Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease

Role of cardiac magnetic resonance imaging in identifying infarct related artery and non-ischemic pathogenesis in patients presenting with non ST elevation myocardial infarction

INTRODUCTION

Identifying an Infarct-related artery (IRA)in Non-STEMI is sometimes tricky. Besides, myocardial infarction with non-obstructive coronary arteries (MINOCA) mimickers are often labeled as myocardial infarction. Late Gadolinium enhancement (LGE) on cardiac MRI can help in identifying IRA besides MINOCA mimickers.

AIMS

To study the role of LGE on cardiac MRI(CMR) in NSTEMI.

MATERIAL METHODS

It was a prospective observational, double-blinded study. 70 NSTEMI patients were prospectively enrolled over two years. CMR was done before coronary angiography (CAG) during the index hospitalization. Matching was done between IRA selected by CAG and IRA as determined by LGE on MRI.

RESULTS

Mean age was 58 ± 15 years. CAG could not identify IRA in 38.6% (n = 27) patients. In this patient group, LGE-CMR identified IRA in 48.1% (n = 13) & a new non-CAD diagnosis was identified in 18.5% (n = 5) patients. IRA was identified in 61.4% (n = 43) by CAG & in this patient group, LGE-CMR identified a different IRA in 6.9% (n = 3) patients. LGE-CMR also identified a new non-CAD diagnosis in 11.6% (n = 5) of patients from this group. Overall, LGE-CMR led to a new IRA diagnosis in 23% (n = 16) patients & a diagnosis of non-ischemic pathogenesis in 14% (n = 10) patients. Non-Ischemic diagnosis on CMR included stress cardiomyopathy in 3, myocarditis in 6, and infiltrative disorder in 1 patient.

CONCLUSION

CMR leads to new IRA diagnoses or non-ischemic pathogenesis in one-third of the cohort.

Acute coronary syndrome with single‑lead ST segment elevation: A rare presentation of multivessel coronary artery disease

We report the case of a 73-year-old male admitted for epigastric pain and syncope with increased troponin level and a rare electrocardiogram (a single‑lead ST-elevation). Coronary angiography showed multi-vessel coronary artery disease. The patient underwent coronary angioplasty with drug-eluting stenting on left anterior descending coronary artery and drug eluting ballooning on first diagonal ostium. Coronary revascularization was completed with a staged stenting on left circumflex artery and right coronary artery. In rare cases of acute coronary syndrome, even isolated ST single lead anomalies may underlie multivessel coronary disease.

Electrocardiogram and echocardiography findings and the outcomes of patients with myocardial infarction: Retrospective study in tertiary care hospitals in Northwest Ethiopia

BACKGROUND

Myocardial infarction (MI) is diagnosed when there is a rise in cardiac biomarkers along with supportive evidence in the form of typical symptoms, suggestive electrocardiographic (ECG) changes, or imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality. The data regarding the use of ECG and echocardiography (Echo) findings and their impact on mortality are still lacking in Ethiopia. This study assessed the utilization of ECG and Echo findings and outcomes of patients with MI in tertiary care hospitals in Northwest Ethiopia.

METHODS

A retrospective chart review was conducted on patients with MI who were admitted to the adult intensive care units (ICUs) of two selected hospitals between January 2018 and July 30, 2021. Data was entered and analyzed using the SPSS 25 software. Logistic regression analysis was used to assess the association between in-hospital mortality and other variables. A P-value < 0.05 was considered significant.

RESULTS

Among the 203 participants, 67.5% were male, and the mean age of the participants was 59 (13.8). Around two-thirds (66.5%) of patients had STEMI and a regional all-motion abnormality. More than half (54.1%) of the cases were in the anteroapical region. For MI, there was a 23.2% inconsistency between ECG and Echo findings. The rate of in-hospital mortality for patients with MI was 23%. Pulmonary hypertension [AOR = 7.8, 95% CI: 1.72-34.93], inferobasal regional wall motion abnormality [AOR = 7.9, 95% CI: 1.340-46.093], Killip's classes III and IV [AOR = 2.7, 95% CI: 1.103-6.314], infection [AOR = 3.2, 95% CI: 1.108-10.65], and ischemic stroke [AOR = 1.9, 95% CI: 1.091-5.222] were significantly associated with in-hospital mortality compared with their counterparts.

