Elevation In aVR Research Articles

P048 A young girl with myocardial infarction

Abstract Background/Aims Takayasu arteritis is a chronic granulomatous inflammatory disease of the aorta and its major branches. It is commonly seen in young women but has been reported in children as young as 6 months. Acute myocardial infarction due to coronary artery involvement is a rare presentation in Takayasu’s arteritis. Methods A previously healthy 13-year-old girl presented with a history of five episodes of short lasting exertional tightening type chest pain with adrenergic symptoms over a week which was relieved by rest. She didn't have any history of shortness of breath, limb claudication or constitutional symptoms. However, on two of the occasions she felt faint. She denied any recreational drug use. There was no family history of cardiovascular disease, connective tissue diseases or sudden cardiac death. On examination she was of average build with no peripheral stigmata of connective tissue diseases or hypercholesterolemia. Apart from a tachycardia of 110 bpm, her cardiovascular examination was normal. There was no BP difference between the arms and no audible bruits. All her peripheral pulses were felt. Results Her ECG showed ST segment depressions in V1-V5. High sensitivity Troponin I was strongly positive. An urgent CT coronary angiogram revealed aortitis involving the ascending and arch of the aorta extending to the left subclavian artery with both coronary arteries showing smooth short segment narrowing at the origin. Doppler USS abdomen showed wall thickening of proximal and mid abdominal aorta. Blood investigations showed a leucocytosis of 14,100/µl and thrombocytosis of 532000/µl. Her ESR was raised at 31 mm/hr and CRP was 5 mg/l. While further awaiting investigations she was started on treatment as for non-ST elevation myocardial infarction according to standard guidelines. Screening for tuberculosis and VDRL were negative . A CT aortic angiogram showed wall thickening involving the aortic root, coronary arteries, ascending aorta and the abdominal aorta with involvement of the origins of coeliac axis and the superior mesenteric artery. Appearance were suggestive of Takayasu arteritis Type v. She was pulsed with intravenous methylprednisolone 30 mg/kg for 3 days followed by oral prednisolone 2 mg/kg. As a steroid sparing agent methotrexate was added. Despite treatment, while in hospital she developed chest pain with ECG showing new onset ST elevation in aVR. An urgent coronary angiogram done showed severe LMCA disease for which stenting was done. At this stage Tocilizumab was initiated. A year later she remains well controlled in terms of her disease activity. Conclusion Though rare, Takayasu’s arteritis should be considered in any adolescent female presenting with ischemic type symptoms and positive inflammatory response. High index of suspicion can lead to early imaging and aggressive immunosuppression that will reduce the morbidity and mortality of this disease. Disclosure S. Janagan: None. M.P.M.L. Gunathilaka: None. L. Rajagopala: None. J.D. Jagoda: None.

Acute Anterior Wall Myocardial Infarction

Background: According to recent research, examining the ST-segment shift in lead aVR provides valuable information on coronary angiographic anatomy and risk categorization. In acute anterior wall myocardial infarction (MI), lead aVR has diagnostic and prognostic relevance. The purpose of this study is to look at the relationship between presenting clinical status and coronary artery disease risk factors and ST-segment deviation in lead aVR. Methods: This prospective observational hospital-based study was carried out in the Department of Cardiology at Batra Hospital and Medical Research Centre in New Delhi. Patients with acute anterior wall ST-elevation MI who presented within 24 h of symptoms were included in the study. Continuous data were expressed as mean standard deviation and categorical variables as the number or percentage of patients. Results: The study involved 73 individuals who met the inclusion and exclusion criteria and had acute anterior wall ST-elevation MI. Thirty of the 73 patients (41%) had ST-segment elevation in lead aVR larger than 0.5 mm. In two groups, the distribution of various cardiovascular risk factors was examined. In all of the cases, the left anterior descending artery was affected. Patients with double- and triple-vessel disease were seen in more significant numbers in Group A than in Group B. Cardiogenic shock occurred in 6 of 30 patients in Group A and 3 of 43 patients in Group B. Conclusions: ST-elevation in lead aVR has predictive value. Patients with higher ST-segment elevation in aVR are more likely to suffer angina, CHF, and cardiogenic shock complications. Providing these patients with percutaneous or surgical revascularization therapy as soon as possible can reduce mortality.

