Exercise-induced ST Elevation Research Articles

Abstract 14062: Accuracy of Exercise Induced St- Elevation in Lead Avr in the Diagnosis of Significant Left Main or Proximal Left Anterior Descending Artery Stenosis: A Systematic Review

Introduction: ST-segment changes during exercise stress testing are diagnostic of myocardial ischemia in patients with suspected coronary artery disease (CAD). Recent studies have shown that exercise-induced ST-elevation in aVR is associated with significant stenosis of the left main (LM) and proximal left anterior descending (pLAD) arteries Methods: Search of electronic databases (Embase, Medline, and Web of Science) using MeSH terms and keywords for exercise stress test, lead aVR and CAD was performed from inception through December 2019. 2 reviewers independently screened results in 2 stages: title/abstract followed by full text. Included studies had adult patients who underwent exercise stress testing and reported the performance of ST-elevation >1 mm in lead aVR for diagnosing significant LM or pLAD disease. Significant disease was defined as luminal narrowing >50% and >70% for LM and pLAD respectively. Pooled sensitivity, specificity, likelihood ratios (LR) and diagnostic odds ratios were calculated using a bivariate model, and a summary receiver operator curve (SROC) was constructed. Results: We included 6 studies with 1128 patients. The pooled sensitivity was 0.8 (95% CI 0.36-0.97; I 2 =94.7) and pooled specificity was 0.78 (95% CI 0.56-0.90; I 2 =97.8). Overall calculated positive LR was 3.56 (95% CI 2.34-5.4) and negative LR was 0.26 (95% CI 0.07-1.01). The pooled diagnostic odds ratio was 13.5 (95% CI 4.8-38.5). Hierarchical SROC curve showed an area under the curve of 0.84 (95% CI 0.81-0.87) (Figure 1). Conclusions: Our analysis showed moderate sensitivity and specificity of exercise-induced aVR ST-elevation for diagnosing significant LM or pLAD disease. The heterogeneity among studies was high, likely due to differences in patient selection. In conclusion, ST-elevation in aVR during exercise stress test increases the likelihood of having LM or pLAD disease. Large studies are needed to substantiate this finding.

ST-Segment Elevation During Treadmill Exercise Test in a Patient without Prior Myocardial Infarction. A Case Report and Literature Review

Exercise-induced ST-elevation is extremely uncommon especially in patients without prior myocardial infarction. It is more common among post-infarction patients with Q waves on the resting ECG. In the current case we report a 50-year-old man with a history of chest pain on exertion started four months ago. During the exercise test, ST-elevation was observed in leads II, III, AVF. Coronary angiography revealed significant stenoses in the right coronary artery and left circumflex artery, which were treated with percutaneous coronary intervention. This case highlights the rare finding of exercise-induced ST-elevation and reviews possible mechanisms.

Exercise-induced ST elevation with minimal ischemia by perfusion imaging

Exercise-induced ST elevation with minimal ischemia by perfusion imaging

Exercise-Induced ST Elevation in Patients With Non-Ischemic Dilated Cardiomyopathy and Narrow QRS Complexes

The clinical significance and prevalence of exercise-induced ST elevation (ESTE) in non-ischemic dilated cardiomyopathy (NIDCM) patients are unknown. We retrospectively examined 12-lead ECGs during cardiopulmonary exercise testing in 360 consecutive NIDCM patients (left ventricular ejection fraction (LVEF) <45%) with narrow QRS. ESTE was defined as ≥1.0mm ST (J-point) elevation compared with baseline. During long-term follow-up for major cardiac events (death, transplantation, or LV assist device implantation), ESTE was recognized in 50 patients (14%). They had much lower LVEF than patients without ESTE (20±7% vs. 27±7%, respectively, P<0.001), whereas the differences in peak VO2 (P=0.01) and VE/VCO2 slope (P=0.04) were relatively small. Major cardiac events occurred more frequently in patients with ESTE than in those without ESTE (39% vs. 12% at 48 months). Increased event rates were associated with low peak VO2 (<14ml·min(-1)·kg(-1)) in patients without ESTE (39% vs. 23%, P<0.05), but not in those with ESTE (50% vs. 62%, NS). Cox multivariate analysis revealed ESTE as the strongest independent prognosticator among exercise parameters (hazard ratio: 2.41 [95% confidence interval 1.03-5.63], P<0.05). A substantial number of NIDCM patients exhibit ESTE, which indicates a poor prognosis. Low peak VO2 and ESTE may reflect different aspects of the pathophysiological processes that deteriorate heart failure.

