Anterior ST-segment Depression Research Articles

Spontaneous thrombosis in an ectatic right coronary artery

A 73-year-old man presented to our cardiology service with intense central chest pain as an ST-segment elevation myocardial infarction (STEMI) call. His ECG showed inferior ST-segment elevation with reciprocal anterior...

Comparison of Electrocardiographic Characteristics in Men Versus Women ≤ 55 Years With Acute Myocardial Infarction (a Variation in Recovery: Role of Gender on Outcomes of Young Acute Myocardial Infarction Patients Substudy)

Young women with acute myocardial infarction (AMI) have a worse prognosis than their male counterparts. We searched for differences in the electrocardiographic presentation of men and women in a large, contemporary registry of young adults with AMI that could help explain gender differences in outcomes. The qualifying electrocardiogram was blindly assessed by a central core lab in 3,354 patients (67% women) aged 18 to 55 years included in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study. Compared with men, women did not have a different frequency of sinus rhythm, and they had shorter PR and QRS intervals and longer QTc intervals. Intraventricular conduction disturbances were not different among genders. Notably, women were more likely than men to have abnormal Q waves in anterior leads and a lower frequency of Q waves in other territories. ST-segment elevation myocardial infarction (STEMI) diagnosis was less frequent in women than in men (44.6% vs 55.1%, p < 0.001). Among patients with STEMI, women had less magnitude and extent of ST-segment elevation than men. In patients with non-STEMI, the frequency, magnitude, and extent of ST-segment depression were not different among genders, but women had anterior ST-segment depression less frequently and anterior negative T waves more frequently compared with men. These differences remained statistically significant after adjusting for baseline characteristics. In conclusion, there are significant gender differences in the electrocardiographic presentation of AMI among young patients. Further studies are warranted to evaluate their impact on gender-related differences in the management and outcomes of AMI.

Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior ST-segment depression

Objectives To evaluate both angiographic and clinical outcomes in patients with acute coronary syndrome (ACS) presenting with isolated anterior ST-segment depression on 12-lead ECG. Background ACS is an umbrella term used to cover a spectrum of events caused by acute myocardial ischemia. Patients and methods The study included 50 consecutive patients with ACS. All patients had isolated ST depression in the anterior leads on admission ECG. Coronary angiography and assessment of cardiac biomarkers were performed at baseline. According to TIMI flow grade in the culprit artery and the result of cardiac markers, patients were subdivided into three groups: group I: TIMI flow grade 0/1 and positive markers, group II: thrombolysis in myocardial infarction (TIMI) flow grade 2/3 and positive markers, and group III: TIMI flow grade 2/3 and negative markers. In-hospital and 30-day outcome were reported. Results On the basis of coronary angiography findings and results of cardiac markers, 12 patients (24%) had totally occluded culprit artery plus positive markers (group I) and 10 patients (20%) had TIMI flow II/III plus subtotal occlusion in the culprit artery and positive markers (group II), whereas 28 patients (56%) patients had TIMI flow II/III and negative markers (group III). In-hospital and 30-day outcomes did not differ between groups. Conclusion Among patients with ACS presenting with isolated anterior ST-segment depression, about one-quarter had an occluded culprit artery and elevated cardiac markers.

The changes of inflammatory cytokines and their clinical significance in patients of inferior ST-segment elevation acute myocardial infarction with anterior ST-segment depression

To investigate the level of Hs-CRP, Fib,IL-6, TNF-α,MDA, SOD, and analyse the correlation between the level of plasma inflammatory cytokines and clinical significance in patients with anterior ST-segment depression. We choose 360 patients with inferior ST Segment elevation acute myocardial infarction from May 2007 to Sep 2012 in rescue Center of Anzhen Hospital, in Anzhen Hospital, and all the patients received percutaneous coronary intervention treatment and the vascular lesions besides culprit vessel were observed. All the patients were divided into two groups: control group (n = 180) and anterior ST-segment depression group (n = 180). 8ml venous blood was obtained from all the patients, and then plasma were separated. The level of plasma Hs-CRP, Fib, IL-6, TNF-α, MDA, SOD were investigated by Biochemistry and ELISA. And the relativity between the level of plasma inflammatory cytokines and anterior ST-segment depression in patients with inferior acute myocardial infarction was analysed. The proportion of double vessel coronary disease, three coronary artery lesion is higher in anterior ST-segment depression group compared with control group (P < 0.01) . Compared with control group, the level of Hs-CRP, Fib, IL-6, TNF-α,MDA, SOD of anterior ST-segment depression group are inclined significantly (P < 0.01). The level of plasma inflammatory cytokines and the degree of lipid peroxidation can reflect the severity of coronary artery disease and may have certain value in predicting the severity of disease.

