ST-segment Depression In V1 Research Articles

Exertional Syncope In A Athlete With Recent SARS-Cov-2 Infection - Endurance Sport

HISTORY: A 53-year-old competitive masters endurance athlete presented for return to sport clearance following SARS-CoV-2 infection (mild symptoms lasting 3-14 days, including nose & throat symptoms, cough, fever, and myalgia). There was a history of episodes of intermittent exertional light-headedness, chest pain, shortness of breath, and syncope for the past 10 years, precipitated by sudden cessation of running and lasting <30 seconds. The patient had no significant past medical history nor risk factors for coronary heart disease. PHYSICAL EXAMINATION: Vital signs were normal. No symptoms on orthostatic testing. Cardiovascular examination revealed an inferiorly displaced apex beat, normal heart sounds, no evidence of a murmur with dynamic movements, no pericardial rub nor pedal oedema. Distal pulses were equal with a normal rhythm, no radio-femoral delay. Respiratory, neurological, abdominal, and otolaryngological examinations were normal. DIFFERENTIAL DIAGNOSIS: 1. Coronary artery disease 2. Exercise associated postural hypotension 3. Cardiac arrhythmia 4. Valvular heart disease (aortic stenosis) 5. Viral myopericarditis 6. Cardiomyopathy 7. Autonomic dysfunction TEST AND RESULTS: Blood results: FBC = normal CRP < 1 mg/L Creatinine kinase = 153 U/L Troponin-T = 7 ng/L. Lung function tests: FEV1/FVC = 108% predicted. Resting ECG: LA enlargement. T-wave inversion in inferior and precordial leads (V2-V6). Stress ECG: Upsloping ST-segment depression in V4 + V5 during exercise, changing to downsloping during recovery. Normal BP and HR response to exercise and recovery. Echocardiogram: Normal except mild mitral regurgitation. Cardiac MRI: Normal heart size. Marked asymmetric thickening of the apex with cavity obliteration during systole. Marked late gadolinium enhancement with near transmural enhancement of the apex with patchy enhancement extending to the hypertrophied area. No epicardial enhancement noted FINAL WORKING DIAGNOSIS: Apical hypertrophic cardiomyopathy TREATMENT AND OUTCOMES: 1. Referred to a specialist cardiologist for 72-hour Holter ECG monitoring. 2. No arrhythmias (rest and exercise) detected. 3. Following extensive counselling by the physician and ensuring comprehension, the patient decided against further testing and wanted to continue with regular exercise.

Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series

BackgroundTrue isolated posterior myocardial infarction is an uncommon finding of acute coronary syndrome, with an incidence rate of 3–7%. The prevalence rates of isolated posterior myocardial infarction in men and women are 72% and 28%, respectively. This uncommon finding may be attributed to multiple factors, such as unremarkable changes on 12-lead electrocardiography, a lack of awareness or knowledge, and an absence of diagnostic consensus, which leads to reperfusion delay and poor clinical outcomes.Case summaryHerein, we report three cases of acute myocardial infarction presenting as isolated ST-segment elevation in the posterior leads (V7–V9): Asian men aged 57, 62, and 53 years, who presented with ST-segment depression in V1–V3 that resolved gradually. Coronary angiography revealed a total/critical occlusion of the proximal circumflex coronary artery in all three cases. Routine and accurate interpretations of 15-lead electrocardiography (12-lead with additional V7–V9) resulted in a better sensitivity for isolated posterior myocardial infarction diagnoses, followed by a timely and opportune primary percutaneous coronary intervention.ConclusionsIsolated posterior myocardial infarction is a rare but potentially fatal event that is often accompanied by atypical and subtle changes on 12-lead electrocardiography (especially in the V1–V3 precordial leads) and may remain undetected by physicians. Therefore, the comprehensive and routine application of posterior leads is a crucial addition to the standard diagnosis and management of acute coronary syndrome in patients with subtle ST-segment changes who do not fulfill the criteria for ST-elevation myocardial infarction.

Influence of Left Bundle Branch Block on the Electrocardiographic Changes Induced by Acute Coronary Artery Occlusion of Distinct Location and Duration.

