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Afify H, Oliynyk V, Burke F. A Silent Killer: Left Main Coronary Artery Disease in Gastrointestinal Bleed. Cureus 2021; 13:e15988. [PMID: 34336479 PMCID: PMC8318611 DOI: 10.7759/cureus.15988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/28/2021] [Indexed: 11/21/2022] Open
Abstract
Left main coronary artery disease (LMCAD) is defined as more than 50% angiographic arterial narrowing and has been demonstrated in nearly 5% of all patients undergoing coronary angiography. It carries an extremely high risk for cardiovascular morbidity and mortality as it impacts more than two-thirds of the left ventricle. Prediction of LMCAD in the right clinical setting is important for the selection of the proper treatment strategies. Typical ECG characteristics are ST elevation (STE) in lead augmented vector right (aVR-STE) of more than 0.5 mV accompanied by ST depression (STD) notably in leads I, II, and V4-6 or STE in aVR ≥ V1. Furthermore, the presence of aVR-STE is associated with worse outcomes and careful evaluation and close monitoring are warranted. However, not every aVR-STE is an acute occlusion of the left main coronary artery (LMCA), as acute occlusion is a catastrophic event. aVR-STE can also be associated with severe triple-vessel disease or diffuse subendocardial ischemia.
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Affiliation(s)
- Hesham Afify
- Internal medicine, University of Central Florida/HCA Healthcare Graduate Medical Education, Orlando, USA
| | - Volodymyr Oliynyk
- Internal Medicine, University of Central Florida/HCA Healthcare Graduate Medical Education, Orlando, USA
| | - Floyd Burke
- Cardiology, Orlando Veterans Affairs (VA) Medical Center at Lake Nona, Orlando, USA.,Medicine, University of Central Florida College of Medicine, Orlando, USA
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Baheti A, Hanson CA, McArdle M, Lall SK, Beller GA, Bourque JM. Lead aVR predicts early revascularization but not long-term events in patients referred for stress electrocardiography. PLoS One 2021; 16:e0249779. [PMID: 33831085 PMCID: PMC8032194 DOI: 10.1371/journal.pone.0249779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Exercise stress electrocardiography (ExECG) is recommended as a first-line tool to assess ischemia, but standard ST-analysis has limited diagnostic accuracy. ST elevation in lead aVR has been associated with left main and LAD disease in the population undergoing coronary angiography but has not been studied in the general population undergoing stress testing for the initial evaluation of CAD without coronary angiography. We sought to determine the predictive value of lead aVR elevation for ischemia, early revascularization, and subsequent cardiac events in consecutive patients undergoing ExECG. METHODS AND RESULTS The study cohort included 641 subjects referred for ExECG who were dichotomized by presence or absence of aVR elevation ≥1mm and compared for prevalence and predictors of ischemia and a composite of cardiac death, nonfatal myocardial infarction, and late revascularization. The cohort had a median age of 57 and 57% were male. The prevalence of aVR elevation was 11.5%. The prevalence of significant ischemia on patients who received imaging was significantly higher with aVR elevation (14.3% vs 2.3%, p<0.001). Early revascularization occurred in 10.9% with vs 0.2% without aVR elevation, p<0.001. No subjects without aVR elevation or ST-depression underwent early revascularization. However, cardiac event rates were similar over a median 4.0 years of follow-up with and without aVR elevation (2.8% vs. 2.6%, p = 0.80). aVR elevation did not predict long-term cardiac events by Kaplan-Meier survival analysis (p = 0.94) or Cox proportional hazards modeling (p = 0.35). CONCLUSIONS aVR elevation during ExECG predicts ischemia on imaging and early revascularization but not long-term outcomes and could serve as a useful adjunct to standard ST-analysis and potentially reduce the need for concurrent imaging.
