ST-segment Elevation In Leads Research Articles

Iatrogenic right coronary artery occlusion during minimally invasive cardiac surgery-tricuspid annuloplasty—a case report

Although rare, right coronary artery (RCA) injury is a serious complication of tricuspid annuloplasty (TAP) and warrants close attention. We report a case of ST elevation myocardial infarction secondary to iatrogenic RCA occlusion during minimally invasive cardiac surgery (MICS). Electrocardiography (ECG) revealed ST segment elevation in lead II. Transesophageal echocardiography (TEE) revealed inferior wall hypokinesis after cardiopulmonary bypass, and coronary angiography revealed peripheral RCA occlusion. Intraoperatively, we detected an atrioventricular groove deformity during the second surgical procedure. Wall motion and ECG abnormalities showed normalization after TAP was reestablished. Vigilant monitoring using TEE and ECG is important to detect intraoperative myocardial ischemia during MICS-TAP.

Is COVID-19 the New Atherosclerosis? Acute Aortic Dissection Type A in the Early Period after COVID -19 Infection

The novel corona virus pandemic has since spread rapidly throughout the world resulting in more than 400 million cases. The clinical manifestations and complications associated with COVID-19 is yet to be elucidated. The clinical presentation may be variable, as it has been previously described. In the published literature many cases of acute aortic dissection caused by COVID-19 infection have been described, but only one in the early period after the resolution of the infection. We present a39year-oldwoman, who was admitted to our department complaining of chest pain after the yoga session. Her past medical history was notable for COVID-19 infection two weeks ago. Her electrocardiogram showed sinus rhythm and mild ST segment elevation in lead a VR, while the transthoracic echocardiogram revealed a dilation of the ascending aorta. After the echocardiographic examination, contrast enhanced computed tomography of aorta was conducted, which revealed an acute aortic dissection (type A- Stanford classification). The patient was admitted for emergent cardiovascular surgery, that was successful and eventually was discharged at the ninth post-operative day.

The Value of Stress Echocardiography Imaging and Functional Parameters in Patients with aVR Lead ST-Segment Elevation during an Exercise Stress Test to Detect Significant Left Main Stenosis.

To evaluate the role of functional and imaging parameters during exercise stress echocardiography (SE) in the presence of ST-segment elevation (ST-E) in aVR leads to predict significant left main/left main equivalent/or ostial left anterior descending (LAD) stenosis (LM+). The study population included 548 patients with ECG and echo markers of myocardial ischemia, in whom diagnostic coronary angiography was performed. We analyzed the patients' clinical characteristics, ECG changes, wall motion score index (WMSI) by stress echocardiography (SE), as well as functional capacity during exercise (METs) and Duke treadmill score. aVR ST-segment elevation was found in 60/548 (11%) patients, whereas aVR ST-E was found in 23/57 patients with left main LM stenosis (Sn 40%, Sp 92%, PPV 38%, NPV 93%). When aVR ST-E was combined with other functional/imaging parameters, patients with aVR ST-E and LM+ had significantly worse functional capacity in METs (5.0±2.2 vs. 6.7±2.3, P=0.005), lower Duke score (-6.8±6.8 vs. -3.6±4.1, P=0.049), and higher deterioration of WMSI (0.51±0.24 vs. 0.39±0.24, P=0.046). Significant multivariable predictors of the left main (LM) stenosis were aVR ST-E and positive SE in LAD territory in the whole group of patients, and Delta WMSI, Duke score and METs achieved in patients presented with aVR ST-E during exercise. The aVR ST-segment alone has intermediate sensitivity in detecting significant LM stenosis in patients referred to SE testing for chest pain. When combined with other functional and imaging parameters, including poor exercise functional capacity in METs, lower Duke score or greater WMA in the territory of LAD, its diagnostic power to detect LM significantly increases.

