ST Elevation In aVR Research Articles

Predictive model for left main coronary artery or triple vessel disease in patients with chronic coronary syndromes.

Data about prediction of left main coronary artery disease (LMCAD)/three-vessel disease (TVD) in patients with chronic coronary syndromes (CCS) are lacking. This study aimed to develop a model for predicting patients at risk of LMCAD/TVD. This study used retrospective data from patients with CCS scheduled for invasive coronary angiography (ICA) and who were retrospectively recruited between January 2018 and December 2020. Predictors were obtained and analyzed by using logistic regression analysis, and generated the prediction score. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The cut-off value and area under the curve (AUC) were analyzed by using the receiver operating characteristic (ROC) curve. We recruited 162 patients with CCS. There were 75 patients in the non-LMCAD/TVD and 87 patients in the LMCAD/TVD groups. After the multivariate analysis, new onset of heart failure (HF) or left ventricular systolic dysfunction (LVSD) and suspected CAD, ST elevation (STE) in aVR, STE in V1 and lateral ST depression (STD) were associated with increased risk of LMCAD/TVD. Based on these 4 predictors, the prediction score was created. The cut-off value of the prediction score by using ROC curve analysis was 3.0. The sensitivity, specificity, PPV, and NPV were 71.26%, 86.67%, 86.11%, and 72.22%, respectively, with an AUC of 0.855. The CCS patients with new onset of HF or LVSD and suspected CAD, STE in aVR, and STE in V1 and lateral STD were associated with increased risk of LMCAD/TVD. The novel prediction score could predict LMCAD/TVD in those patients with acceptable sensitivity, specificity, PPV, and NPV.

Simultaneous ST-elevation in lead augmented vector right (aVR) and III in non-ST-elevation acute coronary syndromes.

The value of ST-elevation in lead augmented vector right (aVR) remains controversial in clinical practice. This study aimed to investigate the association of simultaneous ST-elevation in lead aVR and III with angiographic findings and clinical outcomes in patients with non-ST-elevation acute coronary syndromes (NSTEACS). In this observational study, patients who had been diagnosed with NSTEACS and presented with ST-elevation in lead aVR and without ST-elevation in any other two contiguous leads were enrolled from January 2018 to June 2019. Demographic, baseline clinical, angiographic and interventional characteristics as well as clinical outcomes were collected and recorded on standardized case report forms. A total of 157 patients meeting the criteria were finally enrolled in this study and classified into two groups according to the presence of ST-elevation in lead III. Patients in the two groups were similar in average age and previous history of hypertension, diabetes mellitus, hyperlipidemia, chronic kidney disease, stroke, and peripheral vascular diseases (all P>0.05). Patients with ST-elevation in lead III tended to present with myocardial hypertrophy in the echocardiography (P=0.02). The cases with ST-elevation in lead III showed higher high sensitivity troponin T (hs-TnT; P=0.08) and creatinine kinase MB isoenzyme (CK-MB; P<0.01) whereas those without ST-elevation in lead III showed higher N-terminal pro brain natriuretic peptide (NT-proBNP; P=0.02). Of note, patients with ST-elevation in lead III presented with more ST-depression in multiple leads [especially in lead I, augmented vector left (aVL), V3-V6] as well as higher degree of ST-depression (all P<0.05) and were more likely to develop multi-vessel and left main trunk (LM) lesions (P=0.04), with 20% of the cases having a LM lesion and 60% having triple vessel lesions. Patients with ST-elevation in lead III were at increased risk of 3-year major adverse cardiovascular events (MACEs), despite no significant statistical difference between the two groups (hazard ratio =1.29; P=0.26). The NSTEACS cases with simultaneous ST-elevation in lead III and aVR tended to present with more multiple leads with ST-depression, higher degree of ST-depression, and more LM or multi-vessel lesions, suggesting a broader range of severe myocardial ischemia. The concurrent presentation of ST-elevation in lead III and aVR may play a vital role in the diagnosis, risk-stratification, and prediction of poor prognosis during the management of NSTEACS patients.