ASSOCIATION OF ST ELEVATION IN LEAD AVR WITH LEFT MAIN STEM AND TRIPLE VESSEL DISEASES IN PATIENTS WITH NON-ST ELEVATION MYOCARDIAL INFARCTION

Objectives: To determine frequency of left main stem (LMS) and triple vessel coronary artery disease (3VCAD) in patients of Non-ST-elevation myocardial infarction (NSTEMI) and to compare the frequency of LMS and 3VCAD in patients with NSTEMI with or without ST elevation in lead aVR. Methodology: Total 346 patients with NSTEMI having age 30-70 years were included in this descriptive cross-sectional study. The data on demographic details was collected. All patients underwent electrocardiography (ECG) and cardiac specific troponin-I assessment. Patients were categorized as NSTEMI with or without ST-elevation in lead aVR. Coronary angiography was performed in all patients and angiographic findings were noted. Results: Mean age of patients was 51.87±10.03 years. There were 218 (63.01%) males and 128 (36.99%) female patients. 182 (52.60%) patients of NSTEMI had ST elevation in aVR. LMS disease was found in 53 (29.10%) patients with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for LMS disease was 62.35%, 50.57%, 29.12% and 80.49% respectively. 3 VCAD was found in 54 (29.70%) with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for 3VCAD was 77.14%, 53.52%, 29.67% and 90.24% respectively. Conclusion: NSTEMI patients with ST elevation in aVR may have higher chances of having LMS disease or 3VCAD. There is high negative predictive value for ST elevation in aVR to predict LMS disease or 3VCAD.

Prognostic value of ST segment elevation in aVR in patients with non ST elevation myocardial infarction

Although the presence of an ST segment elevation in the aVR lead was more common in patients with multivessel and/or left main disease, its long-term prognostic value is poorly understood. This study aims to describe the association of an ST segment elevation in AVR with the occurrence of MACE following a non ST elevation myocardial infarction (NSTEMI). A total of 340 patients admitted for NSTEMI were included. Patients were classified as having an ST elevation or having a normal ST segment in aVR based on the admission ECG. The primary endpoint was the onset of major cardiovascular events (MACE) at 1 year. Among 340 patients, 20 patients (5.3%) had ST segment elevation in aVR. Patients with ST elevation had a higher rate of multivessel disease. The ST elevation in AVR was not an independent predictor of in-hospital mortality in patients with NSTEMI (OR: 6.58, 95% CI 1.23-30.22 P = 0.061). However, patients with ST segment elevation in aVR had a higher rate of MACE at 1 year (38% vs. 13%, P = 0.03). The ST segment elevation was an independent predictor of MACE at 1 year (OR 4.31; 95% CI 1.3-14.32; P = 0.03). Based on these results, the ST segment elevation, as a simple marker, appears to be an independent predictor of MACE at 1 year in patients admitted with NSTEMI and may be a useful endpoint in risk stratification for the occurrence of MACE in these patients.

ANGIOGRAPHIC CORRELATION OF ST ELEVATION IN LEAD aVR DURNG TMT IN PATIENTS WITH LMCA DISEASE

BACKGROUND:Treadmill testing is the most widely used method for evaluating patients with coronary artery disease. Predicting the left main coronary artery disease (LMCA) before invasive procedure is important in risk assessment because of its grave clinical outcome. Lead aVR can be very useful in identifying LMCAobstruction. It is also valuable lead not only in diagnosis but also predicting the prognosis. AIM: To examine whether STelevation in aVR during TMTcorrelates with LMCAdisease in coronary Angiogram METHOD: In this study 100 patients with positive TMT were included. The study group consisted of 60 patients with ST elevation of > 1mm in aVR. 40 patients also have TMT positive but with < 1mm of ST elevation in aVR is the control group. All patients underwent coronary angiography. RESULTS: Coronary Angiography in the study group revealed signicant LMCA disease in 36 (63%) patients whereas no LMCA disease in control group 12 (20%) patients had ostioproximal LAD leisions in study group 4 (10%) patients in the control group. Triple vessel disease in 10 (17%) patients in study group 6 (15%) patients in control group. Since the p value was signicant, ST Elevation in aVR during TMT strongly predicts the presence of LMCADisease. CONCLUSION: STsegment elevation in aVR > 1mm during Treadmill testing is a strong predictor of LMCAdisease.