Relationship between aVR lead ST-segment elevation with SYNTAX score in patients with acute non-ST-segment elevation myocardial infarction

Relationship between aVR lead ST-segment elevation with SYNTAX score in patients with acute non-ST-segment elevation myocardial infarction

Cardiac rupture – the most serious complication of Takotsubo syndrome

Abstract Background The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p=0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p=0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p<0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p<0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG). Funding Acknowledgement Type of funding sources: None.

Cardiac Rupture-The Most Serious Complication of Takotsubo Syndrome: A Series of Five Cases and a Systematic Review.

Background: The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods: In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results: Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p = 0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p = 0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p < 0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p < 0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions: Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG).

Prognostic implications of ST-segment elevation in lead aVR in patients with acute coronary syndrome: A meta-analysis.

BackgroundST‐segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established.MethodsWe performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in‐hospital mortality. Secondary outcomes included in‐hospital (re)infarction, in‐hospital heart failure, and 90‐day mortality.ResultsWe included 7 studies with a total of 7,700 patients. The all‐cause in‐hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in‐hospital mortality when compared to lower STE (0.05–0.1 mV) (OR: 2.00, 95% CI 1.11–3.60, p = .02), However, STE in aVR was not independently associated with in‐hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85–8.63, p = .09). The incidence of in‐hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30–5.94, p = .009), in‐hospital heart failure (OR: 2.62, 95% CI 1.06–6.50, p = .04), and 90‐day mortality (OR: 10.19, 95% CI 5.27–19.71, p < .00001) was also noted to be higher in patients STE in lead aVR.ConclusionsThis contemporary meta‐analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in‐hospital mortality, reinfarction, heart failure and 90‐day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.

IMPROVED ACUTE ST-SEGMENT ELEVATION DUE TO AIR EMBOLISM AFTER CORONARY ARTERY BYPASS GRAFT PROCEDURE

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Air embolism is often an iatrogenic complication during coronary artery bypass grafting (CABG) surgery.1 Although infrequent as a complication of CABG surgery it is generally attributed to air introduced into the coronary arteries during the procedure.2 We report a case of ST-segment elevation after triple CABG surgery secondary to the introduction of air into the coronary arteries. CASE PRESENTATION: A 62-year-old male presents to the emergency department with mid-sternal chest pain, radiating to the left arm, his symptoms were associated with diaphoresis and palpitations. Initial Electrocardiogram (ECG) showed lateral ST-segment depressions, the initial troponin was elevated at 0.32 ng/ml (0.015-0.045 ng/ml). Patient underwent a left heart catheterization, which showed severe multi-vessel coronary artery disease. The decision was made to proceed with CABG. CT surgery was consulted and he underwent triple CABG with left internal mammary artery grafting to the anterior descending coronary artery, saphenous venous grafting to obtuse marginal 1 branch and saphenous venous grafting to the posterolateral branch of the right coronary artery. The anastomosis was completed with successful filling of the grafts. The aortic cross-clamp was removed, and the patient was allowed adequately to reperfuse and rewarm. Shortly after that, the patient developed ST-segment elevation in lead II, III, and aVF, along with ST depressions in lead I, aVL, V1, V2. Flow in the grafts were checked and they remained patent. Air embolization of the coronary arteries was suspected. Transthoracic echocardiogram (ECHO) demonstrated ventricular function impairment. Extended reperfusion was performed to force air from the coronaries out. The ECG showed resolution of ST-segment elevations and repeat ECHO showed improved ventricular function. The patient was monitored in the cardiovascular intensive care unit and was discharged home after four days of routine Post-CABG care. DISCUSSION: Air embolization of the coronary arteries may result as a complication of CABG as well as cardiac catheterization, leading to disruption of coronary perfusion.1 There may also be elevations of cardiac enzymes and hemodynamic instability. An extended reperfusion period with increased perfusion pressures usually causes the passing of bubbles through the coronary artery system, during the surgery.3,4 Late embolizations require urgent re-catheterization. 4 CONCLUSIONS: In conclusion, this case illustrates ST-segment elevation on ECG from an air embolism during CABG surgery. Early diagnosis and prompt treatment of this rare iatrogenic complication are crucial to prevent life-threatening cardiac complications. Reference #1: 1. Engelmann U, Minden H, Stock UA, Kühnel R, Albes JM. Late air embolism with interventional removal after isolated coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006;131(6):1403-1404.doi:10.1016/j.jtcvs.2006.01.046 2. Khan M, Schmidt DH, Bajwa T, Shalev Y. Coronary air embolism: Incidence, severity, and suggested approaches to treatment. Cathet Cardiovasc Diagn. 1995;36(4):313-318. doi:10.1002/ccd.1810360406 3. Solodky A, Birnbaum Y, Assali A, Gal T Ben. Coronary Air Embolism Treated by Bubble Aspiration. 2000;454(October 1999):452-454. 4. Patterson MS, Kiemeneij F. Coronary air embolism treated with aspiration catheter. Heart. 2005;91(5):1-2. doi:10.1136/hrt.2005.060129 Reference #2: Figure 1. Initial Electrocardiogram. Figure 2. Post CABG Electrocardiogram. Figure 3. Electrocardiogram at discharge. DISCLOSURES: No relevant relationships by Ahmad ababneh, source=Web Response No relevant relationships by Shubham Adroja, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Ahmad JABRI, source=Web Response

