: Total 107 of first attack of inferior STEMI patients were included and all were thrombolysed by streptokinase. The sample population were divided into three groups based on the condition of ST segment in lead aVR on admission and in hospital outcomes were observed: Group –A: ST segment elevation ≥0.5 mm; Group –B: ST segment depression ≥0.5 mm; Group-C: Iso-electric ST segment.
 Results: 6.54% of study population had ST segment elevation in lead aVR, 53.27% had ST segment depression in lead aVR and 41.12% had isoelectric ST segment in lead aVR. During hospital stay mortality rates of patients of Group A, Group B and Group C were 33.3%, 5.3% and 4.5 % respectively; rates of cardiogenic shock were 33.3%, 8.8% and 2.3% respectively; heart failure rates were 50.0%, 15.8% and 4.5% respectively; rates of recurrent angina after thrombolysis were 66.7%, 33.3% and 6.8% respectively in three groups and the mean LVEF were 40.17, 48.61 and 52.50 respectively.
 Conclusion: The on admission-isoelectric ST segment in lead aVR in acute inferior myocardial infarction predicted better in-hospital outcomes in comparison to ST segment elevation and ST segment depression in aVR. On the other hand, ST segment elevation in lead aVR predicted worse in-hospital outcomes than ST segment depression in acute inferior myocardial infarction in spite of reperfusion by thrombolytic.
 Cardiovasc. j. 2019; 11(2): 123-128

Electrocardiographic Distinction of Left Circumflexand Right Coronary Artery Occlusion in PatientsWith Inferior Acute Myocardial Infarction

Previously reported electrocardiographic (ECG) criteria to distinguish left circumflex (LCCA) and right coronary artery (RCA) occlusion in patients with acute inferior ST-segment elevation myocardial infarction (STEMI) afford a modest diagnostic accuracy. We aimed to develop a new algorithm overcoming limitations of previous studies. Clinical, ECG, and coronary angiographic data were analyzed in 230 nonselected patients with acute inferior STEMI who underwent primary percutaneous coronary intervention. A decision-tree analysis was used to develop a new ECG algorithm. The diagnostic accuracy of reported ECG criteria was reviewed. LCCA occlusion occurred in 111 cases and RCA in 119. We developed a 3-step algorithm that identified LCCA and RCA occlusion with a sensitivity of 77%, specificity of 86%, accuracy of 82%, and Youden index of 0.63. The area under the ROC curve was 0.85 and resulted 0.82 after a 10-fold cross validation. The key leads for LCCA occlusion were V3 (ST depression in V3/ST elevation in III >1.2) and V6 (ST elevation ≥0.1 mV or greater than III). The key leads for RCA occlusion were I and aVL (ST depression ≥ 0.1 mV). Fifteen of 21 reviewed studies had less than 20 cases of LCCA occlusion, only 48% performed primary percutaneous coronary intervention, and previous infarction or multivessel disease were often excluded. The diagnostic accuracy of reported ECG criteria decreased when applied to our study population. In conclusion, we report a simple and highly discriminative 3-step ECG algorithm to differentiate LCCA and RCA occlusion in an "all comers" population of patients with acute inferior STEMI. The diagnostic key ECG leads were V3 and V6 for LCCA and I and aVL for RCA occlusion.

ST-segment depression in left precordial leads in electrocardiogram of patients with acute inferior myocardial infarction undergoing primary percutaneous coronary intervention.

BackgroundThe early identification of patients with acute inferior ST-segment elevation myocardial infarction (STEMI) with high risk features is particularly important. Acute inferior STEMI may be associated with ST-segment depression in the left precordial leads (V4–V6). This study assessed prognostic value of ST-segment depression in these left precordial leads during the admission of patients with acute inferior STEMI treated with primary percutaneous coronary intervention.MethodsThis retrospective study enrolled 1,374 patients with acute inferior STEMI who underwent primary percutaneous coronary angioplasty between March 2011 and June 2014. The patients were divided into two groups: one group (n = 687) with left precordial ST-segment depression and the other (n = 687) without such ST-segment changes.ResultsThe patients with left precordial ST-segment depression were older and had higher incidence of hypertension, diabetes mellitus, and higher levels of troponin. In-hospital mortality was higher in patients with left precordial ST-segment depression. Advanced coronary artery disease was more observed in these patients.ConclusionIn patients with acute inferior STEMI treated with primary coronary intervention, left precordial ST-segment depression during admission of ECG is associated with more advanced coronary artery disease, and worse in-hospital clinical outcomes.

