Depression In aVR Research Articles

Shark Fin Electrocardiogram in the Intensive Care Unit.

Shark Fin Electrocardiogram in the Intensive Care Unit.

A UNIQUE CASE OF PURE ASYMPTOMATIC PERICARDITIS IN COVID-19

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Acute pericarditis in COVID-19 pneumonia (PNA) can present during PNA, after PNA, or even as the main presentation. Chest pain and EKG changes should raise suspicion for pericarditis and be immediately addressed. CASE PRESENTATION: A 43 y/o male with no relevant medical history, presented with respiratory symptoms 20 days with COVID RT-PCR positive 17 days before admission. He was admitted for COVID PNA due to persistent productive cough, increasing dyspnea and decreased exercise tolerance. No chest pain with normal vitals, sat 98% on RA but complained of orthopnea. Labs: Troponin negative x4, potassium 5.1, and D-dimer 2388. He was started on therapeutic enoxaparin and given sodium zirconium cyclosilicate. EKG: diffuse ST segment elevations across precordial leads and lead I with reciprocal ST segment depression in aVR. TTE: small pericardial effusion. This would indicate 2/4 pericarditis diagnosis criteria. CXR and CTPE: b/l patchy and scattered ground-glass opacities. Ibuprofen 600 mg was started; however, colchicine was not initiated. ST segment elevations improved and he was discharged with ibuprofen and apixaban without complications. DISCUSSION: There are few reports on patients who developed pericarditis and pericardial effusions with COVID-19 infection. Most have been associated with myocardial involvement with increasing troponin. Treatment is an on-going debate, but consensus is that corticosteroids and colchicine are safe. CONCLUSIONS: This is a unique case of COVID-19 PNA complicated with troponin negative pericarditis. DISCLOSURE: Nothing to declare. KEYWORD: covid pericarditis

Polycythemia Vera Presenting as ST-Segment Elevation Myocardial Infarction

An 80-year-old woman with a history of hypertension, prediabetes, chronic kidney disease (stage 3b), and a remote ischemic stroke without residual deficits presented to the emergency department complaining of several hours of epigastric discomfort and malaise. An electrocardiogram (ECG) performed at triage revealed normal sinus rhythm with >1 mm ST elevation in leads V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves in V1 and V2 (Fig. 1). The troponin I was elevated to 1.66 ng/mL (reference range <0.03).

The Relationship Between ST-Segment Depression in Lead aVR and Coronary Microvascular Function in Acute Inferior Myocardial Infarction

Aim: The aim of this study was to investigate the relationship between ST-segment depression in the aVR lead and coronary microvascular function in acute inferior myocardial infarction undergoing primary percutaneous intervention.&#x0D; Methods: 287 patients with inferior myocardial infarction confirmed by coronary angiography were divided into two groups with and without ST-segment depression in lead aVR ≥ 0.1 mV on the 12 lead ECG. Electrocardiographic recordings were made for the evaluation of ST-segment resolution before and after primary PCI. Angiographic assessment in the infarct-related artery was performed by using the myocardial blush grade and thrombolysis in myocardial infarction flow. &#x0D; Results: Overall, 51 of 287 patients had ST-segment depression in lead aVR. The number of patients with RCA-induced infarction was higher in the group with ST-segment depression in lead aVR. RCA involvement was present in 44 patients. Peak troponin was higher in the group with ST-segment depression in lead aVR compare to the other group (P &lt;0.001). The MBG was more impaired, and the STR was less regressed in patients with ST depression in lead aVR (p&lt;0,001). The ejection fraction of patients with ST-segment depression in lead aVR was lower.&#x0D; Conclusion: We found that ST-segment depression in lead aVR was associated with impaired myocardial perfusion in patients with inferior myocardial infarction.