A CASE OF VASOSPASTIC ANGINA: A DIAGNOSTIC DILEMMA

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronary artery spasm is characterized by episodic angina typically occurring at rest with transient ST-segment elevation on electrocardiogram (EKG). This syndrome occurs as a brief and unexpected narrowing of one of the coronary arteries. CASE PRESENTATION: We present a 60-year-old man with acute onset of typical chest pain. He has a history of coronary artery disease status post bypass surgery with left internal mammary artery (LIMA) to the left anterior descending artery (LAD), coronary artery spasm, and a 40-pack-year smoking history. In the Emergency Department, he developed a second episode of squeezing chest pain with left arm numbness resolving spontaneously. Initial EKG demonstrated minimal anterior lead ST-segment elevation with elevated high sensitivity troponin I of 30 ng/L. Cardiovascular exam was unremarkable. He was admitted with concerns for acute coronary syndrome and over the course of his hospitalization he developed a recurrent episode of acute chest pain with dyspnea. His EKG revealed sinus bradycardia with ST-segment elevation in leads II, III, and aVF, thus prompting transfer to the critical care unit and initiation of nitroglycerin drip and a heparin infusion. A repeat EKG nine minutes later showed resolution of ST-segment elevation. The patient underwent diagnostic angiography, results including patency of LIMA to LAD and a 99% occlusion of the right coronary artery (RCA). Intracoronary nitroglycerin provided complete relief of symptoms and a now normal appearing RCA with no evidence for occlusive disease. A diagnosis of vasospastic angina was made and the patient was started on amlodipine along with isosorbide mononitrate. DISCUSSION: The diagnosis of coronary spasm may be overlooked as its presentation mimics an acute myocardial infarction. Improvement of symptoms with EKG resolution following the administration of nitroglycerin is suggestive of vasospasm. CONCLUSIONS: Cigarette smoking remains a major risk factor for vasospastic angina and cessation should be the mainstay treatment. Medical management includes calcium channel blockers as first-line and nitrates as second-line therapy. Reference #1: Tandon V, Mosebach CM, Kumar M, Joshi S. Refractory Vasospastic Angina: When Typical Medications Don't Work. Cureus. 2019;11(2):e4134. Published 2019 Feb 25. doi:10.7759/cureus.4134 Reference #2: Davies O, Ajayeoba O, Kurian D. Coronary artery spasm: An often overlooked diagnosis. Niger Med J. 2014;55(4):356–358. doi:10.4103/0300-1652.137231 DISCLOSURES: No relevant relationships by Jessica Boldridge, source=Web Response No relevant relationships by Steve Isserman, source=Web Response No relevant relationships by David Moore, source=Web Response No relevant relationships by Rahul Sampath, source=Web Response No relevant relationships by Ly Tran, source=Web Response