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Affiliation(s)
- Aparna Baheti
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Christopher A. Hanson
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
| | - Michael McArdle
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Sumeet K. Lall
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - George A. Beller
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
| | - Jamieson M. Bourque
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
- * E-mail:
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3
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Is isolated ST segment elevation in Lead aVR associated with high grade coronary artery disease? J Electrocardiol 2020; 62:170-177. [PMID: 32947239 DOI: 10.1016/j.jelectrocard.2020.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/04/2020] [Accepted: 08/31/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS). METHODS Pooled sensitivity, specificity, positive, and negative likelihood ratios were calculated using a random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. RESULTS This meta-analysis included 14 studies. The pooled sensitivity of STEaVR for LM/3VD was 0.40 (95% CI; 0.38 0.43, p < 0.001), specificity 0.82 (95% CI; 0.81-0.83, p < 0.001). Pooled positive likelihood ratio 2.49 (95% CI; 1.62-3.81, p < 0.001) and negative likelihood 0.54 (95% CI; 0.39-0.76, p < 0.001). The pooled sensitivity of STEaVR for LM was 0.39 (95% CI; 0.34-0.45, p < 0.001) specificity was 0.86 (95% CI; 0.85-0.87, p < 0.001) with an AUC of 0.79. The pooled positive likelihood ratio (LR) for LM was 2.78 (95% CI, 2.28-3.39, p < 0.001) negative likelihood ratio 0.51 (95% CI, 0.33-0.78, p < 0.001). CONCLUSION Our study shows that in patients presenting with an ACS, presence of STEaVR may indicate the presence of LM or 3VD. STEaVR has a high specificity for both LM and 3VD, with a high pooled LR.
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D'Angelo C, Zagnoni S, Gallo P, Tortorici G, Casella G, Di Pasquale G. Electrocardiographic changes in patients with acute myocardial infarction caused by left main trunk occlusion. J Cardiovasc Med (Hagerstown) 2018; 19:439-445. [PMID: 29889168 DOI: 10.2459/jcm.0000000000000684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Left main trunk (LMT) occlusion is a rare angiographic finding. The primary purpose was to investigate the ECG pattern of patients with angiographic confirmation of LMT as culprit lesion. METHODS Forty-eight patients (32 men; mean age 73 years) with angiographic total (21 patients; 44%) or subtotal (27 patients; 56%) occlusion of the LMT were analyzed. Twenty patients (42%) were found to have concomitant coronary lesions. Eighteen patients (38%) required intra-aortic balloon pump support. RESULTS A significant left axis deviation was observed in 26 cases (54%) and an intraventricular conduction delay in 32 patients (67%). The average QRS width and QTc interval were 122 and 433 ms, respectively. ST-segment elevation in lead aVR occurred in 32 patients (67%). ST-segment elevation in leads V2-5 and in leads I and aVL [classic left anterior descending (LAD) type] was frequently observed (18 cases; 35%). In six patients (13%), a partial LAD type was observed with ST-segment elevation in leads I and aVL, but not in peripheral leads. The remaining patients showed ST-segment elevation only in peripheral leads (12 cases), in inferior leads III + aVF (six cases), whereas six patients had no ST-segment elevation. Diffuse ST-segment depression only (>6 leads) was observed in 15 cases (31%). Eighteen patients (38%) died during hospitalization. CONCLUSION ST-segment elevation in lead aVR or a LAD-type pattern can be associated with LMT disease. Other relevant aspects are the presence of cardiogenic shock at admission, the left axis deviation and marked prolongation of QTc interval and QRS width.
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Wagener M, Abächerli R, Honegger U, Schaerli N, Prêtre G, Twerenbold R, Puelacher C, Sunier G, Reddiess P, Rubini Gimenez M, Wildi K, Boeddinghaus J, Nestelberger T, Badertscher P, Sabti Z, Schmid R, Leber R, Widmer DF, Shrestha S, Strebel I, Wild D, Osswald S, Zellweger M, Mueller C, Reichlin T. Diagnostic and Prognostic Value of Lead aVR During Exercise Testing in Patients Suspected of Having Myocardial Ischemia. Am J Cardiol 2017; 119:959-966. [PMID: 28215415 DOI: 10.1016/j.amjcard.2016.11.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 11/26/2022]
Abstract
We aimed to assess the diagnostic and prognostic value of ST-segment deviation in aVR, a lead often ignored in clinical practice, during exercise testing and to compare it to the most widely used criterion of ST-segment depression in V5. We enrolled 1,596 patients with suspected myocardial ischemia referred for nuclear perfusion imaging undergoing bicycle stress testing. ST-segment amplitudes in leads aVR and V5 were automatically measured. The presence of inducible myocardial ischemia was the diagnostic end point and adjudicated based on nuclear perfusion imaging and coronary angiography. Major adverse cardiac events (MACE) during 2 years of follow-up including death, acute myocardial infarction, and coronary revascularization were the prognostic end point. Exercise-induced myocardial ischemia was detected in 470 patients (29%). Median ST amplitudes for leads aVR and V5 differed significantly among patients with and without ischemia (p <0.01). The diagnostic accuracy of ST changes for myocardial ischemia as quantified by the area under the receiver operating characteristic curve was highest 2 minutes into recovery and similar in aVR and V5 (0.62, 95% confidence interval CI 0.60 to 0.65 vs 0.60, 95% confidence interval 0.58 to 0.63, p = 0.08 for comparison). In multivariate analysis, ST changes in lead aVR, but not lead V5, contributed independent diagnostic information on top of clinical parameters and manual electrocardiographic interpretation. Within 2 years of follow-up, MACE occurred in 33% of patients with ST elevations in aVR and in 16% without (p <0.001). In conclusion, ST elevation in lead aVR during exercise testing indicates inducible myocardial ischemia independently of ST depressions in lead V5 and clinical factors and also predicts MACE during follow-up.