Myocardial bridge: an unusual cause of asymptomatic ST-elevation during treadmill stress test causing functional ischaemia.

Myocardial bridges are congenital structural abnormalities with debated clinical relevance; they may be traditionally asymptomatic or associated with various clinical manifestations, some of which may be potentially fatal. We report on a 60 years old man, who underwent a follow-up stress/rest myocardial perfusion scintigraphy developing asymptomatic exercise-induced ST-elevation and demonstrating completely reversible ischaemia in the scintigraphic images. Subsequent coronary angiography showed no artery stenosis, but revealed an intramyocardial pathway of the left anterior descending artery throughout a myocardial bridge. In conclusion, to our knowledge, this is the first reported case of asymptomatic exercise-induced ST-elevation secondary to a myocardial bridge.

Significance of exercise-induced ST segment elevation in Q leads in patients with a recent myocardial infarction and an open infarct-related artery: Analysis with angiography, intracoronary myocardial contrast echocardiography and cardiac magnetic resonance

Aims The significance of exercise-induced ST segment elevation in Q leads in patients with a recent myocardial infarction and without significant residual stenosis in the infarct-related artery has not been defined. We aimed to elucidate the role of myocardial perfusion and viability in this scenario. Methods and Results Sixty-six patients with a first myocardial infarction, single-vessel disease and an open artery were studied. Myocardial perfusion was assessed with angiographic blush, intracoronary myocardial contrast echocardiography and magnetic resonance. Myocardial viability was quantified by means of magnetic resonance (transmural extent of necrosis). Exercise-induced ST elevation in Q leads was observed only in 13 cases (20%); 53 patients (80%) did not show this finding. The group with ST elevation had fewer cases with normal perfusion: Blush 3 (15% vs. 74%, p=0.001), myocardial contrast echocardiography score >0.75 (8% vs. 81%, p=0.001) and magnetic resonance score >0.75 (31% vs. 68%, p=0.03). Similarly, myocardial viability (necrosis <50%) was less frequent in patients with ST elevation (8% vs. 72%, p=0.001). Conclusion In patients with a first myocardial infarction and without residual ischemia, exercise-induced ST segment elevation in Q leads is an uncommon finding and it is related to a more damaged coronary microcirculation and to less viable myocardium.

Prediction of Infarct-Related Coronary Artery of Patients with Acute Inferior Myocardial Infarction by a Predischarge Exercise Test Index

The predictive accuracy of electrocardiographic markers in identifying the infarct-related artery of myocardial infarctions has been a subject of extensive investigation. The present study was designed to test whether the index L II/L III ratio adapted to exercise electrocardiograms could be utilized as a marker to distinguish right coronary and left circumflex arteries as culprit coronaries in acute inferior myocardial infarctions. For this purpose, 82 patients with a positive-symptom-limited and/or submaximal treadmill exercise test with modified Bruce protocol after an acute inferior myocardial infarction were studied. Those patients with ST segment elevation during the stress test were included in the study. ST segment index was defined as the ratio of exercise-induced ST elevation amplitude in L II/L III. Patients were classified as having an index > 1 (n = 24) and 1, whereas most (51/58; 88%) patients with an index <1 had the culprit lesion in their right coronary artery (p<0.001). The ratio of exercise-induced ST elevations in leads L II and L III has a significantly high ability to discriminate the infarct-related coronary artery in patients with uncomplicated inferior myocardial infarction. Considering the prognostic importance of the type of coronary involvement, this index could be a part of predischarge evaluation in this patient group.

Prediction of Infarct-Related Coronary Artery of Patients with Acute Inferior Myocardial Infarction by a Predischarge Exercise Test Index

The predictive accuracy of electrocardiographic markers in identifying the infarct-related artery of myocardial infarctions has been a subject of extensive investigation. The present study was designed to test whether the index L II/L III ratio adapted to exercise electrocardiograms could be utilized as a marker to distinguish right coronary and left circumflex arteries as culprit coronaries in acute inferior myocardial infarctions. For this purpose, 82 patients with a positive-symptom-limited and/or submaximal treadmill exercise test with modified Bruce protocol after an acute inferior myocardial infarction were studied. Those patients with ST segment elevation during the stress test were included in the study. ST segment index was defined as the ratio of exercise-induced ST elevation amplitude in L II/L III. Patients were classified as having an index > 1 (n=24) and < 1 (n=58), and the findings were compared with the findings on coronary angiography. The groups were comparable with respect to age, gender, peak exercise level, and double products achieved. Circumflex artery was the infarct-related one in the majority (21/24; 88%) of patients with an index > 1, whereas most (51/58; 88%) patients with an index < 1 had the culprit lesion in their right coronary artery (p<0.001). The ratio of exercise-induced ST elevations in leads L II and L III has a significantly high ability to discriminate the infarct-related coronary artery in patients with uncomplicated inferior myocardial infarction. Considering the prognostic importance of the type of coronary involvement, this index could be a part of predischarge evaluation in this patient group.