Background: Electrocardiographic (ECG) diagnosis of acute myocardial ischemia is hampered in the presence of left bundle branch block (LBBB).Objectives: We analyzed the influence of location and duration of myocardial ischemia on the ECG changes in pigs with LBBB.Methods: LBBB was acutely induced in 14 closed chest anesthetized pigs by local electrical ablation. Thereafter, episodes of 5 min catheter balloon occlusion followed by 10 min reperfusion of the left anterior descending (LAD), left circumflex (LCX), and right (RCA) coronary arteries were done sequentially in 5 pigs. Additionally, a 3-h occlusion of these arteries was performed separately in the other 9 pigs. A 15-lead ECG including leads V7 to V9 was continuously recorded.Results: Ablation induced LBBB showed QRS widening, loss of r wave in V1, and predominant R waves in V2 to V9. After 5 min of ischemia the occluded artery could be identified in all cases: the LAD by R waves and ST elevation in V1–V3; the LCX by both ST segment elevation in II, III, aVF, V7 to V9 and ST segment depression in V1 to V4; and the RCA by ST depression and new S-waves in all precordial leads. Three hours after coronary occlusion, ST segment changes declined progressively and only the LAD occlusion could be reliably recognized.Conclusion: LBBB did not mask the ECG recognition of the occluded coronary artery during the first 60 min of ischemia, but 3 h later only the LAD occlusion could be reliably identified. ST elevation in leads V7 to V9 is specific of LCX occlusion and it could be useful in the diagnosis of acute myocardial ischemia in the presence of LBBB.

0074: The stress test as a diagnostic toolfor coronary artery disease in hypertensive patients

In hypertensive patients, there are multiplecauses of error in the diagnosis of coronary artery disease: The objective of this study was to evaluate the sensitivity of the positive electrical criteria in the stress test in diagnosing coronary artery disease within the hypertensive patients. 120 hypertensive patients with positive stress test underwent coronary angiography. 33 % of patients had significant coronary lesions and 67% had normal coronary angiography. Two groups of patients were identified: group A (77 patients) withST segment depression in DII, DIII, aVF and V6 with maximal effort and group B (43 patients) with a ST segment depression in DII, DIII, aVF and/or V4, V5, V6 with maximal effort. In group A, 65 patients (84.4%) had normal coronary angiography. In group B, 31 patients (72%) had significant coronary lesions. In a subgroup of 46 patients in group A with persistent ST segment depression in V4 to V6 and recovering for 4 to 6 minutes, 93% of coronary angiograms were normal. In another subgroup of 19 patients in group B with persistent ST segment depressionin V4 to V6 and recovering for 4 to 8 minutes, 16 patients (86%) had significant lesions on coronary angiograms. hypertensive patients with stress test showing ST segment depression in DII, DIII, aVF and/or V4, V5, V6 on maximum effort and persisting for 4-8 minutes recovering have a high probability of significant coronary artery disease.

Unstable angina pectoris complicated with fatal massive intramyocardial dissecting haemorrhage

A 71-year-old man was admitted with accelerated chest pain for 3 days. There were no history of hypertension, diabetes mellitus, heart failure, coronary artery disease, and trauma. Physical examination was unremarkable. Electrocardiogram showed minimal ST-segment depression in V1–3 derivations. Echocardiogram revealed apical and anterior wall hypokinesia with ejection fraction around 25%. Intramyocardial dissection flap filling with massive …

Oxaliplatin-induced acquired long QT syndrome with torsades de pointes and myocardial injury in a patient with dilated cardiomyopathy and rectal cancer

A 67-year-old woman presented with a history of dilated cardiomyopathy with congestive heart failure since 2003, who subsequently developed lower rectal cancer (adenocarcinoma) with liver, bone, and lymph node metastasis. Abdominoperineal resection and hepatectomy were performed. The patient received two rounds of intravenous chemotherapy, including 12 and six courses of FOLFOX4 (5-fluorouracil, leucovorin, and oxaliplatin; 85 mg/m2 per cycle). She underwent a third round of intravenous FOLFOX4 because of tumor progression. During the 21st course of FOLFOX4 regimen, the patient developed ST segment depression in lead II and prolongation of QT interval with polymorphic ventricular tachycardia, torsades de pointes right after the start of oxaliplatin infusion. Immediate defibrillation and cardiopulmonary resuscitation were administered, and the patient regained spontaneous circulation and consciousness. Twelve-lead electrocardiogram showed ST segment elevation in III, aVF, and ST segment depression in V4–6 after resuscitation. To our knowledge, prolongation of QT interval with torsades de pointes and coronary spasm with myocardial injury that were stabilized in one patient following oxaliplatin infusion has not been reported. We present a patient with these rare complications.