A Study of the ST Changes in the aVR Lead on 12-Lead ECG to Identify Infarct - Related Artery (IRA) in Patients With Acute Inferior Wall Myocardial Infarction

BACKGROUND: Lead avR is a valuable but mostly ignored lead in clinical electrocardiography. Recently, ST-segment depression in lead aVR during an inferior wall myocardial infarction has been suggested as a predictor of LCX artery involvement.&#x0D; METHODS: This study was a single centre cross sectional observational study done in BPKIHS, Dharan from February 2018 to January 2020. Patients presenting to the OPD or emergency room of BPKIHS diagnosed as acute inferior wall myocardial infarction based on clinical symptoms, ECG and/or Cardiac tropinin I levels, and planned for coronary angiography, meeting the inclusion and exclusion criterias were included.&#x0D; RESULTS: Among 134 cases, male:female ratio was 1.3:1. Overall, 38 patients (28.4%) were found to have aVR depression and 96 patients (71.6%) were without aVR depression. The culprit artery was found to be the right coronary artery in 95 patients (70.9%), the LCx in 39 patients (29.1%). The sensitivity and specificity of ST-segment depression in lead aVR for LCx as the culprit artery were 92.3% and 97.9% respectively. Positive predictive and Negative predictive value for LCx as the culprit arteries were 94.74% and 96.87%. The sensitivity, specificity, positive predictive value and negative predictive value for RCA as the culprit artery were 97.89%, 92.3%, 96.89% and 94.73% respectively.&#x0D; CONCLUSION: Significant ST depression in aVR is associated with a higher specificity and good sensitivity for LCX lesions, the ST changes in this lead should be carefully examined in all patients who are suspected of having inferior wall myocardial infarction.

Abstract 13718: Automatic Microvolt-level Measurement of ST Level at J-point on 12-lead Electrocardiography Can Distinguish Takotsubo Syndrome and Acute Anterior Myocardial Infarction

Introduction: ST elevation/depression on 12-leads electrocardiography (ECG) at onset was recognized difficult to distinguish Takotsubo syndrome (TTS) and acute anterior myocardial infarction (ant AMI). Diagnostic performance of automatic microvolt-level measurement of the ST levels was not elucidated. Hypothesis: Microvolt-level differences of ST level at J-point on ECG can distinguish TTS and ant AMI in acute phase. Methods: We firstly enrolled consecutive 40 patients of TTS, and among 500 ant AMI patients, one to two random matching was done by their age and gender. Finally, 40+80 patients (74.5±11.2 years, 87 females) were enrolled. ECG at onset of both group was measured by automated system (ECAPs12c: Nihon-Koden). Results: ST level of TTS at J-point in I/II/V4-6 lead was significantly elevated comparing to that of ant AMI. Conversely, Conversely, significant ST depression in aVR and no ST elevation in V1 of TTS was observed in TTS. Logistic regression analysis revealed that ST elevation in I lead and no ST elevation in V1 lead showed high odds ratio and low P value. Conclusions: Automated measurement of microvolt-level difference of ST level at J-point was a powerful tool to distinguish TTS and ant AMI at onset.

Differences of ST level at J-point on 12-lead electrocardiography can distinguish takotsubo syndrome and acute anterior myocardial infarction

Abstract Background Qualitative difference of ST elevation/depression on 12-leads electrocardiography (ECG) at onset was reported in patients with Takotsubo syndrome (TTS) and acute anterior myocardial infarction (ant AMI). However, quantitative difference of those was not elucidated. Purpose To investigate differences of ST level at J point on ECG between TTS and ant AMI by automated calculating system. Methods We firstly enrolled consecutive 40 patients of TTS, and among 500 ant AMI patients, one to two random matching was done by their age and gender. Finally, 40+80 patients (74.5±11.2 years, 87 females) were enrolled. ECG at onset of both group was measured by automated system (ECAPs12c: Nihon-Koden). Results ST level of TTS at J-point in I/II/V4–6 lead was significantly elevated comparing to that of ant AMI. Conversely, Conversely, significant ST depression in aVR and no ST elevation in V1 of TTS was observed in TTS. Logistic regression analysis revealed that ST elevation in I lead and no ST elevation in V1 lead showed high odds ratio and low P value. Conclusion Automated measured ST level at J-point was a powerful tool to distinguish TTS and ant AMI at onset. Funding Acknowledgement Type of funding source: None

PR depression with multilead ST elevation and ST depression in aVR by left circumflex artery occlusion: How to differentiate from acute pericarditis

PR‐segment depression with multilead ST‐segment elevation and ST‐segment depression in lead aVR are classic ECG manifestation of acute pericarditis. We present a patient, where the etiology of these ECG features was acute ST‐elevation myocardial infarction due to left circumflex artery occlusion. To avoid misdiagnosis, unnecessary examinations, and inappropriate therapeutic decisions, the possibility of ST‐segment elevation myocardial infarction should be kept in mind even when ECG changes typical for pericarditis are encountered in chest pain patients. Findings of QRS widening and QT interval shortening in leads with ST‐segment elevation could help to differentiate acute ST‐segment elevation myocardial infarction from acute pericarditis.