Predictors of complicated athero-thrombotic lesions in non-ST segment acute coronary syndrome

Non-ST segment elevation acute coronary syndrome (NSTE-ACS) is a heterogeneous syndrome in terms of patho-physiological mechanisms and prognosis. We sought to investigate the clinical features associated with complicated athero-thrombotic (CAT) coronary lesions and their prognostic relevance in NSTE-ACS. We enrolled 701 consecutive NSTE-ACS patients without previous coronary bypass undergoing coronary angiography. The study population was divided into two groups according to the presence/absence of angiographic signs of endoluminal thrombi and/or plaque rupture, defined as CAT lesions. Multivariable analyses were used to identify predictors of CAT lesions. Their relation to composite endpoint of death, re-myocardial infarction, and re-unstable angina was investigated with the use of multivariable logistic regression. Patients with CAT lesions (n = 279, 40%) had a higher incidence of the combined endpoint (11.5 vs. 4.3%; P < 0.001). On multivariable analysis male sex [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.17-2.30, P = 0.004], previous percutaneous coronary intervention (PCI) (OR 0.48, 95% CI 0.32-0.72, P < 0.001), severe angina (OR 1.72, 95% CI 1.18-2.52, P = 0.005) and anterior (i.e. V1-V4) ST segment depression (STD) were independently associated with CAT lesions (OR 1.71, 95% CI 1.14-2.57, P = 0.01). After adjustment for the Global Registry of Acute Coronary Events (GRACE) score only the presence of anterior STD emerged as an independent predictor of the clinical endpoint (OR 2.68, 95% CI 1.38-5.20, P = 0.003). The incorporation of anterior STD into the GRACE risk score showed an important trend toward improving prediction of endpoint as assessed by c-statistic (0.72 vs. 0.67; P = 0.08). In patients with NSTE-ACS male sex, severe angina and anterior STD were associated with an increased risk of CAT lesions. Patients with anterior STD were also at increased risk of in-hospital clinical events.

Angiographic and Clinical Outcomes Among Patients With Acute Coronary Syndromes Presenting With Isolated Anterior ST-Segment Depression: A TRITON–TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis In Myocardial Infarction 38) Substudy

This study sought to determine angiographic and clinical outcomes among patients with acute coronary syndrome (ACS) presenting with isolated anterior ST-segment depression on 12-lead electrocardiogram (ECG). In patients with ACS, anterior ST-segment depression on 12-lead ECG may represent plaque rupture with: 1) acute thrombotic occlusion with elevation of cardiac biomarkers (+Tn); 2) a patent artery with +Tn; or 3) a patent artery with -Tn. The TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis In Myocardial Infarction 38) enrolled 13,608 ACS patients. Those with isolated anterior (leads V(1) to V(4)) ST-segment depression were analyzed. Angiograms and ECGs were interpreted by local investigators. There were 1,198 (8.8%) patients with isolated anterior ST-segment depression. Of those, 314 (26.2%) had an occluded culprit artery (TIMI flow grade 0/1) and +Tn, 641 (53.5%) had a patent culprit artery (TIMI flow grade 2/3) and +Tn, and 243 (20.3%) had TIMI flow grade 2/3 and -Tn. Among patients with an occluded artery, the culprit artery was most often the left circumflex artery (48.4%). The 30-day incidence of the composite of death and MI was significantly higher among patients with an occluded artery (8.6%) than among those with a patent culprit artery and either +Tn (6.3%) or -Tn (2.9%) (3-way p = 0.006). Among patients with an occluded artery, the median time from ECG to percutaneous coronary intervention was 29.4 h (interquartile range 26.1 to 44.1 h). Among ACS patients presenting with isolated anterior ST-segment depression, over one-quarter had an occluded culprit artery and elevated cardiac biomarkers. These patients had significantly worse clinical outcomes, and few underwent urgent angiography.