Understanding ST equivalents on ECG part II

In reality, many acutemyocardial infarction patients with ST deviations observed in other conditions in which the characteristics of these ECG do not meet the criteria of STEMI. They are called: ST equivalents. STEMI equivalents represent coronary occlusion without meeting the traditional STE criteria and are equally important to recognize in a timely fashion. Emergency physicians must know to involve interventional cardiologists for patients with dynamic ECG changes, persistent ischemic chest pain, hemodynamic instability, and STEMI equivalent patterns that require emergent PCI to minimize morbidity and mortality. This is the reason why we would like to propose this review to present some common ST equivalents for physicians and cardiologists to apply to the clinical practice. These are: de Winter ST/T complex, Wellens syndromes, ST-elevation in lead AVR, LBBB with Sgarbossa criteria, isolated posterior MI, T waves upright in V1. This review is the part two of the topic.

Abstract 19071: An Agitated Young Heart: A Rare Presentation With a Favorable Outcome Under the Right Circumstances

Introduction: Commotio cordis (Latin: agitation of heart) is sudden death triggered by a blunt, often innocent-appearing blow to the chest. It is the third most common cause of sudden cardiac death (SCD) in young athletes, after hypertrophy cardiomyopathy, and coronary anomalies. Around 10-20 cases are added to the Commotio Cordis (CC) registry annually. Ventricular fibrillation seems to be the most common arrhythmia in commotio cordis in 40% of cases. Case Presentation: A 22-year-old male with no known medical illness presented after sudden cardiac arrest. According to a bystander, he fell to the ground and lost consciousness within a few seconds of being “elbowed in his chest” during a basketball game. EMS provided bag valve mask ventilation for respiratory distress but were unable to record the rhythm. On initial presentation to the emergency room, he was found to be in ventricular tachycardia (VT) with hemodynamic instability. He was cardioverted, and his VT deteriorated to ventricular fibrillation. He was intubated for airway protection, received two rounds of CPR and another 200 J defibrillation that restored his sinus rhythm with return ofspontaneous circulation (ROSC). Bedside echocardiogram revealed global hypokinesis with EF 30-35%. EKG showed marked ST elevation in AvR with deep ST depression in other leads. Code STEMI was activated, and an emergent coronary angiogram was done which revealed normal coronary arteries and anatomy. Subsequent EKG within an hour was essentially normal. A repeat echocardiogram on the next day showed an improved EF of 65%. Discussion: Commotio cordis is fatal, with only about 25% of the cases on CC registry resulting in survival. A chest blow must be confined to a small area of the precordium within a 20 msec window during upstroke of T wave that results in ventricular fibrillation. Sustained ventricular tachycardia is even rare, with only one case report found on literature review. It is likely that his VT favored a better prognosis.

Abstract 11597: A Rare Cause of an NSTEMI: Left Main Coronary Artery Compression in a Patient With Pulmonary Hypertension

Background: Pulmonary hypertension has varying effects on cardiac function. Though uncommon, a dilated pulmonary artery can cause decreased coronary perfusion through extrinsic compression of the left main coronary artery (LMCA). While the most common presentation of LMCA compression is angina, acute coronary syndrome is rare. Case Summary: An 81-year-old female with a history of group 3 pulmonary hypertension presenting with neck and shoulder pain was found to have elevated cardiac biomarkers and EKG findings remarkable for isolated ST elevation in aVR with diffuse ST depressions in all other leads, consistent with a non-ST elevation myocardial infarction. Coronary angiography revealed left main coronary artery compression that was successfully intervened on with placement of a single drug eluding stent. Right heart catheterization was remarkable for evidence of severe pulmonary hypertension with a mean pulmonary artery pressure of 60 mmHg. Discussion: Given the patient’s past medical history, presenting symptoms, coronary and right heart catheterization findings the etiology of her acute coronary syndrome presentation was thought to be driven by left main coronary artery compression from pulmonary artery dilation. Pulmonary artery dilation in individuals with a history of pulmonary hypertension is common, with several modalities available to evaluate for this anatomic compensatory measure. Management for left main coronary artery compression in this patient population is percutaneous coronary intervention. Future studies to determine if routine screening for coronary compression in patients with pulmonary hypertension is needed.