De Winter pattern in inferior leads: a rare case presentation

A 60-year-old female with a history of hypertension, diabetus mellitus, presented to the emergency room with acute chest pain. The physical examination didn´t show any abnormalities. The electrocardiogram showed upsloping ST depression at J point in the inferior leads (II, III, and aVF) with positive T wave consistent with De Winter syndrome and ST elevation in aVR. Troponin was positive (54301ng/l). The echocardiography revealed an inferior and lateral wall hypokinesia. The coronary angiography showed a circumflex sub occlusion (culprit artery), a significant stenosis of the left ascending artery and a mild right coronary artery stenosis requiring coronary bypass graft. The patient declined surgery. De Winter pattern is a STEMI-like entity. It is usually observed in anterior leads in left ascending artery (sub) occlusion. Dewinter pattern in inferior leads is very uncommon. It occurs in circumflex or right coronary artery (sub) occlusion.

272 Combined rotational atherectomy and intravascular lithotripsy for heavy calcified coronary artery

Abstract Aims Percutaneous coronary intervention (PCI) of heavily calcified coronary lesions still represents a challenge for interventional cardiologists, with higher risk of immediate complications, late failure due to stent underexpansion or malapposition and consequent poor clinical outcome. Rotational atherectomy (RA) is a well-known calcium debulking modality. However, when coronary plaques present a significant amount of circumferential deep calcium, RA alone may not be able to achieve adequate lesion preparation. The combined use of intravascular lithotripsy (IVL) and RA, a technique called ‘Rotatripsy’, can be an effective approach in order to enable optimal stent implantation. We present a case of a calcific right coronary artery (RCA) PCI successfully treated by ‘Rotatripsy’ technique. Methods and results A 78-years-old man presented to our emergency department complaining of acute chest pain and dyspnoea. The electrocardiogram revealed ST-segment elevation in aVR and a diffuse ST-segment depression. Transthoracic echocardiography showed left ventricular anterior, septal, and apical walls akinesia. An urgent coronary angiography showed a critical distal left main (LM) stenosis involving the left anterior descending (LAD) artery ostium and a heavy calcified dominant RCA with two tandem sub-occlusive stenosis in the mid segment (Figure 1A). An immediate PCI with two drug eluting stents (DES) in the LM and LAD was performed. The patient was scheduled two days later for RCA PCI. RCA was engaged via left radial approach with a 6-Fr AL1 guiding catheter and the lesions were crossed with a Sion Blue wire. Using a Finecross MG microcatheter, an extra-support Rotawire was placed distally in the RCA. However, after multiple rotablation with 1.5 mm burr (Figure 1B), the mid segment lesion (Figure 1C) was still undilatable with a 3.5 mm non-compliant balloon (NCB) at 22 atm showing a partial dog bone effect (Figure 1D). We decided to attempt adjunctive IVL for calcium debulking. Using a Finecross MG and the trapping technique, a Gran Slam wire was placed distally; a 4.0 mm IVL balloon was delivered at the undilatable lesion and 80 pulses were applied (Figure 1E). Once the IVL treatment was completed (Figure 1F), a 4.0 mm NCB was inflated to 20 atm to further dilate the segment with an optimal expansion (Figure 1G). Finally, a DES Synergy 4.0 × 48 mm was implanted (Figure 1H) and it was post-dilated with a 4.5 mm NCB inflated to 22 atm (Figure 1I) with a perfect angiographic result (Figure 1J). Conclusions Coronary calcifications can lead to stent underexpansion, which is related to a higher rate of future complications, such as restenosis or thrombosis. If conventional lesion dilatations are not effective, alternative techniques should be considered (cutting balloon, scoring balloon, RA, orbital atherectomy, IVL). In case of circumferential deep calcium plaques, RA may not be able to achieve an adequate lesion preparation. RA allows the treatment of intimal calcium and permits to cross balloons or stents through severe lesions. However, when adequate expansion of the balloons is not achieved after RA, Shockwave IVL, that is not usually able to cross critical stenosis due to its bulky profile, represents an optimal complementary device, in order to fracture deep calcium and facilitate stent delivery and optimal expansion. In this case, we have successfully used the hybrid approach called ‘Rotatripsy’, which combines RA and IVL, in order to avoid more aggressive RA, which would have required the use of 7-Fr guiding catheter setting and may have increased the risk of complications.