HIGHER ST-SEGMENT ELEVATION IN LEAD III THAN LEAD II IN ACUTE INFERIOR MYOCARDIAL INFARCTION CAN BE A PREDICTOR OF SHORT-TERM MORBIDITY AND MORTALITY

Background:The incidence of mortality and complications are high in patients with acute inferior wall ST-segment elevation myocardial infarction with right ventricular involvement, which has been reported to be an independent predictor of significant complications and in-hospital mortality. Objective:To investigate the feasibility of using electrocardiographic changes in inferior myocardial infarction represented by ST-segment elevation ratio in lead II and III as a predictor of right ventricular infarction and in-hospital morbidity and mortality. Methods:Ninety-nine patients were studied in this prospective study, their ages ranged from 19-90 years, average 58.12 (±12.7 SD). They were presented to the Coronary Care Unit of Basrah General Hospital with acute inferior ST-segment elevation myocardial infarction. The 12 leads plus right-sided precordial electrocardiograms were done to all patients within 12 hours of the onset of symptoms, and ST-segment elevation was measured. ST-segment elevation in lead III exceeding lead II was defined as a ratio of elevation in lead III: II&gt;1. Patients grouped according to ST-segment elevation III:II ratio into either &gt;1 or ≤1. In-hospital morbidity and mortality were studied in both groups. Results:ST-segment elevation ratio &gt; 1was detected in 68 patients (68.7%) with acute inferior myocardial infarction at time of admission. Right ventricular infarction was diagnosed in 33 (33.3%) patients, with the majority (32 patients) have ST-elevation ratio &gt; 1. Thirty-Six patients had at least one of the in-hospital complications with significantly higher incidence (51.4%) in patients with higher ST elevation ratio. The mortality was statistically higher when ST segment elevation level in the lead III &gt; than that in the lead II. Conclusion:In patients with inferior STEMI, ST-segment elevation in the lead III more than lead II can be a potential marker of the presence of right ventricular infarction in association with inferior myocardial infarction. Short-term prognosis is possibly worse in the presence of a higher ratio between lead III and II ST-segment elevation. However, further studies are needed to validate this conclusion. Keywords:Inferior MI, right ventricular infarction, ST-segment changes Citation:Al-Mansouri LA, Al-Obaidi FR, Al-Humrani AH. Higher ST-Segment elevation in lead III than lead II in acute inferior myocardial infarction can be a predictor of short-term morbidity and mortality. Iraqi JMS. 2019; 17(3&amp;4): 168-174. doi: 10.22578/IJMS.17.3&amp;4.2

Electrocardiographic findings of acute total occlusion associated with a sub-occlusion involving the left anterior descending and the right coronary artery

BackgroundThe ECG characteristics of simultaneous acute occlusion/sub-occlusion of two coronary arteries involving the left anterior descending (LAD) and right (RCA) coronary artery have been rarely described in the literature. MethodsWe present two patient cases, where one of the arteries was totally occluded and the other one had a sub-occlusion with severely limited flow to demonstrate the ECG characteristics of this severe presentation of acute coronary syndrome. ResultsTwo ECG patterns suggested simultaneous occlusions of the RCA and LAD. One pattern was ST-segment elevation (STE) in lead III higher than in lead II with concomitant STE in leads V3-V4. The other pattern was STE in lead III higher than in lead II with the concomitant Dressler - de Winter ECG pattern in leads V2-V4. ConclusionsWe present two ECG presentations of simultaneous RCA and LAD occlusion/sub-occlusion. We consider these ECG features as high-risk markers in acute ST-elevation myocardial infarction.