Usefulness of predischarge exercise electrocardiographic testing in detecting the late patency status of the infarct-related artery.

Predischarge exercise electrocardiographic testing (PEET) represents a widely accepted clinical tool for prognostic and functional assessment of patients who experience an uncomplicated acute myocardial infarction (AMI). However, there are no data suggesting any relation between PEET results and patency status of the infarct-related artery (IRA). The aim of this study was to investigate whether ST and/or QT-dispersion (QTD) changes induced by a low-level PEET, after uncomplicated ST-elevation AMI, are related to the late patency status of the IRA. We prospectively evaluated 61 consecutive patients who had suffered a first uncomplicated ST-elevation AMI. All of them successfully carried out four stages of the modified Bruce protocol exercise testing before discharge, and thereafter were subjected to coronary angiography. Exercise-induced ST elevation and QTD shortening were found significantly more frequently in patients with persistently occluded IRA, as compared to patients with patent IRA (ST elevation 65% vs 27%, P = 0.006; QTD shortening 80% vs 29%, P < 0.0001). The coexistence of the two variables predicted the presence of occluded IRA with a positive predictive value of 75%, whereas the absence of both predicted the patency of IRA with a negative predictive value of 100%. These results indicate that ST-elevation and QT-dispersion changes induced by a predischarge exercise testing after a first ST-elevation AMI may effectively predict the late patency status of the infarct-related artery.

Significance of exercise-induced ST changes in leads aVR, V5, and V1. Discrimination of patients with single- or multivessel coronary artery disease.

It is known that exercise-induced ST-segment elevation in lead V1 (V1-E) detects left anterior descending (LAD) stenosis. It was also postulated that ST elevation in aVR and simultaneous ST depression in V5 (aVR-E + V5-D) is a marker of ischemia due to significant stenosis of the LAD in patients with single-vessel disease. This study was undertaken to investigate the significance of the concomitant appearance of both electrocardiographic (ECG) ischemic markers, and of each of them alone during exercise, to detect either LAD stenosis as single-vessel coronary artery disease (CAD), or multivessel CAD involving LAD stenosis. A total of 196 consecutive patients (152 men and 44 women, mean age 54 +/- 7 years) with at least one of these ECG markers, who underwent treadmill exercise testing with the Bruce protocol and coronary arteriography, were studied. Patients were divided into three groups. In Group A (83 patients with V1-E + aVR-E & V5-D), 93% of patients with single-vessel disease had significant LAD stenosis (p<0.001), whereas 75% of patients with double-vessel disease had significant stenoses of the LAD and the left circumflex (LCx) coronary arteries (p<0.01). In Group B (97 patients with aVR-E & V5-D but without V1-E), 43% of patients with single-vessel disease had significant LAD stenosis (p<0.08), whereas 85% of patients with double-vessel disease had significant stenoses of the LAD and the right coronary artery (RCA) (p<0.01). In Group C (16 patients with only V1-E), 60% of patients with single-vessel disease had significant LAD stenosis (p<0.05), whereas 75% of patients with double-vessel disease had significant LAD and LCx stenoses (p<0.05). The concomitant appearance of exercise-induced ST elevation in lead V1, ST elevation in lead aVR, and ST depression in lead V5, as well as the isolated appearance of ST elevation in lead V1 detect significant LAD stenosis as single-vessel disease, or significant stenoses of LAD and LCx arteries in patients with double-vessel disease, whereas the appearance of ST elevation in aVR & ST depression in V5 but without ST elevation in V1 correlates strongly with significant LAD and RCA stenoses and usually indicates double-vessel disease.

