Segment Elevation In Lead aVR Research Articles

Features of acute coronary syndrome after a COVID-19 in the aspect of pulmonary hypertension

BACKGROUND: After recovery from COVID-19 patients may develop new risk factors that lead to changes in cardiopulmonary interactions, i.e. an increase in the afterload on the right ventricle due to increased pressure in the pulmonary artery and change in pulmonary vascular resistance. It can be assumed that the presence of such a spectrum of problems can influence the severity of dyspnea and the development of pathogenetic events (pulmonary hypertension, right ventricular failure, subendocardial ischemia), which in turn can determine the outcome. AIM: To identify the characteristics of acute coronary syndrome after a COVID-19, taking into account angiographic data on coronary artery lesions and hemodynamic manifestations. MATERIALS AND METHODS: A comparative analysis of the clinical and hemodynamic consequences of the COVID-19 and the development of acute coronary syndrome in 157 patients was carried out. The group 1 included 69 patients who had had COVID-19 (vaccinated — 24.6%) during the 6 months preceding acute coronary syndrome; group 2 — 88 patients without a history of COVID-19 (vaccinated — 42%). The 12-lead electrocardiogram has been used in the diagnosis of subendocardial ischemia in acute coronary syndrome. The ST segment displacement in lead aVR was analyzed. RESULTS: After COVID-19, dispnoe occurred in 52% of the patients and in 14.8% without previous infection. Echocardiographic signs of right ventricular overload were present in 42% of the patients in group 1 and 10.2% in group 2. The mean pressure in the pulmonary artery was increased after COVID-19 in 58% of the patients in group 1 and in 10.2% of group 2 in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29% of the patients in group 1 and 2.3% of the patients in group 2. The average value of left ventricular ejection fraction in the patients who had had COVID-19 was 55.9 ± 14%, which was less than in the patients in the control group (63.2 ± 5.5%; p 0.001). ST segment elevation in lead aVr indicated high incidence of subendocardial ischemia. 40.6% in group 1, and 11.4% in group 2 (χ2 = 17.9; p 0.001); in group 1 vaccinated — 17.6%, and not vaccinated — 48.1% (χ2 = 4.9; p = 0.027), in group 2 vaccinated — 8.1%, and not vaccinated — 13.7% (χ2 = 0.7; p = 0.41). All the patients had drug-eluting stents implanted in the infarct-related artery. After stenting, no recurrence of pain or further increase in chest pain was observed. CONCLUSIONS: After coronavirus infection COVID-19, 58% of patients have increased mean pressure in the pulmonary artery in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29%. Atherothrombosis is the main mechanism of acute coronary syndrome after COVID-19 coronavirus infection. The main feature of acute coronary syndrome after a coronavirus infection COVID-19 is increased pressure in the pulmonary artery after a lung injury, which must be taken into account when planning surgical treatment tactics and management tactics in the postoperative period.

Percutaneous coronary intervention in patients admitted with acute coronary syndrome within 6 months after COVID-19 (retrospective single-center study)