Electrocardiographic changes in the differentiation of ischemic and non-ischemic ST elevation

Objectives. Pericarditis, takotsubo cardiomyopathy and early repolarization syndrome (ERS) are well-known to mimic ST elevation myocardial infarction (STEMI). We aimed to study whether ECG findings of reciprocal ST depression, PR depression, ST-segment convexity or terminal QRS distortion can discriminate between ST elevation due to ischemia and non-ischemic conditions. Design. Eighty-five patients with STEMI and 94 patients with non-ischemic ST elevation were included. All patients had acute chest pain and at least 0.1 mV ST elevation. Presence of PR depression, ST-segment convexity, terminal QRS distortion or reciprocal ST depression was assessed in each ECG. Results. In anterior ST elevation, ST depression in lead II (≥0.025 mV) occurred in 40% of patients with STEMI but in none of the non-ischemic cases. In inferior ST elevation, ST depression in lead I (≥0.025 mV) was present in 83% of patients with STEMI but in none of the non-ischemic cases. Chest-lead PR depression was uncommon in STEMI (12%) compared to non-ischemic cases (38%; p < .001). Convex ST elevation occurred in 22% of STEMI cases and in 9% of non-ischemic cases (p = .01). Terminal QRS distortion was more prevalent in STEMI (40%) than in non-ischemic ST elevation (7%). In multivariable analysis, reciprocal ST depression was associated with an ischemic diagnosis, whereas ST depression in aVR and chest-lead PR depression were associated with a non-ischemic diagnosis. Conclusions. Identification of true STEMI among patients with different ST-elevation etiology may be improved by considering reciprocal ST depression, ST depression in aVR and chest-lead PR depression.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; Cardiovasc. j. 2019; 11(2): 123-128

Electrocardiographic and Seasonal Patterns Allow Accurate Differentiation of Tako-Tsubo Cardiomyopathy from Acute Anterior Myocardial Infarction: Results of a Multicenter Study and Systematic Overview of Available Studies.

Background. Though several studies about prevalence, etiology, clinical characteristics, preceding events, clinical management, and outcome of Tako-Tsubo cardiomyopathy (TTC) exist, the current knowledge of TTC remains limited. Objective. In 2006, TTC was classified among the acquired forms of cardiomyopathy. On the basis of pathophysiological implications, we analyzed whether the presence of ST-segment elevation in lead -aVR (i.e., ST-segment depression in aVR) and the simultaneous absence of ST-segment elevation in lead V1 allow a reliable differentiation of TTC from acute anterior ST-segment elevation myocardial infarction (STEMI). A further investigative feature is the seasonal variation of TTC. Since acute cardiovascular events exhibit definite chronobiological patterns, various small studies have tried to evaluate whether this is also the case for TTC. Because results are conflicting, we also conducted a multicenter study and analyzed the findings in context with a systematic overview of available studies. Methods. We compared the ECG patterns of 115 patients with TTC, who were admitted to five large acute cardiac care centers associated with university hospitals in Southwestern Germany between January 2001 and June 2011, with those of 100 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) treated in one of these centers. In addition, we performed a computer-assisted MEDLINE search of the literature from January 2000 to September 2011 and analyzed the chronobiological patterns of available TTC cases, including our TTC cohort. Results. Testing the predefined diagnostic criteria was superior to any other electrocardiographic finding and differentiated TTC from anterior STEMI with a sensitivity of 73%, a specificity of 84%, a positive predictive value of 63%, and a negative predictive value of 89%. Beyond that, the onset of TTC showed a clear variation as a function of season and month. While events occurred most frequently during summer (38.4%, p < 0.01), the event rate was the lowest in autumn (16.4%) and winter (21.9%). Chronobiological analyses on a monthly basis identified a significant annual rhythmic pattern in TTC, which peaked in August (11.9%; p < 0.01) and had its nadir in November (6.3%). Conclusions. Our data illustrate that the ST-segment changes in leads aVR and V1 represent a simple and accurate ECG criterion to differentiate TTC from anterior STEMI in patients who are admitted within 12 h of symptom onset. Similarly, the results of our seasonal analysis indicate a distinct chronobiological variation in TTC occurrence. TTC, thereby, differs from major acute cardiovascular diseases, especially acute myocardial infarction (AMI), which is characterized by winter peaks and troughs in summer. If these results are confirmed in large independent cohorts, they may yield diagnostic implications, changing the regular invasive AMI management in TTC patients.