3520 Exercise-induced ST-elevation on Q leads after a first myocardial infarction in patients with an open infarct-related artery. Relationship with myocardial viability and coronary microcirculation

3520 Exercise-induced ST-elevation on Q leads after a first myocardial infarction in patients with an open infarct-related artery. Relationship with myocardial viability and coronary microcirculation

Contribution of the sT elevation/T-wave normalization in q-wave leads during routine, pre-discharge treadmill exercise test to patient management and risk stratification after acute myocardial infarction

This study investigated whether ST-segment elevation and T-wave normalization (TWN) in Q-wave leads on pre-discharge exercise electrocardiogram (ECG) can contribute to patient management after a recent myocardial infarction (MI). The clinical relevance of these exercise ECG changes remains controversial despite accumulating evidence of their association with myocardial viability. Because discrepancies of previous studies may depend on patient selection, the value of these ST/T abnormalities in the thrombolytic era should be better defined. One-hundred one patients, age 58 +/- 11 years, with a recent, first Q-wave MI (57% thrombolyzed, ejection fraction 43 +/- 7%) underwent pre-discharge, submaximal treadmill testing followed, in the absence of severe ischemia, by dobutamine stress echocardiography, thallium-201 single photon emission computed tomography, and coronary angiography. ST elevation at peak exercise, but not TWN, was associated with more severe infarctions as indicated by higher peak creatine kinase (p < 0.05) and with a greater number of scarred segments both on echocardiography (p < 0.05) and scintigraphy (p < 0.01). However, the incidence of myocardial viability and ischemia did not differ between groups with or without these ST/T changes. Anterior infarction location and >or=3 echocardiographically scarred segments were among the independent predictors of ST elevation at peak ergometric exercise. During follow-up (31 +/- 13 months), the rate of hard events was low (8%) and similar between the study groups. In patients after acute Q-wave MI without severe ischemia according to clinical and standard ECG criteria, exercise-induced ST elevation, but not TWN, is associated with larger infarctions. The contribution of these ST/T abnormalities toward identifying patients with myocardial viability or ischemia and determining risk stratification is poor. In-hospital management of such patients based on routine clinical practice is sufficient for selection of a population with a relatively low long-term risk.

Exercise versus dobutamine-induced ST elevation in the infarct-related electrocardiographic leads: Clinical significance and correlation with functional recovery

Background The clinical significance of stress-induced ST elevation early after acute myocardial infarction and its relation to functional recovery remain controversial. The aims of this study were (1) to determine the incidence of ST elevation during dobutamine and exercise tests and (2) to assess the relative accuracy of exercise and dobutamine ST elevation for predicting functional recovery after acute myocardial infarction. Methods and Results We investigated 52 patients who underwent supine exercise (from 25 W to maximal charge) and dobutamine (from 5 to 40 μg/kg per minute and up to 1 mg atropine) stress electrocardiography in the same position. ST elevation was defined as new or worsening at >1 mm, 80 ms after J point. Echocardiography and quantitative angiography were available in all patients before hospital discharge. The follow-up resting echocardiogram was recorded 30 ± 6 days after the acute event. ST elevation developed during 30 (58%) dobutamine and 24 (46%) exercise tests. The sum of ST elevation was higher during dobutamine testing (7.7 ± 3.8 mm) than during exercise (5.5 ± 2.5 mm) (P =.03). A low peak creatine kinase level was the single independent predictor of dobutamine-induced ST elevation. Functional improvement occurred in 35 patients. Two independent predictors of functional recovery were selected from multivariate analysis: dobutamine ST elevation (χ2 = 9.1; P =.0026) and low peak creatine kinase level (χ2 = 5.1; P =.025). When dobutamine ST elevation was not included in multivariate analysis, exercise-induced ST elevation emerged as an independent predictor of functional recovery (χ2 = 5.0; P =.023). Significant linear correlation was found between the sum of ST elevation at peak dobutamine stress and the extent of functional recovery (r = 0.87; P <.0001). In contrast, no correlation was observed with exercise ST elevation (r = 0.06; P = not significant). Conclusions Stress-induced ST elevation is an ancillary sign of viable myocardium that can recover. The sum of ST elevation at peak dobutamine stress correlates with the extent of functional recovery. (Am Heart J 2001;141:772-9.)

Dobutamine- vs exercise-induced ST segment elevation early after Q wave myocardial infarction. Prediction of functional recovery after revascularization.