CONCLUSIONS

The mortality of patients with MI in this study was higher than in other reports. Killip's class, pulmonary hypertension, infection, ischemic stroke, and inferobasal regional wall motion abnormalities were significantly associated with the in-hospital mortality of the patients with MI. There was a higher degree of inconsistency between ECG and Echo findings. The treatment of patients with MI should be tailored to their specific risk factors and causes.

The relationship of the changes in lateral leads I and aVL in electrocardiogram with echocardiography and coronary angiography findings in patients with acute coronary syndrome

BACKGROUND

Electrocardiographic (ECG) study is a principle for the symptoms contributed to the acute myocardial infarction (AMI)/acute coronary syndrome (ACS). The diagnosis of involved coronary artery based on ECG changes is still a challenge. This study is aimed to evaluate the association of mere changes in I and aVL leads with the involved region found through echocardiography and involved coronary artery through angiography.

METHODS

This cross-sectional study was conducted on 100 patients referred with AMI/ACS symptoms that had mere ECG changes in I and aVL leads (ST elevation + Q wave/ST depression + inverted-T). Transthoracic echocardiography (TTE) and coronary angiography (CAG) were performed for the patients. The correlation of ECG with echocardiography and angiography was assessed.

RESULTS

Among the studied population, 39 patients (39%) were women with the mean ± standard deviation (SD) of age of 64.60 ± 9.39 years. There was no significant association between ECG changes in leads I and aVL with neither the stenosis of first diagonal (D1) coronary artery found through angiography (P = 0.580) nor the mid-anterior wall dyskinesia found through echocardiography (P = 0.380). A remarkable association between the echocardiographic findings representing mid-anterior wall ischemic dyskinesia with the stenosis of D1 coronary artery was detected (P < 0.001). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 54.54%, 94.68%, and 100% were respectively found as the diagnostic values of mentioned factors.

CONCLUSION

Our findings showed significant association between D1 involvement and mid-anterior dyskinesia in echocardiography, while the changes in ECG were associated neither with echocardiographic nor angiographic outcomes.

Screening and identification of potential protein biomarkers for the early diagnosis of acute myocardial infarction

Background

Acute myocardial infarction (AMI) is the most serious type of heart disease. Clinically, there is an urgent need to discover diagnostic biomarkers for the early diagnosis of AMI.

Methods

Serum proteomic profiles in AMI patients, healthy controls, and stable angina pectoris (SAP) patients were explored and compared by iTRAQ-2DLC-MS/MS. The clinical data of AMI patients were also analyzed. Differentially expressed proteins were validated by enzyme linked immunosorbent assay (ELISA), and diagnostic models were constructed.

Results

A total of 39 differentially expressed proteins were identified in AMI patients. The results showed that the serum levels of apolipoprotein E (APOE) in AMI patients were notably higher than those in the healthy controls (P=0.0172). The serum levels of aspartate aminotransferase (AATC) in AMI patients were markedly higher than those in the healthy controls and SAP patients (P<0.0001 and P<0.0001, respectively). The serum levels of fibronectin (FINC) in SAP patients were significantly higher than those in the healthy controls and AMI patients (P=0.0043 and P=0.0044, respectively). Clinical data analysis showed a considerable difference in blood glucose levels, troponin I (TNI), and creatine kinase (CK) in AMI patients compared with SAP patients and healthy controls. A diagnostic model consisting of AATC and clinical indicators [lactate dehydrogenase (LDH) and CK] was established to distinguish between AMI patients and healthy controls, with an area under the curve (AUC) value of 0.993 sensitivity and specificity of 96.2% and 96.3%, respectively. A diagnostic model consisting of AATC and CK was established to distinguish between AMI patients and SAP patients, with an AUC value of 0.975 and a sensitivity and specificity of 85.2% and 79.30%, respectively.

