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Michaelides AP, Psomadaki ZD, Aigyptiadou MNK, Richter DJ, Andrikopoulos GK, Dilaveris PE, Tsioufis K, Tousoulis D, Stefanadis C, Toutouzas PK. Significance of exercise-induced ST changes in leads aVR, V5, and V1. Discrimination of patients with single- or multivessel coronary artery disease. Clin Cardiol 2006; 26:226-30. [PMID: 12769250 PMCID: PMC6654754 DOI: 10.1002/clc.4960260506] [Citation(s) in RCA: 16] [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: 11/05/2022] Open
Abstract
BACKGROUND 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. HYPOTHESIS 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Andreas P Michaelides
- Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece.
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Michaelides AP, Psomadaki ZD, Richter DJ, Dilaveris PE, Andrikopoulos GK, Stefanadis C, Gialafos JE, Toutouzas PK. Significance of exercise-induced simultaneous ST-segment changes in lead aVR and V5. Int J Cardiol 1999; 71:49-56. [PMID: 10522564 DOI: 10.1016/s0167-5273(99)00115-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study was undertaken to investigate the ability of the exercise-induced ST depression in lead V5 and concomitant ST elevation in lead aVR for the identification of the significantly narrowed coronary artery in patients with single vessel disease. We studied 229 consecutive patients who developed the aforementioned exercise-induced electrocardiographic changes. All underwent Thallium-201 scintigraphy and coronary arteriography. Patients were divided into three groups. In group A, 58 patients with ST depression in V5 and ST elevation in aVR, in group B 149 patients with ST depression in V5 without ST elevation in aVR, and in group C 22 patients with ST elevation in aVR without ST depression in V5 induced with exercise, were included. In group A, 81% of the patients while in group B, 29% and in group C only 18% of the patients had left anterior descending artery disease. According to Thallium-201 scintigraphy, 80% of the group A, 27% of the group B and 12% of the group C patients developed myocardial ischemia in areas supplied by the left anterior descending artery. Thus, exercise-induced ST depression in V5 and concomitant ST elevation in aVR, may detect left anterior descending artery significant stenosis in patients with single vessel disease.
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Affiliation(s)
- A P Michaelides
- Department of Cardiology, University of Athens Medical School, Hippokration Hospital, Greece.
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Cantwell JD. Chest Pain and a 'Normal' Exercise ECG in a 44-Year-Old Runner. PHYSICIAN SPORTSMED 1998; 26:64-7. [PMID: 20086854 DOI: 10.3810/psm.1998.09.1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 44-year-old man was evaluated because of new-onset chest pain. The patient reported that 4 days earlier, at a stressful out-of-town business meeting, he had experienced anterior chest pain while sitting. It improved when he lay on his side. The pain was steady for 1 hour, then intermittent for several hours. The patient went the same day to an ambulatory care clinic, where an electrocardiogram (ECG) and chest x-ray were said to be normal, and an antacid was prescribed. The chest pain recurred the following day while he was running on a treadmill, but did not return during a 30-minute run the morning I initially examined him.
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Affiliation(s)
- J D Cantwell
- Cardiology of Georgia PC, Atlanta, GA, 30328, USA
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Kamalesh M, Chandrasekaran K, Sivaram CA, Thadani U. Lack of arrhythmogenicity with ST-segment elevation during high-dose of dobutamine atropine stress in patients with documented or suspected coronary artery disease. Am J Cardiol 1997; 80:341-3. [PMID: 9264431 DOI: 10.1016/s0002-9149(97)00358-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The angiographic, echocardiographic, and electrocardiographic correlates of ST-segment elevation during high-dose dobutamine-atropine stress were prospectively looked at in a group of high-risk patients. Unlike exercise-induced ST elevation, ST-segment elevation with dobutamine-atropine stress, while indicating transmural ischemia, did not increase rate of arrhythmias and hence by itself may not be an indication to terminate the test.