Comparing the Frequency of Left Main Stem Disease Among Patients with ST Elevation in AVR Lead

Background: Coronary artery disease (CAD) is one of the leading causes of mortality worldwide with similar prevalence in Pakistan. The main objective of the study is to compare the frequency of left main stem disease among patients with STelevation in aVR. Methods:This cross-sectionalstudywas conducted inDepartment of cardiology,Punjab institute of cardiology,Lahore. Sample size of 151 cases is calculated with 95% confidence level,7%margin of error and taking expected percentage of LMS is 74.2%. The data was collected through non probability consecutive sampling technique. Results: Mean age of the study population was 55.54±10.1 years. Majority of the cases were male 117(77.5%)and 34(22.5%) were female which were less in quantity. Mean body mass index was 28.61±2.58. Conclusion: Majority of the cases developed left mainstem disease who have been diagnosed with STelevation in aVR. A significant difference of the diabetic versus non diabetic was observed who have been noted for LMS disease.

P40 LIGHTS AND SHADOWS OF THE MICROCOAXIAL PUMP DEVICE IN A UNIQUE SETTING: CARDIOGENIC SHOCK DUE TO ACUTE MYOCARDIAL INFARCTION IN PATIENT WITH UNKNOWN HYPERTROPHIC CARDIOMYOPATHY

Abstract Cardiogenic shock remains the leading cause of death in patients with acute myocardial infarction (AMICS). The IntraAortic Balloon Pump (IABP) has been the device of first choice for these patients for years, but it has not shown a mortality benefit over optimal medical therapy. The Impella (AbioMed, Danvers, Massachusetts) is an alternative circulatory support system that produces cardiac output appropriate for the needs of the patient. A 59–year–old mailman suddenly lost consciousness during his work. Basic life support was administered, and ROSC was achieved after a single effective defibrillator discharge. When the ambulance arrived, the patient presented conscious but complained of oppressive chest pain, with soreness in his left arm and head. EKG showed an ST elevation in aVR and aVL and a right bandle branch block (Fig 1). Aspirin, Heparin, and opioids were administered. During the transport, hemodynamic parameters appeared to deteriorate towards cardiogenic shock. Coronary angiography showed a total occlusion of the left main. Cangrelor was started promptly. Hemodynamic conditions dictated the application of a mechanical circulatory support device (MCSD), so IABP was applied. Primary angioplasty was performed with restoration of TIMI 3 flow. A 3.50 x 23 mm everolimus–eluting stent was implanted with a good result. Norepinephrine was ineffective in achieving satisfactory hemodynamic status with systemic arterial pressure below 50 mmHg. After volemic restoration, neither IABP nor the vasopressor could interrupt the spiral of cardiogenic shock. A coaxial pump, i.e. the Impella CP, was applied via left arterial femoral access. Despite the precise placement of this device, the parameters suggested a poor suction capacity from the pump–inlet into the left ventricle (LV) to systemic circulation in aorta. Meanwhile, echocardiogram revealed an unknown and severe hypertrophic cardiomyopathy that did not allow a proper functioning of the Impella CP device (Fig. 2). When a temporary pacemaker was applied due to reperfusion bradycardia, there were a better LV diastolic filling and Impella functioning due to right pacing. The patient was transferred to the intensive care unit, Impella was removed after 3 days, he was extubated within two weeks, no brain damage was reported but he is still hospitalised after a concomitant urinary infection, with predictable low ejection fraction (around 30%). We‘ll see: luckily, slow improvement, it is still an improvement!

Electrocardiogram Changes in Patients with Positive Troponin I Presenting with Non-ST-Elevation Myocardial Infarction

Objectives: Unlike “ST-segment elevation myocardial infarction (STEMI)”, there is a wide spectrum of ECG changes for Non-STEMI (NSTEMI) patients with varying prognostic implications. Therefore, the purpose of this study was to determine the frequency of ECG changes in patients with positive high-sensitive troponins (hs-cTn) presenting with NSTEMI. Methodology: This Cross sectional study included 282 patients with positive hs-cTn diagnosed with NSTEMI. Standard 12-lead ECG was performed for all the patients. The clinical profile and ECG changes such as ST elevation in aVR, T wave inversion, and ST depression were noted. Results: Out of 282 patients, 68.1% (192) were male, mean age was 58.5 ± 10.6 years, 56.7% (160) were hypertensive, and 39.7% (112) were diabetic. The ECG was normal in 8.2% (23) while, 64.5% (182) had ST-depression, out of which 1.1% (2) had ST-depression of &lt;1mm, 78% (142) had ST-depression of 1-2mm, and remaining 20.9% (38) had ST-depression of &gt;2mm. T-wave inversions were observed in 45.7% (129). ST-elevation of ≥1 mm in lead aVR was noted in 19.1% (54) patients. Conclusion: A considerable number of NSTEMI patients with positive hs-cTn showed no specific ECG changes. ST-depression followed by T wave inversion and ST-elevation in aVR were the most commonly observed ECG findings in these patients. Considering the prognostic implications and association of these changes with the severity of diseases, prompt decision-making regarding invasive management strategy could be helpful in improving the outcomes of these patients.