Conclusions

In this study, differentially expressed proteins in AMI patients were combined with clinical indexes, LDH and CK, and two diagnostic models were constructed. This study may provide meaningful data for the early diagnosis of AMI.

Culprit lesion detection in patients presenting with non-ST elevation acute coronary syndrome and multivessel disease

BACKGROUND/PURPOSE

Identification of the culprit lesion in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) allows appropriate coronary revascularization but may be unclear in patients with multivessel coronary disease (MVD). Therefore, we investigated the rate of culprit lesion identification during coronary angiography in NSTE-ACS and multivessel disease.

METHODS/MATERIALS

Consecutive patients presenting with NSTE-ACS and MVD, between January 2012 and December 2016 were evaluated. Coronary angiograms, intravascular imaging, and ECGs were analyzed for culprit lesion identification. Long-term clinical outcomes in terms of major adverse cardiac events (MACE) and mortality were reported in patients with or without culprit identification.

RESULTS

A total of 1107 patients with NSTE-ACS and MVD were included in the analysis, 310 (28.0%) with unstable angina and 797 (72.0%) with non-ST elevation myocardial infarction. The culprit lesion was angiographically identified in 952 (86.0%) patients, while no clear culprit lesion was found in 155 (14.0%) patients. ECG analysis allowed to predict the location of the culprit vessel with low sensitivity (range 28.4%-36.7%) and high specificity (range 90.6%-96.5%). Higher lesion complexity was associated with inability to identify the culprit. Intravascular imaging was applied in 55 patients and helped to identify the culprit lesion in 53 patients (96.4%). There was no difference in all-cause mortality (21.4% vs. 25.8%, p = 0.24) and MACE (39.2% vs. 47.6%, p = 0.07) between the cohorts with or without culprit lesion identification by angiography.

CONCLUSIONS

The culprit lesion appeared unclear by coronary angiography in >10% of patients with NSTE-ACS and MVD. Complementary invasive imaging substantially enhanced the diagnostic accuracy of culprit lesion detection.

Electrocardiographic identification of the culprit coronary artery in acute non-ST-elevation myocardial infarction: predictive value of N-wave and T-wave precordial instability

BACKGROUND

Recently, novel ischemic electrocardiographic changes have been described, which may be clinically significant in the identification of the culprit coronary vessel in patients with non-ST-elevation myocardial infarction (NSTEMI). We sought to determine the predictive value of N-wave, T-wave precordial instability, de-Winter ST/T-wave complex, and inferolateral myocardial infarction in the identification of the culprit artery in patients with NSTEMI referred for early invasive (<24 h) treatment.

METHODS

A total of 148 patients with NSTEMI, aged 40-91 years, were enrolled from a cohort of 510 consecutive NSTEMI subjects, hospitalized in our center in 2015-2017.

RESULTS

Of the evaluated ischemic ECG changes, the most common finding in patients with culprit left circumflex (LCx)/obtuse marginal artery or right coronary artery was T-wave precordial instability (28.3 and 13.5%, respectively), whereas in individuals with culprit left anterior descending/diagonal artery, T-wave precordial instability and N-wave in leads II, III or aVF occurred equally often (16.0%). A significant relationship was found between the occurrence of N-wave in inferolateral leads and culprit LCx/obtuse marginal. In multivariable analysis, N-wave in lead aVL [odds ratio (OR) 2.10; 95% confidence interval (CI), 1.15-3.81], and T-wave precordial instability (OR 1.56; 95% CI, 1.02-2.41) were independent predictors of culprit LCx/obtuse marginal. The accuracy of N-wave in lead aVL in predicting the culprit LCx/obtuse marginal was 73.9% and was higher than the accuracy of T-wave precordial instability, which was 69.1%.

CONCLUSIONS

In patients with NSTEMI referred for early invasive treatment, the presence of N-wave or T-wave precordial instability may be of greater clinical importance in the prediction of culprit LCx/obtuse marginal than classic ischemic changes.

