ST Elevation In Leads V1 Research Articles

Temporal Variability in Electrocardiographic Indices in Subjects With Brugada Patterns.

IntroductionPatients with Brugada electrocardiographic (ECG) patterns have differing levels of arrhythmic risk. We hypothesized that temporal variations in certain ECG markers may provide additional value for risk stratification. The present study evaluated the relationship between temporal variability of ECG markers and arrhythmic outcomes in patients with a Brugada pattern ECG. Comparisons were made between low-risk asymptomatic subjects versus high-risk symptomatic patients with a history of syncope, ventricular tachycardia (VT) or ventricular fibrillation (VF).MethodsA total of 81 patients presenting with Brugada patterns were recruited. Serial ECGs and electronic health records from January 2004 to April 2019 were analyzed. Temporal variability of QRS interval, J point-Tpeak interval (JTp), Tpeak-Tend interval (Tp-e), and ST elevation (STe) in precordial leads V1-3, in addition to RR-interval from lead II, was assessed using standard deviation and difference between maximum and minimum values over the serial ECGs.ResultsPatients presenting with type 1 Brugada ECG pattern initially had significantly higher variability in JTp from lead V2 (SD: 33.5 ± 13.8 vs. 25.2 ± 11.5 ms, P = 0.009; max-min: 98.6 ± 46.2 vs. 78.3 ± 47.6 ms, P = 0.047) and ST elevation in lead V1 (0.117 ± 0.122 vs. 0.053 ± 0.030 mV; P = 0.004). Significantly higher variability in Tp-e interval measured from lead V3 was observed in the VT/VF group compared to the syncope and asymptomatic groups (SD: 20.5 ± 8.5 vs. 16.6 ± 7.3 and 14.7 ± 9.8 ms; P = 0.044; max-min: 70.2 ± 28.9 vs. 56.3 ± 29.0 and 43.5 ± 28.5 ms; P = 0.011).ConclusionTemporal variability in ECG indices may provide additional value for risk stratification in patients with Brugada pattern.

In inferior myocardial infarction, neither ST elevation in lead V1 nor ST depression in lead I are reliable findings for the diagnosis of right ventricular infarction

ObjectiveIn the presence of inferior myocardial infarction (MI), ST depression (STD) in lead I has been claimed to be accurate for diagnosis of right ventricular (RV) MI. We sought to evaluate this claim and also whether ST Elevation (STE) in lead V1 would be helpful, with or without STD in V2. MethodsRetrospective study of consecutive inferior STEMI, comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. STE and STD were measured at the J-point, relative to the PQ junction. The primary outcomes were sensitivity/specificity of 1) STD in lead I ≥ 0.5 mm and 2) STE in lead V1 ≥ 0.5 mm, stratified by presence or absence of posterior (inferobasal) MI, as determined by ≥0.5 mm STD in lead V2, for differentiating RVMI from non-RVMI. ResultsOf 149 patients with inferior STEMI, 43 (29%) had RVMI and 106 (71%) did not. There was no difference in the presence or absence of at least 0.5 mm STD in Lead I between patients with (37/43, 86%) vs. without RVMI (85/106, 80%, p = 0.56). In those with, vs. without, RVMI, (15/43, 35%) had STE in V1, versus (17/106, 16%) (p = 0.015). Specificity of STE in V1 for RVMI was 84%; sensitivity was 35%. Sensitivity was higher without (69%), than with (35%), STD in V2. ConclusionAmong inferior STEMI, the presence of any ST depression in lead I does not help to diagnose RVMI. ST elevation ≥0.5 mm in lead V1 is specific for RVMI, and moderately sensitive only if concomitant STD ≥ 0.5 mm in V2 is not present. Although STE in V1 is quite specific, overall the diagnostic characteristics of the standard 12‑lead ECG are inadequate to definitively diagnose, or exclude, RVMI, as defined angiographically.

Predictive Value of Exercise Stress Test-Induced ST-Segment Changes in Leads V1 and avR in Determining Angiographic Coronary Involvement.