True posterior myocardial infarction: the importance of leads V7–V9

An ambulance crew attended a patient complaining of chest pain with a clinical picture strongly suggestive of acute myocardial infarction (AMI). A 12-lead electrocardiogram (ECG) was obtained, which demonstrated ST...

Thoracic Cavity Irrigation: An Unusual Cause of Acute ST Segment Increase

Thoracic Cavity Irrigation: An Unusual Cause of Acute ST Segment Increase

The Diagnosis

The Diagnosis

Relationship between exercise-induced ST segmental depression and myocardial ischemia assessed by technetium-99m tetrofosmin SPECT imaging in patients with inferior Q wave myocardial infarction.

ST segment depression (STD) is a standard electrocardiographic sign of myocardial ischemia. Although STD may represent reciprocal changes in patients with previous myocardial infarction, studies of reciprocal changes during exercise testing are scarce. From December 1999 to December 2000, 160 patients (119 males, 41 females, mean age 54 +/- 8 years), undergoing, maximal or symptom-limited exercise treadmill test (Bruce-protocol), myocardial perfusion scintigraphy using technetium-99m tetrofosmin single photon emission computed tomography (SPECT) imaging, within 30 days of an uncomplicated inferior Q wave myocardial infarction. The location of STD at the electrocardiogram (ECG) was defined as anterior (V1-4), high lateral (I, aVL), and lateral (V5-6). Ischemia was defined as reversible perfusion abnormalities. STD occurred in anterior leads in 29 patients (18.1%), in the lateral leads in 41 patients (25.6%), in the high lateral leads in 20 patients (12.5%). In 70 patients (43.8%) no significant STD occurred during the exercise test. ST segment elevation occurred in 28 patients (17.5%) in inferior leads. High lateral STD was associated with inferior ST elevation in 16 patients (80%), whereas only eight patients (19.5%) with lateral STD and nine patients (31%) with anterior STD were associated with inferior ST elevation. Ischemia was detected in 63 of 90 patients (70%) with and in 10 of 70 patients (14.3%) without STD (p < 0.0001). Patients with high lateral STD had a higher prevalence of fixed perfusion defects in the inferior wall (95 vs. 27.8%) and in posterolateral wall (75 vs. 18.9%) compared with other patients (p = 0.003 and 0.002, respectively). Ischemia was more prevalent in patients with lateral STD than without (87.8 vs. 14.3%, p < 0.0001). In patients with inferior Q wave, the presence of exercise-induced STD in lateral and anterior leads appears to be a sign of myocardial ischemia, and may require invasive evaluation; on the other hand, the presence of STD in high lateral leads should be recognized as a reciprocal change for ST elevation in the inferior leads, and may not be an indication for invasive evaluation.

New electrocardiographic criteria for posterior wall acute myocardial ischemia validated by a percutaneous transluminal coronary angioplasty model of acute myocardial infarction

The standard 12-lead electrocardiogram (ECG) fails to detect ST-segment elevation in patients with posterior wall acute myocardial ischemia. However, additional posterior leads V 7-9 provide limited additional diagnostic information to the standard 12-lead ECG when an ischemic criterion of 1-mm ST elevation is used. No study is available to delineate the ischemic criteria in the posterior electrocardiographic leads. Continuous 15-lead ECGs (standard 12 lead + V 7-9) were recorded in 53 subjects undergoing elective left circumflex coronary angioplasty (posterior ischemia model). ST amplitudes (J + 60 ms) at preangioplasty baseline were subtracted from maximal ST amplitudes during balloon occlusion to create a positive or negative change score (ΔST) for each of the 15 leads. During 53 left circumflex occlusions, 26 subjects (49%) had ΔST elevation of ≥1 mm and 24 subjects (45%) had ΔST elevation ranging from 0.5 to 0.95 mm in ≥1 posterior leads. Five subjects (9%) had ΔST elevation of ≥1 mm in the posterior leads without ΔST elevation anywhere in any of the 12 leads. The sensitivity in detecting myocardial ischemia using 15-lead ECGs (58%) was not statistically different from the standard 12-lead ECG (49%) (p = 0.06). Adjusting the ischemic criterion from 1 to 0.5 mm in V 7-9 significantly improved the sensitivity from 49% in the 12-lead ECG to 94% in the 15-lead ECG (p = 0.000). In addition, 12 subjects (23%) had posterior ST-segment elevation without anterior ST-segment depression. Thus, posterior leads V 7-9 contribute significant additional diagnostic information above and beyond the standard 12-lead ECG only when a new ischemic criterion of 0.5 mm instead of 1 mm ST elevation is applied to the posterior leads.

