Degree Of ST-segment Elevation Research Articles

ASSESSMENT OF THE ST-ELEVATION IN RIGHT BUNDLE BRANCH BLOCK PATIENTS COMPARED TO CORONARY ARTERY ANGIOGRAPHY

Background: Evaluation of patients with myocardial infarction in the setting of bundle branch block on electrocardiogram is a new approach in clinical practice. Subjects and research methods: Cross-sectional descriptive study with comparison with a control group. 67 patients with myocardial infarction (28 patients with bundle branch block and 39 patients without bundle branch block) were evaluated clinically, paraclinical, and with coronary angiography. Results: There were no statistically significant differences between the two study groups in terms of age and gender (p>0.05). The rate of patients with heart failure Killip II and above was 42.9%, much higher than the group of patients without bundle branch block (p=0.026). Complications of acute heart failure/cardiogenic shock during hospital stay were 48.4% in the group with bundle branch block, statistically significantly higher than in the group without bundle branch block (p = 0.024). The mean enddiastolic left ventricular diameter was 53.57 ± 6.268 (p<0.01). The median Syntax score was 20.25, higher than that of the myocardial infarction group without bundle branch block (p=0.021). The ST elevation on the electrocardiogram was lower in the right bundle branch block group than in the no right bundle branch block group (p=0.021). The degree of ST segment elevation was positively correlated with Syntax I score (p < 0.01), syntax II (p < 0.05), the degree of coronary artery stenosis (p < 0.05). Conclusion: Myocardial infarction with right bundle branch block had more severe clinical and laboratory signs than myocardial infarction without bundle branch block. Key words: ST elevation, right bundle branch block, coronary artery angiography

Platelet Count Applicability in Predicting the Degree of ST-Segment Depression and Coronary Flow Rate in Acute Myocardial Infarction Patients

Introduction: It is still unclear whether platelet count can predict the outcomes of acute myocardial infarction. In this study, we assessed the relationship between the initial platelet count on the degree of ST-segment depression and coronary flow rate among patients with MI who underwent percutaneous coronary intervention (PCI). Methods: In this study, a total of 218 patients suffering from MI, who underwent primary PCI during 2016-2017 (Seyed-Shohada hospital, Urmia, Iran) were selected by consensus method. Demographic information and past medical history such as diabetes mellitus (DM), cigarette smoking, using Integrilin, and door-to-balloon (DTB) time were recorded. All patients were investigated in terms of cell blood count. Serial electrocardiogram (ECG) was also performed and the degree of ST-segment elevation was measured. Results: The mean (SD) age of participants was 58.67 (11.44) years. The initial platelet count was similar between patients with and without improvement in the ST-segment (P = 0.275). There was no significant difference regarding thrombolysis in myocardial infarction (TIMI) between patients with and without improved ST-segment (P = 0.380). Conclusion: According to our results, the initial platelet count in patients who underwent angioplasty was not associated with coronary flow and echocardiographic responses to treatment.

Degree of ST-segment elevation in patients with STEMI reflects the acute ischemic burden and the salvage potential

BackgroundST-segment elevation myocardial infarction (STEMI) is clinically diagnosed by significant ST-segment elevation (STE) in the electrocardiogram (ECG). The importance of the sum of significant ST-segment elevation (∑STE) before primary percutaneous coronary intervention (PPCI) – considered an indicator of the degree of ischemia - is sparse. We evaluated the association of ∑STE before PPCI with respect to area at risk, infarct size and myocardial salvage. MethodsA total of 503 patients with STEMI and available cardiac magnetic resonance (CMR) were included. CMR was performed at day 1 (interquartile range [IQR], 1–1) and at follow-up at day 92 (IQR, 88–96). The ECG before PPCI with the most prominent STE was used for analysis. Results∑STE divided into quartiles were progressive linearly associated with area at risk (p < 0.001), final infarct size (p < 0.001) and extent of microvascular obstruction (p < 0.001) and inverse linearly associated with final myocardial salvage (p < 0.001). Similar results were found for linear regression analyses. However, ∑STE was not associated with final myocardial salvage in patients with pre-PCI TIMI (thrombolysis in myocardial infarction) flow 0/1 (p = 0.24) in contrast to patients with pre-PCI TIMI flow 2/3 (p ≤ 0.001). ConclusionIn patients with STEMI presenting within 12 h of symptom onset, the degree of STE in the ECG before PPCI is a marker of the extent of myocardium at risk that in turn affects the infarct size in patients with pre-PCI TIMI flow 0/1, whereas the degree of STE in patients with pre-PCI TIMI flow 2/3 is a marker of the extent of the myocardium at risk as well as myocardial salvage – both affecting the myocardial damage.