BACKGROUND: Assessing clinical manifestations in patients during the period of destabilization of the course of coronary artery disease after COVID-19 coronavirus infection remains a clinical problem. Identifying features of coronary artery lesions in such patients will help to prevent the development of complications and may influence the tactics of active dynamic monitoring.
 AIM: To evaluate the structure of coronary artery lesions and clinical manifestations in patients with acute coronary syndrome that developed within 6 months after COVID-19 new coronavirus infection.
 MATERIALS AND METHODS: A comparative analysis of the results of coronary artery stenting in 157 patients admitted with acute coronary syndrome has been carried out. The 1st group included 69 patients who had COVID-19 (vaccinated — 24.6%) during the 6 months preceding acute coronary syndrome; in the 2nd — 88 patients without a history of COVID-19 (vaccinated — 42%). All the patients had drug-eluting stents implanted in the infarct-related artery. Long-term results have been observed in 151 (96.2%) patients.
 RESULTS: Before the development of acute coronary syndrome, dispnoe was more often observed in patients of the 1st group (36; 52%) than in patients of the 2nd group (13; 14.8%). There were no focal neurological symptoms in the patients of both groups. Dizziness more often preceded acute coronary syndrome in the patients of the 1st group (26; 38.2%) compared to the control group (5; 5.7%). Decreased motivation and fatigue were detected in 27 (67.5%) patients in the 1st group, which was more common than in the 2nd group (13; 32.5%). Acute coronary syndrome with ST elevation was treated in 47 % and 38.6% of the patients in the 1st groups and the 2nd, respectively. The development of acute coronary syndrome with ST segment elevation with previous clinical manifestations of post-covid syndrome in the 1st group was observed in 95.8%, whereas in the absence of post-covid syndrome in 53.3%. The mean value of LVEF in patients who had COVID-19 was 55.9 ± 14%, which was significantly lower than in the patients in the control group (63.2 ± 5.5%; р 0.001). During the course of coronavirus infection in the patients in the first group, lung damage of degrees I–II according to CT scan data was observed in 76.8% of the patients and in 23.2% of degrees III–IV. The frequency of lesions of the circumflex branch in the 1st group was 15.9%, in the 2nd — 11.4% (р = 0.403); of the right coronary artery — 33.3%, and 22.7% (р = 0.41); of the diagonal branch — 5.8%, and 3.4% (р = 0.47); of the left main coronary artery — 5.8%, and 6.8% (р = 0.79), of the left anterior descending branch — 52.2%, and 35.2% (р = 0.033), respectively. The incidence of vasospastic angina in the 1st group was 53.6%, in the 2nd — 15.9% (р 0.0001). ST segment elevation in lead AVR as a manifestation of subendocardial ischemia was registered in the 1st group — 40.6%, the 2nd — 11.4% (р 0.0001). All the patients had drug-eluting stents implanted in the infarct-related artery. Overall survival (in-hospital and long-term) was 100% for the first group and 100 % for the second one.
 CONCLUSIONS: In the structure of coronary arteries lesions after COVID-19 new coronavirus infection in patients with acute coronary syndrome, damage to the anterior interventricular artery dominates (52.2%). The likelihood of having a left anterior descending lesion during the development of acute coronary syndrome with ST segment elevation in patients who have had COVID-19 is 1.5 times higher. The structure of clinical manifestations after COVID-19 in patients before the development of acute coronary syndrome is dominated by shortness of breath (52 %) and decreased motivation and fatigue (67.5 %).

A Rare Case Report of Ruptured Sinus of Valsalva Aneurysm

<p>主動脈竇動脈瘤是一種罕見的心臟結構病變，因具非特異性表徵及困難診斷，容易導致高死亡風險。本案例是一位53歲男性患者，因急性胸痛入院治療，藉由實驗室檢查發現心肌酵素升高、D-二聚體升高，心電圖檢查為aVR導程ST段上升、於第I、II、V4~6導程出現ST-T波段變化，初步診斷為左冠狀動脈主幹心肌梗塞，立即行冠狀動脈攝影檢查發現無異常。個案出現胸痛合併心因性休克之症狀，從中排除主動脈剝離、肺栓塞、心包填塞等診斷，深入檢視病史紀錄及影像報告，發現心臟超音波、胸部電腦斷層及冠狀動脈血管攝影檢查有由左流向右心室的瘻管分流，最終確診為主動脈竇動脈瘤破裂。患者緊急接受右冠狀竇動脈瘤修補及主動脈瓣置換手術治療後，胸痛、休克狀況改善且左心室功能恢復，術後預後良好。在面對急性胸痛合併血液動力學不穩定的患者時，除了須考慮症狀相關的疾病診斷外，當聽診發現S1及S2連續性心雜音時，建議將主動脈竇動脈瘤破裂列入考慮，以掌握治療處置之重要時機。</p> <p> </p><p>Aneurysm of the sinus of Valsalva is a rare cardiac anomaly due to the nonspecific symptoms and dif-ficult confirmation of diagnosis leading to high mortality. This report describes the case of a 53-year-old man who had suffered from acute chest pain. The electrocardiogram showed the ST segment ele-vation in lead aVR and ST-T wave changes in leads I, II and V4-6. Elevated D-dimer levels and cardi-ac enzymes were also observed. Acute myocardial infarction caused by the left main coronary artery obstruction was initial diagnosed. Coronary angiogram was performed immediately and the result indicated non-obstructive coronary artery. However, cardiogenic shock with persistent chest pain was discovered. Aortic dissection, pulmonary thromboembolism and cardiac tamponade were gradually excluded. Through detailed review and analysis of medical history, physical assessment and image ex-aminations with echocardiography, chest computed tomography and coronary angiogram, a ruptured sinus of Valsalva aneurysm was eventually diagnosed based on image examinations which revealed left-to-right shunt communicating with the right-sided heart chambers. The patient received emergen-cy right coronary sinus aneurysm repairment and aortic valve replacement surgery. Symptoms with chest pain and shock gradually disappeared and left ventricular function was restored postoperatively. The patient demonstrated excellent recovery. In facing relevance diagnostics for patients with acute chest pain and hemodynamic instability, a ruptured sinus of Valsalva aneurysm must be considered to endure best treatment timing if heart auscultation reveals S1 and S2 continuous murmurs.</p> <p> </p>