Clinical Case 29—The role of transthoracic echocardiography on patients presenting with shock of unknown etiology

Abstract Seventy-six-year-old woman, with a previous medical history of arterial hypertension, dyslipidaemia, hypothyroidism and mitral valve plasty (previous rheumatic fever) presents to the emergency department with unspecific complaints of malaise, productive cough and dyspnoea for the past 15 days. At admission, the patient was conscient, apyretic, tachycardic, hypotensive and with peripheric oxygen saturation of 90% (on room air). The patient became haemodynamically unstable and unresponsive. Electrocardiogram with sinus tachycardia, SIQIII pattern and a slight ST elevation in aVR and ST depression in DI, aVL and precordial leads. TTE revealed right cavities dilatation and the presence of a serpiginous echogenic mass that protruded from the inferior vena cava crossing the right atrium and reaching the right ventricle. Thrombolysis, fluid challenge and vasopressor perfusion were immediately started with a good clinic response. Haemodynamic stability was achieved 5 hours after the thrombolysis. An unfractionated heparin perfusion was initiated after the thrombolysis and discontinued 24 h after the patient was admitted. The remaining hospitalization was uneventful and the patient was discharged 7 days after on a non-vitamin K antagonist oral anticoagulant. TTE revaluation before discharge revealed mild dilatation of the right cavities with mild systolic dysfunction of the right ventricle and a normal PSAP. There is no scientific evidence regarding the best strategy to approach a patient with a migrating thrombus and TTE is of high value in the case of shock due to its high specificity as a rule-in test, especially when the patient cannot undergo other types of exams. Figure 1Transthoracic echocardiography (subcostal 4 chamber view) showing the presence of a serpiginous echogenic mass in the right atrium (red arrow).

DEALING WITH DOUBLE TROUBLE: EMERGENT CARDIAC CATHETERIZATION COMPLICATED BY PERIPROCEDURAL ISCHEMIC STROKE

DEALING WITH DOUBLE TROUBLE: EMERGENT CARDIAC CATHETERIZATION COMPLICATED BY PERIPROCEDURAL ISCHEMIC STROKE

Myocardial Infarction Due to Nonvalvular Papillary Fibroelastoma of the Left Coronary Sinus: The Importance of Multimodal Imaging

A 44-year-old woman with a history of type II diabetes and obesity presents, with a two- month history of syncope. In the week prior to presentation, she reported exertional angina. She presented to the emergency department with a 2-hour history of chest pain at rest (intensity 8/10 on the visual analog scale), that radiated to her left arm. Her blood pressure on presentation was 95/60 mmHg and heart rate was 88 bpm. The initial electrocardiogram demonstrated diffuse ST-segment depression and ST elevation in aVR (Figure 1).

Combining electrocardiographic criteria for predicting acute total left main coronary artery occlusion.

