Reciprocal changes in 12-lead electrocardiography can predict left main coronary artery lesion in patients with acute myocardial infarction

Clinical and electrocardiographic features in acute total left main coronary artery occlusion without collateral circulation

BACKGROUNDS

Study concerning the clinical features, electrocardiogram (ECG) findings and outcomes in patients presenting with acute total occlusion of left main coronary artery (LM) without collateral circulation is limited.

METHODS

25 patients with acute total LM occlusion without collateral circulation by emergency coronary angiography, from muti-center registry, were retrospectively studied. The clinical and angiographic characteristics, ECG and in-hospital mortality were reviewed.

RESULTS

Nineteen patients (76%) presented with cardiogenic shock. Twelve (60%, 12/20) patients had coronary slow flow or no reflow phenomenon after primary percutaneous coronary intervention (PCI). The in-hospital mortality rate was 88% (n = 22). All the patients presented with ST-segment elevation myocardial ischemia (STEMI) pattern, mostly involving leads I, aVL, V2, V3, V4, V5 and ST-segment depression in leads II, III and aVF.

CONCLUSIONS

Acute total LM occlusion without collateral circulation portends high in-hospital mortality. Anterior ST elevation in the precordial leads from V2 to V4 through V6, and ST elevation in leads I and aVL, accompanying with ST depression in the inferior leads is associated with acute total LM occlusion without collateral circulation.

Comparing Door-To-Balloon Time between ST-Elevation Myocardial Infarction Electrocardiogram and Its Equivalents

Background: In patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (pPCI), longer door-to-balloon (DTB) time is known to be associated with an unfavorable outcome. A percentage of patients with acute coronary occlusion present with atypical electrocardiographic (ECG) findings, known as STEMI-equivalents. We investigated whether DTB time for STEMI-equivalent patients was delayed. Methods: This is a retrospective study including patients arriving at an emergency department with the acute coronary syndrome in whom emergent pPCI was performed. ECGs were classified into STEMI and STEMI-equivalent groups. We compared DTB time, with its components, between the groups. We also investigated whether STEMI-equivalent ECG was an independent predictor of DTB time delayed for more than 90 min. Results: A total of 180 patients were included in the present study, and 23 patients (12.8%) presented with STEMI-equivalent ECGs. DTB time was significantly delayed in patients with STEMI-equivalent ECGs (89 (80–122) vs. 81 (70–88) min, p = 0.001). Multivariable logistic regression analysis showed that STEMI-equivalent ECG was an independent predictor of delayed DTB time (odds ratio: 4.692; 95% confidence interval: 1.632–13.490, p = 0.004). Conclusions: DTB time was significantly delayed in patients presenting with STEMI-equivalent ECGs. Prompt recognition of STEMI-equivalent ECGs by emergency physicians and interventional cardiologists might reduce DTB time and lead to a better clinical outcome.

Combining electrocardiographic criteria for predicting acute total left main coronary artery occlusion

Background

Prediction of left main artery (LM) occlusion may contribute to the administration of early reperfusion. We sought to identify electrocardiographic (ECG) features associated with acute total LM occlusion and explore the relationship between ECG features and collateral circulation.

Methods

We retrospectively studied ECGs in 84 consecutive patients with LM occlusion between January 2001 and April 2022. The ECG findings in these patients were compared with those in 468 consecutive patients with LM subtotal occlusion and non-LM occlusion.

Results

Three main ECG patterns were described according to the characteristics of ST elevation (STE) in LM occlusion: ST-segment elevation myocardial infarction (STEMI), STE in aVR with diffuse ST depression, and STE in both aVR and aVL. These ECG patterns were associated with different collateral filling territories. One-third STEMI in LM occlusion showed STE in the precordial leads including V1, while 2/3 STEMI showed STE in the precordial leads from V2 to V5 without STE in V1. The following ECG characteristics predicted LM occlusion: STE in both aVR and aVL; STE in I, aVL, and V2–V5 without V1; left anterior fascicular block (LAFB); right bundle branch block (RBBB) + LAFB; and prolongation of the QRS interval. The incidences of STE in aVR and STE in aVR and V1 were higher in LM subtotal occlusion than in LM occlusion. The combination of two different STE criteria (STE in aVR and aVL and STE in I, aVL, V2-V5 without V1) predicted LM occlusion with 62% sensitivity and 95% specificity. The combination of the STE criteria and fascicular block criteria (LAFB and LAFB + RBBB) further improved the specificity to 99% but reduced the sensitivity to 39%.

Conclusion

The combination of STE criteria predicted LM occlusion with high specificity and moderate sensitivity, and the addition of fascicular block criteria further improved the specificity with some loss of sensitivity.

Electrocardiographic patterns predict the presence of collateral circulation and in-hospital mortality in acute total left main occlusion

Background

Data on the clinical characteristics, electrocardiogram (ECG) findings and outcomes of patients with acute myocardial infarction (AMI) due to total unprotected left main (ULM) artery occlusion is limited.

Methods

Between 2009 and 2021, 44 patients with AMI due to total ULM occlusion underwent primary percutaneous coronary intervention (PCI) at our institution. The ECG, collateral circulation, clinical and procedural characteristics, and in-hospital mortality were retrospectively evaluated.