Effect and Significance of Electrocardiographic Changes on Standing and Hyperventilation Prior to Exercise Electrocardiographic Testing

Electrocardiographic changes on standing from supine position and subsequent hyperventilation were studied in 100 persons. Changes were correlated with any evidence of myocardial ischemia during stress and/or recovery phase of treadmill stress testing. 15 individuals showed electrocardiographic changes on standing from supine position. Increase in heart rate of more than 30 beats per minute without a fall of more than 20 mm Hg in systolic blood pressure was seen in three cases. Two of them developed ischemic changes during exercise. Decrease in R wave amplitude in leads V2 to V6 was seen in one individual who developed ischemic changes during exercise. New inversion of T waves in leads V2 to V4 in a case with pre-existing RBBB and inverted T wave becoming positive in lead V2 were also associated with electrocardiographic evidence of myocardial ischemia during exercise testing. Mild change in QRS axis, decrease in R wave amplitude in leads II, III, aVF and/or V3 to V5 , ST segment depression of less than 1 mm and decrease in amplitude or inversion of T waves in leads II, III, aVF and V1 to V6 did not have any correlation with evidence of myocardial ischemia during exercise. Fourteen persons showed new electrocardiographic changes during hyperventilation after standing. Three cases had decrease in heart rate. All the three had evidence of myocardial ischemia during treadmill testing. Increase in amplitude of R wave in lead V4, normalization of pre-excitation with unmasking of old myocardial infarction and ST segment depression of more than 2 mm in inferior and lateral precordial leads with ST segment elevation in lead aVR were also associated with development of ECG evidence of myocardial ischemia during treadmill testing. Decrease in R wave amplitude in leads II, III, aVF and/or V4 - V6 , ST segment depression of less than 1mm in inferior or lateral precordial leads and inversion of T waves did not have any significant correlation with development of electrocardiographic signs of myocardial ischemia during treadmill stress test.

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.

Is isolated ST segment elevation in Lead aVR associated with high grade coronary artery disease?

BackgroundThe diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS). MethodsPooled sensitivity, specificity, positive, and negative likelihood ratios were calculated using a random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. ResultsThis meta-analysis included 14 studies. The pooled sensitivity of STEaVR for LM/3VD was 0.40 (95% CI; 0.38 0.43, p < 0.001), specificity 0.82 (95% CI; 0.81–0.83, p < 0.001). Pooled positive likelihood ratio 2.49 (95% CI; 1.62–3.81, p < 0.001) and negative likelihood 0.54 (95% CI; 0.39–0.76, p < 0.001). The pooled sensitivity of STEaVR for LM was 0.39 (95% CI; 0.34–0.45, p < 0.001) specificity was 0.86 (95% CI; 0.85–0.87, p < 0.001) with an AUC of 0.79. The pooled positive likelihood ratio (LR) for LM was 2.78 (95% CI, 2.28–3.39, p < 0.001) negative likelihood ratio 0.51 (95% CI, 0.33–0.78, p < 0.001). ConclusionOur study shows that in patients presenting with an ACS, presence of STEaVR may indicate the presence of LM or 3VD. STEaVR has a high specificity for both LM and 3VD, with a high pooled LR.