Value of ST-segment change in lead aVR in diagnosing left main disease in Non-ST-elevation acute coronary syndrome-A meta-analysis.

Previous researches proved that the ST-segment elevation (STE) in lead aVR had great significance on the prediction of severe left main lesion or serious multivessel lesions. The current research is to summarize the published data and evaluate the overall association of STE in lead aVR and left main coronary artery disease (LMD) in Non-ST-elevation acute coronary syndrome. Literature searching was performed in the online database, and a systematic review was conducted based on the searched results. Meaningful STE in lead aVR was summarized and analyzed for odds ratio (OR) and 95% confidence intervals (95% CI). Twenty-seven articles were included for final data analysis. Compared with STE<0.05, STE≥0.05mV was associated with a higher incidence rate of LMD (OR=6.64, 95% CI: 4.80~9.17), and the degree of STE in lead aVR was significantly associated with LMD. Myocardial infarction was more likely to occur in patients with STE≥0.05mV than in patients with STE<0.05mV (OR=3.12, 95% CI: 1.73~5.62). The STE in lead aVR and the degree of STE are independent predictors in diagnosing LMD or myocardial infarction.

Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest

AimThere is no simple clinical tool that reliably indicates the presence of acute coronary lesions in out-of-hospital cardiac arrest (OHCA) patients without typical ST-segment elevations. ST-segment elevation in electrocardiographic lead aVR suggests global subendocardial ischemia. This study aimed to evaluate the diagnostic value of lead aVR for identifying acute coronary lesions following resuscitation from OHCA. MethodsA total of 74 patients without evidence of ST-segment elevations, who were resuscitated from OHCA, were examined. The degree of ST-segment elevation in lead aVR was measured directly after return of spontaneous circulation (ROSC) and at early follow-up. Coronary angiograms were retrospectively reviewed. ResultsAcute coronary lesions were detected in 20 patients (27%). No difference in ST-segment elevation in lead aVR directly after ROSC was observed between patients with or without acute coronary lesions. However, ST-segment elevation values significantly decreased at early follow-up (median, 137 min) in patients without acute coronary lesions. An ST-segment elevation ≥0.5 mm in lead aVR at early follow-up was associated with a higher prevalence of multivessel coronary artery disease and was an independent indicator of the presence of acute coronary lesions (odds ratio, 4.41; 95% confidence interval, 1.12–17.4; p = 0.034). ConclusionST-segment elevation in lead aVR at early follow-up was associated with the presence of acute lesions accompanied by severe coronary artery disease in post-cardiac arrest patients without other ST-segment elevations. The analysis of ST-segment elevation in lead aVR may aid in the identification of patients who will benefit from further invasive coronary diagnostic procedures.

The Interaction Between Pericardial Fat Volume and Myocardial Strain in ST-Elevation Myocardial Infarction Patients

Background: Global longitudinal strain (GLS) reflects left ventricular (LV) contractility. GLS is more sensitive than LV ejection fraction as a marker of LV dysfunction and has better prognostic value for future adverse cardiovascular events. Larger pericardial fat volumes (PFV) tend to be associated with larger infarct scar volumes and predict the presence of microvascular obstruction. Our study aimed to assess the relationship between PFV and GLS. Methods: 140 STEMI patients underwent paired cardiac magnetic resonance imaging (CMR) and transthoracic echocardiography (TTE) studies at a median of 4 days (early) and 55 days (late). PFV was quantified on CMR by tracing pericardial fat on consecutive end-diastolic short axis cine images and indexed to body surface area. GLS was determined by 2D speckled tracking strain using offline software from TTE. A change in GLS >10% from baseline was considered clinically significant. Results: With increasing PFV, there was a statistically significant absolute decrease in early and late GLS (r = 280, p < 0.001; r = 256, p = 0.002 respectively), independent of sex, age, diabetes, hypertension, affected coronary arteries and the degree of ST segment elevation. Early PFV did not predict change in GLS from early to late. Conclusion: The magnitude of GLS is inversely related to early and late PFV after STEMI. Early PFV does not appear to predict which patients positively remodel, as pericardial fat may be protective for LV function at follow-up after STEMI. Further studies are required to evaluate whether PFV may have a protective effect on LV remodelling post myocardial infarction.