The association between stress-induced ST elevation and functional recovery following revascularization after myocardial infarction remains unclear. We assessed the relative accuracy of dobutamine- and exercise-induced ST elevation in Q wave leads in predicting functional recovery following revascularization, and we investigated the relationship of ST elevation to different wall motion responses to dobutamine. Thirty-nine patients underwent dobutamine stress echo and exercise test 8+/-2 days after Q wave myocardial infarction. All patients underwent angiography and subsequent revascularization. Follow-up echocardiograms were obtained 7+/-4 weeks after revascularization. Functional recovery was assessed by the difference between the baseline and the follow-up asynergy index. Nineteen patients (48%) developed dobutamine- and exercise-induced ST elevation. There was significant agreement between the tests (k=0.58, P<0.001). We found a significant correlation between dobutamine and exercise-induced ST elevation with functional recovery following revascularization (r=0. 45, P<0.005 and r=0.7, P<0.001, respectively). The parameters with the highest predictive value for functional recovery were: (a) the biphasic response during dobutamine infusion, (b) the development of ST elevation in both tests, and (c) the development of exercise-induced ST elevation in more than three leads. There is a strong association between dobutamine- and exercise-induced ST elevation with functional recovery following revascularization. Exercise-induced ST elevation in more than three leads and a biphasic response during dobutamine infusion accurately predict functional recovery.

Exercise-induced negative U waves in precordial leads as a marker of viable myocardium in patients with recent anterior myocardial infarction

Patients with recent anterior myocardial infarction and a significant stenosis in the left anterior descending coronary artery were divided into two groups according to the presence (Group A, n=24) or absence (Group B, n=77) of negative U waves in the precordial leads during exercise stress test to compare the coronary arteriographic findings. Both total occlusion of the left anterior descending coronary artery (79% vs. 31%, P<0.01)) and good (index=2,3) collateral circulation to the territory of this artery (92% vs. 36%, P<0.01) were observed more often in group A than in group B. In order to determine whether detection of exercise-induced negative U waves in precordial leads can predict the presence of viable myocardium, the 56 patients (20 of group A and 36 of group B) with total or subtotal occlusion of the left anterior descending coronary artery were studied further. The coronary arteriographic and exercise 201Tl scintigraphic findings were compared between the groups. Good collateral circulation to the territory of this artery was observed significantly ( P<0.05) more often in group A (100%) than in group B (61%). Patients with multivessel disease were significantly ( P<0.05) more prevalent in group A (70%) than in group B (33%). The incidence of a significant partial redistribution in the anteroseptal area in the 20Tl images 4 h after exercise was significantly ( P<0.01) higher in group A (85%) than in group B (39%). In 29 patients with anterior Q-wave myocardial infarction and exercise-induced ST elevation in precordial leads, a significant 201Tl redistribution in the anteroseptal area was observed in 8 (80%) of 10 patients of group A in contrast to only 4 (21%, P<0.05) of 19 in group B. In the diagnosis of the viability associated with 201Tl redistribution in the anteroseptal area by the finding of exercise-induced negative U waves, the sensitivity was 67% and the specificity was 88% in these patients. We conclude that exercise-induced negative U waves in precordial leads are a convenient and specific marker for the presence of viable myocardium in patients with recent anterior myocardial infarction.

Exercise-induced ST elevation in patients with arrhythmogenic right ventricular dysplasia

To test the hypothesis that local or diffuse wall motion abnormalities in the right ventricle in patients with arrhythmogenic right ventricular dysplasia (ARVD) may induce the ST-segment elevation in response to exercise, we examined exercise electrocardiograms in patients with ARVD. In 17 patients with ARVD, who demonstrated right ventricular wall motion abnormalities without organic coronary lesions, we conducted a treadmill exercise test. Significant exercise-induced ST-segment elevation (ESTE) was defined as a 0.1 mV or more ST-segment elevation at J point. ESTE was observed in 11 patients (65%). It manifested most frequently in right-sided precordial leads. Severe right ventricular asynergy was seen in all but one (91%) among 11 with ESTE, whereas it was seen only in two (33%) among six without ESTE ( P < .05). The maximal magnitude of ESTE inversely correlated with right ventricular ejection fraction (r = −0.58, P < .05). ESTE was seen in two thirds of ARVD patients, helping us noninvasively diagnose ARVD. The fact that ventricular wall motion abnormalities could cause ESTE in the absence of organic coronary lesions suggested the critical role of mechanical factors in the genesis of ESTE.