P4639Electrocardiographic diagnosis of atrial infarction in patients with acute inferior ST-segment elevation myocardial infarction

P4639Electrocardiographic diagnosis of atrial infarction in patients with acute inferior ST-segment elevation myocardial infarction

Electrocardiographic diagnosis of atrial infarction in patients with acute inferior ST-segment elevation myocardial infarction.

Patients with atrial myocardial infarction (ATMI) have frequent cardiac and noncardiac complications. However, ATMI is uncommonly diagnosed because of its nonspecific ECG changes. Our objective was to analyze the ECG characteristics of ATMI in patients with inferior STEMI. Electrocardiographic P wave parameters can help in diagnosis of ATMI. We evaluated 932 patients who underwent coronary angiography and recruited 39 patients with ATMI and 33 patients without ATMI with inferior STEMI for a retrospective study. Twelve-lead ECGs were obtained to measure P-wave parameters in diagnosis of ATMI. P-wave parameters and PR-segment displacement were compared in patients with and without ATMI. In inferior leads, PWD and PWDisp were significantly longer in the ATMI group than in the non-ATMI group (limb lead II, 109.79 ±15.51 ms and 86.65 ±5.02 ms, respectively; P < 0.001; limb lead III, 108.31 ±12.51 ms and 85.27 ±7.47 ms, P < 0.001; aVF, 106.49 ±13.68 ms and 83.01 ±7.89 ms, P < 0.001; PWDisp, 41.67 ±10.72 ms and 25.18 ±5.17 ms, P < 0.001). By contrast, PWA was significantly lower in the ATMI group than in the non-ATMI group (limb lead II, 0.96 ±0.18 mV and 1.39 ±0.22 mV, respectively; P < 0.001; limb lead III, 0.90 ±0.11 and 1.21 ±0.23, P < 0.001; aVF, 0.88 ±0.17 and 1.26 ±0.28, P < 0.001). PR-segment displacement was found in 8 (20.5%) patients with ATMI. A PWD ≥95.5 ms in lead DII diagnosed ATMI with a higher sensitivity and specificity (90%, 94%) than did PWA or PWDisp. This study suggests P-wave parameters might be considered ECG findings in diagnosis of ATMI in patients with inferior STEMI.

Predicting the culprit artery in acute inferior wall STEMI using ST segment elevation in leads V7-9 and accessing the significance of previously published criteria

BackgroundIn acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to new algorithm using information regarding ST elevation in posterior leads to predict culprit artery in inferior STEMI. Method260 consecutive patients with ST-segment elevation in the inferior ECG leads, and coronary arteriography performed within 7 days of the onset of symptoms were retrospectively analysed. The culprit vessel was predicted by the ECG, and findings were correlated with angiography. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them for predicting the culprit artery, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery. ResultsSensitivity and specificity of our algorithm to predict RCA as culprit artery were 83% and 93%, respectively, 93% and 83%, respectively for predicting the LCX as the culprit. When we applied the algorithms of Fiol et al and Tierala et al to our study population, they both resulted in slightly lower specificities for RCA prediction and lower sensitivities for LCX prediction as the culprit artery, compared to our algorithm. ConclusionRoutine recording of posterior precordial leads (V7-9) increases the accuracy of predicting infarct related artery in acute inferior wall MI.

Case of Percutaneous Extracorporeal Femoro-Femoral Bypass for Acute Limb Ischemia From Large Bore Access

An 80-year-old man presented with acute inferior ST-segment elevation myocardial infarction and cardiogenic shock. Cardiac catheterization revealed 99% stenosis in the mid-right coronary artery, a 95% focal severe stenosis in mid-left anterior descending coronary artery and a 60% to 70% stenosis in

Acute inferior st segment elevation myocardial infarction due to chemotherapy in a young man with testicular cancer

SUMMARY Testicular cancer is the most common malignancy in men between 15 and 29 years of age. cisplatin, etoposide and bleomycin combination chemotherapy remains the mainstay of testicular cancer treatment. Acute myocardial infarction is a rare complication of these chemotherapeutics. In this case report, we present a case of 36-year-old male with acute inferior ST-segment elevation myocardial infarction after bleomycin injection. Because the patient had no significant risk factors for coronary artery disease, the infarction was likely caused by the chemotherapy regimen. Keywords: Testicular Cancer, Acute Myocardial Infarction, Cisplatin, Bleomycin, Etoposide