Correlation of ECG Changes with Coronary Angiographic Findings in Acute Inferior Myocardial Infarction

The determination of infarct related artery in acute inferior myocardial infarction is extremely important for the prediction the amount of myocardium at risk and guide decisions regarding urgency of revascularization. Urgent decision may facilitate management and prevention of complication. Our objective was to Identification of the infarct related artery involving either right coronary artery (RCA) or left circumflex artery (LCX) in acute inferior wall myocardial infarction using electrocardiographic criteria and comparing with angiographic finding. This prospective, observational study was done in Chittagong Medical College Hospital from June 2013 to May 2014. A total of 112 Patients with acute inferior myocardial infarction were included in this study. The electrocardiogram of these patients evaluated for ST segment elevation in lead III exceeding that in lead II (i.e. a ratio of ST elevation in lead III/elevation in lead II &gt; 1) and S/R wave ratio &gt; 0.33 plus ST segment depression &gt; 1 mm in lead aVL as a prediction for right coronary artery occlusion. If criteria are negative, LCX obstruction is likely. Coronary angiogram was done within 2-6 weeks in cath lab, department of cardiology, CMCH to identify the culprit artery. The infarct related artery (IRA) was identified from total occlusion or significant stenosis (&gt; 70%) of the RCA or LCX or their major branches, or from arteriographic evidence of intraluminal thrombosis. To minimize the chance of misclassifying the culprit artery, patients with significant stenosis of both the RCA and the LCX were excluded from the study. The study population consisted of 112 patients (94 male and 18 female) with a mean ± SD age of 51 ± 8.6 years. On coronary angiography, the culprit artery was shown to be the RCA in 92 patients and the LCX in 20 patients. It was evident that the degree of ST segment elevation in lead III was significantly higher in right coronary artery group (92 patients) vs left circumflex group (20 patients) 3.16±1.14mm vs 1.35±0.24mm (p&lt;0.001) respectively. While its comparable in lead II 2.18±0.95mm vs 1.7±0.34mm (p&gt;0.05). In respect to leads AVL, we found that deeper ST segment depression was in right coronary artery group as compared to left circumflex group 1.11±0.25mm vs 0.2 ±0.34mm (p&lt;0.001). ECG parameters for implicating the RCA were a higher ST elevation in lead III than lead II (specificity 98%, sensitivity 97%) and an S/R wave ratio &gt; 0.33 plus ST segment depression &gt; 1 mm in lead aVL (specificity 96%, sensitivity 95%). Absence of these criteria was associated with LCX occlusion (specificity 100%, sensitivity 85%). It is possible to predict the culprit artery whether right coronary artery or left circumflex by examining the surface electrocardiography in patients with acute inferior myocardial infarction.Medicine Today 2017 Vol.29(2): 33-37

Electrocardiographic characteristics associated with in-hospital outcome in patients with left main acute coronary syndrome: For contriving a new risk stratification score.