The de Winter Pattern as Pre-Anterior ST-Elevation-Myocardial-Infarction. “An Evolution Sequence”: A Case Report

Introduction: The de Winter pattern (dWP) was first described by de Winter and colleagues in 2008 as static pattern associated with anterior myocardial infarction. A recent study showed the evolution sequence of this pattern into typical ST-elevation myocardial infarction (STEMI). This case discussed dWP who present as pre-anterior STEMI.
 Case Illustration: A-56-year old Male arrived in the emergency room complained chest pain about 3 hours. The patient also complained of diaphoresis, nausea, and fatigue. The patient has a previous history of hypertension. The vital signs were stable with an unremarkable physical examination. The initial electrocardiogram (ECG) revealed sinus rhythm with j-point depression followed by prominent T wave in precordial leads, slight ST-segment elevation in aVR, and loss of precordial R-wave progression. The initial-troponin-T was 31 pg/mL. Follow-up 1-hour after initial ECG showed typical ST-segment-elevation in V1-V4. The patient undergoing thrombolytic, followed by angiography that showed subtotal occlusion in the proximal left anterior descending (LAD) artery, occlusion in the proximal circumflex artery and stenosis in proximal right coronary artery, echocardiography revealed regional wall motion abnormality in the septal and anterior segments and preserved ejection fraction 58%, the patient was discharged after 8-days treated in intensive cardiac care unit.
 Conclusion: dWP has been shown as static and dynamic pattern in some conditions and associated with acute LAD occlusion. In this case, we showed dWP as early anterior STEMI, recognition of this pattern lead to early reperfusion and better myocardial salvage as anterior STEMI has a poor outcome.

A broad complex tachycardia suggesting global ischemia or repolarization abnormalities.

Our case presents a ​cavotricuspid isthmus (CTI​)-dependent atrial flutter (AFL) with 1:1 atrioventricular conduction and pronounced ST-segment elevation in aVR, previously described as a "shark fin phenomenon," mimicking a broad complex tachycardia with a ventricular origin.

Widespread ST depression and ST elevation in avR in severe hypokalaemia

A 35-year-old man with past medical history of sarcoidosis and chronic kidney disease stage III presented with cough, diarrhoea, weakness and pleuritic chest pain. SARS-CoV-2 RNA test was positive....

Ventricular Tachycardia with ST Elevation in Lead aVR Associated with Normal Coronary Arteries: A Case Report and Review of Literature.

As per the 2013 guidelines of ACCF/AHA (American College of Cardiology Foundation/American Heart Association), ST Elevation (STE) in lead augmented vector right (aVR), along with ST depression in multiple leads, is associated with critical stenosis of left main coronary artery (LMCA), left anterior descending artery (LAD) or a triple vessel disease (TVD). Early identification of ST-Elevation Myocardial Infarction (STEMI) is important as timely reperfusion with intervention can save myocardium and improve survival. We present a case of a 70 years old female, with cardiovascular risk factors, who presented to the emergency department with chest pain decompensating with ventricular tachycardia. On cardioversion, she was found to have ST elevation in aVR with ST depression in V4-V6, I, II, and aVL. However subsequent echocardiogram and coronary angiogram showed normal coronary arteries and left ventricular function.

ST Elevation in Lead aVR with Malperfusion Syndrome: Sign of Severe Aortic Dissection

Aortic dissection presenting with ST elevation in lead aVR of electrocardiogram is strongly associated with mortality. It is also associated with dissection involving the root of aorta and coronary vessels. We report a case of young male with hypertension, who presented with severe chest pain and unilateral lower limb pain. Physical examination of the left lower limb was consistent with acute limb ischemia. Electrocardiogram revealed acute anterolateral myocardial infarction together with ST elevation in aVR. Bedside transthoracic echocardiography showed a dilated aortic root measuring 4.51 cm with presence of intimal flap which raised the suspicion of dissection of root of aorta and left coronary artery. Computed tomography angiogram revealed aortic dissection from the root of aorta including the intimal flap near the origin of the left coronary artery, down to common iliac extending to the left iliac artery. Unfortunately, the patient opted for non-surgical intervention and succumbed 48 hours later. This case highlights that in case of aortic dissection, which presents with malperfusion syndrome, the presence of ST segment elevation at lead aVR should raise the suspicion for extensive aortic dissection involving the aortic root and left coronary artery which signifies unfavourable outcome

