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Alsagaff MY, Amalia R, Dharmadjati BB, Appelman Y. Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series. J Med Case Rep 2022; 16:321. [PMID: 36030271 PMCID: PMC9420295 DOI: 10.1186/s13256-022-03570-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 08/16/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND True 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. Herein, 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. CONCLUSIONS Isolated 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.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University-Dr Soetomo General Hospital Surabaya, Jalan Mayjen Prof. Dr. Moestopo No. 6-8, Surabaya, 60286 Indonesia
| | - Rizki Amalia
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University-Dr Soetomo General Hospital Surabaya, Jalan Mayjen Prof. Dr. Moestopo No. 6-8, Surabaya, 60286 Indonesia
| | - Budi Baktijasa Dharmadjati
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University-Dr Soetomo General Hospital Surabaya, Jalan Mayjen Prof. Dr. Moestopo No. 6-8, Surabaya, 60286 Indonesia
| | - Yolande Appelman
- Department of Cardiology, VUmc-University of Amsterdam, Amsterdam, North Holland The Netherlands
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Synthesized 18-Lead Electrocardiogram in Diagnosing Posteriorstemi-Equivalentacute Coronary Syndrome in Patients with NSTEMI. Cardiol Res Pract 2022; 2022:9582174. [PMID: 36082208 PMCID: PMC9448611 DOI: 10.1155/2022/9582174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Objective. To assess the clinical utility of synthesized V7–V9 ST-segment elevation (sV7-9 STE) in patients with 12-lead-electrocardiogram (ECG)-based non-STE myocardial infarction (NSTEMI) in diagnosing left circumflex artery (LCx) STEMI-equivalent acute coronary syndrome (ACS). Background. The 12-lead-ECG is insufficient for diagnosing patients with ACS, especially those with an LCx culprit. Methods. We retrospectively examined 219 patients with NSTEMI who underwent synthesized 18-lead ECG acquisition on admission and urgent catheterization. Associations between baseline variables, including sV7-9 STE and LCx STEMI-equivalent ACS, were analyzed using logistic regression models and receiver operating characteristics. LCx-culprit ACS was defined as thrombolysis in myocardial infarction (TIMI) 0–1 flow. The association between sV7-9 STE and myocardial damage was also assessed. Results. The mean (SD) age of the population was 68.8 (12.0) years, and 81.7% were men. LCx-culprit NSTEMI occurred in 58 (26.5%) patients and 15 (6.8%) were LCx STEMI-equivalent. SV7-9 STE was observed in 16 patients (7.9%). SV7-9 STE was the sole significant predictor of LCx STEMI-equivalent ACS with an odds ratio of 19.0 (95% CI: 5.6–63.9,
), area under the curve of 0.71 (95% CI: 0.58–0.84), sensitivity of 46.7%, and specificity of 95.6%. After adjustment for confounders, sV7-9 STE was significantly associated with a 308% (95% CI: 78–834%) increase in peak high-sensitivity cardiac troponin I (
). Conclusions. SV7-9 STE had sole preprocedural diagnostic utility in detecting LCx STEMI-equivalent ACS with greater myocardial damage among patients with 12 ECG-based NSTEMI. The use of synthesized extra leads on admission may help identify patients with NSTEMI requiring primary revascularization.
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Vogiatzis I, Koulouris E, Ioannidis A, Sdogkos E, Pliatsika M, Roditis P, Goumenakis M. The Importance of the 15-lead Versus 12-lead ECG Recordings in the Diagnosis and Treatment of Right Ventricle and Left Ventricle Posterior and Lateral Wall Acute Myocardial Infarctions. Acta Inform Med 2019; 27:35-39. [PMID: 31213741 PMCID: PMC6511271 DOI: 10.5455/aim.2019.27.35-39] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction The 12-lead ECG at admission of patients suffering from acute myocardial infarction (AMI) is mandatory for accurate diagnosis and prompt therapeutic measures, mainly reperfusion. It has been shown that recording additional ECG leads may improve the diagnostic accuracy and therefore, the prognosis of selected cases. Aim The aim of the study was to assess the usefulness of the 15-lead ECG (12 classic plus 3 posterior leads) in the management of chest pain patients, especially when 12-lead ECG is not diagnostic of AMI. Methods Total amount of 186 consecutive patients (127 men, 59 women, mean age 69.7±13.8 years) were admitted with an acute coronary syndrome. The initial ECG recorded the 12 classic leads, and subsequently, the 3 additional posterior leads. Demographic and clinical data, including ECG alterations and selected treatment strategy, were also studied. The cumulative impact of the 15-lead ECG on the diagnosis and management of AMI were, overall, evaluated. Results The 12-lead ECG was diagnostic of ST-elevation AMI (STEMI) in 158 patients (Group A-84.5%) who were promptly reperfused. On the other hand, the interpretation of the posterior leads was required in 28 patients (Group B-15.1%) to establish the STEMI diagnosis warranting reperfusion therapy. Multivariate analysis illustrated that the 15-lead ECG was the only factor associated with achieving the STEMI diagnosis in non-conclusive 12-lead ECG cases (OR=2.43-p=0.04). Conclusion The use of the 15-lead ECG contributes to a faster and more accurate diagnosis of STEMI, particularly in the Emergency Department, facilitating the prompt reperfusion therapy.