Differences in initial electrocardiographic findings between ST-elevation myocardial infarction due to left main trunk and left anterior descending artery lesions

BackgroundEarly discrimination of ST-elevation myocardial infarction (STEMI) due to a left main trunk (LMT) lesion provided by straightforward electrocardiographic criteria is useful for prompt treatment. The purpose of this study is to investigate differences in electrocardiographic findings between STEMI due to lesions of LMT and those of left anterior descending artery (LAD).MethodsInitial electrocardiogram (ECG) recordings of 435 patients with analyzable ECGs from a cohort of 940 consecutive STEMI patients were analyzed retrospectively for presence of LMT lesions (LMT, n = 39), proximal (pLAD, n = 224) and distal LAD lesions (dLAD, n = 172). ST-segment deviations in 12 leads were assessed among 3 groups without bundle branch block (n = 17 in LMT, n = 180 in pLAD, and n = 159 in dLAD).ResultsMagnitudes of ST-segment deviations showed significant differences in leads II, III, aVR aVL, aVF, and V2–V6 across the three groups. This difference suggested two possible characteristic findings in the LMT group, allowing it to be distinguished from the pLAD or dLAD group; (A) larger magnitude of ST-segment depression in lead II than that of ST-segment elevation in lead V2 (47.1% in LMT vs. 0.6% in pLAD vs. 1.3% in dLAD, P < 0.0001), and (B) ST-segment depression in lead V5 (58.8% in LMT vs. 6.7% in pLAD vs. 2.5% in dLAD, P < 0.0001). These findings exhibited superior negative predictive value over conventional ST-segment elevation in lead aVR.ConclusionsA large reciprocal ST-segment depression in inferior leads and ST-segment depression in lead V5 are useful ECG findings allowing determination of STEMI due to an LMT lesion.

Prognostic Value of ECG in Patients with Pulmonary Embolism

Aim. To study the significance of electrocardiography (ECG) signs for determining the hospital prognosis in patients with pulmonary embolism (PE).Material and methods. 472 consecutive patients (49.6% men; average age 58.06±14.28 years) with PE, hospitalized to our center from 23.04.2003 to 18.09.2014 were enrolled into the study. In all cases PE was confirmed by computed tomographic pulmonary angiography and rarely by pulmonary angiography, or by pathology. Patients management was in accordance with appropriate European guidelines. Data of patients' history, clinical symptoms, biochemical markers and instrumental methods (ECG, echocardiography) were analyzed by one-dimensional logistic regression. The end points were: death, shock and hypotension, right ventricular dysfunction and pulmonary hypertension, positive cardiac biomarkers.pulmonary embolism, electrocardiography, prognosis, collapse, hypotension, dysfunction of the right ventricle. 443 patients (93.9%) without fatal outcome were the first group and 29 patients (6.1%) with a fatal outcome – the second group. SIQIII pattern (33 vs 55.2%; p=0.015), non-complete right bundle branch block (RBBB) (16.3 vs 37.9%; p=0.001), ST segment elevation in lead III (9.7 vs 20.7%, p=0.034), atrial fibrillation (12.9 vs 37.9%, p=0.048) were observed more frequently among patients of group 2. Multivariate analysis revealed that SIQIII pattern (odds ratio [OR] 2.26; 95% confidence interval [95%CI] 1.046-4.868; p=0.038) and RBBB (OR 2.84; 95%CI 1.272-6.327; p=0.011) were associated with worse prognosis. The SIQIII pattern was significantly associated with a fatal outcome with a sensitivity of 55% and a specificity of 33% (AUC=0.611) according to ROC-analysis. Risk of hypotension was related to the following ECG-signs: the p-pulmonale (OR 1.76; 95%CI 1.001-3.088; p=0.049), negative T-wave in lead III (OR 1.8; 95%CI 1.035-3.144; p=0.037). Inversion of the T wave in lead III was associated with the development of shock (OR 1.98; 95%CI 0.891-4.430; p=0.043).ECG-signs were also associated with the development of right ventricular dysfunction and pulmonary hypertension: right axis deviation (OR 1.035; 95%CI 1.008-1.062; p=0.01), ST-segment elevation in the AVR lead (OR 3.769; 95%CI 1.018-13.955; p=0.047), negative T wave in leads III, V1-V3 (OR 1.015; 95%CI 1.008-1.023; p=0.001 and OR 1.014; 95%CI 1.005-1.022; p=0.001, respectively), RBBB (OR 1.013; 95%CI 1.003- 1.024; p=0.012), p-pulmonale (OR 1.015; 95%CI 1.007-1.023; p=0.001), deep S in leads V5-V6 (OR 1.015; 95%CI 1.006-1.024; p=0.001). However, there was no significant relationship between ECG signs and cardiac biomarkers (troponin I and BNP).Conclusions. SIQIII pattern, RBBB and inversion of the T wave in lead III have prognostic value in unselected population of patients with PE.