The significance of electrocardiographic changes during exercise tolerance testing for distinguishing occluded artery is not well known. We tried to determine the role of ST elevation in leads aVR and V1 during exercise in detecting stenosis of left main coronary artery and proximal left anterior descending artery. ST segment changes during exercise in 230 patients, who underwent diagnostic angiography, were documented. The association of ST elevation in lead aVR, V1 , leads aVR + V1 , and STE in leads aVR + V1 with ST depression in other leads with pattern of coronary stenosis were investigated. Left main and proximal left anterior artery stenosis were more common in patients with ST elevation in lead aVR (P < 0.001 for both). Similar association was found in the presence of ST elevation in lead V1 . The presence of ST elevation ≥1 mm in lead aVR had a sensitivity of 100% and 94.3% for detecting left main and left anterior descending artery stenosis, respectively. The specificity was 33.5% and 26.6%, respectively. ST elevation in leads aVR + V1 had a sensitivity of 74.4% and 65.9% and a specificity of 68.5% and 64.4% for detecting left main and left anterior descending arteries stenosis, respectively. ST elevation in lead aVR is highly sensitive for left main and proximal left anterior descending artery lesions. Using ST elevation in lead V1 in addition to lead aVR as a positive finding increases the specificity with a further decrease in sensitivity.

Fatty Acid Metabolism and Perfusion Mismatch in Acute Chest Pain Syndrome

A 70 year old woman was admitted to our hospital on March 20, 2014 due to suspected acute myocardial infarction. Her ECG showed ST elevation in lead V1 and V2 at her family physician7s clinic(Fig. 1). Emergency coronary angiography(CAG)showed normal coronary. However, left ventriculography(LVG)showed severely reduced wall motion in anteroseptum(Fig. 2). LVG did not show apical ballooning. The ECG showed inverted T waves in lead V1 to V5 on next day. Peak creatinine kinase was 153 IU/L at 12 hours after the onset of chest pain. Five days after the admission, the patient had rest nuclear cardiology imaging. Rest thallium showed normal perfusion at rest. In contrast, rest 123 Ibetamethyl-p-iodophenyl-pentadecanoic acid (BMIPP)showedmoderate intensity of defect in anterior to septum(Fig. 3). Thus, there was perfusion and fatty acid mismatch in anterior. This 123 I BMIPP finding agreed with ECG changes and LVG findings. Although, we did not perform acetylcholine provocation, the acute chest pain syndrome might be associated with vasospastic angina(1,2). Takotubo cardiomyopathy was also another possible causes of this chest pain syndrome(3). However, LVG findings did not agree with the typical apical ballooning pattern. In the current case, I BMIPP might accurately detect stunned myocardium related to acute chest pain syndrome(1,2,4,5). Annals of Nuclear Cardiology Vol. 1 No. 1 95-97

PROGNOSTIC VALUE OF ST-ELEVATION IN LEADS V1 FOR INFERIOR AND AVR FOR ANTERIOR STEMI UNDERGOING PRIMARY PCI

Among patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolysis, ST-elevation in leads aVR for anterior STEMI and V1 for inferior STEMI have been associated with increased mortality. For STEMI patients with these findings treated with primary percutaneous coronary intervention, we explored both acute and long term outcomes. A prospective cohort of 2070 patients with inferior STEMI and 1499 patients with anterior STEMI undergoing primary PCI were recruited into the study from Jan 1, 2002 to Dec 31, 2012. We excluded patients with left bundle branch block. At least 1mm of ST-elevation in leads V1 or aVR were the exposures of interest, for inferior or anterior STEMI patients, respectively. Using the absence of at least 1mm of ST-elevation in leads aVR for anterior STEMI and V1 for inferior STEMI as a reference, crude and adjusted odds ratios (ORs) for ventricular tachycardia/fibrillation (VT/VF) during PCI, 30-day and 1-year mortality were determined. For patients with inferior STEMI and at least 1mm ST-elevation in V1, ORs for 30-day and 1-year mortality were 1.71 (95% CI 0.90-3.26) and 1.89 (1.14-3.15), respectively; and 1.68 (0.86-3.29) and 1.92 (1.12-3.29) following adjustment. The adjusted OR of life threatening arrhythmia during PCI was 2.36 (1.40-4.00). Among those with anterior STEMI and at least 1mm ST-elevation in aVR, ORs for 30-day and 1-year mortality were 2.12 (1.14-3.97) and 1.85 (1.07-3.21); and 2.24 (1.18-4.26) and 1.97 (1.12-3.46) following adjustment. The adjusted OR of VT or VF during PCI was 3.10 (1.68-5.71). In patients undergoing primary PCI for inferior STEMI, ST-elevation in lead V1 predicts increased mortality at 1 year. Among patients with anterior STEMI, ST-elevation in lead aVR predicts increased mortality at 30 days and 1 year. Both findings were predictive of malignant ventricular arrhythmias during PCI.