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Affiliation(s)
- M Kamalesh
- Department of Medicine, University of Oklahoma Health Sciences Center and Department of Veterans Affairs Medical Center, Oklahoma City, USA
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Ricci R, Bigi R, Galati A, Bandini P, Coletta C, Fiorentini C, Lumia F, Occhi G, Ceci V. Dobutamine-induced ST-segment elevation in patients with acute myocardial infarction and the role of myocardial ischemia, viability, and ventricular dyssynergy. Am J Cardiol 1997; 79:733-7. [PMID: 9070550 DOI: 10.1016/s0002-9149(96)00859-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We analyzed the relation between dobutamine-induced Q-wave ST-segment elevation and regional contraction during low (5 to 10 microg/kg/min) and high doses (20 to 40 microg/kg/min) of dobutamine in a series of 391 dobutamine echocardiographic tests performed 10 +/- 2 days after a first uncomplicated acute myocardial infarction (AMI). ST-segment elevation was defined as > or = 1 mm new or additional J-point elevation with a horizontal or upsloping ST segment lasting 80 ms. Wall motion score index at rest was derived using a 16 segment-4 grade score model. Patients with dobutamine-induced ST-segment elevation had a higher wall motion score index at rest (anterior wall AMI: 1.67 +/- 0.27 vs 1.43 +/- 0.30, p = 0.0001; inferior wall AMI: 1.44 +/- 0.27 vs 1.30 +/- 0.18, p = 0.0001) and similar incidence and extent of myocardial viability and homozonal ischemia in comparison with those without ST-segment elevation. The sensitivity, specificity, and accuracy of dobutamine-induced ST-segment elevation for detecting residual homozonal ischemia were 51%, 55%, and 54%, respectively, in patients with anterior wall AMI, and 42%, 68%, and 58%, respectively, in patients with inferior wall AMI. In conclusion, dobutamine-induced ST-segment elevation is not associated with higher incidence and extent of viable or jeopardized myocardium but rather to a greater extent of wall motion abnormalities at rest. Thus, this finding does not represent a clinically reliable discriminator for selecting patients for coronary angiography and possible revascularization procedures.
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Affiliation(s)
- R Ricci
- Division of Cardiology, S. Spirito Hospital, Rome, Italy
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Mickley H, Nielsen JR, Berning J, Junker A, Møller M. Characteristics and prognostic importance of ST-segment elevation on Holter monitoring early after acute myocardial infarction. Am J Cardiol 1995; 76:537-42. [PMID: 7677072 DOI: 10.1016/s0002-9149(99)80150-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The correlation between episodes of ST-segment elevation on Holter monitoring, clinical characteristics, left ventricular function, exercise testing, and long-term prognosis was determined in 123 consecutive patients 55 +/- 8 years old (mean +/- SD) with a first acute myocardial infarction (AMI). During 36 hours of Holter recording 11 +/- 5 days after AMI, 11 patients (9%) had 91 episodes of ST-segment elevation (group 1), whereas 112 patients had no such episodes (group 2). Most episodes of ST-segment elevation occurred in leads with pathologic Q waves or small, indistinct R waves. Large, anterior Q-wave AMIs were more prevalent in group 1 than in group 2, and in-hospital heart failure also occurred more frequently in group 1 patients (82% vs 23%; p < 0.0005). Regional and global left ventricular function was reduced in group 1 compared with group 2: ejection fraction 33 +/- 11% vs 50 +/- 11% (p = 0.0001). All episodes of ST-segment elevation were asymptomatic and did not correlate with different indicators of myocardial ischemia. Indeed, exercise-induced ST-segment depression was more prevalent in group 2 than in group 1: 57 vs 18% (p < 0.035). Over a mean of 5 years (range 4 to 6) of follow-up, an association between episodes of ST-segment elevation on Holter monitoring and (1) cardiac death (Kaplan-Meier analysis; p < 0.005), and (2) cardiac death and nonfatal reinfarction (Kaplan-Meier analysis; p < 0.025) was found.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H Mickley
- Department of Cardiology B, Odense University Hospital, Denmark
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Elhendy A, Geleijnse ML, Roelandt JR, van Domburg RT, Cornel JH, TenCate FJ, Postma-Tjoa J, Reijs AE, el-Said GM, Fioretti PM. Evaluation by quantitative 99m-technetium MIBI SPECT and echocardiography of myocardial perfusion and wall motion abnormalities in patients with dobutamine-induced ST-segment elevation. Am J Cardiol 1995; 76:441-8. [PMID: 7653441 DOI: 10.1016/s0002-9149(99)80127-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