The significance of stress-induced ST segment depression in patients with inferior Q wave myocardial infarction

OBJECTIVESThis study was conducted to evaluate the relationship between ST segment depression (STD) during dobutamine stress tests in different electrocardiogram (ECG) leads and myocardial ischemia assessed by simultaneous single photon emission computed tomography (SPECT) imaging in patients with inferior Q wave myocardial infarction.BACKGROUNDSTD is a standard electrocardiographic sign of myocardial ischemia. Although STD may represent reciprocal changes in patients with previous myocardial infarction, studies of reciprocal changes during stress tests are scarce.METHODSDobutamine (up to 40 μg/kg/min) stress and rest myocardial perfusion scintigraphy using technetium SPECT imaging was performed in 125 patients >3 months after Q wave inferior myocardial infarction. The location of STD at the ECG was defined as anterior (V1–4), high lateral (I, aVL) and lateral (V5,6). Ischemia was defined as reversible perfusion abnormalities.RESULTSSTD occurred in the high lateral leads in 20 patients, in the anterior leads in 12 patients and in the lateral leads in 2 patients. ST segment elevation occurred in 25 patients in the inferior leads. High lateral STD was associated with inferior ST elevation in 16 patients (80%). There was a significant inverse linear correlation between the magnitude of ST segment shift from rest to peak stress in the inferior and the high lateral leads (r = −0.8, p < 0.0005), whereas no significant correlation was found between ST segment shift in the inferior and the anterior leads (r = −0.1, p = NS) or between the inferior and the lateral leads (r = 0.15, p = NS). Ischemia was detected in 45% of patients with and in 42% of patients without high lateral STD (p = NS). Patients with high lateral STD had a higher prevalence of fixed perfusion defects in the inferior wall (100% vs. 70%) and in the posterolateral wall (55% vs. 29%) compared with other patients (both p < 0.05). Ischemia was more prevalent in patients with anterior STD than without (75% vs. 39%, p < 0.05).CONCLUSIONSIn patients with inferior Q wave myocardial infarction, stress-induced STD in high lateral leads should be recognized as a reciprocal change for ST elevation in the inferior leads, and therefore, should be interpreted with the consideration of the significance of ST elevation if present, rather than being indicative of myocardial ischemia on its own. The STD found in the anterior leads appears to be a sign of myocardial ischemia. These findings should be considered in the definition of a positive ECG stress test and in establishing the criteria for the termination of stress test.

Primary angioplasty versus thrombolysis in inferior acute myocardial infarction with anterior ST-segment depression, a single-center randomized study

Primary angioplasty versus thrombolysis in inferior acute myocardial infarction with anterior ST-segment depression, a single-center randomized study

790-4 The Prognostic Importance of Anterior ST-Segment Depression in Inferior Myocardial Infarctions: Results in 16,185 Patients