Differences in ST-elevation and T-wave amplitudes do not reliably differentiate takotsubo cardiomyopathy from acute anterior myocardial infarction

BackgroundPrevious efforts to distinguish acute anterior ST-elevation myocardial infarction (anterior-STEMI) from various forms of takotsubo cardiomyopathy (TTC) by electrocardiography (ECG) have produced differing results. MethodsWe performed a retrospective comparison of acute ECGs between 48 apical and 9 mid-ventricular TTC patients, with 96 anterior-STEMI patients. ECG was recorded in acute phase (<24h from onset of pain), and analyzed for ST-changes, negative T-waves, abnormal Q-waves and QT-interval duration. Time from onset of pain to ECG was gathered from patient records. ResultsAnterior-STEMI patients had ST-elevation in lead V1 more frequently than apical (70% vs 15%, p<0.0001) or mid-ventricular TTC patients (70% vs 0%, p<0.0001), and higher ST-elevation amplitudes in leads V2–V5 (p<0.02). Lack of ST-elevation in lead V1 and ST-elevation amplitude <2mm in lead V2 distinguished TTC from anterior-STEMI patients with 63% sensitivity and 93% specificity, with 79% predictive value. ConclusionsIn patients with anterior ST-elevation and acute chest pain, lack of ST-elevation in lead V1 and ST-elevation amplitude <2mm in lead V2 suggests a TTC diagnosis. However, this criterion is not reliable enough in clinical practice to distinguish between TTC and anterior-STEMI patients.

Electrocardiographic Changes in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is a unique transient nonischemic cardiomyopathy that mimics acute myocardial infarction (MI). The aim of our study was to evaluate electrocardiographic changes in patients with TC, including the frequency of ST elevation and other abnormalities. Eleven patients were retrospectively identified from echocardiography database. All patients underwent coronary angiography and fulfilled the Mayo criteria for diagnosis of TC during the period November 2005 to September 2010. Standard 12-lead electrocardiograms recorded daily during the first week of hospitalization, after onset of symptoms were analyzed. Eight of 11 patients were found to have ST elevation, of which two patients had ST depression in reciprocal leads. No patient had ST elevation in lead V1, most likely reason being that wall-motion abnormalities in TC rarely extend to the region faced by lead V1. Pathological Q waves were found in five patients, of which two patients had transient Q waves, suggesting less myocardial damage. All 11 patients had T-wave inversion; eight of these patients had diffuse symmetric T-wave inversion, extending beyond the perfusion territory of any single coronary artery. QTc interval prolongation was found in 10 patients. All patients had left ventricular ejection fraction between 25% and 35% on presentation, which could not be predicted by the extent of electrocardiogram (ECG) changes. ECG changes in TC are distinctive and differ from those typically seen in acute anterior MI. The ECG abnormalities described may be important clues for the clinician to suspect diagnosis of TC in the right clinical setting.

Effect of Alcohol Septal Ablation in Patients With Hypertrophic Cardiomyopathy on the Electrocardiographic Pattern

Alcohol septal ablation (ASA) of patients with hypertrophic cardiomyopathy (HC) allows study of the electrocardiographic effects of myocardial necrosis confined to the base of the interventricular septum, a rare event in atherothrombotic coronary artery disease. Eighty-four consecutive patients were studied after ASA for HC. After excluding 20 with pacing before ASA and 6 with no available preprocedure electrocardiograms, the electrocardiograms of the remaining 58 patients were compared with those of 58 consecutive patients with anterior ST elevation myocardial infarctions who underwent primary intervention for left anterior descending coronary artery (LAD) occlusions. In 25 patients, the occlusions were proximal to the first septal perforator, and in 33 patients, the occlusions were more distal. All electrocardiograms were analyzed with respect to conduction abnormalities and ST-segment changes. Patients with HC developed right bundle branch block significantly more often than those with LAD occlusions (50% vs 14%, p = 0.001) Moreover, patients with HC required postprocedure pacing more frequently (14% vs 2%, p <0.05). A distinctive pattern of ST displacement was found. There was more frequent ST depression in leads I and aVF and greater ST elevation in lead V(1) in patients who underwent ASA, indicating a greater tendency toward a rightward direction than was true in patients with LAD occlusions. In conclusion, in addition to more frequent right bundle branch block after ASA, a distinctive a characteristic pattern of ST-segment deviation similar to but distinct from that produced by proximal LAD occlusion appeared.