ST-segment elevation during exercise testing has been attributed to myocardial ischemia and wall motion abnormalities (WMA). However, the functional significance of ST-segment elevation during dobutamine stress testing (DST) has not been evaluated in patients referred for diagnostic evaluation of myocardial ischemia. DST (up to 40 micrograms/kg/min) with simultaneous echocardiography and technetium-99m sestamibi single-photon emission computed tomography (SPECT) was performed in 229 consecutive patients with suspected myocardial ischemia who were unable to perform an adequate exercise test; 127 (55%) had a previous acute myocardial infarction (AMI). ST elevation was defined as > or = 1 mm new or additional J point elevations with a horizontal or upsloping ST segment lasting 80 ms. Reversible perfusion defects on SPECT and new or worsening WMA during stress on echocardiography were considered diagnostic of ischemia. ST elevation occurred in 40 patients (17%) during the test; 34 of them (85%) had previous AMI. All patients with ST-segment elevation had abnormal scintigrams (fixed or reversible defects, or both) and abnormal wall motion (fixed or transient defect, or both) at peak stress. In patients who had ST elevation and no previous AMI (n = 6), ischemia was detected in all by echocardiography and in 5 (83%) by SPECT. In patients with previous AMI, the prevalence of ischemia was not different with or without ST elevation (53% vs 43% by echocardiography and 53% vs 48% by SPECT, respectively). Baseline regional wall motion score in the infarct zone was higher in patients with ST elevation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Elhendy
- Department of Nuclear Medicine, University Hospital Rotterdam-Dijkzigt, The Netherlands
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Alperovich A, Van Tosh A, Lanes N, Berger M. Marked PR interval prolongation simulating ST-segment elevation during exercise testing. A case report. J Electrocardiol 1995; 28:153-5. [PMID: 7616147 DOI: 10.1016/s0022-0736(05)80286-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
ST-segment elevation during exercise testing is usually indicative of severe proximal coronary artery disease. In this report, the authors describe a patient who underwent exercise stress testing and developed apparent ST elevation in the inferolateral leads. However, noninvasive imaging studies revealed no evidence of myocardial ischemia or other recognized causes of this exercise electrocardiographic (ECG) finding. Analysis of the ECG tracings showed that ST elevation was produced by marked prolongation of the PR interval, super-imposing the P wave on the J-junction of the preceding QRS-ST-segment complex. The authors suggest that marked PR prolongation during exercise may mimic ST elevation, and this possibility should be considered in patients with this exercise ECG finding in whom cardiac evaluation is negative.
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Affiliation(s)
- A Alperovich
- Department of Medicine, Beth Israel Medical Center, New York, NY 10003, USA
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Coma-Canella I, del Val Gómez M, Terol I, Rodrigo F, Castro JM. Radionuclide studies in patients with stress-induced ST-segment elevation after acute myocardial infarction. Am Heart J 1994; 128:459-65. [PMID: 8074005 DOI: 10.1016/0002-8703(94)90617-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The meaning of a stress-induced ST-segment elevation (delta ST) after acute myocardial infarction is still controversial. Some studies show it is related to asynergy, and other studies show it is related to ischemia. However, no study has compared the delta ST with both stress-induced ischemia and stress-induced asynergy in the same group of patients. With this purpose, 88 patients were studied 16 +/- 4 days after acute myocardial infarction. They were submitted to a dobutamine stress test on two different occasions 1 to 2 days apart. Dobutamine was infused up to 40 micrograms/kg/min with blood pressure and electrocardiographic controls. Thallium-201 single-photon emission computed tomography was performed during the highest dobutamine dose and 3 to 4 hours later. Equilibrium radionuclide ventriculography was performed at rest and during the highest dobutamine dose. Global and regional (hypokinetic area) ejection fractions were quantified. The ST segment was elevated > or = 1 mm in 33 patients at rest and in 71 during stress. A stress-induced delta ST was seen in 66 patients. Redistribution was detected in 65 patients. Multiple regression analysis showed a significant correlation between ST elevation and thallium defect score both at rest and during stress. No correlation was found between delta ST and redistribution score. However, a significant inverse linear correlation was found between the delta ST and the change in regional ejection fraction: the greater the delta ST, the smaller the change in regional ejection fraction with dobutamine. In conclusion, a stress-induced delta ST is not related to ischemia but to stress-induced left ventricular asynergy.