PR depression with multi‑lead ST elevation and ST depression in aVR: Is it always acute pericarditis?

The classic electrocardiographic (ECG) manifestation of stage I of acute pericarditis is diffuse ST elevation and PR depression with ST depression in lead aVR. One of the most common conditions, that is often confused with acute pericarditis, is the benign diffuse ST elevation, termed “early repolarization with ST elevation” (ERSTE). ERSTE often presents with diffuse ST elevation in the inferior and anterolateral leads, with or without terminal QRS notching or slurring. As ERSTE often presents with ST elevation in leads I and II, frequently there is concomitant ST depression in lead aVR, similar to the acute pericarditis ECG pattern. Moreover, PR depression in the inferior leads and/or PR elevation in lead aVR is often seen. Here we describe four patients with ERSTE, all had ST elevation in II with either ST elevation or isoelectric ST in lead I and concomitant ST depression in aVR. Two also had PR depression in the inferior leads. None of the patients had clinical symptoms or signs of acute pericarditis. In conclusion, diffuse ST elevation in the inferolateral leads associated with ST depression in aVR and even with PR segment depression is commonly found in ERSTE and should not be considered as pathognomonic of only acute pericarditis.

Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome

Background: The lead aVR is neglected electrocardiography (ECG) lead while interpreting various cardiac diseases including coronary artery disease (CAD). The aVR lead is a potentially useful tool in ECG in diagnosing and managing patients with CAD. Aim and Objectives: The aim is to study the usefulness of ECG in localizing the culprit vessel by coronary angiogram (CAG) in patients with the acute coronary syndrome (ACS) and to find the relation of ECG findings, with regional wall motion abnormality (RWMA) and CAG profile. \Materials and Methods: This was a cross-sectional observational study done on patients admitted with the diagnosis of ACS. A total of 54 patients were included in this study satisfying the inclusion criteria presented with ACS. Results: A total of 54 patients (males: 55.7% and females: 46.3%) were enrolled fulfilling inclusion criteria of the study (male: 59.72 [±10.59], female: 55.24 [±11.93]). A total 59.36% of patients had resulting RWMA. About 33.33% of patients had single-vessel disease, 24.07% had double-vessel disease , and 18.52% had triple-vessel disease (TVD) with P = 0.081. A total 79.62% of patients ECG could able to diagnose CAD. About 100% of patients with proximal left anterior descending (LAD) lesion 85.71% with LMCA, 40% with TVD had ST elevation in aVR lead. About 66.67% of patients with the right coronary artery (RCA) and 50% with left circumflex infarction (LCx) lesion had ST depression in aVR lead. About 59.36% had RWMA on echocardiogram. Conclusions: The presence of ST elevation in aVR indicates a culprit lesion in the proximal segment of LAD or LMCA. The absence ST elevation in aVR excludes the left main coronary artery as the underlying cause in the context of anterior wall ST-elevation myocardial infarction (STEMI). ST elevation in aVR is valuable for distinguishing proximal from distal lesions in the LAD in anterior wall STEMI. ST-segment depression in lead aVR is valuable for differentiating RCA from those with LCx in the inferior STEMI. Echocardiography findings aid triage for the management of the patient with ACS.

The predictive value of aVR in determining the infarct related artery during primary percutaneous coronary intervention

BackgroundIsolation of infract related artery and timely revascularisation remains vital in the setting of primary percutaneous coronary intervention. ObjectivesTo analyse the predictive value of ST-T changes in lead aVR in inferior myocardial infarction in terms of prognosis and timely risk stratification. MethodsWe conducted a prospective analysis of acute inferior wall myocardial infarction patients. One hundred patients were categorised into two groups according to the culprit artery: group I, right coronary artery (RCA) and group II, left circumflex coronary artery (LCX), with 50 patients in each group. A comparative study was performed between the two groups, comprising the following data outputs: electrocardiogram (ECG) changes that could help determine the culprit artery, cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. The same patients were divided into two groups according to the presence or absence of 1 mm ST depression in lead aVR. A comparison analysis was performed between the two groups including: cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. ResultsST depression in aVR ≥ 1 mm predicted the LCX as a culprit artery with sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) recorded at 66%, 84%, 80.5% and 71.2%, respectively. Also, patients with ST depression in aVR ≥ 1 mm showed significantly higher cardiac enzyme levels, indicating larger infarct size, with mean peak creatinine kinase (CK) = 1560 (1057–2375) IU/L versus 970 (613–1683) IU/L, (P value = 0.014), lower ejection fraction (Ef) with mean Ef = 47.93 ± 8.04 versus 54.66 ± 6.52, (P value < 0.001) and more significant mitral regurgitation: 17 (41.5%) patients versus 11 (18.6%) patients (P value = 0.012). Regarding in-hospital complications, there were no significant differences. ConclusionsST depression of >1 mm in lead aVR predicts LCX as the infarct related artery and is a predictor of poor outcome in patients with inferior myocardial infarction.