The aim of this study was to evaluate electrocardiographic characteristics associated with in-hospital prognosis in patients with left main acute coronary syndrome. A total of 89 left main acute coronary syndrome subjects were selected from 3357 consecutive acute coronary syndrome patients (2.7%). Patients of this study were divided into two groups; those who survived and those who died. Patients' characteristics and electrocardiogram on admission were then retrospectively analyzed between the two groups. In-hospital mortality was 28.1%. The prevalence and degree of ST-segment elevation at lead aVL were significantly higher in the deceased group than in the survival group ( p<0.001). However, those at lead aVR did not show significant differences between the two groups. Moreover, the width of the QRS-complex was significantly wider (lead V3; p<0.001), and the level of five minus the absolute value of five minus number of ST-segment elevation (5-|5-ST|; due to the highest in-hospital mortality (70%) in the five-lead ST-segment elevation group) was significantly larger in the deceased group than in the survival group ( p<0.001). The odds ratios that predicted in-hospital cardiac death were 1.03 for width of the QRS-complex at lead V3 (95% confidence interval (CI); 1.01-1.06; p=0.003), 1.74 for 5-|5-ST| (95% CI; 1.03-3.00; p=0.040), and 1.44 for ST-segment elevation at lead aVL (95% CI; 0.93-2.23; p=0.100). ST-segment elevation at lead aVL rather than aVR, width of the QRS-complex at lead V3 and number of ST-segment elevation were the prognostic predictors for in-hospital mortality in patients with left main acute coronary syndrome. Electrocardiographic characteristics should be assessed in addition to the established risk score in patients with left main acute coronary syndrome.

Protective effect of Suxiao jiuxin pill, a traditional Chinese medicine, against acute myocardial ischemia in dogs.

BackgroundThe purpose of this study was to investigate the effect of Suxiao Jiuxin Pill (SX), a traditional Chinese medicine, on acute myocardial ischemia induced by coronary occlusion in anesthetized dogs.MethodsAcute myocardial ischemia model was established by ligating the left anterior descending artery to reduce flow by 90 %. Adult mongrel dogs were randomly divided into six groups: model, SX high dose, SX middle dose, SX low dose, Isosorbide dinitrate (ISD) and Sham groups. Adult mongrel dogs were anesthetized and instrumented for measurements of heart rate (HR), mean arterial pressure (MAP), left ventricular systolic pressure (LVSP), left ventricular dP/dt, coronary blood flow (CBF), myocardial blood flow (MBF), coronary vascular resistance (CVR), and epicardial electrocardiogram (EECG). After administration with SX, changes in hemodynamics were recorded. Serum enzymes and blood gas analysis were also detected.ResultsSX has a dose-dependent effect on the reduction of infarct size. Besides, SX exerted a notable inhibition on the elevation of serum creatine kinase MB (CK-MB), lactate dehydrogenase (LDH), malondialdehyde (MDA), and elevation in the superoxide dismutase (SOD) activity. SX also showed a capacity to recover myocardial function by significantly reducing MAP, CVR, LVSP, left ventricular systolic pressure (LVEDP), systolic blood pressure (SBP), diastolic blood pressure (SDP), and increasing CBF and myocardial blood flow (MBF). In addition, SX high dose group markedly reduced total mV of ST segment elevation (Σ-ST), total number of sites with this degree of ST segment elevation (N-ST) and oxygen extraction ratio (O2 Extr).ConclusionSX can improve hemodynamic and myocardial oxygen metabolism, reduce the degree and scope of myocardial ischemia, and hence exert notable anti-anginal ischaemic effect.

Abstract 9408: ST-Segment Elevation in Leads V5-6 Predicts In-Hospital Adverse Outcomes in Patients With Reperfused Inferior Acute Myocardial Infarction

Introduction: In inferior wall acute myocardial infarction (IWMI), ST-segment elevation in leads V5-6 (STE V5-6) is often observed, but its prognostic impact is unclear. Methods: We examined admission ECGs in 361 patients with a first IWMI who had TIMI 3 flow of the right coronary artery (RCA) or left circumflex artery (LCX) by reperfusion therapy within 6 hours after symptom onset. Patients were divided according to the presence (n=77) or absence (n=284) of STE V5-6 &gt;2 mm, and the former was subdivided into the 2 groups according to the degree of STE in leads III and V6: STE:III&gt;V6 (n=53) and STE:III≤V6 (n=24). The perfusion territory of the culprit artery was assessed by angiographic distribution score, and mega-artery was defined as a score ≥0.7. Results: Age, sex, time to admission, reperfusion therapy, or time to reperfusion was similar in the 3 groups. STE V5-6 was associated with mega-artery occlusion, larger infarction, and in-hospital adverse events (death, reinfarction, or heart failure). RCA occlusion was most common in STE V5-6 with STE:III&gt;V6, whereas LCX occlusion, especially proximal LCX occlusion, was most common in STE V5-6 with STE:III≤V6. In multivariate analysis, STE V5-6 with STE:III&gt;V6 (OR 2.90, 95%CI 1.10-7.02, p&lt;0.01) and that with STE:III≤V6 (OR 3.63, 95%CI 1.58-8.96, p&lt;0.01) were independent predictors of in-hospital adverse events. Conclusions: In reperfused IWMI, ST-segment elevation in leads V5-6 on admission ECG strongly predicts in-hospital adverse outcomes; furthermore, comparing the degree of ST-segment elevation in leads III and V6 is useful for predicting the culprit artery (i.e., RCA or LCX).