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Affiliation(s)
- Ioannis Vogiatzis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | | | | | - Evangelos Sdogkos
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - Maria Pliatsika
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - Pavlos Roditis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - Markos Goumenakis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
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Hebbal VP, Setty HSN, Sathvik CM, Patil V, Sahoo S, Manjunath CN. Acute ST-segment elevation myocardial infarction: The prognostic importance of lead augmented vector right and leads V 7-V 9. J Nat Sci Biol Med 2017; 8:104-109. [PMID: 28250684 PMCID: PMC5320809 DOI: 10.4103/0976-9668.198364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Acute myocardial infarction (MI) is associated with high mortality and among survivors have high morbidity. Electrocardiogram (ECG), a cost-effective and easily available, has traditionally been used not only just for diagnosis of MI but also for culprit vessel recognition and for prognostication. However, the role of lead augmented vector right (aVR) and leads V7–V9 in acute MI are often neglected in clinical practice. We studied the role of lead aVR and leads V7–V9 in ST-elevation MI (STEMI) patients. Methods: A total of 209 patients presenting with STEMI were enrolled in the study. History of comorbid conditions and habits was enquired. Routine blood tests were performed. Full spectrum ECG (including V7–9) and 2D-ECHO was performed on all patients. All the patients underwent revascularization by primary percutaneous coronary intervention. The role of lead aVR, lead V7, and leads V8–9 was analyzed in anterior wall MI (AWMI) and inferior wall MI. All the patients were followed up for 1 month for outcome assessment. Results: Of the 209 patients, 85.1% were males and 35.8% were diabetic, 60.2% were smokers, AWMI accounted for 55.5%. Lead aVR ST deviation was noted in 75.1% of patients (elevation in 17.7% and depression in 47.1%). V7 ST elevation occurred in 27.6% and V8–9 elevation occurred in 7.5% of the study population. Total death was 11.9% in the study (including the in-hospital mortality), all these patients had lead aVR ST segment deviation (P < 0.001). Conclusion: Lead aVR ST deviation and Lead V7 ST deviation helps to prognosticate the STEMI patients as high risk and those with aVR ST depression had higher mortality compared to aVR ST elevation because of larger myocardial involvement.
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Affiliation(s)
- Veeresh Patil Hebbal
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | | | | | - Vikram Patil
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Sarthak Sahoo
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Ashida T, Tani S, Nagao K, Yagi T, Matsumoto N, Hirayama A. Usefulness of synthesized 18-lead electrocardiography in the diagnosis of ST-elevation myocardial infarction: A pilot study. Am J Emerg Med 2017; 35:448-457. [PMID: 27931763 DOI: 10.1016/j.ajem.2016.11.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/20/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022] Open
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Wong CK. Reperfusion therapy for ST-segment elevation myocardial infarction: has ECG information been underutilized? Expert Rev Cardiovasc Ther 2014; 12:803-13. [PMID: 24813345 DOI: 10.1586/14779072.2014.918504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This perspective makes a contentious viewpoint that ECG information is underutilized in ST-segment elevation myocardial infarction (STEMI) and the next breakthrough rests on its full utilization. This is to better diagnose difficult cases such as ST changes during bundle branch block, posterior ST elevation and right-sided ST elevation during normal conduction, and aVR ST elevation. More importantly, this is to better characterize the STEMI for tailored reperfusion. The proposal is to develop a system capable of recording from multiple electrodes that one can apply onto oneself, and having analysis coordinated centrally via phone-internet transmission. This provides 'longitudinal' in addition to 'cross-sectional' ECG information. STEMI will be classified on a gray-scale according to its potential size and speed of Q wave evolution. The hypothesis is that large rapidly progressive STEMI is best treated by on-site fibrinolysis with prompt transferral to a percutaneous coronary intervention center; while small stuttering STEMI is best treated by primary percutaneous coronary intervention despite a long delay.