Electrocardiographic localization of infarct related coronary artery in acute inferior wall ST elevation myocardial infraction and in hospital outcome in tertiary cardiac care center

Background: In addition to diagnosing the acute ST Elevation MI stratifying (STEMI) high-risk patients and proper treatment strategies are important issues in managing patients. The goal of this study was to determine the relation of ST segment changes in Electrocardigram with the site of occlusion in vessel , to evaluate the prognostic value of ST segment deviation in aVR and its role in identification of Infarct Related Artery (IRA) in patients with acute inferior myocardial infarction.Methods: The study included 56 patients with acute inferior wall STEMI. All patients underwent Coronary Angiogram. Patients were divided into two groups based on the IRA and were followed up during their hospital stay for complications.Result: The culprit artery was Right Coronary Artery (RCA) in 40 patients (71.4%) and Left Circumflex Artery (LCX) in 13 patients (23.2%). Study showed 92% sensitivity, 80% specificity for predicting RCA related infarction with ST elevation lead III &gt; lead II and 83% sensitivity ,90% specificity for (LCX) with ST elevation lead II &gt; lead III . The overall in-hospital mortality was 3.5%.ST depression in aVR was associated with 87.5% specificity and 83% sensitivity in diagnosing LCX as the Infarct Related Artery (IRA). The in-hospital mortality rates for patients with ST segment deviation in aVR (20 patients) and no ST segment changes (36 patients) were 5% and 2.7% respectively.Conclusion: In addition to the conventional ECG criteria for identifying culprit vessel, lead aVR may be useful in clinical practice when assessing patients with inferior STEMI and with poor in-hospital outcome.Nepalese Heart Journal 2018; 15(1): 23-27

Electrocardiographic approach to classification of acute pericarditis in emergency department: Typical and atypical pericarditis

BACKGROUND: In typical pericarditis, concave ST–segment elevation can be characteristically seen in electrocardiogram (ECG). However, PR-segment depression may be the earliest ECG change in patients with acute pericarditis and in following time, from atypical pattern to typical pattern transition may be occur. Without ST-segment elevation in ECG may undergo misdiagnosed or overestimated condition, including acute coronary syndrome. Therefore, we classified acute pericarditis by highlighting ECG features to prevent any possible failure to notice acute pericarditis in emergency department (ED). METHODS: This study included 216 patients selected from the 2140 patients acute chest pain admitted into ED between 2015 and 2018. The two groups were retrospectively created by virtue of the presence or absence of typical ECG findings. Typical ECG refers to diffuse or regional concave ST-segment elevations with reciprocal ST-segment depression in aVR, and V1 in ECG, and atypical ECG refers to PR-segment depression in leads V5 to V6 in ECG. 100 patients (group I) had typical ECG, whereas 116 patients (group II) had atypical ECG changes. RESULTS: The mean age of the patients with typical pericarditis was higher than those with atypical pericarditis (P<0.05). Typical pericarditis group had higher CRP level (P<0.05). Atypical pericarditis group had more recurrence rate than typical pericarditis (P<0.05). In ECG following time, 10 patients with the atypical pericarditis pattern were transformed typical pericarditis pattern. CONCLUSION: We classified acute pericarditis as typical and atypical by highlighting ECG features to prevent any possible failure to notice acute pericarditis. Thanks to PR-segment recognition, acute pericarditis diagnosis may confirm and prevent the inappropriate coronary intervention. It is recommended that the ECG features should be examined thoroughly, especially with a focus on ST-segment elevation besides PR-segment depression.