556 ST Segment Elevation in Lead AVR: Initial Management and Outcomes

556 ST Segment Elevation in Lead AVR: Initial Management and Outcomes

A case of left circumflex artery stenosis involving ST segment depression in multiple leads with ST elevation in lead augmented vector right

Electrocardiography (ECG) patterns of ST-segment elevation in lead aVR with or without diffuse ST segment depression may predict either left main coronary artery or triple vessel stenosis. Here, we have presented the case of a 56-year-old female involving such an ECG pattern with ST-segment depression in more than eight leads and ST Segment elevation in lead aVR, however, showing stenosis of the mid-segment of the left circumflex artery (LCX). She was scheduled to undergo percutaneous coronary intervention with implantation of a drug-eluting stent with respect to mid LCX stenosis. The patient was asymptomatic post procedure and was discharged on beta blockers. To conclude, the ECG pattern of ST depression in multiple leads with ST-elevation in aVR lead can occur in LCX obstruction as well.

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

Significance of ST Segment Elevation in Lead aVR in Patients with Non-ST Elevation Acute Coronary Syndrome

Background: As acute occlusion of the left main (LM) artery causes life-threatening hemodynamic deterioration and malignant arrhythmias, resulting in an adverse outcome, a rapid diagnosis and subsequent urgent revascularization with percutaneous coronary intervention (PCI) or coronary bypass surgery is very important in this subset of patients. The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years.&#x0D; Objective: To determine the accuracy of 12-lead electrocardiography in predicting left main and/or triplevessel disease in patients with non-ST elevation acute coronary syndrome (NSTE- ACS). Methodology: This cross sectional observational study carried out among patients presenting with non-ST elevation acute coronary syndrome at Cardiac Emergency Department or CCU of BSMMU. This study was conducted from May 2017 to April 2018. A total of 36 patients meeting the eligibility criteria were consecutively included. Data collection was carried out by using a questionnaire. Informed written consent was obtained from the hospital authority. Analysis of data was finally done with Statistical Package for Social Science program 17 version of computer on the basis of different variables.&#x0D; Result: As ST-segment elevation in lead aVR is a continuous variable, a suitable cut-off for ST- elevation in lead aVR was found out for diagnosing LM and/or triple vessel disease (TVD) using ROC curve. The cut-off value was 0.75 mm which gave us an optimum sensitivity of 88.5% and a specificity of 80% with an area under the curve being 0.892(95% CI = 0.785-1.000), p &lt; 0.001. The area under the curve demonstrated that 89.2% of the LM and/or TVD were correctly diagnosed with ST elevation e” 0.75 mm in lead aVR in patients with non-ST segment elevation acute coronary syndrome. The positive predictive value was commendably high (92%) and negative predictive value was no less (72.7%) with an overall diagnostic accuracy of 86%.&#x0D; Conclusion: From the findings of the study it can be concluded that ST- segment elevation e”0.75 mm in lead aVR in patients of non-ST segment elevation acute coronary syndrome had optimum sensitivity and specificity with an appreciably high overall diagnostic accuracy. The ST- segment elevation e”0.75 mm in lead aVR in patients with non-STE-ACS can differentiate LM and/or triple vessel disease with fair degree of accuracy.&#x0D; University Heart Journal Vol. 14, No. 2, Jul 2018; 71-76

Diffuse ST segment depression and ST segment elevation in lead aVR and V1 by left circumflex artery occlusion

The current guidelines for resting electrocardiograms of diffuse ST segment depression coupled with ST segment elevation in aVR and/or V1 that are otherwise unremarkable indicate multivessel or left main coronary artery obstruction. However, our case meets the above electrocardiogram changes, but involves left circumflex artery occlusion.

Anomalous Left Coronary Artery From the Right Sinus of Valsalva in a Patient Presenting with ST-Segment Elevation in Lead aVR: A Case Report

BackgroundAnomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia. Case ReportWe describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%). Why Should an Emergency Physician Be Aware of This?ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization.

Clinical Significance of the Forsaken aVR in Evaluation of Tachyarrhythmias: A Reminder.