Electrocardiographic and Seasonal Patterns Allow Accurate Differentiation of Tako-Tsubo Cardiomyopathy from Acute Anterior Myocardial Infarction: Results of a Multicenter Study and Systematic Overview of Available Studies.

Background. Though several studies about prevalence, etiology, clinical characteristics, preceding events, clinical management, and outcome of Tako-Tsubo cardiomyopathy (TTC) exist, the current knowledge of TTC remains limited. Objective. In 2006, TTC was classified among the acquired forms of cardiomyopathy. On the basis of pathophysiological implications, we analyzed whether the presence of ST-segment elevation in lead -aVR (i.e., ST-segment depression in aVR) and the simultaneous absence of ST-segment elevation in lead V1 allow a reliable differentiation of TTC from acute anterior ST-segment elevation myocardial infarction (STEMI). A further investigative feature is the seasonal variation of TTC. Since acute cardiovascular events exhibit definite chronobiological patterns, various small studies have tried to evaluate whether this is also the case for TTC. Because results are conflicting, we also conducted a multicenter study and analyzed the findings in context with a systematic overview of available studies. Methods. We compared the ECG patterns of 115 patients with TTC, who were admitted to five large acute cardiac care centers associated with university hospitals in Southwestern Germany between January 2001 and June 2011, with those of 100 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) treated in one of these centers. In addition, we performed a computer-assisted MEDLINE search of the literature from January 2000 to September 2011 and analyzed the chronobiological patterns of available TTC cases, including our TTC cohort. Results. Testing the predefined diagnostic criteria was superior to any other electrocardiographic finding and differentiated TTC from anterior STEMI with a sensitivity of 73%, a specificity of 84%, a positive predictive value of 63%, and a negative predictive value of 89%. Beyond that, the onset of TTC showed a clear variation as a function of season and month. While events occurred most frequently during summer (38.4%, p < 0.01), the event rate was the lowest in autumn (16.4%) and winter (21.9%). Chronobiological analyses on a monthly basis identified a significant annual rhythmic pattern in TTC, which peaked in August (11.9%; p < 0.01) and had its nadir in November (6.3%). Conclusions. Our data illustrate that the ST-segment changes in leads aVR and V1 represent a simple and accurate ECG criterion to differentiate TTC from anterior STEMI in patients who are admitted within 12 h of symptom onset. Similarly, the results of our seasonal analysis indicate a distinct chronobiological variation in TTC occurrence. TTC, thereby, differs from major acute cardiovascular diseases, especially acute myocardial infarction (AMI), which is characterized by winter peaks and troughs in summer. If these results are confirmed in large independent cohorts, they may yield diagnostic implications, changing the regular invasive AMI management in TTC patients.