Clinical Significance of ST Segment Depression in Lead aVR to Predict Culprit Artery in An Acute Inferior Wall Myocardial Infarction

Background and Aims: The main objective of this study is to analyze between left circumflex artery and right coronary artery as a presumptive predictor of a culprit artery in patients with an acute inferior wall ST elevation myocardial infarction according to ST segment change in lead aVR. Methods: This study included 145 consecutive patients who presented with an inferior wall ST elevation myocardial infarction and underwent coronary angiography. Clinical and angiographic findings were compared between patients with and without aVR depression ≥ 0. 1mV. Results: The sensitivity and specificity of ST segment depression in lead aVR to predict left circumflex artery as the culprit artery were 69% and 85%, respectively, and the positive predictive value and negative predictive value to predict left circumflex artery as the culprit arteries were 66% and 87%, respectively. Conclusion: Our study supports, the presence of ST segment depression in lead aVR is associated with good specificity and negative predictive value and modest sensitivity and positive predictive value to determine left circumflex artery as an infarct related artery in an acute ST segment elevation inferior wall myocardial infarction.DOI: http://dx.doi.org/10.3126/njh.v12i1.12324 Nepalese Heart Journal Vol.12(1) 2015: 5-9

Clinical Implication of ST Segment Depression in aVR &amp;amp; aVL in Patients with Acute Inferior Wall Myocardial Infarction

Objectives: The aim of the study was to assess the role of ST segment depression in the limb leads aVR and aVL for the diagnosis of acute posterior wall infarction and the identification of infarct related artery (IRA) in patients with acute inferior wall MI. Methods: In 159 patients with I-STEMI, 127 (80%) had RCA occlusion and 32 (20%) had LCX occlusion. In the ECG algorithms, RCA occlusion was indicated by ST depression in lead aVL higher than lead aVR and no ST depression in lead aVL and aVR. LCX occlusion was indicated by ST depression in lead aVR higher than or equal to lead aVL and no ST depression in aVL and aVR. Results: The sensitivity, specificity, positive and negative predictive values of these algorithms were high (98%, 82%, 92% and 95% for RCA occlusion and 83%, 98%, 95% and 92% for LCX occlusion). Conclusion: The ECG algorithms can reliably identify the culprit artery in I-STEMI. ST segment depression in limb leads aVR and aVL with avR ≥ aVL helps to diagnose left circumflex artery as a culprit IRA in an acute inferior wall MI.

Acute electrocardiographic differences between Takotsubo cardiomyopathy and anterior ST elevation myocardial infarction

BackgroundThe aim of this study was to compare ECG findings between anterior ST elevation myocardial infarction (STEMI) and Takotsubo cardiomyopathy (TC) in a similar sample of postmenopausal women. MethodsBetween 2008 and 2011, 27 patients with TC were retrospectively enrolled and matched with 27 STEMI patients with the same age and sex taken from the prospective database of our laboratory. ResultsThe absence of abnormal Q waves, the ST depression in aVR and the lack of ST elevation in V1 were significantly associated with TC (respectively: 52% vs 18%, p=0.01; 47% vs 11%, p=0.01; 80% vs 41%, p=0.01). The combination of these ECG findings identified TC with a specificity of 95% and a positive predictive value of 85.7%. ConclusionsThe ECG on admission may be useful to distinguish TC from anterior STEMI. The combination of three ECG findings identifies patients with TC with high specificity and positive predictive value.

ST-segment depression in aVR as a predictor of culprit artery in acute inferior wall ST-segment elevation myocardial infarction

To investigate whether the ST changes in the aVR lead on 12-lead ECG can be used to identify infarct-related artery (IRA) in patients with acute inferior ST-segment elevation myocardial infarction. The ECG features were studied in 56 patients with acute inferior myocardial infarction where IRA was confirmed by coronary angiography. Right coronary artery (RCA) and the left circumflex coronary artery (LCX) were identified as IRA in 41 and 15 patients, respectively. ST depression in aVR ⩾ 0.1 mV was found in 9 (60%) patients who had LCX as the IRA, and in 5 (12.2%) (2p < 0.001) patients with RCA as IRA. Using ST segment depression ⩾ 0.1 mV in aVR as a criterion, the sensitivity and specificity in differentiating LCX as IRA was 60% and 87.80%, respectively. ST depression in aVR is common in patients with LCX-related acute inferior myocardial infarction. The ST changes in this lead are associated with an excellent specificity and a good sensitivity in differentiating LCX from RCA as the IRA.