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6
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Russo G, Ravenna SE, De Vita A, Aurigemma C, Lamendola P, Lanza GA, Crea F. Exercise test predictors of severe coronary artery disease: Role of ST-segment elevation in lead aVR. Clin Cardiol 2017; 40:102-108. [PMID: 28244598 DOI: 10.1002/clc.22637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/17/2016] [Accepted: 09/21/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The role of exercise stress test (EST)-induced ST-segment elevation (STE) in electrocardiographic lead aVR in predicting severe coronary artery disease (CAD) is controversial. HYPOTHESIS Assessment of lead aVR during EST can be helpful to identify patients with severe CAD. METHODS We performed maximal EST in 200 patients undergoing coronary angiography for suspect of CAD. Four angiographic findings of severe CAD were considered: (1) left main (LM) disease; (2) LM or equivalent LM (LM/EQLM) disease; (3) LM or proximal left anterior descending (LAD) artery (LM/proxLAD) disease; and (4) LM or 3-vessel (LM/3V) disease. RESULTS LM, LM/EQLM, LM/proxLAD, and LM/3V disease were shown in 6 (3%), 13 (6.5%), 33 (16.5%), and 27 (13.5%) patients, respectively. EST-induced STE in aVR occurred in 41 patients (20.5%). ST-segment depression (STD) in ≥5 leads was the only predictor of LM stenosis (odds ratio [OR]: 6.18, 95% confidence interval [CI]: 1.19-32.2, P = 0.03) and the most significant variable associated with LM/proxLAD stenosis (OR: 4.73, 95% CI: 2.0-11.2, P = 0.0001); maximal STD ≥3 mm was the most significant variable associated with LM/EQLM (OR: 7.58, 95% CI: 2.31-24.9, P = 0.001) and LM/3V (OR: 3.86, 95% CI: 1.47-10.1, P = 0.006) CAD. EST-induced STE in aVR was associated with LM/proxLAD disease only (OR: 3.23, 95% CI: 1.44-7.24, P = 0.004). At multivariate analysis, STD in ≥5 leads was the only independent predictor of LM/proxLAD disease (OR: 3.99, 95% CI: 1.58-10.1, P = 0.003). CONCLUSIONS EST-induced STE in lead aVR does not significantly increase the prediction of severe CAD compared with severity and extension of STD as assessed in the other electrocardiographic leads.
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Affiliation(s)
- Giulio Russo
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Antonio De Vita
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cristina Aurigemma
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Filippo Crea
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome, Italy
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7
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Ghaffari S, Asadzadeh R, Tajlil A, Mohammadalian A, Pourafkari L. Predictive Value of Exercise Stress Test-Induced ST-Segment Changes in Leads V 1 and avR in Determining Angiographic Coronary Involvement. Ann Noninvasive Electrocardiol 2017; 22:e12370. [PMID: 27220780 PMCID: PMC6931716 DOI: 10.1111/anec.12370] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Samad Ghaffari
- Cardiovascular Research CenterTabriz University of MedicineTabrizIran
| | - Reza Asadzadeh
- Cardiovascular Research CenterTabriz University of MedicineTabrizIran
| | - Arezou Tajlil
- Cardiovascular Research CenterTabriz University of MedicineTabrizIran
| | | | - Leili Pourafkari
- Cardiovascular Research CenterTabriz University of MedicineTabrizIran
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Sareen N, Ananthasubramaniam K. Left main coronary artery disease: A review of the spectrum of noninvasive diagnostic modalities. J Nucl Cardiol 2016; 23:1411-1429. [PMID: 26487011 DOI: 10.1007/s12350-015-0152-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/15/2015] [Indexed: 11/29/2022]
Abstract
Medically managed significant left main (LM) stem disease has been considered a determinant of increased cardiac mortality approaching 50% at 3-year follow-up. Despite the clinical significance of LM disease, studies comparing the various diagnostic modalities, especially noninvasive, are sparse. Clinicians, particularly imagers, should be aware of the strengths and weaknesses of existing modalities to diagnose LM disease as integrating many clues (history, symptoms, electrocardiogram, and stress hemodynamics are essential to suspect this diagnosis and proceed to the next step). Here we review the existing data on the current role of electrocardiography, nuclear myocardial perfusion imaging (single photon emission computed tomography and positron emission tomography), stress echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging in diagnostic evaluation of LM disease. Wherever applicable we have extended our discussion to multivessel coronary artery disease encompassing scenarios where LMS can present as LM equivalent with or without extensive multivessel coronary artery disease.