Tako-tsubo-like transient left ventricular dysfunction—A new cause of diastolic heart failure

A 49-year-old women presented with severe chest pain typical of myocardial infarction with vomiting and sweating during emotional stress (funeral). The initial ECG revealed normal sinus rhythmwith STelevation in leadsV1–V3,T-wave inverted in I, aVL, V5–V6 (Fig. 1-1). Admission Troponin I (1.4 ng/ml — normalb0.1 ng/ml) and creatinine kinase-MB (5.4 ng/ml, normalb3.6 ng/ml) level were positive. Other laboratory tests were normal. The patient underwent emergency coronary angiography which revealed normal coronary arteries (Fig. 2-1, 2). However contrast left ventriculography demonstrated typical view of tako-tsubo cardiomyopathy with markedly reduced left ventricular ejection fraction (Fig. 2-3). This observation was confirmed in transthoracic echo. Subsequent echocardiography performed 4 days after admission revealed a normal ejection fraction of 55% with grossly normal wall motion but with a relaxation abnormality. No valvular and right ventricular dysfunctions were observed in those examinations. The patient remained clinically and hemodynamically stable during 6 days of hospitalization and was discharged home (ECG at discharge — Fig. 1-2). Discharged medications included an aspirin, beta-blocker, calcium channel antagonist and statin. After 1 month patient had signs of heart failure and the transthoracic echo showed preserved left ventricular function with normal ejection fraction (Fig. 3-1, 2) and impaired

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

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

Correlation between the Electrocardiogram and Regional Wall Motion Abnormalities as Detected by Echocardiography in First Inferior Acute Myocardial Infarction

We assessed the correlation between ST deviation in each of the six precordial leads and the presence of regional wall motion abnormalities (RWMA) as assessed by transthoracic echocardiography in 109 patients with first inferior acute myocardial infarction. ST depression in lead V1 and V2 was associated with higher incidence of RWMA of the mid-posterior segment (p < 0.02 for both leads). The specificity of ST segment depression in leads V1 and V2 for RWMA in mid-posterior segment was 87 and 57%, and the sensitivity 36 and 70%, respectively. Patients with ST depression in leads V2 or V3 had worse global RWMA score than patients without ST depression in these leads (p = 0.009 and p = 0.025, respectively). Patients with an ST elevation in lead V1, but not in leads V2 or V3, had a higher prevalence of right ventricular involvement (p < 0.0001). ST elevation in lead V5 was associated with more frequent involvement of the apical portion of the inferior wall (p < 0.02), with specificity of 88% and sensitivity of 33%. Global RWMA score was significantly worse for patients with ST elevation than for patients with isoelectric ST in lead V5 (p = 0.024). ST elevation in lead V6 was associated with RWMA in the mid-posterior segment (p < 0.006), with specificity of 91% and sensitivity of 33%, and worse global RWMA score (p = 0.022).

Correlation between the Admission Electrocardiogram and Regional Wall Motion Abnormalities As Detected by Echocardiography in Anterior Acute Myocardial Infarction

We correlated ST elevation in various leads on admission and regional dysfunction in 132 patient with first anterior acute myocardial infarction using echocardiography. ST elevation in leads I and a VL and II, III and aVF was not associated with a specific pattern of regional dysfunction. Basal anterior and septal regional dysfunction were seen more often in patients with ST elevation in V1 (49 vs. 25%, p = 0.006; 35 vs. 17%, p = 0.048, respectively). Patients with ST elevation in V2 had more regional dysfunction of the apical inferior region (84 vs. 53%; p = 0.01). ST elevation in V5 and V6 was not associated with more apical or lateral wall motion abnormalities. ST elevation in lead V1 in anterior myocardial infarction is associated with a high incidence of regional dysfunction of the basal anterior, anteroseptal and septal regions.

Usefulness of ST-Segment Elevation in Lead III Exceeding That of Lead II for Identifying the Location of the Totally Occluded Coronary Artery in Inferior Wall Myocardial Infarction

The presence of ST-segment elevation in lead III exceeding that of lead II, particularly if combined with ST elevation in lead V1, proved to be a powerful marker for occlusion of the proximal or midportion of the right coronary artery. These findings helped to determine the extent of myocardium at risk in inferior wall myocardial infarction and may further guide the decision to administer thrombolytics.