Mechanism of a regular, monomorphic Wide QRS Complex Tachycardia (WCT) is an important diagnostic challenge in day to day practice for the clinicians and affects further management and prognosis. Many of the WCT and Narrow Complex Tachycardia (NCT) produce certain characteristic changes in lead aVR by which we can differentiate between them. The present study was aimed to evaluate tachyarrhythmias in relation to lead aVR and to highlight the clinical significance of lead aVR, "The Neglected Lead". This is prospective study in which 55 consecutive cases of tachyarrhythmias excluding sinus tachycardia, atrial fibrillation and atrial flutter were taken for the study admitted in from ICCU of Department of Medicine at S.S. Medical College and S.G.M. Hospital Rewa (M.P.), India, during July 2014 to September 2015, fulfilling the required study protocol. The data was collected regarding detailed history, physical examination; necessary investigations (including ECG and echocardiography) were done. Among 55 patients, 30 were of WCT and 25 were of NCT. The most common cause of WCT was Ventricular Tachycardia (VT) (83.3%) and rest were Supra Ventricular Tachycardia (SVT) with aberrancy (16.7%). The most common cause of NCT was Atrioventricular Nodal Tachycardia (AVNRT) (84%) followed by Atrioventricular Reciprocating Tachycardia (AVRT) (16%). The present study observed that 38.1% of the AVNRT cases and 50% of AVRT cases showed positive 'p' wave in lead aVR. The present study observed that 75% cases of AVRT showed ST segment elevation in lead aVR while only 33.3% cases of AVNRT showed ST elevation. In the present study 80% of the patients with WCT were diagnosed to have VT using Brugada algorithm while using Vereckei's new aVR algorithm, 83.3% were diagnosed to have VT. Lead aVR, one of the most neglected leads on 12 lead ECG, is a very important diagnostic tool for identification and categorization of different type of tachyarrhythmias. The presence of ST elevation in lead aVR on ECG showing NCT is relatively sensitive for diagnosing AVRT. New aVR algorithm by Vereckei is more sensitive for differential diagnosis of WCT. One should pay careful attention to lead aVR which provides essential diagnostic information.

Abstract 18729: Prosthetic Valve Positioning - Not a Static Question

A 65-year-old female with a history of bicuspid aortic valve s/p AVR with a Medtronic Hall mechanical valve presented with chest pain. Her recent history was notable for one week of intermittent substernal chest pain present when lying in the left lateral position. Initial ECG, obtained during an episode of chest pain, revealed 2 mm ST segment depression in the anterolateral leads and ST segment elevation in lead aVR. The ECG changes normalized with cessation of her chest pain. Laboratory evaluation showed an INR of 3.5 (on warfarin), and normal cardiac biomarkers. Chest imaging, including CT angiography, was unremarkable. Physical examination demonstrated a normal jugular venous pressure, a mechanical second heart sound, and a II/VI crescendo-decrescendo systolic murmur at the right upper sternal border. Transthoracic echocardiography (TTE) revealed normal biventricular systolic function and a mechanical valve in the aortic position, associated with mild aortic regurgitation. Valve fluoroscopy revealed an aortic monoleaflet mechanical prosthesis with normal opening and closing angles in the supine position, but with closing restriction when in the left lateral decubitus position (closing angle 46 degrees, associated with recurrent chest pain and ischemic ECG changes). Transesophageal echocardiography (TEE) showed moderate aortic stenosis, mild aortic regurgitation, and multiple linear echodensities on the aortic prosthesis. These echogenicities were felt to represent thrombi, and the patient was treated with 5 doses of tPA and intravenous heparin. Subsequent TEE and valve fluoroscopy revealed improved prosthetic leaflet motion in supine and lateral decubitus positions. This case describes an unusual presentation of mechanical aortic valve thrombosis. The contiguous association of the mechanical valve with the coronary ostia can contribute to ischemic complications, in this case positionally induced. It also highlights the value of timely valve fluoroscopy and the consideration of patient maneuvers to delineate valve function. Current guidelines support the use of thrombolytic therapy for small, left-sided thrombi, with recent literature suggesting that slowly infused low-dose tPA provides the optimal risk-benefit profile.