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Affiliation(s)
- Cheuk-Kit Wong
- Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin Public Hospital, Dunedin, New Zealand
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Wong CK. iPhone ECG monitoring — the gateway to the new paradigm of STEMI therapy. Int J Cardiol 2013; 168:2897-8. [DOI: 10.1016/j.ijcard.2013.03.167] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/30/2013] [Indexed: 11/16/2022]
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White HD, Wong CK, Gao W, Lin A, Benatar J, Aylward PE, French JK, Stewart RA. New ST-depression: an under-recognized high-risk category of 'complete' ST-resolution after reperfusion therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:210-21. [PMID: 24062909 DOI: 10.1177/2048872612454841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 06/25/2012] [Indexed: 11/15/2022]
Abstract
AIM It is not known if there is an association between resolution of ST-elevation to ST-depression following fibrinolysis and 30-day mortality. METHODS In an ECG substudy of HERO-2, which compared bivalirudin to unfractionated heparin following streptokinase in 12,556 patients with ST-elevation myocardial infarction ECGs were recorded at baseline and at 60 minutes after commencing fibrinolysis. The main outcome measure was 30-day mortality. RESULTS Using summed ST-segment elevation and five categories of changes in the infarct leads, further ST-elevation, 0-30% ST-resolution, >30-70% (partial) ST-resolution, >70% (complete) ST-resolution, and new ST-depression occurred in 21.7, 24.9, 36.8, 14.8, and 1.8% of patients, with 30-day mortality of 12.3, 11.7, 8.0, 4.2, and 8.1%, respectively. For the comparison of new ST-depression with complete ST-resolution and no ST-depression, p<0.01 with 24-hour mortality 4.5 vs. 1.3%, respectively (p=0.0003). Patients with new ST-depression had similar peak cardiac enzyme elevations as patients with complete ST-resolution without ST-depression. On multivariate analysis including summed ST-elevation at baseline, age, sex, and infarct location, new ST-depression was a significant predictor of 30-day mortality (OR 1.82, 95% CI 1.42-4.29). CONCLUSIONS In patients with complete ST-resolution following fibrinolysis, new ST-depression at 60 minutes developed in 10.8% of patients. These patients had higher mortality than patients with complete ST-resolution without ST-depression and represent a high-risk group which could benefit from rapid triage to early angiography and revascularization as appropriate.
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Wong CK. How much does AVR ST change help stratify patients with coronary disease? Int J Cardiol 2013; 166:526-8. [DOI: 10.1016/j.ijcard.2012.09.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022]
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Wong CK. When should a non-STEMI be treated with primary PCI as for STEMIs? Int J Cardiol 2012; 158:477-8. [DOI: 10.1016/j.ijcard.2012.05.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/12/2012] [Indexed: 11/17/2022]
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Wong CK. The evolution of reperfusion management in patients with suspected myocardial infarction and bundle branch block: How ECG language will intertwine with angiographic findings. Int J Cardiol 2011; 153:326-7. [DOI: 10.1016/j.ijcard.2011.09.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 09/17/2011] [Indexed: 11/25/2022]
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Detecting ST deviations: Does body surface mapping help or have we missed information from lead aVR? Int J Cardiol 2011; 152:403-7. [DOI: 10.1016/j.ijcard.2011.08.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 08/17/2011] [Indexed: 11/23/2022]
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Wong CK. Isolated right ventricular infarction as a cause for anterior (V1–V3) ST elevation — Review of publications since 2006 and re-appraisal of direct vs reciprocal ST changes. Int J Cardiol 2011; 151:239-41. [DOI: 10.1016/j.ijcard.2011.06.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/06/2011] [Accepted: 06/09/2011] [Indexed: 10/18/2022]
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Wong CK, Gao W, Stewart RAH, French JK, Aylward PEG, White HD. The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction. Eur Heart J 2011; 33:384-92. [PMID: 21856681 DOI: 10.1093/eurheartj/ehr301] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS ST-elevation in lead aVR is known to be associated with a worse prognosis in patients with acute ST elevation myocardial infarction (MI) but the significance of ST depression in lead aVR has been unclear. Infarction of the inferior apex of the left ventricle may not be appreciated on the standard 12-lead electrocardiogram (ECG) except by observing ST depression in lead aVR which is reciprocal to lead V(7). We therefore determined the prognostic value of the full spectrum of aVR ST changes in patients presenting with acute ST elevation MI. METHODS AND RESULTS Lead aVR ST level was measured on randomization and 60 min ECGs in 15 315 patients with normal conduction from the HERO-2 trial. The outcome measure was 30-day mortality. aVR ST elevation ≥1 mm was associated with higher 30-day mortality for both inferior (22.5% for ≥1.5 mm and 13.2% for 1 mm) and anterior (23.5% for ≥1.5 mm and 11.5% for 1 mm) infarction. In contrast, deeper aVR ST depression (0, 0.5, 1, and ≥1.5 mm) was associated with higher mortality for anterior infarction (9.8, 13.2, 12.8, and 16.8%, respectively, trend P-value <0.0001) but not for inferior infarction. The resolution of aVR ST depression and ST elevation 60 min after fibrinolysis was associated with lower mortality. CONCLUSION There is a U-shaped relationship between 30-day mortality and aVR ST level in patients presenting with anterior but not inferior ST elevation MI.
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Affiliation(s)
- Cheuk-Kit Wong
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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