Electrocardiographic signs of the left main coronary artery disease in acute coronary syndrome

Myocardial infarction (MI) due to the left main coronary artery (LMCA) disease is a life-threatening condition. Evaluation of ECG signs of LMCA occlusion is important because of revascularization emergency. There is no single ECG pattern for LMCA occlusion. The purpose of the present literature review is to reveal ECG potential in diagnosing LMCA occlusion in acute coronary syndrome. Variability of ECG abnormalities was noted depending on the degree of LMCA occlusion, collateral blood flow from the right coronary artery, and concomitant stenosis. ST elevation in aVR is an evident predictor of LMCA lesion. Electrophysiological mechanisms of its formation were described. Diagnostic significance of additional ECG signs of LMCA disease was presented. Diagnostic and treatment strategies for patients with ECG signs of severe LMCA disease were summarized.

Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction.

Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.

LIGHTS AND EMPYEMA CRITERIA FOR THE DIAGNOSIS OF PURULENT PERICARDITIS

SESSION TITLE: Fellows Disorders of the Mediastinum Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Purulent pericarditis incidence has declined significantly, though some cases emerge sporadically. Here we present a case of cardiac tamponade secondary to pericardial effusion. The fluid analysis was consistent with complicated pericardial effusion with parameters comparable to exudative pericardial effusion and empyema CASE PRESENTATION: 45 year old male, presented with fever, chest pain, and shortness of breath. Vital signs with BP of 102/62, MAP of 75 mmHg, HR 107 BPM, tachypnea at 32 BPM, Oxygen saturation at 82% on room air, and fever of 101.3 F orally. Physical exam showed a male in mild distress, muffled heart sounds, absent air entry on right lower lung zone with dull percussion note, otherwise unremarkable. Lab workup (table 1A) showed leukocytosis, lactic acidosis, acute hepatitis, coagulopathy. (ECG) (Image 1A) with ST elevations in inferior and lateral leads, PR depression in inferior, septal and lateral leads, PR elevation in aVR, and Spodick's sign. Chest XRay (Image 1B) with enlarged cardiac silhouette, right lower lobe airspace disease, and effusion. Patient was started on Empiric antibiotics. Transthoracic ECHO showed thick circumferential pericardial effusion, stranding, early tamponade, with septation observed (Image 2) A pericardial drain was inserted, and fluid analysis was consistent with infected complicated effusion that met light’s criteria for exudative effusion and complicated infected effusion (table 1B) he was treated in a similar fashion to complicated pleural effusion. DISCUSSION: Diagnosis of purulent pericardial effusion is mainly based on fluid analysis showing elevated WBC ranging from 6000 to 240,000 with predominant neutrophilia, elevated protein, and low glucose. Our patient's fluid analysis was comparable to empyema in terms of low pH, low glucose, elevated LDH, positive culture, and thick, yellow, dusky appearance. We treated him similarly to empyema with a pericardial drain and directed antimicrobial therapy with complete resolution. The literature review revealed that light’s criteria applied to pericardial effusion yielded a diagnostic efficiency of 94%, with a sensitivity and specificity in identifying exudates of 98% and 72%, respectively (1). Sensitivity for detecting exudates was high for fluid total protein >3.0 g/dL (97%), fluid to serum protein ratio >0.5 (96%), fluid lactate dehydrogenase ratio >0.6 (94%), and fluid to serum glucose ratio <1.0 (85%). None of these was specific (2). Pericardial fluid pH discriminated between inflammatory (pH 7.06 ± 0.07) and noninflammatory (pH 7.42 ± 0.06) (3) CONCLUSIONS: Clear criteria to differentiate between transudation or exudative pericardial effusions are not well described, utilization of Light's criteria and criteria diagnostic for complicated pleural effusions when applied to pericardial effusions in the right context can be of great diagnostic value to help direct medical therapy. Reference #1: Pleural, peritoneal and pericardial effusions – a biochemical approach, Lara Milevoj Kopcinovic, and Jelena Cule, Biochem Med (Zagreb). 2014 Feb; 24(1): 123–137. DOI: 10.11613/BM.2014.014 Reference #2: The Usefulness of Diagnostic Tests on Pericardial Fluid, David G. Meyers et al, Chest Journal Volume 111, Issue 5, Pages 1213–1221, DOI: https://doi.org/10.1378/chest.111.5.1213 Reference #3: Clinical utility of pericardial fluid pH determination, The American Journal of Internal medicine, VOLUME 75, ISSUE 6, P1077-1079, DECEMBER 01, 1983 DOI: https://doi.org/10.1016/0002-9343(83)90892-6 DISCLOSURES: No relevant relationships by Mohammed Aljasmi, source=Web Response No relevant relationships by Rami Batarseh, source=Web Response No relevant relationships by Christopher Lipinski, source=Web Response