BackgroundPrediction of left main artery (LM) occlusion may contribute to the administration of early reperfusion. We sought to identify electrocardiographic (ECG) features associated with acute total LM occlusion and explore the relationship between ECG features and collateral circulation.MethodsWe retrospectively studied ECGs in 84 consecutive patients with LM occlusion between January 2001 and April 2022. The ECG findings in these patients were compared with those in 468 consecutive patients with LM subtotal occlusion and non-LM occlusion.ResultsThree main ECG patterns were described according to the characteristics of ST elevation (STE) in LM occlusion: ST-segment elevation myocardial infarction (STEMI), STE in aVR with diffuse ST depression, and STE in both aVR and aVL. These ECG patterns were associated with different collateral filling territories. One-third STEMI in LM occlusion showed STE in the precordial leads including V1, while 2/3 STEMI showed STE in the precordial leads from V2 to V5 without STE in V1. The following ECG characteristics predicted LM occlusion: STE in both aVR and aVL; STE in I, aVL, and V2–V5 without V1; left anterior fascicular block (LAFB); right bundle branch block (RBBB) + LAFB; and prolongation of the QRS interval. The incidences of STE in aVR and STE in aVR and V1 were higher in LM subtotal occlusion than in LM occlusion. The combination of two different STE criteria (STE in aVR and aVL and STE in I, aVL, V2-V5 without V1) predicted LM occlusion with 62% sensitivity and 95% specificity. The combination of the STE criteria and fascicular block criteria (LAFB and LAFB + RBBB) further improved the specificity to 99% but reduced the sensitivity to 39%.ConclusionThe combination of STE criteria predicted LM occlusion with high specificity and moderate sensitivity, and the addition of fascicular block criteria further improved the specificity with some loss of sensitivity.

OMI GOD, IT’S MYOCARDIAL INFARCTION!

TYPE: Case Report TOPIC: Critical Care INTRODUCTION: Acute Coronary Syndromes (ACS) caused by Occlusion Myocardial Infarctions (OMI) are potentially treatable events with percutaneous coronary interventions (PCI). A ST-elevation myocardial infarction (STEMI) is classically used to diagnose OMI, besides being an imperfect surrogate. CASE PRESENTATION: An 89-year-old man with a history of a valvular and ischemic cardiopathy [synchronous aortic biologic prosthesis insertion and coronary arterial bypass graft due to left anterior descendant artery (LAD) occlusion nine years ago] was admitted for a 3-weeks exertional dyspnea. He had already consulted health care services thrice for the same reason, always directly discharged. At presentation, he had no remarkable findings. An electrocardiogram revealed a normal sinus rhythm, a previous known complete right bundle branch block, new-onset ST-elevation in aVR, ST-depression in V4-V6 and hyperacute T waves in V1-V3. Laboratory values revealed Troponin I (0.86 ug/L) and NTproBNP (4896 pg/ml) elevation. A transthoracic echocardiogram revealed mild systolic left ventricular function. An ACS with NSTEMI was admitted, besides suggestion of OMI. A late catheterization was performed, revealing a >90% right coronary artery stenosis, and a PCI was finally performed with success. DISCUSSION: Under the STEMI/NSTEMI dichotomic paradigm, up to 30% ACS classified as NSTEMI are missed OMI, as well as up to 30% ACS classified as STEMI lead to unnecessary urgent catheterization. The OMI/nonOMI classification encompasses both STEMI and STEMI-equivalents, being a more accurate way of stratifying ACS that require PCI. CONCLUSIONS: ACS due to OMI was repeatedly misdiagnosed and classified as NSTEMI along the 3-weeks course. Therefore, is mandatory not to overlook STEMI equivalents and OMI in order to better rationalize urgent treatment DISCLOSURE: Nothing to declare. KEYWORD: OMI

P407 WHEN A SUPRA–VENTRICULAR TACHYCARDIA SAVES A LIFE

Abstract The Case A 76–year–old man came to ER because of palpitations and a worsening chest discomfort. His clinical history included hypertension, dyslipidemia, diabetes and gouth. 12–leads ECG revealed a supraventricular tachycardia with heart rate of 190 bpm. It also demonstrated: widespread deep ST depression involving V2–6, I, II, aVL ST elevation in aVR &amp;gt; V1 (Figure 1). Adenosine (6 mg) intravenous administration led to sinus rhythm restoring with symptoms regression. 12–leads ECG after sinus rhythm restoring demonstrated a ST–T segment normalization (Figure 2). Trans–thoracic echocardiogram, acquired in sinus rhythm, showed a picture of left ventricle systolic dysfunction with ejection fraction of 35% due to a severe hypokinesis of mid–apical wall segments. A moderate mitral regurgitation with central jet was visible. An urgent coronary angiography was performed. It demonstrated a LEFT MAIN CORONARY ARTERY (LMCA) very severe (95%) proximal lesion. Patient was sent to urgent coronary artery bypass grafting (CABG). Discussion Widespread ST depression (with reciprocal STE in aVR) is a common finding in patients with supraventricular tachycardias such as AVNRT or atrial flutter. The significance of this finding in individual patients is unclear and may be due to: rate–related ischaemia (O2 demand higher than supply) unmasking of underlying coronary artery disease (i.e. tachycardia as a “stress test”) a pure electrical phenomenon (e.g. the young patient with SVT who is relatively asymptomatic and has normal coronary arteries). In this case, primary ECG pattern and then echocardiographic findings suggested a potentially lethal coronary artery disease which was confirmed by coronary angiography. Conclusion Sometime a supraventricular tachycardia may be helpful in order to bring out life–threatening disease.