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Affiliation(s)
- Nishtha Sareen
- Department of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
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9
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McKinney J, Pitcher I, Fordyce CB, Yousefi M, Yeo TJ, Ignaszewski A, Isserow S, Chan S, Ramanathan K, Taylor CM. Prevalence and Associated Clinical Characteristics of Exercise-Induced ST-Segment Elevation in Lead aVR. PLoS One 2016; 11:e0160185. [PMID: 27467388 PMCID: PMC4965008 DOI: 10.1371/journal.pone.0160185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 07/14/2016] [Indexed: 11/17/2022] Open
Abstract
Background Exercise-induced ST-segment elevation (STE) in lead aVR may be an important indicator of prognostically important coronary artery disease (CAD). However, the prevalence and associated clinical features of exercise-induced STE in lead aVR among consecutive patients referred for exercise stress electrocardiography (ExECG) is unknown. Methods All consecutive patients receiving a Bruce protocol ExECG for the diagnosis of CAD at a tertiary care academic center were included over a two-year period. Clinical characteristics, including results of coronary angiography, were compared between patients with and without exercise-induced STE in lead aVR. Results Among 2227 patients undergoing ExECG, exercise-induced STE ≥1.0mm in lead aVR occurred in 3.4% of patients. Patients with STE in lead aVR had significantly lower Duke Treadmill Scores (DTS) (-0.5 vs. 7.0, p<0.01) and a higher frequency of positive test results (60.2% vs. 7.3%, p<0.01). Furthermore, patients with STE in lead aVR were more likely to undergo subsequent cardiac catheterization than those without STE in lead aVR (p<0.01, odds ratio = 4.2). Conclusions Among patients referred for ExECG for suspected CAD, exercise-induced STE in lead aVR was associated with a higher risk DTS, an increased likelihood of a positive ExECG, and referral for subsequent coronary angiography. These results suggest that exercise-induced STE in lead aVR may represent a useful ECG feature among patients undergoing ExECG in the risk stratification of patients.
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Affiliation(s)
- James McKinney
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Ian Pitcher
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- University of British Columbia, Vancouver, British Columbia, Canada.,Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Masoud Yousefi
- Clinical Research Unit, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | | | - Andrew Ignaszewski
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Saul Isserow
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Sammy Chan
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Krishnan Ramanathan
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Carolyn M Taylor
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
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Ostovan MA, Zolghadrasli AA. Exercise-Induced ST-Segment Elevation in Lead aVR as a Predictor of LCx Stenosis. IRANIAN RED CRESCENT MEDICAL JOURNAL 2011; 13:901-2. [PMID: 22737438 PMCID: PMC3371902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 08/12/2011] [Indexed: 11/13/2022]
Affiliation(s)
- M A Ostovan
- Department of Cardiology, School of Medicine,Shiraz University of Medical Sciences, Shiraz, Iran
| | - A A Zolghadrasli
- Student Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Abdolali Zolghadrasli, MD, Student Research Center, Shiraz University of Medical Sciences, Shiraz, Po Box 71345- 1975, Iran. Tel.: +98-711-2122390, Fax: +98-711-2122390, E-mail:
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Ducas R, Ariyarajah V, Philipp R, Ducas J, Elliott J, Jassal D, Tam J, Garber P, Shaikh N, Hussain F. The presence of ST-elevation in lead aVR predicts significant left main coronary artery stenosis in cardiogenic shock resulting from myocardial infarction: the Manitoba cardiogenic shock registry. Int J Cardiol 2011; 166:465-8. [PMID: 22126854 DOI: 10.1016/j.ijcard.2011.