Prinzmetal angina: ECG changes and clinical considerations: a consensus paper.

We will focus our attention in this article in the ECG changes of classical Prinzmetal angina that occur during occlusive proximal coronary spasm usually in patients with normal or noncritical coronary stenosis. The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve. The most frequent ECG changes associated with ST-segment elevation are: (a) increased height of the R wave, (b) coincident S-wave diminution, (c) upsloping TQ in many cases, and (d) alternans of the elevated ST-segment and negative T wave deepness in 20% of cases. The presence of arrhythmias is very frequent during Prinzmetal angina crises, especially ventricular arrhythmias. The prevalence and importance of ventricular arrhythmias were related to: (a) duration of episodes, (b) degree of ST-segment elevation, (c) presence of ST-T wave alternans, and (d) the presence of >25% increase of the R wave. The incidence of Prinzmetal angina is much lower then 50 years ago for many reasons including treatment with calcium channel blocks to treat hypertension and ischemia heart disease and the decrease of smoking habits.

Cardioprotection of electroacupuncture against myocardial ischemia-reperfusion injury by modulation of cardiac norepinephrine release

Augmentation of cardiac sympathetic tone during myocardial ischemia has been shown to increase myocardial O(2) demand and infarct size as well as induce arrhythmias. We have previously demonstrated that electroacupuncture (EA) inhibits the visceral sympathoexcitatory cardiovascular reflex. The purpose of this study was to determine the effects of EA on left ventricular (LV) function, O(2) demand, infarct size, arrhythmogenesis, and in vivo cardiac norepinephrine (NE) release in a myocardial ischemia-reperfusion model. Anesthetized rabbits (n = 36) underwent 30 min of left anterior descending coronary artery occlusion followed by 90 min of reperfusion. We evaluated myocardial O(2) demand, infarct size, ventricular arrhythmias, and myocardial NE release using microdialysis under the following experimental conditions: 1) untreated, 2) EA at P5-6 acupoints, 3) sham acupuncture, 4) EA with pretreatment with naloxone (a nonselective opioid receptor antagonist), 5) EA with pretreatment with chelerythrine (a nonselective PKC inhibitor), and 6) EA with pretreatment with both naloxone and chelerythrine. Compared with the untreated and sham acupuncture groups, EA resulted in decreased O(2) demand, myocardial NE concentration, and infarct size. Furthermore, the degree of ST segment elevation and severity of LV dysfunction and ventricular arrhythmias were all significantly decreased (P < 0.05). The cardioprotective effects of EA were partially blocked by pretreatment with naloxone or chelerythrine alone and completely blocked by pretreatment with both naloxone and chelerythrine. These results suggest that the cardioprotective effects of EA against myocardial ischemia-reperfusion are mediated through inhibition of the cardiac sympathetic nervous system as well as opioid and PKC-dependent pathways.