P048 A young girl with myocardial infarction

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

Acute Anterior Wall Myocardial Infarction

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

Association of aVR ST-elevation with outcomes in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Evaluation of the lead aVR in the diagnosis of acute coronary syndrome has been neglected before.1 However, there is evidence that an ST segment elevation in that lead correlates to a significant coronary artery disease.1,2 This study aimed to determine the association with clinical outcomes of an aVR ST elevation in patients with acute coronary syndrome. Purpose Identify patients who are at high risk on presentation at the emergency department. Methods This was a retrospective cohort study. Patients aged 19 years and above who were diagnosed with either unstable angina, non ST-elevation MI or ST elevation MI were eligible subjects. The medical records of patients in a tertiary referral government hospital were evaluated. The independent variable was the lead aVR ST elevation, while the primary outcome was the in-hospital mortality. Descriptive statistics was used to summarise the demographic and clinical characteristics of the patients. Frequency and proportion was used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and standard deviation for normally distributed continuous variables. Independent Sample T-test and Fisher’s Exact test was used to determine the difference of mean and frequency, respectively, between patients with and without in-hospital outcomes. Odds ratio and corresponding 95% confidence intervals from binary logistic regression was computed to determine significant predictors of in-hospital outcomes. Missing variables was neither replaced nor estimated. Null hypotheses was rejected at 0.05α-level of significance. Results There were a total of 108 patients included. Most subjects were males and aged 57-62 years old. Majority had NSTE-ACS and STEMI at presentation. Lead aVR ST elevation group had an OR of 17 (95% CI 4.38-67.50 and p &amp;lt; 0.001) for in-hospital mortality, compared to the group without. On coronary angiogram, these patients had either a significant left main coronary artery disease or a multi-vessel coronary artery disease. Conclusion The presence of a lead aVR ST segment elevation in patients with acute coronary syndrome at presentation in the emergency department is associated with increased in-hospital mortality.

The utility of SYNTAX score predictability by electrocardiogram parameters in patients with unstable angina

BackgroundSYNTAX score is one of the risk assessment systems to predict cardiac events in acute coronary syndrome patients. Despite the large number of SYNTAX score benefits, invasive methods such as coronary angiography are necessary to perform the scoring. We hypothesized that ECG parameters could predict the SYNTAX score in unstable angina patients.MethodsDuring the retrospective cohort study, a total number of 876 patients were diagnosed with unstable angina. After applying the exclusion criteria, 600 patients were divided into tertiles based on the SYNTAX scores as low (0–22), intermediate (23–32), and high (≥ 33). The association between ECG parameters and SYNTAX score was investigated.ResultsThe study included 65% men and 35% women with a mean age of 62.4 ± 9.97 years. The delayed transition zone of QRS complex, ST-depression in inferior-lateral territories or/and in all three territories, and T-wave inversion in lateral territory were significant (p < 0.05) independent predictors of intermediate SYNTAX score. High SYNTAX score was predicted by the presence of prolonged P wave duration, ST-depression in lateral territory or/and anterior-lateral territories, ST-elevation in aVR–III leads or/and aVR–III–V1 leads. Among those, all three territories ST-depression (AUC: 0.611, sensitivity: 75%, specificity: 51%) and aVR + III ST-elevation (AUC: 0.672, sensitivity: 50.12%, specificity: 80.50%) were the most accurate parameters to predict intermediate and high SYNTAX scores, respectively.ConclusionThe present study demonstrates that accompanying the STE in the right side leads (aVR, III, V1) with ST-depression in other leads indicates the patients with high SYNTAX score; meanwhile, diffuse ST-depression without ST-elevation is a marker for intermediate SYNTAX score in unstable angina patients and can be applied for early risk stratification and intervention.

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

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

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

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