ST Depression In aVR Research Articles

Polycythemia Vera Presenting as ST-Segment Elevation Myocardial Infarction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Acute ST-segment elevation myocardial infarction: The prognostic importance of lead augmented vector right and leads V7-V9.

Background:Acute myocardial infarction (MI) is associated with high mortality and among survivors have high morbidity. Electrocardiogram (ECG), a cost-effective and easily available, has traditionally been used not only just for diagnosis of MI but also for culprit vessel recognition and for prognostication. However, the role of lead augmented vector right (aVR) and leads V7–V9 in acute MI are often neglected in clinical practice. We studied the role of lead aVR and leads V7–V9 in ST-elevation MI (STEMI) patients.Methods:A total of 209 patients presenting with STEMI were enrolled in the study. History of comorbid conditions and habits was enquired. Routine blood tests were performed. Full spectrum ECG (including V7–9) and 2D-ECHO was performed on all patients. All the patients underwent revascularization by primary percutaneous coronary intervention. The role of lead aVR, lead V7, and leads V8–9 was analyzed in anterior wall MI (AWMI) and inferior wall MI. All the patients were followed up for 1 month for outcome assessment.Results:Of the 209 patients, 85.1% were males and 35.8% were diabetic, 60.2% were smokers, AWMI accounted for 55.5%. Lead aVR ST deviation was noted in 75.1% of patients (elevation in 17.7% and depression in 47.1%). V7 ST elevation occurred in 27.6% and V8–9 elevation occurred in 7.5% of the study population. Total death was 11.9% in the study (including the in-hospital mortality), all these patients had lead aVR ST segment deviation (P < 0.001).Conclusion:Lead aVR ST deviation and Lead V7 ST deviation helps to prognosticate the STEMI patients as high risk and those with aVR ST depression had higher mortality compared to aVR ST elevation because of larger myocardial involvement.

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

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

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

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

The forgotten lead: Does aVR ST-deviation add insight into the outcomes of ST-elevation myocardial infarction patients?

Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction patients treated with fibrinolysis. However, its prognostic value in a contemporaneous population undergoing primary percutaneous coronary intervention is unknown. A core laboratory examined the 12-lead baseline electrocardiogram in 5,683 patients presenting within 6 hours of symptom onset in the APEX-AMI trial, and readers were blinded to study treatment and clinical outcomes. aVR ST-deviation was significantly associated with 90-day death when compared with patients with no aVR ST-deviation (aVR ST-depression [ST-D] 5%, aVR ST-elevation [ST-E] 10.2%, no ST-deviation [N] aVR 3.8%, P < .001). After multivariable adjustment, aVR ST-E was strongly associated with 90-day death in inferior myocardial infarction (MI) (adjusted hazard ratio [HR] 5.87, 95% CI 2.09-16.5), whereas aVR ST-D was associated with excess mortality in noninferior MI (1.53, 1.06-2.22; P [interaction] < .001). aVR ST-E was also significantly associated with the presence of left main coronary (N aVR 1.8%, aVR ST-E 7.7%, P ≤ .001) and multivessel coronary disease (N aVR 41.3%, aVR ST-E 53.3%, P ≤ .001). Lead aVR ST-deviation is common, occurring in one-third of all ST-elevation myocardial infarction patients and independently associated with increased 90-day death. Myocardial infarction location modulates the prognostic significance of aVR ST-deviation such that lead aVR ST-E in inferior MI and ST-D in noninferior MI represent 2 high-risk groups. There was also more frequent advanced coronary disease in patients with aVR ST-E.

Allergic myocardial infarction

Allergic myocardial infarction

263 The Forgotten Lead: Does aVR ST-Deviation Add Insight Into STEMI Patients?

Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction (STEMI) patients (pts) treated with fibrinolysis. However, its prognostic value in patients undergoing primary percutaneous coronary intervention (PCI) is unknown. We examined this question in nearly 5700 high-risk STEMI pts presenting within 6 hours of symptom onset in the Assessment of PEXelizumab in Acute Myocardial Infarction (APEX-AMI) trial. A core laboratory examined the 12-lead baseline electrocardiogram (ECG) in 5683 pts, and readers were blinded to study treatment and clinical outcomes. The association between aVR ST-elevation or depression (≥1mm at the J-point) versus no ST-deviation and 90-day mortality was examined via Cox regression (adjusted Hazard Ratio (HR) and 95% confidence intervals (CI) reported), and the interaction with MI location was tested. Six percent (n=352) had ST-elevation in lead aVR and 27% (n=1512) had ST-depression in lead aVR. The pts with aVR ST-elevation were older, higher heart rate, higher Killip class, and more prior MI compared to pts with no aVR ST-deviation (Table). They were also more likely to have a non-inferior MI. Mortality within 90 days was highest among those with aVR ST-elevation, particularly among pts with inferior MI (Table). After adjustment for age, systolic blood pressure, heart rate, creatinine, Killip class and MI location, both ST-depression and ST-elevation in aVR were associated with increased hazard of 90-day mortality (Table). The interaction with MI location was also significant (p<0.001) such that ST-depression was associated with higher risk in non-inferior MI pts; ST-elevation in aVR in inferior MI pts.Tabled 1 aVR ST deviation, occurring in one third of STEMI pts, was associated with a similar increase in 90-day mortality after multivariable adjustment. aVR ST-depression was most strongly associated in non-inferior MI whereas aVR ST-elevation was in those with inferior MI. When assessing risk from baseline ECG, the evaluation of ST-deviation in lead aVR provides valuable prognostic insight into STEMI pts treated with PCI.