Results

Twenty five patients presented with shock and 18 patients had in-hospital mortality. Nineteen patients presented with ST-segment elevation myocardial infarction (STEMI), while 25 presented with non-ST-segment elevation myocardial infarction (NSTEMI). ST-segment elevation (STE) in I and STEMI were associated with the absence of collateral circulation, while STE in aVR was associated with its presence. In the NSTEMI group, patients with STE in both aVR and aVL showed more collateral filling of the left anterior descending coronary artery (LAD) territory, while patients with STE in aVR showed more collateral filling of the LAD and the left circumflex artery territory. Compared with total ULM occlusion, patients with partial ULM obstruction presented with more STE in aVR, less STE in aVR and aVL, and less STEMI. Shock, post-PCI TIMI 0–2 flow, non-STE in aVR, STEMI, and STE in I predicted in-hospital mortality. STEMI and the absence of collateral flow were significantly associated with shock.

Conclusions

STE in the precordial leads predicted the absence of collateral circulation while STE in aVR and STE in both aVR and aVL predicted different collateral filling territories in ULM occlusion. STE in I, non-STE in aVR, and STEMI predicted in-hospital mortality in these patients.

Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry

INTRODUCTION

Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients.

METHODS

The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI).

RESULTS

Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (-61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5-21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4-52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02-1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01-0.81), p = 0.03).

CONCLUSIONS

aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

New Insights Into the Use of the 12-Lead Electrocardiogram for Diagnosing Acute Myocardial Infarction in the Emergency Department

The 12-lead electrocardiogram (ECG) remains the most immediately accessible and widely used initial diagnostic tool for guiding management in patients with suspected myocardial infarction (MI). Although the development of high-sensitivity cardiac troponin assays has improved the rule-in and rule-out and risk stratification of acute MI without ST elevation, the immediate management of the subset of acute MI with acute coronary occlusion depends on integrating clinical presentation and ECG findings. Careful interpretation of the ECG might yield subtle features suggestive of ischemia that might facilitate more rapid triage of patients with subtle acute coronary occlusion or, conversely, in identification of ST-elevation MI mimics (pseudo ST-elevation MI patterns). Our goal in this review article is to consider recent advances in the use of the ECG to diagnose coronary occlusion MIs, including the application of rules that allow MI to be diagnosed on the basis of atypical ECG manifestations. Such rules include the modified Sgarbossa criteria allowing identification of acute MI in left bundle branch block or ventricular pacing, the 3- and 4-variable formula to differentiate normal ST elevation (formerly called early repolarization) from subtle ECG signs of left anterior descending coronary artery occlusion, the differentiation of ST elevation of left ventricular aneurysm from that of acute anterior MI, and the use of lead aVL in the recognition of inferior MI. Improved use of the ECG is essential to improving the diagnosis and appropriate early management of acute coronary occlusion MIs, which will lead to improved outcomes for patients who present with acute coronary syndrome.

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1–V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20–40% of misdiagnosed myocardial infarctions.

Sweating: A Specific Predictor of ST-Segment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group

BACKGROUND

Today, cardiologists seek to minimize time from symptom onset to interventional treatment for the most favorable results.

HYPOTHESIS

In the acute coronary syndrome (ACS) symptom complex, sweating can differentiate ST-segment elevation myocardial infarction (STEMI) from non-ST-segment elevation ACS (NSTE-ACS) during early hours of infarction.

METHODS

This single-center, prospective, observational study compared symptoms of STEMI and NSTE-ACS patients admitted from August 2012 to July 2014.

RESULTS

Of 12 913 patients, 90.56% met ACS criteria. Among these, 22.51% had STEMI. Typical angina was the most common symptom (83.82%). On stepwise multiple regression, sweating (odds ratio: 97.06, 95% confidence interval [CI]: 82.16-114.14, P < 0.0001) and typical angina (odds ratio: 2.72, 95% CI: 2.18-3.38, P < 0.001) had significant association with STEMI. For diagnosis of STEMI, positive likelihood ratio (LR) and positive predictive value (PPV) were highest for typical angina with sweating (LR: 11.17, 95% CI: 10.31-12.1; PPV: 76.09, 95% CI: 74.37-77.75), followed by sweating with atypical angina (LR: 3.6, 95% CI: 3.07-4.21; PPV: 50.61, 95% CI: 46.45-54.76), typical angina (LR: 1.05, 95% CI: 1.03-1.07; PPV: 22.97, 95% CI: 22.11-23.84), and atypical angina (LR: 0.77, 95% CI: 0.69-0.87; PPV: 18.09, 95% CI: 16.32-19.97). C statistic values of 0.859 for typical angina with sweating and 0.519 for typical angina alone reflected high discriminatory value of sweating for STEMI prediction.

CONCLUSIONS

Presence of sweating with ACS symptoms predicts probability of STEMI, even before clinical confirmation. Sweating in association with typical or atypical angina is a much better predictor of STEMI than NSTE-ACS.

ST Segment Elevation in aVR: Clinical Significance in Acute Coronary Syndrome

A 59-year-old-male patient with no previous medical history presented with oppressive chest pain; initial electrocardiogram showed ST segment elevation in aVR and V1, with intermittent right bundle branch block. Emergent coronary angiogram showed a proximal sub-occlusive stenosis of the left anterior descending artery, and the patient was hemodynamically unstable during the first 72 hours. Insights into the significance of ST segment elevation in aVR are presented and discussed in light of the current medical data.

Thrombotic occlusion of the ostial left main coronary artery in a patient with acute coronary syndrome

Ostial left main coronary artery (LMCA) occlusion is rarely seen in patients with acute coronary syndrome. Acute coronary syndrome resulting from an LMCA occlusion is associated with a significant morbidity and mortality rate, if it is managed with fibrinolysis. Electrocardiography can predict LMCA occlusion in patients with acute coronary syndrome. We report a 52-year-old male who presented with acute coronary syndrome and ostial LMCA occlusion. (Neth Heart J 2009;17:295-6.).