The prognostic significance of anterior ST-segment depression (ST DEP) in patients with an acute inferior MI remains controversial, in part because of limited sample size in previous studies. Using data from the GUSTO trial, we investigated the clinical outcomes of 16,185 patients with inferior MI. 12,019(74.3%) of these patients had at least 0.1 mV ST DEP in leads Vl–V3 on initial EKG as determined by Core Lab review. Patients with anterior ST DEP were older and more likely to be female or have a history of smoking. Patients with anterior ST DEP also had significantly higher peak CPK levels Imean 2,520 vs. 1,216 ng/dL, p &lt; 0.01). Of the 7,455 (46%) patients with an inferior MI who received cardiac catheterization, those with anterior ST DEP had similar rates of LAD disease (24.8% vs 24.9%, p &gt; 0.5), and multivessel disease (31.1% vs. 29.4%, P &gt; 0.25), but a significantly lower mean LVejection fraction (53.8% vs. 56.4%, p &lt; 0.01) compared with those without ST DEP. In-hospital complications and 3D-day mortality results as a function of the sum of anterior ST DEP are displayed below: Sum of Anterior % %2°–3° % %30-day ST DEP (mV) Killip ≥ 3 * AV Block * Reinfarction Mortality * None (n = 4,166) 3.9 9.6 3.4 3.2 0.1-0.2 (n = 4,449) 5.3 11.2 4.4 3.6 03-0.4 (n = 3,328) 5.6 11.9 4.3 4.4 ≥ 0.5 In = 4,244) 9.2 14.5 4.6 6.6 * p &lt; 0.001 comparing inferior MI patients with and without anterior STDEP Among inferior MI patients, the presence of anterior STsegment depression predicted larger infarctions and predicted worse postMI LV function. Although the overall rates of complications and mortality were low in inferior AMI patients, these risks increased substantially with increasing anterior ST depression. Thus, the magnitude of anterior ST de-pression may be applied to stratify risk in inferior MI patients.

Dipyridamole echocardiography evaluation of acute inferior myocardial infarction with concomitant anterior ST segment depression.

The significance of anterior ST segment depression in inferior acute myocardial infarction (AMI) remains controversial. The aim of this study was to relate precordial ST segment depression to the topography of residual myocardial ischaemia, with myocardial mapping of the asynergic area and coronary anatomy. Twenty-five patients with first inferior AMI (15 patients with anterior ST segment depression: group A and 10 patients without anterior ST segment shift: group B), all underwent: (1) electrocardiographic evaluation on admission to the Coronary Care Unit and at 24 h intervals thereafter; (2) 2D-echocardiographic study within 3 h of CCU admission; (3) dipyridamole echocardiographic test (DET) (doses of dipyridamole up to 0.84 mg.kg-1 i.v. over 10 min) 4 days after AMI; (4) coronary arteriography within 14 days from AMI. To assess regional left ventricular wall motion, a 16 segment model was used and a wall motion score index (WMSI) was derived. The results of DET were correlated to the anatomy of the infarct-related vessel. Compared to group B, group A patients showed a significantly greater maximal ST segment elevation in inferior limb leads (lead III: 3.9 +/- 1.9 mm vs 2.2 +/- 1.1 mm, P < 0.05; aVF: 3.5 +/- 1.3 mm vs 1.7 +/- 0.8 mm, P < 0.001). Group A patients showed greater WMSI (1.35 +/- 0.22 vs 1.17 +/- 0.12, P < 0.05), with more frequent postero-lateral wall involvement (72% vs 20%, P < 0.05). No patient of either group showed asynergy of the anterior, anterolateral or anteroseptal segments. No differences in the distribution of coronary artery disease were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

The cause of anterior ST segment depression during complete obstruction of right coronary artery

The cause of anterior ST segment depression during complete obstruction of right coronary artery

Timing of stress testing in an asymptomatic survivor of inferior myocardial infarction.

Exercise electrocardiography with or without thallium-201 scintigraphy was performed (pre-hospital discharge) in 66 asymptomatic survivors of a first inferior myocardial infarction (IMI). Although coronary angiography revealed an 82% incidence of multivessel coronary artery disease (MV-CAD) in the total cohort, the sensitivity of exercise ECG for MV-CAD in the group with absent anterior ST-depression in the acute phase was low (11%). In contrast the presence of acute phase anterior ST-segment depression improved the yield for MV-CAD to 55%. Forty-six patients agreed to a symptom-limited exercise ECG plus/minus thallium imaging at 8-10 weeks post IMI. The sensitivity of detecting MV-CAD improved by 15% in patients with no acute phase anterior ST-segment depression and 16% in patients with acute phase anterior ST-segment depression. At each exercise protocol, thallium improved the sensitivity of exercise in detecting ischemia in the noninfarct zone. It is concluded that following IMI, a high percentage of asymptomatic patients whose acute phase ECG showed anterior ST-segment depression will have MV-CAD detected by heart-rate limited and, more so, by symptom-limited exercise ECG. The detection rate will double in patients with no anterior ST-segment depression if exercise testing is delayed until 8-10 weeks post IMI.