A Rare Case of Fatal Hyponatremia Due to a Combination of Psychotropic Polypharmacy and Hypothyroidism

A Rare Case of Fatal Hyponatremia Due to a Combination of Psychotropic Polypharmacy and Hypothyroidism

Electrocardiographic identification of the culprit coronary artery in inferior wall ST elevation myocardial infarction

Electrocardiograms (ECGs) are essential in identifying the type and location of acute myocardial infarction. In the setting of inferior wall myocardial infarction (IWMI), identification of the right coronary artery (RCA) as the culprit artery is important because of the potential complications associated with its involvement. To evaluate previous ECG criteria used for the identification of RCA involvement and validate them in the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT 4 PCI) cohort; and to develop an improved simplified score to identify RCA involvement. ASSENT 4 PCI patients with IWMI (n=710) were included in the present study. A literature review was conducted to identify previously published criteria to detect RCA involvement. Logistic regression was used to develop a new simplified algorithm for identifying RCA involvement. The sensitivities and specificities of six previous ECG criteria were substantially lower when applied to the ASSENT 4 PCI population. A new algorithm found that ST segment depression in leads I, aVL and V6, and ST segment elevation of greater than 1 mm in lead aVF was associated with a higher likelihood of RCA involvement, and any ST segment depression in V1 and V3 was associated with a lower likelihood of RCA involvement. A simplified risk score found a prevalence of RCA involvement of over 90% among patients with scores of greater than two. The ECG is useful in identifying RCA involvement in IWMI before angiography. Previously published criteria appear to be inadequate, and the simple algorithm presented in the current study may be a useful tool in identifying RCA involvement at the bedside.

Non-ST Elevation Myocardial Infraction after High Dose Intravenous Immunoglobulin Infusion

Intravenous immunoglobulins (IVIgs) are used for several indications, including autoimmune conditions. IVIg treatment is associated with several possible adverse reactions including induction of a hypercoagulable state. We report a 76-year-old woman treated with IVIg for myasthenia gravis, which developed chest pain and weakness following IVIg infusion. The symptoms were associated with ST segment depression in V4–6 and elevated troponin levels. The patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI). The patient had no significant risk factor besides age and a cardiac perfusion scan was interpreted as normal (the patient refused to undergo cardiac catheterization). This case is compatible with IVIg-induced hypercoagulability resulting in NSTEMI. Cardiac evaluation should therefore be considered prior to initiation of IVIg treatment especially in patients with multiple cardiovascular risks.

An elderly man with syncope caused by right ventricular infarction and anomalous coronary vasculature.

Up to half of inferior infarctions involve the right ventricle. Typical signs of right ventricular infarction include hypotension, jugular venous distention, clear lung fields, ST-segment depression in V1 and V2, and elevations in V3R and V4R.

Clinical utility of ST-segment depression in lead AVR in acute myocardial infarction

The present study evaluated the prevalence and significance of ST-segment depression (STD) in lead aVR on the admission 12-lead electrocardiogram in 307 consecutive patients with an acute myocardial infarction (AMI) with ST-segment elevation. STD in aVR was present in a significantly higher proportion of patients with inferior/posterior AMIs. Within inferior/posterior AMIs those with STD in aVR had significantly more concomitant STD in V1, V2, V3 and more concomitant STesegment elevation in V5, V6 and right precordial leads. These data suggests that STD in aVR may point to a coronary artery with a large area of supply as the culprit vessel responsible for the AMI.

Precordial T-wave Polarity Changes in Acute Inferior Infarction: A Poor Indicator of Associated Disease of the Left Anterior Descending Coronary Artery

T-wave polarity in V1 to V3 was examined in 70 patients with acute inferior wall myocardial infarctions (IWMI) as an indicator of significant disease in the left anterior descending coronary artery (LAD). Fifty-three percent (37/70) had precordial T-wave inversions, and of these 38 percent (14/37) had angiographically significant LAD disease. Conversely, 47 percent (33/70) had upright T waves in V1 to V3, and of these, 52 percent (17/33) had significant LAD disease. Likewise, 41 percent of the patients with ST segment depression in V1 to V3 had significant LAD disease, while 50 percent of those with isoelectric ST segments were similarly affected. Finally only 39 percent of those patients with both precordial ST segment depression and T-wave inversion had significant LAD disease. We conclude that neither anterior ST depression, T-wave inversion, nor a combination of both is a sensitive or specific indicator of LAD disease in patients with acute IWMI.