Comments on the 2018 ESC Fourth Universal Definition of Myocardial Infarction

The ECG characteristics of simultaneous acute occlusion/sub-occlusion of two coronary arteries involving the left anterior descending (LAD) and right (RCA) coronary artery have been rarely described in the literature.We present two patient cases, where one of the arteries was totally occluded and the other one had a sub-occlusion with severely limited flow to demonstrate the ECG characteristics of this severe presentation of acute coronary syndrome.Two ECG patterns suggested simultaneous occlusions of the RCA and LAD. One pattern was ST-segment elevation (STE) in lead III higher than in lead II with concomitant STE in leads V3-V4. The other pattern was STE in lead III higher than in lead II with the concomitant Dressler - de Winter ECG pattern in leads V2-V4.We present two ECG presentations of simultaneous RCA and LAD occlusion/sub-occlusion. We consider these ECG features as high-risk markers in acute ST-elevation myocardial infarction.

An algorithm for the differentiation of the infarct territory in difficult to discern electrocardiograms

BackgroundIn a minority of the patients presenting with ST-segment elevation (STE) myocardial infarction (MI), electrocardiogram (ECG) may show a balanced STE in both anterior and inferior lead groups and may cause diagnostic confusion about involved myocardial territory. In this study, we sought ECG clues which may facilitate discriminating (1) MI location and then (2) culprit artery in patients with difficult-to-discern ECGs. Material and methodsConsecutive patients with the diagnosis of STEMI were scanned and patients with ECGs displaying both anterior and inferior STE were enrolled. ECGs with obvious ST elevation in either lead group and reciprocal ST-segment depression were excluded. Predictive power of several ECG variables has been analyzed and an algorithm has been constructed. ResultsA total of 959 STEMI cases were scanned, the final study population was consisted of 114 patients. Our algorithm for locating MI territory had a sensitivity, specificity, positive and negative predictive value of 72.1%, 92.5%, 91.7% and 74.2% for inferior versus anterior location, respectively (P < 0.001, φ = 0.652). As anterior MI was strictly reserved for left anterior descending (LAD) artery occlusion, these diagnostic values were also valid for discriminating circumflex artery [Cx]/right coronary artery [RCA] versus LAD as the culprit artery. In patients classified as having inferior MI, an STE in lead III greater than STE in lead II favored RCA over Cx as the culprit artery with a sensitivity, specificity, positive and negative predictive value of 97%, 46.6%, 80% and 87.5%, respectively (P < 0.001; φ = 0.544). ConclusionOur algorithm can be used in difficult-to-discern ECGs for defining involved myocardial territory and culprit artery.

Recognising the de Winter ECG pattern – A time critical electrocardiographic diagnosis in the Emergency Department

The de Winter ECG pattern is associated with proximal left anterior descending artery occlusion, being a significant risk factor for anterior wall ST elevation myocardial infarction. We present a case of a patient who attended our Emergency Department with chest pain and a prehospital ECG demonstrating transient infero-lateral lead ST segment elevation, which changed to the de Winter ECG pattern in our Emergency Department. She subsequently underwent primary PCI of the culprit lesion within the left anterior descending artery (LAD). Recognition of de Winter ECG pattern in the Emergency Department results in a time critical diagnosis for acute coronary occlusion and should be followed by emergency coronary revascularization.

The added value of ST-elevation in lead aVR to clinical thrombolysis in myocardial infarction risk score in predicting the angiographic severity and extent of coronary artery disease in patients with non-ST-elevation acute coronary syndrome