Electrocardiographic predictors of culprit artery in acute inferior ST elevation myocardial infarction

Background In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to ST depression in lead aVR to predict culprit artery in inferior STEMI. Methods In 106 patients with acute inferior STEMI who underwent emergent coronary angiography, we correlated electrocardiographic and angiographic findings pertaining to the culprit artery. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them and our own from Kanei et al using ST depression in aVR for predicting the left circumflex artery (LCx) as the culprit, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery. Results The sensitivity and specificity of ST depression in lead aVR to predict LCx as the culprit were 53% and 86%, respectively, and 86% and 55%, respectively for predicting the right coronary artery (RCA) as the culprit. When their algorithms were applied to our population, the sensitivities and specificities of Fiol et al and Tierala et al were slightly higher. Conclusion Compared to other proposed algorithms, ST depression in aVR is a simple method with satisfactory sensitivity and specificity to predict the culprit artery in inferior STEMI.

Electrocardiographic characteristics in angiographically documented occlusion of the dominant left circumflex artery with acute inferior myocardial infarction: limitations of ST elevation III/II ratio and ST deviation in lateral limb leads

Background The prognosis of dominant left circumflex artery (LCx) occlusion-related inferior acute myocardial infarction (AMI) patients is poor, but the electrocardiographic (ECG) characteristics of this AMI entity have not been described. Methods One hundred thirty-five patients with first dominant right coronary artery (RCA) or dominant LCx-related inferior AMI were included. The characteristics of ECG obtained on admission for 55 patients with culprit lesions proximal to the first major right ventricular (RV) branch of dominant RCA (group proximal dominant RCA), 62 patients with culprit lesions distal to the first major RV branch of dominant RCA (group distal dominant RCA), and 18 patients with culprit lesions in dominant LCx (group dominant LCx) were compared. Results There were no significant differences among the 3 groups in the prevalence regarding an S/R ratio greater than 1:3 in aVL, ST elevation in aVR (ST↑ aVR), ST depression in aVR (ST↓ aVR) of 1 mm or more, and atrioventricular block. Greater ST elevation in lead III than in II and greater ST depression in aVL than I showed specificity of 17% and 44% to identify dominant RCA as culprit lesion, respectively. All 3 groups could be distinguished on the basis of ST↑ V4R, ST↓ V4R, ST↓ V3/ST↑ III of 1.2 or less, and ST↓ V3/ST↑ III of more than 1.2. Conclusions Greater ST elevation in lead III than in II, greater ST depression in aVL than I, and an S/R ratio of greater than 1:3 in aVL were not useful to discriminate between dominant RCA and dominant LCx occlusion-related inferior AMI. ST-segment deviation in lead V 4R and the ratio of ST↓ V3/ST↑ III were useful in predicting the dominant artery occlusion-related inferior AMI.

The Value of ECG Lead aVR in the Differential Diagnosis of Acute Inferior Wall Myocardial Infarction

To investigate whether the ST changes in the aVR lead on 12-lead ECG can be used to identify infarct-related artery (IRA) in patients with acute inferior myocardial infarction. The ECG features were studied in 90 patients with acute inferior myocardial infarction where IRA was confirmed by coronary angiography. Right coronary artery (RCA) and the left circumflex coronary artery (LCX) were identified as IRA in 70 and 20 patients, respectively. ST depression in aVR > or = 0.1 mV was found in 14 (70%) patients who had LCX as the IRA, and in 4 (5.7%, p<0.001) patients with RCA as IRA. Using ST segment depression > or = 0.1 mV in aVR as a criterion, the sensitivity and specificity in differentiating LCX as IRA was 70.0% and 94.3%, respectively. ST depression in aVR is common in patients with LCX-related acute inferior myocardial infarction. The ST changes in this lead are associated with an excellent specificity and a good sensitivity in differentiating LCX from RCA as the IRA.

Effect of Cromakalim (BRL 34915) on hemodynamic and electrocardiographic changes induced by endothelin in dogs

We evaluated whether cromakalim (BRL 34915), a vasorelaxant agent which acts by opening potassium channels, could affect the systemic effects of endothelin, a newly discovered vasoconstrictive peptide. Intravenous administration of endothelin alone (400 pmol/kg) to anesthetized dogs produced blood pressure elevation, which was associated with an increase in cardiac output in the early phase, and was associated with an increase in total peripheral resistance in the late phase. Electrocardiogram showed significant ST-elevation in II, III, and aVF, and ST-depression in aVR and aVL. The same dose of endothelin given to dogs pretreated with cromakalim did not induce these hemodynamic and electrocardiographic changes. Thus, cromakalim, a potassium activator, inhibited the hemodynamic and electrocardiographic actions of endothelin, suggesting that hyperpolarization due to potassium channel activation inhibited the voltage-dependent calcium channel, which is thought to be a major mechanism for the pressor action of endothelin.