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 08/18/2011] [Accepted: 11/01/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Electrocardiographic (ECG) predictors of significant angiographic left main coronary artery stenosis (LMCS>50%) have been described in acute myocardial infarction using ST-segment elevation in lead aVR (aVR-STE). However, there is a paucity of data on its association with LMCS>50% in the setting of cardiogemic shock (CGS). METHODS We investigated 210 consecutive, unselected, patients from Sept. 2002-2006 with CGS due to acute myocardial infarction undergoing cardiac catheterization. Of those, 191 patients with interpretable ECG tracings for aVR-STE analysis formed our study sample. aVR-STE was defined as ST-segment elevation≥1mm in aVR while LMCS>50% on coronary angiogram was defined as any left main lesion that demonstrated >50% lumen narrowing or equivalent by direct visualization or quantitative coronary angiography analysis. RESULTS There was 59% survival to discharge of this predominantly male cohort (median age 68±12years; 31% females). Fifty three (28%) cases had aVR-STE while 27 (14%) had LMCS>50%. Of those, 16 patients who had aVR-STE also had LMCS>50% (sensitivity 59%, specificity 77%, positive predictive value 30%, negative predictive value 92% for predicting LMCS>50%). Multivariate analysis revealed that aVR-STE was the only significant predictor of LMCS>50% was (p=0.014; Odds Ratio=3.06; 95% Confidence Interval 1.26-7.47). CONCLUSION In CGS due to acute myocardial infarction, aVR-STE>1mm proves to be an important predictor of LMCS>50%. Such data could be helpful in further risk stratification for optimal management during CGS.
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Affiliation(s)
- Robin Ducas
- Department of Cardiac Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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12
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Vorobiof G, Ellestad MH. Lead aVR: dead or simply forgotten? JACC Cardiovasc Imaging 2011; 4:187-90. [PMID: 21329904 DOI: 10.1016/j.jcmg.2010.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/17/2010] [Indexed: 11/20/2022]
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13
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Exercise-Induced ST-Segment Elevation in ECG Lead aVR Is a Useful Indicator of Significant Left Main or Ostial LAD Coronary Artery Stenosis. JACC Cardiovasc Imaging 2011; 4:176-86. [DOI: 10.1016/j.jcmg.2010.11.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 10/29/2010] [Accepted: 11/09/2010] [Indexed: 11/18/2022]
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14
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Tuna Katircibaşi M, Tolga Koçum H, Tekin A, Erol T, Tekin G, Baltali M, Müderrisoğlu H. Exercise-induced ST-segment elevation in leads aVR and V1 for the prediction of left main disease. Int J Cardiol 2008; 128:240-3. [PMID: 17658634 DOI: 10.1016/j.ijcard.2007.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2007] [Revised: 04/27/2007] [Accepted: 05/11/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study investigated the value of exercise-induced ST-segment elevation in lead aVR with or without concomitant ST-segment elevation in lead V(1) for detection of left main (LM) coronary artery disease in patients with Duke treadmill score <or=-11. METHODS One hundred and four patients with Duke treadmill score <or=-11 were retrospectively screened for presence of ST-segment elevation in lead aVR and lead V(1). RESULTS Twenty-six out of 65 patients with ST-segment elevation in lead aVR and 24 out 38 patients with ST-segment elevation in lead aVR with concomitant ST-segment elevation in lead V(1) were found to have LM disease. Exercise-induced ST-segment elevation in lead aVR had a sensitivity of 92.9% and a specificity of 48.6% and ST-segment elevation in lead aVR accompanied by ST-segment elevation in lead V(1) had a sensitivity of 85.7% and a specificity of 81.6% in predicting LM disease. CONCLUSIONS This study shows that the observation of exercise-induced ST-segment elevation in lead aVR is a sensitive, but not a specific, electrocardiographic finding of significant LM coronary artery disease. However, exercise-induced ST-segment elevation in lead aVR accompanied by ST-segment elevation in lead V(1) might be not only a sensitive but also a specific finding of LM stenosis in these patients.
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Affiliation(s)
- M Tuna Katircibaşi
- Department of Cardiology, Faculty of Medicine, Başkent University, Dadaloğlu Mahallesi, 39 Sok No 6, 01250 Yuregir, Adana, Turkey.
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