VALUE OF ST-SEGMENT ELEVATION IN LEAD aVR IN NON STELEVATION MYOCARDIAL INFARCTION/UNSTABLE ANGINA IN PREDICTING DISEASE EXTENT, SEVERITY AND OUTCOMES.

Background: ST -segment elevation (STE) in lead aVR has been associated with three vessel disease and left main coronary stenosis in acute coronary syndrome, but prognostic relevance of this finding as an independent predictor in patients with non ST elevation myocardial infarction(NSTEMI) or unstable angina (UA) remains unknown. Methodology: We prospectively evaluated the initial electrocardiogram (ECG) in 112 patients with NSTEMI or UA. ST-elevation in lead aVR was measured. Echocardiography was performed, mitral regurgitation and left ventricular ejection fraction (LVEF) were assessed. Selective coronary angiography was performed at median of 3 days after admission, SYNTAX and Gensini scores were calculated. All the patients were followed up in hospital and 3 months after discharge. Results: Overall, 34 patients (30.3%) had STE in lead aVR (group A) and remaining 78 patients (68.7%) had NSTE (Group B). Group A patients had a higher prevalence of lateral leads ST–segment depression (p=0.001). However, group A peak troponin I (p =0.14) and LVEF ( p= 0.22) were not significantly different, but had a higher incidence of mitral regurgitation (MR) (p=0.02). The incidence of single vessel disease, double vessel disease and triple vessel disease in group A were 41%, 29.3% and 23.5%, whereas in group B they were 49%, 33.3% and 10% respectively (p=0.43, p=0.67 and p=0.06 respectively). The mean SYNTAX score was 24.56±16.43 in group A and 19.46±14.39 in group B (p = 0.47). The mean Gensini score was 64.73±40.70 in group A as compared to 46.32±39.43 in group B (p =0.53). There was no significant difference in 3 months clinical outcomes in the two groups. Conclusion: Our study showed that in NSTEMI/Unstable angina, ST elevation in aVR is associated with ST depression in lateral leads and significant MR. Readmission due to acute coronary syndromes was significantly higher in patients with STE in aVR. However, there was no significant difference in troponin I levels, LVEF, disease extent by Gensini and SYNTAX score between the two groups.

Značaj prehospitalnog prepoznavanja ST elevacije u aVR odvodu u akutnom koronarnom sindromu

Introduction/Objective the acute coronary syndrome is a medical condition that Emergency Medical Service physicians deal with daily. An especially prompt reaction is required when an ST elevation in the aVR lead is discovered, as it signifies a critical coronary lesion. The objective of the article is to present how educated the Emergency Medical Service doctors included in the STEMI network are in recognizing and treating the aVR lead elevation, as an atypical ECG finding. Case report Three patients with chest pain lasting from 30 minutes to 2.5 hours are presented. The ECG recording shows significant ST segment depressions >1mm in 6 or more leads (I, II, III, aVL, aVF, V2-V6) coupled with a 3-4mm ST elevation in the aVR lead and similar or slightly less pronounced ST elevation in V1. The strategy for primary PCI had been initialized for all three patients, who were then, after consultation with interventional cardiologists in UHMC Bezanijska kosa, Clinical Hospital Centre Zvezdara and the Military Medical Academy and having taken the initial dose of dual antiplatelet therapy (except for the third patient), transported to the hospital catheterization labs in these three institutions. Conclusion ST segment depression of 1 mm or more in six or more leads (inferolateral depression) coupled with ST segment elevation in aVR and/or V1 points to the threevessel disease (3VD) or left main coronary artery (LMCA) obstruction. The Emergency Medical Service doctors react adequately and promptly and, pending consultation with interventional cardiologists, the patients arrive directly into the catheterization lab. The final decision about reperfusion therapy is made by cardiologists and cardiac surgeons. Early invasive approach and adequate therapy (PCI/CABG) lower the risk of cardiogenic shock development and death.