Natural history of ST-segment potential distribution determined by body surface mapping in patients with acute inferior infarction

The authors studied the natural history of the electrocardiographic ST-segment using body surface mapping in 123 patients with acute inferior infarction who were not treated with thrombolytic agents. In 91 patients they compared body surface ST-segment maps recorded at 7.9 ± 5.4 hours after the onset of acute myocardial infarction with maps recorded at 32.6 ± 21.6 hours after infarction. In 46% of the patients the ST-segment distribution map pattern was unchanged. Twenty-eight percent of the patients moved to a ST-segment distribution associated with low mortality, and 7% correlated with a normal ST-segment distribution. Patients who started in a group dominated by marked anterior ST-segment depression or who developed this pattern at the time of the late map had a 45% morbidity, compared to 13% for patients who never developed this pattern (p < 0.005). In a second group of 61 patients they compared maps recorded at 15.0 ± 15.8 hours after infarction and repeat maps 19.6 ± 13.0 recorded months later. At follow-up mapping, 44% of the patients correlated with a normal ST-segment distribution, 38% of patients had a lowrisk pattern map and in 7% the map pattern was dominated by anterior ST-segment potential depression. The latter patients had a higher morbidity than patients in the other groups, but this did not reach statistical significance. Four of seven patients in this last group had significant angina at the time of followup mapping, compared to 2 of 54 patients in the other two groups (p < 0.001).

Occurrence of anterior ST depression in inferior myocardial infarction and relation to clinical outcome.

In 229 patients admitted to the coronary care unit (CCU) at Sahlgren's Hospital developing inferior myocardial infarction, and with no previous myocardial infarction, the clinical outcome was related to the presence of ST-segment depression in 16 anterior chest leads. In all, 64% had anterior ST-segment depression. These patients differed from those not having ST depression in several aspects. They had larger infarcts, as assessed by serum enzyme activity and ECG recording. They were more prone to congestive heart failure and required more treatment for this complication. Their intensity and duration of pain during the first 4 days appeared to be more substantial. During a 5-year follow-up, patients with anterior ST depression tended to have a higher mortality. We conclude that among patients with inferior myocardial infarction and no previous infarction, those with anterior ST-segment depression form a subgroup with a more severe clinical course.

Anterior ST-Segment Depression Associated with Acute Inferior Myocardial Infarction: Clinical, Hemodynamic, and Angiographic Correlates

Clinical, hemodynamic, and angiographic data were analyzed in relation to the presence or absence of anterior (I, aVL, and V(1(1–6)) electrocardiographic ST-segment depression in 21 patients with acute inferior myocardial infarction. All data were obtained within 12 h of onset of chest pain. Greater than 1 mm anterior ST-segment depression was frequent (19 of 21 patients) during the early phase of acute infarction. There was a significant correlation between the single electrocardiographic lead with the greatest inferior ST-segment elevation and the single anterior lead with the greatest ST-segment depression (r = 0.87, p < 0.001), and between the sum of STsegment elevation in the inferior leads and the sum of ST-segment depression in the anterior leads (r = 0.77, p < 0.001). The patients with >2 mm anterior ST-segment depression had a higher left ventricular end-diastolic pressure than those with ≤2 mm ST-segment depression (18.4 vs. 10.8 mm Hg, p < 0.01) only when leads I and aVL were included, but there were no clinical, angiographic,or other hemodynamic differences between the groups. These findings do not correlate anterior ST-segment depression associated with inferior myocardial infarction with a higher cardiovascular risk with regard to the variables examined.