Predictors of significant left main/ostial left anterior descending coronary artery stenosis in patients with exercise induced ST segment elevation in lead aVR

Predictors of significant left main/ostial left anterior descending coronary artery stenosis in patients with exercise induced ST segment elevation in lead aVR

AVR the ignored lead in pre hospital management of STEMI patients

Purpose: The prognostic value of lead aVR has recently been underlined by different studies even though a long time neglected. Our objective is to evaluate the role played by lead aVR in the pre hospital management of STEMI patients. Method: Observational cohort study including consecutive STEMI patients treated with prehospital fibrinolysis in the French SAMU emergency medical system from 2003 to 2007. Baseline demographic caracteristics at admission, ECG features and outcome data were collected and entered in an univariate analysis to determine the role played by lead aVR in triaging STEMI patients. Results: 200 consecutive patients were included. Pre hospital medical reports and prehospital ECG were reviewed to stratify patients in accordance with ST segment shift in lead aVR (trigger 0.5mm). The prevalence of ST shift in lead aVR was 41% (82 patients), ST segment elevation, 25% and ST depression, 75%. but never notified in medical reports. ST segment elevation in lead aVR was significantly correlated in the acute phase with cardiogenic shock and major cardiac events such as ventricular dysrhythmias and acute heart failure. Results are shown in table below. Univariate analysis results Conclusion: ST elevation in lead aVR has a high prognostic value in our study, correlating with early cardiogenic shock and acute cardiac events. It should be considered as a marker of worse outcome and must participate in triaging STEMI patients.

New ECG index as a marker of poor prognosis in acute pulmonary embolism: ST segment elevation in lead aVR with ST segment depression in lateral leads

New ECG index as a marker of poor prognosis in acute pulmonary embolism: ST segment elevation in lead aVR with ST segment depression in lateral leads

Acute Coronary Syndromes Presenting with Transient Diffuse ST Segment Depression and ST Segment Elevation in Lead aVR not Caused by “Acute Left Main Coronary Artery Occlusion”: Description of Two Cases

Diffuse ST-segment depression in the inferior + anterolateral leads with ST-segment elevation in lead aVR has been described as characteristic of diffuse circumferential subendocardial ischemia caused by acute subtotal occlusion of the left main coronary artery. Here we describe two patients admitted for acute neurological disorders who developed transient diffuse ST-segment depression in the inferior + anterolateral leads with ST-segment elevation in lead aVR, associated with elevation of cardiac troponin-I. In both cases subsequent coronary angiography did not show significant left main stenosis or "left main equivalent" narrowings. As both patients had acute neurological disorders, a possible association between the two conditions is discussed.

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

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

Therapeutic hypothermia in combination with percutaneous coronary intervention in out-of-hospital cardiac arrest due to left main coronary artery disease

A 59-year-old man had a witnessed collapse while driving a car. Approximately 10 min after the call to emergency services, paramedics arrived and initiated cardiopulmonary resuscitation. The first electrocardiogram (ECG) obtained by paramedics showed pulseless electrical activity. Review of his prehospital records documented that he experienced approximately 13 min of no flow or low flow before return of spontaneous circulation. On admission, he was still comatose with midrange dilated pupils. Electrocardiogram showed sinus rhythm, ST segment elevation in lead aVR, and ST segment depression in leads I, II, and V4-6. Coronary angiography showed 99% narrowing of the left main coronary artery (LMCA), but did not show any disease in the right coronary artery. A bare-metal stent was placed in the LMCA, and postdilated at 20 atmospheres. Immediately after return to the coronary care unit, therapeutic hypothermia was initiated. Hypothermia with a target temperature of 33.0 degrees C was maintained for 30 h. During this period, no significant hemodynamic instability occurred under intra-aortic balloon pumping (IABP) and intravenous catecholamines. Subsequently, he was slowly rewarmed at a rate of 0.3 degrees C/h up to 36.0 degrees C. Next day, the neurological condition improved and IABP was stopped. Creatine kinase increased to 2182 IU/l. Stent thrombosis did not occur despite the ad hoc loading of antiplatelet drugs. Follow-up echocardiography 9 days later showed mild hypokinesia of the anterior wall with an ejection fraction of 77%. He was discharged with no neurologic complications 18 days later.