New ST-segment algorithms to determine culprit artery location in acute inferior myocardial infarction

ObjectivesIn acute inferior ST-segment elevation myocardial infarction (STEMI), multiple criteria have been proposed to predict the culprit artery based on the 12-lead electrocardiogram (ECG). We assessed the utilities of 11 traditional and 2 new criteria to devise a new ECG algorithm to localize the culprit artery in acute inferior STEMI. MethodsWe analyzed electrocardiographic and angiographic findings of 194 consecutive patients with acute inferior STEMI to devise a new ECG algorithm, further validated in another cohort of 80 patients with acute inferior STEMI. ResultsIn derivation cohort, the 2 new criteria including (1) ST-segment depression in lead I equal to half of that in lead aVL and (2) equal ST-segment elevation in leads II, III, and aVF did not prove useful. The most powerful electrocardiographic criteria were (1) the ratio of ST elevation in lead III to that in lead II, (2) the ratio of ST depression in lead I to that in lead aVL, and (3) ST changes in lead I; these formed a 3-step algorithm. Application of this algorithm suggested the location of the culprit artery in 192 of 194 patients (nearly 99%) in the derivation cohort. In validation cohort, the algorithm possessed a sensitivity and specificity of 100% and 89%, respectively, for predicting the right coronary artery and 89% and 100%, respectively, for predicting the left circumflex artery. ConclusionsA new 3-step algorithm based on 12-lead ECG is proposed to localize the culprit artery at the bedside of acute inferior STEMI patients before primary percutaneous coronary intervention, allowing immediate decisions about therapy.

Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction.

Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.

Impact of intracoronary eptifibatide on the right ventricular function in patients with acute inferior myocardial infarction

Background and aim Distal embolization during primary percutaneous coronary intervention of the proximal right coronary artery (RCA) leads to impairment of flow of right ventricular (RV) branches and RV dysfunction. Glycoprotein IIb/IIIa receptor antagonists improve microcirculation and decrease the incidence of distal embolization. In the present study we aimed to assess RV function in patients with acute inferior ST-segment elevation myocardial infarction who received intracoronary (i.c.) bolus eptifibatide, and to compare them with patients who received a standard intravenous (i.v.) dose. Patients and methods Sixty-six patients with acute inferior myocardial infarction who underwent primary percutaneous coronary intervention and whose culprit lesion was RCA proximal to major RV branch were included in the present study. Patients were divided into two groups. In the first group, 36 patients received double bolus intracoronary eptifibatide followed by i.v. infusion. In the second group, 30 patients received standard i.v. dose. Forty-eight hours after the index procedure, all the patients underwent standard echocardiography assessment of RV function using conventional two-dimensional and tissue Doppler imaging. Results There were no significant differences regarding baseline characteristics, final Thrombolysis In Myocardial Infarction (TIMI) flow, and left ventricular systolic function between the two groups. RV function indices, including tricuspid annular plane systolic excursion, myocardial performance index-tissue Doppler imaging, and RV fractional area change, were significantly better in patients who received i.c. bolus eptifibatide (P Conclusion I.c. double bolus eptifibatide followed by i.v. infusion was found to be superior to the standard i.v. dose with respect to RV function in patients with acute inferior ST-segment elevation myocardial infarction due to proximal RCA occlusion.

Free-Wall Rupture Post–Reperfused Acute Myocardial Infarction

A 37-year-old man presented with acute inferior ST-segment–elevation myocardial infarction (MI). His only risk factor for coronary artery disease was smoking. He underwent urgent x-ray coronary angiography, which showed a chronically occluded left anterior descending artery and recannulized right coronary artery. A bedside echocardiogram was performed to assess left ventricular function and any postinfarct complications. It demonstrated severely impaired left ventricular systolic function and an aneurysmal apex with a mobile intracavity mass (Figure 1A and 1B, online-only Data Supplement Movies I and II). Further views demonstrated hemopericardium suggesting concealed free-wall rupture (Figure 1B, purple arrow). An intramyocardial tear at the level of the midinferior wall (Figure 1B, red arrow) was suspected. Figure 1. A and B , Echocardiogram demonstrating a hemopericardium located posteriorly to the inferior wall (purple arrow) and intramyocardial dissection …