Electrocardiography as a predictor of left main or three-vessel disease in patients with non-ST segment elevation acute coronary syndrome

Acute coronary syndrome remains the leading cause of morbidity and mortality worldwide. It will continue to rise as the prevalence of patients with obesity and diabetes increases. Patients with non-ST segment elevation acute coronary syndrome had a bad prognosis in patients with left main ± three vessel diseases, so early identification of these patients by electrocardiography if ST segment elevation in lead aVR ⩾0.5 m and maximal QRS duration of ⩾90 ms is important for the selection of optimal treatment. The study was designed as a multicenter cross-sectional study that was conducted on 150 patients presenting with non-ST segment elevation acute coronary syndromes, 80 patients had non-ST segment elevation myocardial infarction and 70 patients had unstable angina in the period between January 2009 till January 2010. All patients had full history, clinical examination, laboratory investigations including lipid profile, blood glucose, cardiac Troponin T and renal function, also electrocardiography and coronary angiography was done to prove the diagnosis. ECG was analyzed to assess the degree of ST segment elevation in aVR, ST segment depression in other leads and the maximal QRS was analyzed. Coronary angiography was done to all patients with detection of the presence of left main 50% stenosis at least with or without other three significant coronary vessels showing 70% stenosis or more to be included in 67 patients in group I. Group II include 83 patients with normal coronaries or significant stenosis in one or two vessels. Left main coronary stenosis with or without three significant coronary vessel stenosis occurs in 67 patients (44.7%) in group I vs. 83 patients (55.3%) in group II (i.e. without left main disease or three vessel disease). The mean age of the patients 59 ± 9 years which was not significant in both the groups ( P > 0.05). The following also were not significant gender, smoking, dyslipidemia, renal impairment, hypertension and positive family history. Diabetes was considered significant in 44 patients (65.7%) in group I in comparison to 34 patients (41%) in group II ( P < 0.003). Positive Troponin T was also significant in group I in 47 patients (70.1%) vs. 33 patients (39.8%) in group II. ST segment elevation ⩾0.5 mm in lead AVR is significant in group I in 52 patients (77.6%) vs. 29 patients (34.9%) in group II ( P < 0.001). ST segment depression ⩾0.5 mm in leads other than aVR is significant in group I in 56 patients (83.6%) vs. 41 patients (49.4%) in group II ( P < 0.001). The presence of QRS duration > 90 ms in the admission ECG was significant in group I in 45 patients (67.2%) vs. 16 patients (19.3%) in group II ( P < 0.001). ST-segment elevation in lead aVR ⩾0.5 mm and QRS duration ⩾90 ms are good electrocardiographic predictors of left main or three vessel disease in patients with non-ST segment elevation acute coronary syndrome.

Prognostic Impact of Early ST-Segment Resolution and Biochemical Markers in Patients With ST-Elevation Myocardial Infarction

Refer to the page 372-378 Considerable variability exists for the reported mortality risk among patients with ST-elevation myocardial infarction (STEMI) and who are treated with primary percutaneous coronary intervention (PCI). The diversity in the clinical out comes for these patients challenges the physician at each step: risk stratification, planning the treatment and monitoring the response to PCI. In this regard, the current guidelines for the treatment of patients with acute coronary syndrome (ACS) recommend risk stratification using a variety of clinical vari ables. Clinical variables such as biomarkers, electrocardiography (ECG), and the imaging modalities have been studied for whether these variables may improve the risk assessment and clinical care. The standard 12-lead ECG has been used as the single most important diagnostic tool for the evaluation of ACS. Measurement via ECG is very useful and informative for determining the quality of reperfusion in patients with acute STEMI. The degree of ST segment deviation also confers prognostic information. 1) Since it was first documented in 1971 in an animal study that the magnitude of ST segment elevation was well correlated well with depressed myocardial creatine kinase activity as well as myocardial necrosis, 2) the degree of ST segment elevation has been used as an

An Early and Simple Predictor of Severe Left Main and/or Three-Vessel Disease in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