Acute Coronary Syndrome with Persistent ST Segment Elevation Isolated in aVR: A Case Study

A 53 years old female patient with hypertension presented with constrictive retrosternal chest pain. Initial Electrocardiogram (ECG) showed ST elevation in aVR and high level cardiac Troponin-I. Thrombolysis with streptokinase was performed and she underwent coronary angiography who showed a long tight anterior inter ventricular lesion, occlusion of the proximal circumflex and an intermediate lesion of segment 2 of the right coronary.

P631 A misleading EKG and the saviour echo

Abstract Introduction Floating right heart thrombi (in transit from the legs to the pulmonary arteries) are a severe form of venous thromboembolism, with a high early mortality rate without treatment. Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism. Case Report Woman, 76 years old. Previous medical history of hypertension, dyslipidaemia, mitral valve repair and hypothyroidism. Recent admission in our cardiology department with de diagnosis of NSTEMI. She performed an echocardiogram that revealed only an enlarged left atrium, with no other changes. EKG only revealed inversion of T waves in V2-V4 with posterior normalization during hospital stay. She underwent to coronary angiography and right dominance without any coronary lesions was showed. The presence of a fistula, with a badly defined route, was also pointed in the coronary angio. One month after this episode she was admitted again in our emergency department due to onset of dyspnoea and productive cough. The physical examination showed SatO2: 90%; BP: 95/53 mmHg; HR: 100 bpm; Respiratory rate: 27 cpm; Apyretic (36,9ºC). Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. EKG revealed a sinus tachycardia, HR 122 bpm, with ST elevation in aVR and ST depression in DI, DII, aVL and V2-V6. Presence of S wave in DI and Q wave in DIII. While the EKG was being performed the patient presented a sudden cardiovascular deterioration (with blood pressure (BP: 67/35mmHg) drop and appearance of chest pain). We performed an arterial-blood gas test that revealed: pH7,16; pCO2 26,5; pO78,7; Potassium 4; Sodium 138; lactates 8,8. With these findings we decided to perform an echocardiogram to identify a possible cause for the shock. The echo showed right dilated chambers (with D-shape in parasternal short axis) with dilated IVC. We also point out the presence of a mobile intra-cardiac mass at the level of right atrium, suggestive of thrombus. We assumed the presence of obstructive shock in the context of pulmonary embolism. Thrombolysis was performed with clinical improvement of the patient. Medical therapy was optimized and heparin was initiated after the patient finished alteplase perfusion. During hospital stay the patients didn’t have any other cardiovascular complication and went home after 7 days in hospital. A venous doppler was performed before hospital discharge and it revealed the presence of a deep venous thrombosis at the level of right femoral vein. Conclusion The authors presented a didactic clinical case where the EKG mislead us to a possible Acute Coronary Syndrome involving the left main artery. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.

Elevation of ST-segment in aVR is predictive of cardiogenic shock but not of multivessel disease in inferior myocardial infarction

IntroductionSome studies suggest that ST elevation in aVR (aVR-STE) can predict the presence of left main or multivessel disease (MVD) and relates to prognosis. Our purpose was to analyze the relationship of aVR-STE to MVD disease or cardiogenic shock (CS) in patients with inferior myocardial infarction (inferior STEMI). MethodsWe analyzed two cohorts of consecutive patients admitted for inferior STEMI in the Coronary Unit of two university hospitals. ST elevation and ST depression in each derivation were compared between patients with and without MVD and with and without CS. ResultsWe included 342 patients—19.6% women and 80.4% men—with a median age of 60 (52, 70); 18 patients (5.2%) had MVD, and 25 (7.3%) patients presented CS. There was no relationship between ST elevation or ST depression in either derivation and MVD. In contrast, CS was associated with aVR-STE, ST-segment depression in lead aVL, and the sum of ST-segment depression. aVR-STE of 0.25 mm had a sensitivity of 24.0% and a specificity of 95.9% for CS. After multivariate analysis including clinical variables, aVR-STE was independently associated with CS. ConclusionsIn patients with inferior STEMI, ST-segment analysis was not useful in predicting multivessel disease. aVR-STE was an independent predictor of CS, with high specificity but low sensitivity.