Introduction The use of ST-segment elevation (STE) in lead aVR in addition to thrombolysis in myocardial infarction (TIMI) risk score may improve the early risk stratification and the management of patients at high-risk coronary artery disease, with subsequent effect on morbidity and mortality. Patients and methods A total of 65 patients who underwent coronary angiograms in Sohag Heart Specialized Center in the period between September 2013 and March 2014 were the participants of the study. All patients were subjected to full history taking, clinical evaluation, laboratory investigations, ECGs, TIMI scoring, and coronary angiography by femoral approach. Results Of the 65 patients, 59 patients were found to have significant coronary artery disease with 39 of them had STE in aVR lead, and none of the normal coronary angiography (CA) cases had STE in this lead. Of the 39 with STE-aVR, 13 patients had left main disease and 30 of them had multivessel disease. ST-aVR was elevated in 17 cases with low or intermediate risk according to TIMI score (9.1 and 55% of both groups, respectively), and was normal in three (12%) of the patients with high-risk TIMI score. Thus, STE-aVR could predict another 28.8% of high-risk cases that would not be detected by TIMI. Conclusion STE in lead aVR has a diagnostic and prognostic value in patients with non-STE acute coronary syndrome and may provide an additional prognostic value to the conventional cardiovascular risk factors, particularly in patients from the TIMI low-risk and intermediate-risk groups.

Correlation of ECG Changes with Coronary Angiographic Findings in Acute Inferior Myocardial Infarction

The determination of infarct related artery in acute inferior myocardial infarction is extremely important for the prediction the amount of myocardium at risk and guide decisions regarding urgency of revascularization. Urgent decision may facilitate management and prevention of complication. Our objective was to Identification of the infarct related artery involving either right coronary artery (RCA) or left circumflex artery (LCX) in acute inferior wall myocardial infarction using electrocardiographic criteria and comparing with angiographic finding. This prospective, observational study was done in Chittagong Medical College Hospital from June 2013 to May 2014. A total of 112 Patients with acute inferior myocardial infarction were included in this study. The electrocardiogram of these patients evaluated for ST segment elevation in lead III exceeding that in lead II (i.e. a ratio of ST elevation in lead III/elevation in lead II &gt; 1) and S/R wave ratio &gt; 0.33 plus ST segment depression &gt; 1 mm in lead aVL as a prediction for right coronary artery occlusion. If criteria are negative, LCX obstruction is likely. Coronary angiogram was done within 2-6 weeks in cath lab, department of cardiology, CMCH to identify the culprit artery. The infarct related artery (IRA) was identified from total occlusion or significant stenosis (&gt; 70%) of the RCA or LCX or their major branches, or from arteriographic evidence of intraluminal thrombosis. To minimize the chance of misclassifying the culprit artery, patients with significant stenosis of both the RCA and the LCX were excluded from the study. The study population consisted of 112 patients (94 male and 18 female) with a mean ± SD age of 51 ± 8.6 years. On coronary angiography, the culprit artery was shown to be the RCA in 92 patients and the LCX in 20 patients. It was evident that the degree of ST segment elevation in lead III was significantly higher in right coronary artery group (92 patients) vs left circumflex group (20 patients) 3.16±1.14mm vs 1.35±0.24mm (p&lt;0.001) respectively. While its comparable in lead II 2.18±0.95mm vs 1.7±0.34mm (p&gt;0.05). In respect to leads AVL, we found that deeper ST segment depression was in right coronary artery group as compared to left circumflex group 1.11±0.25mm vs 0.2 ±0.34mm (p&lt;0.001). ECG parameters for implicating the RCA were a higher ST elevation in lead III than lead II (specificity 98%, sensitivity 97%) and an S/R wave ratio &gt; 0.33 plus ST segment depression &gt; 1 mm in lead aVL (specificity 96%, sensitivity 95%). Absence of these criteria was associated with LCX occlusion (specificity 100%, sensitivity 85%). It is possible to predict the culprit artery whether right coronary artery or left circumflex by examining the surface electrocardiography in patients with acute inferior myocardial infarction.Medicine Today 2017 Vol.29(2): 33-37

P559The aVR lead ST-segment elevation during the exercise stress test as a predictor of a left main stenosis

P559The aVR lead ST-segment elevation during the exercise stress test as a predictor of a left main stenosis