Reduced regional strain rate is the most accurate dysfunction in predicting culprit lesions in patients with acute coronary syndrome

BACKGROUND AND AIM

Predicting culprit lesions in acute coronary syndrome (ACS) could be a challenge. The aim of this study was to assess the accuracy of regional wall motion abnormalities (RWMA) using various echocardiographic techniques and ECG changes in predicting the culprit coronary lesion in a group of patients with ACS.

METHODS

In 80 consecutive patients with ACS (age 55·7 ± 9·4 years, 77% male, 15% with CCS Angina III), an echocardiographic examination of left ventricle (LV) RWMA, tissue Doppler imaging (TDI) and speckle tracking myocardial strain and strain rate (SR) were performed before intervention.

RESULTS

Of the 80 patients, one-vessel stenosis (>70%) was present in 53 (66%), two-vessel disease in 12 (15%) and multivessel disease in 15 patients (19%). About 51% of patients had hypertension, 40% diabetes and 23% dyslipidaemia. There was no relationship between individual segmental RWMA and SR. Mean regional SR, but not peak strain, correlated with culprit lesion branch: left anterior descending - LAD (r = 0·35, P = 0·005), circumflex LCx (r = 0·32, P = 0·03) and right coronary RCA (r = 0·37, P = 0·01). Only ECG changes in the LAD territory (r = 0·26, P = 0·04) correlated with the culprit lesion. SR of LAD territories ≤-0·74 was 71% sensitive and 70% specific (AUC = 0·70, CI = 0·67-0·93, P = 0·01), SR of LCx territories of ≤-0·67 was 75% sensitive and 63% specific (AUC = 0·72, CI = 0·58-0·87, P = 0·02) and SR of RCA territories ≤-0·83 was 73% sensitive and 71% specific (AUC = 0·80, CI = 0·66-0·93, P = 0·001) in predicting significant stenosis. SR was more accurate than all other techniques in predicting the culprit lesion.

CONCLUSION

In ACS, mean regional speckle tracking SR is more sensitive than peak strain, TDI, ECG changes and wall motion abnormalities in detecting significant coronary artery stenosis.

Effect of infarct site on the clinical endpoints of thrombolytic-treated ST-elevation myocardial infarction

INTRODUCTION

Some studies suggest better outcomes after the use of thrombolytics in inferior ST-elevation myocardial infarction (STEMI) compared to other locations. The goal of this study is to compare the clinical endpoints of thrombolytic-treated STEMI based on coronary artery distribution.

METHODS

The study population was extracted from the 2014 Nationwide Readmissions Data using the International Classification of Diseases, Ninth Revision, Clinical Modifications codes for STEMI, thrombolytic infusion, and complications of STEMI. Primary study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), cardiogenic shock, and mechanical complications of STEMI.

RESULTS

A principal diagnosis of thrombolytic-treated STEMI was identified for in 1231 patients (mean age 61.5 years; 26.5% female). Four hundred and thirty-one STEMIs occurred in the left anterior descending (LAD) artery distribution, 124 in the left circumflex (LCX) artery distribution, and 676 in the right coronary artery (RCA) distribution. In comparison to the LAD and LCX distributions, thrombolytic-treated STEMIs in the RCA distribution were associated with lower mortality (6.5% with LAD, 5.7% with LCX, and 3.6% with RCA; p = 0.02), fewer cardiogenic shock (12.3% with LAD, 12.1% with LCX, and 7.7% with RCA; p = 0.01), and shorter LOS (4.5 days with LAD, 3.9 with LCX, and 3.6 days with RCA; p < 0.01). Mechanical complications showed no significant difference based on coronary distribution (2.3% with LAD, 3.2% with LCX, and 1.2% with RCA; p = 0.17).

CONCLUSIONS

Thrombolytic-treated STEMIs in the RCA distribution were associated with lower in-hospital all-cause mortality, cardiogenic shock, and shorter LOS. Mechanical complications were not different based on coronary distribution.