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Gallik DM, Mahmarian JJ, Verani MS. Therapeutic significance of exercise-induced ST-segment elevation in patients without previous myocardial infarction. Am J Cardiol 1993; 72:1-7. [PMID: 8517412 DOI: 10.1016/0002-9149(93)90209-u] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Twelve patients with exercise-induced ST-segment elevation without prior myocardial infarction, electrocardiographic evidence of left ventricular hypertrophy or left bundle branch block underwent thallium-201 tomography immediately after exercise and 4 hours later. Coronary angiography and left ventriculography were performed within an average of 8 days of exercise testing. Five patients had repeat exercise thallium-201 tomography after medical therapy or revascularization. All patients had large, reversible perfusion defects (average defect size 33.5 +/- 13%), with 11 of 12 patients having a > or = 25% stress perfusion defect. In 10 patients with atherosclerotic coronary artery disease, the average stenosis of the involved vessel was 93 +/- 9% (range 70 to 100). The electrocardiographic leads with ST-segment elevation predicted the site of reversible hypoperfusion. Two patients had extensive, reversible anterior hypoperfusion due to exercise-induced spasm of minimally stenosed left anterior descending coronary arteries. Follow-up exercise testing in 5 patients showed abolition of reversible hypoperfusion and ST changes after medical therapy or revascularization. In patients without prior myocardial infarction, exercise-induced ST-segment elevation signifies extensive, reversible hypoperfusion that can be abolished by revascularization in patients with critical coronary stenoses and by medical therapy in those with coronary vasospasm.
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Affiliation(s)
- D M Gallik
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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Ogawa T, Ishii M, Iida K, Iida K, Ajisaka R, Yamaguchi I, Sugishita Y, Ito I. Mechanisms of stress-induced ST elevation and negative T-wave normalization studied by serial cardiokymogram in patients with a previous myocardial infarction. Am J Cardiol 1990; 65:962-6. [PMID: 2327356 DOI: 10.1016/0002-9149(90)90997-f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Seventeen patients with a previous myocardial infarction were studied during pacing to characterize the clinical correlates of ST elevation, to analyze the relation between ST elevation and negative T-wave normalization and to investigate the mechanism of these electrocardiographic changes. Myocardial ischemia was evaluated by measurement of blood lactate, and wall motion was analyzed using cardiokymographs concurrently and serially. Results show that ST elevation and negative T-wave normalization were most marked in leads containing abnormal Q waves, that ST elevation greater than or equal to 1 mm during pacing was associated with a significant increase in left ventricular end-diastolic pressure and deterioration of left ventricular wall motion and that the magnitude of ST elevation and negative T-wave normalization was significantly correlated, but the latter appeared earlier and more markedly. In addition, there was no significant correlation between the extent of either ST elevation or negative T-wave normalization and myocardial lactate production. Thus, ST elevation and negative T-wave normalization are caused by abnormal left ventricular wall motion rather than myocardial ischemia. Negative T-wave normalization is a more sensitive marker of abnormal wall motion than ST elevation in patients with a previous myocardial infarction.
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Affiliation(s)
- T Ogawa
- Department of Internal Medicine, University of Tsukuba, Japan
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