Clopidogrel should be initiated as soon as possible in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) except those who urgently require coronary artery bypass grafting (CABG). The present study assessed the ability to predict severe left main coronary artery and/or 3-vessel disease (LM/3VD) that would most likely require urgent CABG based on only clinical factors on admission in 572 patients with NSTE-ACS undergoing coronary angiography. Severe LM/3VD was defined as ≥75% stenosis of LM and/or 3VD with ≥90% stenosis in ≥2 proximal lesions of the left anterior descending coronary artery and other major epicardial arteries. Patients were divided into the 3 groups according to angiographic findings: no LM/3VD (n = 460), LM/3VD but not severe LM/3VD (n = 57), and severe LM/3VD (n = 55). Severe LM/3VD was associated with a higher rate of urgent CABG compared to no LM/3VD and LM/3VD but not severe LM/3VD (46%, 2%, and 2%, p <0.001). On multivariate analysis, degree of ST-segment elevation in lead aVR was the strongest predictor of severe LM/3VD (odds ratio 29.1, p <0.001), followed by positive troponin T level (odds ratio 1.27, p = 0.044). ST-segment elevation ≥1.0 mm in lead aVR best identified severe LM/3VD with 80% sensitivity, 93% specificity, 56% positive predictive value, and 98% negative predictive value. In conclusion, ST-segment elevation ≥1.0 mm in lead aVR on admission electrocardiogram is highly suggestive of severe LM/3VD in patients with NSTE-ACS. Selected patients with this finding might benefit from promptly undergoing angiography, withholding clopidogrel to allow early CABG.

Abstract 4861: Prolonged QRS Duration is a Strong Predictor of Adverse Outcomes in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Background: Although ECG assessment of myocardial ischemia is usually based on ST-segment changes, prolonged QRS duration (QRSd) has been shown to be more sensitive than ST-segment change for the detection of ischemia. However, the implication of QRSd in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is not known. Methods: We studied 501 patients with NSTE-ACS who underwent coronary angiography during hospitalization. Patients with bundle branch block, left ventricular hypertrophy, and paced rhythm were excluded. Maximal QRSd and ST-segment deviation were measured on admission 12-lead ECG. Patients were divided into the 4 groups according to QRSd: ≤80 ms (n=153, G-A); 81–90 ms (n=214, G-B); 91–100 ms (n=86, G-C); and ≥101 ms (n=48, G-D). Troponin T (TnT), brain natriuretic peptide (BNP), and high-sensitivity C-reactive protein (hsCRP) were measured on admission. Results: There were no differences in sex or coronary risk factors except for diabetes mellitus in the 4 groups. In G-A, G-B, G-C, and G-D, age was 64±12, 67±11, 68±11, and 69±11 years; the rates of diabetes mellitus were 23%, 33%, 49%, and 50%; Killip class ≥2 was 3%, 6%, 11%, and 31%; positive TnT was 16%, 36%, 44%, and 56%; the levels of BNP were 105±259, 158±235, 306±355, and 391±390 pg/ml; hsCRP was 0.180±0.233, 0.400±0.748, 0.417±0.530, and 0.716±1.230 mg/dl; the degrees of summed ST-segment depression in all leads except aVR were 1.8±2.8, 2.8±3.6, 5.4±5.1, and 8.7±6.0 mm; ST-segment elevation in lead aVR was 0.1±0.2, 0.1±0.3, 0.5±0.6, and 0.8±0.6 mm; the frequencies of left main or 3-vessel disease (LM/3VD) were 1%, 5%, 49%, and 88%; and major adverse events (death, [re]infarction, or urgent revascularization) at 30 days were 5%, 13%, 24%, and 67%, respectively (all p&lt;0.01). Multivariate analysis showed that QRSd was the strongest predictor of 30-day adverse events (OR 2.40, 95%CI 1.54 –3.24, p&lt;0.001), followed by the degree of ST-segment elevation in lead aVR (OR 1.97, 95%CI 1.20 –5.82, p=0.039) and positive TnT (OR 1.60, 95%CI 1.10 –3.17, p=0.048). Conclusions: In patients with NSTE-ACS, prolonged QRSd on admission ECG is strongly associated with LM/3VD and predicts adverse outcomes, even after adjusting for ST-segment changes, biomarker profiles and traditional risk factors.