Lack of Arrhythmogenicity with ST-Segment Elevation During High-Dose of Dobutamine Atropine Stress in Patients With Documented or Suspected Coronary Artery Disease

The angiographic, echocardiographic, and electrocardiographic correlates of ST-segment elevation during high-dose dobutamine-atropine stress were prospectively looked at in a group of high-risk patients. Unlike exercise-induced ST elevation, ST-segment elevation with dobutamine-atropine stress, while indicating transmural ischemia, did not increase rate of arrhythmias and hence by itself may not be an indication to terminate the test.

Assessment of residual tissue viability by exercise testing in recent myocardial infarction: Comparison of the electrocardiogram and myocardial perfusion scintigraphy

The assessment of residual myocardial viability in infarcted areas is relevant for subsequent management and prognosis but requires expensive technology. To evaluate the possibility that simple, easily obtainable clinical markers may detect the presence of within-infarct viable tissue, the significance of exercise-induced ST elevation occurring in leads exploring the area of a recent Q wave myocardial infarction was assessed.Twenty-five patients with recent (<6 months) myocardial infarction were studied. All had angiographically documented coronary artery disease, diagnostic Q waves (n = 24) or negative T waves (n = 25) on the rest 12-lead electrocardiogram and exhibited during exercise a ≥1.5 mm ST segment elevation (n = 17) or isolated T wave pseudonormalization (n = 8) in the infarctrelated leads.ST-T wave changes were reproduced in all patients during thallium-201 exercise myocardial scintigraphy. A fixed perfusion defect was observed in 24 of the 25 patients. A reversible defect was seen in 16 (94%) of 17 patients who exhibited transient ST elevation during exercise but in only 4 (50%) of the 8 patients who had only T wave pseudonormalization.In conclusion, in patients with recent myocardial infarction, analysis of simple ST segment variables obtained during exercise testing may allow a first-line discrimination of those who may potentially benefit from a revascularization procedure.

Significance of signal-averaged P-wave changes during exercise in patients with coronary artery disease and correlation with angiographic findings

The maximal P-wave duration in all time-aligned leads, and the maximal P-wave amplitude in leads V 5 and V 6 were measured on a 12-lead, signal-averaged electrocardiogram during the recovery period of an exercise stress test (EST). The study group consisted of 75 patients with coronary artery disease (CAD) documented by ≥50% diameter stenosis in 1 or more arteries and a control group of 47 subjects, 15 of them young volunteers and 32 with no or minimal coronary atherosclerosis and normal left ventricular function. All subjects underwent a symptom limited EST, with use of the Ellestad protocol. Signal-averaged P waves recorded before exercise, and for the first 6 minutes in recovery were measured using a 5X magnifier. The mean P duration before exercise in the control group was 107 ± 16 ms (±1 standard deviation) and 111 ± 15 ms at the third minute of recovery, (p < 0.001). In patients with CAD it was 112 ± 12 and 129 ± 19 ms (±1 standard deviation), p < 0.001, respectively. Differences in P-wave duration were found to be statistically significant (p < 0.001) throughout recovery in the group with CAD when compared with control and maximal values at the third minute. The increase in P-wave duration (≥20 ms) was used as an additional parameter to exercise-induced ST-segment depression, ST elevation, or anginal pain for the test interpretation. The sensitivity increased from 57 to 75% and the specificity decreased from 85 to 77%. It is concluded that the measurement of the P-wave duration during recovery adds diagnostic power during EST.

Is ST elevation the only electrocardiographic response of the ischemic right ventricle?

Right ventricular (RV) infarction is frequently associated with transient ST elevation in right precordial leads 1,2. Studies of patients with an inferior infarction have shown that right precordial ST elevation is predictive of a proximal right coronary artery (RCA) occlusion 3, and that the duration of the ST elevation is predictive of the extent of early RV dysfunction 4. The spectrum of electrocardiographic response to ventricular ischemia is well described in the left coronary distribution 5–7 but not in the RCA distribution. Stenosis of the proximal RCA before the major RV branches is uniformly associated with exercise-induced right precordial ST elevation 8–10. Proximal RCA lesions have also been associated with a reduction in RV ejection fraction during exercise and during balloon occlusion. 11,12 Two studies of 8 and 13 patients undergoing RCA angioplasty showed right precordial ST elevation, but did not report the occurrence of right precordial ST depression 13,14. This study was performed prospectively to determine the electrocardiographic response in V 4R in consecutive patients undergoing coronary angioplasties, using angioplasty as a model of reversible ischemia. We hypothesized that ischemia during proximal RCA angioplasty would be similar to exercise-induced ischemia—that is, ST elevation and not ST depression would be seen in the right precordial leads.