Early, Accurate, Non-Invasive Predictors of Left Main or 3-Vessel Disease in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

In patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), identification of left main and/or 3-vessel disease (LM/3VD) is crucial for deciding whether to initiate early treatment with clopidogrel, which can increase the risk of surgical bleeding. On admission, the clinical factors of 501 patients with NSTE-ACS, who underwent coronary angiography, were evaluated. ST-segment shifts and the widest QRS duration were measured on an admission 12-lead electrocardiogram. Ninety-six patients had LM/3VD. Univariate analysis indicated that many factors were related to LM/3VD. On multivariate analysis, QRS duration (odds ratio (OR) 9.04, P<0.01), the degree of ST-segment elevation in lead aVR (OR 7.10, P<0.01), and positive-troponin T (OR 1.52, P<0.05) were independent predictors of LM/3VD. A QRS duration of >90 ms and a ST-segment elevation in lead aVR of >or=0.5 mm best identified LM/3VD. A QRS duration of >90 ms, a ST-segment elevation in lead aVR of >or=0.5 mm, and a positive-troponin T identified LM/3VD with sensitivities of 88%, 76%, and 54% (P<0.01), and specificities of 88%, 86%, and 71% (P<0.01), respectively. A prolonged QRS duration, ST-segment elevation in lead aVR, and a positive-troponin T on admission are useful predictors of LM/3VD in patients with NSTE-ACS. In particular, a maximal QRS duration of >90 ms was the most sensitive predictor of LM/3VD.

ST-Segment Elevation Resolution in Lead aVR A Strong Predictor of Adverse Outcomes in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

The impact of ST-segment elevation resolution in lead aVR on outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is unclear. Electrocardigrams (ECGs) were recorded on admission and 6 h later in 367 patients with NSTE-ACS. ST-segment deviation >or=0.5 mm was considered significant: 92 patients had ST-segment elevation in lead aVR on admission ECG (ST upward arrowaVR), and 275 did not. Among patients with ST upward arrowaVR, 50 had ST resolution, defined as a reduction >50% in the degree of ST-segment elevation in lead aVR from admission to 6 h later, and 42 did not. ST upward arrowaVR without ST resolution was associated with older age, greater ST-segment depression in other leads on admission and 6 h later, higher rates of positive troponin T, left main and/or 3-vessel coronary disease, and adverse events such as death, (re)infarction, or urgent revascularization within 30 days after admission. Multivariate analysis showed that ST upward arrowaVR without ST resolution was the strongest independent predictor of death or (re)infarction within 30 days after admission (hazard ratio 5.62, p=0.018). ST upward arrowaVR without ST resolution is a strong predictor of 30-day adverse outcomes and correlates with the extent and severity of coronary artery disease in patients with NSTE-ACS.

Sex differences in the degree of ST-segment elevation during acute myocardial infarction

Sex differences in the degree of ST-segment elevation during acute myocardial infarction

123I-metaiodo-benzylguanidine myocardial scintigraphy in the Brugada-type ECG

The degree of ST-segment elevation and amplitude of J waves, which may change in patients with the Brugada-type electrocardiogram (ECG) over time, are influenced by autonomic nervous activity and the administration of antiarrhythmic drugs. In the present study, we evaluated whether the shape of ST-segment elevation in patients with a Brugada-type ECG might alter the parameters of an 123I-MIBG myocardial scintigraphy and body surface signal-averaged ECG (SAECG). The subjects consisted of 12 patients with a Brugada-type ECG and 15 healthy volunteers (N group). The patients with a Brugada-type ECG were classified into the following 2 groups based on the type of ST-segment elevation: 6 patients with the coved type ST-segment elevation (C group), and 6 patients with the saddle-back type ST-segment elevation (S group). Planar and SPECT images were obtained 15 minutes (early images) and 3 hours (delayed images) after the administration of 123I-MIBG, respectively. In addition, the washout rate (% WR) of 123I-MIBG was obtained in a bull's eye map of the SPECT image. There were no significant differences in the early H/M ratio between the C and S groups. In the C group, however, there were some patients who showed a decreased accumulation or defect of 123I-MIBG in the planar and SPECT images. Furthermore, in contrast to the N and S groups, the C group showed a decreased delayed H/M ratio and increased % WR. SAECG did not show any significant differences between the S and C groups. These results of the present study suggest that the shape of ST-segment elevation may be associated with myocardial autonomic nervous function. In addition, the electric heterogeneity of the action potential in the right ventricular epicardial myocardium, which is frequently influenced by autonomic nervous activity, is closely associated with the development of Brugada syndrome.