DIFFUSE ST DEPRESSION WITH ST ELEVATION AVR IN ACUTE CORONARY SYNDROME AND ITS ASSOCIATION WITH SIGNIFICANT LEFT MAIN OR THREE VESSEL CORONARY ARTERY DISEASE AND ITS CONFOUNDERS
Keywords:Global ST depression, significant Left main stem disease, significant triple vessel disease, TIMI score
AbstractBackground: Global ST depression in 8 or more leads along with ST elevation in aVR has been considered as hallmark of widespread sub-endocardial ischemia. It has been associated with left main (LM) stem or three vessel disease (3VD). But different studies have shown different results. We collected data from patients to see association of these ECG changes with significant LM stem disease and/or significant (3VD). Methods: It was a prospective observational study performed at tertiary care cardiac center. All patients with acute coronary syndrome (ACS) having global ST depression and ST Elevation in aVR (that is ST depression of at least 0.5 mv in ≥8 leads along with ST elevation in aVR of at least 0.5 mv) and have undergone coronary angiogram were included. Results: Our study included 404 patients with above mentioned ECG findings. We observed significant LM stem or significant 3VD in 67% (n=274), 3VD in 55% (n=222) and significant LM stem in only 29% (n=118). Risk factors like diabetes, hypertension and smoking increase probability of these ECG changes up to 40.4%, 32.1% and 33.3% for significant LM stem disease and 62.7%, 57.1% and 57.5% for significant 3VD. Magnitude of ST elevation in aVR leads ≥1 mm increase sensitivity for LM stem disease 35% and for 3VD up to 60.4% and TIMI score ≥4 up to 36.7% for significant LM stem disease and 62.5% for significant 3VD. Conclusion: Global ST depression along with ST elevation in aVR in patients with ACS has low probability for significant LM stem intermediate probability for significant 3VD. Factors like presence of diabetes, hypertension, smoking, magnitude of ST elevation in aVR, and TIMI score improves its diagnostic yield.
Bauersachs R, Zeymer U, Brière JB, Marre C, Bowrin K, Huelsebeck M. Burden of coronary artery disease and peripheral artery disease: a literature review. Cardiovasc Ther 2019;2019:8295054.
Zalewska-Adamiec M, Bachórzewska-Gajewska H, Kralisz P, Nowak K, Hirnle T, Dobrzycki S. Prognosis in Patients With Left Main Coronary Artery Disease Managed Surgically, Percutaneously or Medically: A Long-Term Follow-Up. Kardiol Pol 2013;71(8):787–95.
Su CS, Chen YW, Shen CH, Liu TJ, Chang Y, Lee WL. Clinical outcomes of left main coronary artery disease patients undergoing three different revascularization approaches. Medicine 2018;97(7):e9778.
Yuan D, Jia S, Zhang C, Jiang L, Xu L, Zhang Y, et al. Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease. BMC Cardiovasc Disord 2021;21(1):316.
Máchal J, Pavkova-Goldbergova M, Hlinomaz O, Groch L, Vašků A. Patients with chronic three-vessel disease in a 15-year follow-up study: genetic and non-genetic predictors of survival. Medicine (Baltimore). 2014;93(28):e278.
Kireyev D, Arkhipov MV, Zador ST, Paris JA, Boden WE. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol 2010;15(2):175–80.
Tamura A. Significance of lead aVR in acute coronary syndrome. World J Cardiol 2014;6(7):630–7.
Goldberger AL, Goldberger ZD, Shvilkin A. Goldbergers clinical electrocardiography. 8th ed. A Simplified Approach: Elsevier; 2013.
Kosuge M, Ebina T, Hibi K. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol 2011;107(4):495–500.
Wong CK, Gao W, Stewart RA. The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction. Eur Heart J 2012;33(3):384–92.
Barrabes JA, Figueras J, Moure C, Cortadellas J, Soler-Soler J. Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction. Circulation 2003;108(7):814–9.
Wagner GS, Macfarlane P, Wellens H, Josephson M, Gorgels A, Mirvis DM, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;53(11):1003–11.
Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment. Eur Heart J 2021;42(14):1289–367.
Task Force Members, Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33(20):2569–19.
Knotts RJ, Wilson J, Birnbaum Y. Diffuse ST depression with ST elevation in AVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013;46(3):240–8.
Nikus K, Pahlm O, Wagner G, Birnbaum Y, Cinca J, Clemmensen P, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. J Electrocardiol 2010;43(2):91–103.
Fiol M, Carrillo A, Rodríguez A, Pascual M, Bethencourt A, de Luna AB. Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: differential diagnosis and clinical considerations. J Electrocardiol 2012;45:487–90.
Nikus KC. Electrocardiographic presentations of acute total occlusion of the left main coronary artery. J Electrocardiol 2012;45(5):491–3.
Kosuge M, Kimura K, Ishikawa T, Ebina T, Shimizu T, Hibi K, et al. Predictors of left main or three-vessel disease in patients who have acute coronary syndromes with non–ST-segment elevation. Am J Cardiol 2005;95(11):1366–9.
Hussien A, Battah A, Ashraf M, El-Deen TZ. Electrocardiography as a predictor of left main or three-vessel disease in patients with non-ST segment elevation acute coronary syndrome. Egypt Heart J 2011;63(2):103–7.
Nikus KC, Eskola MJ. Electrocardiogram patterns in acute left main coronary artery occlusion. J Electrocardiol 2008;41(6):626–9.
Harhash AA, Huang JJ, Reddy S, Natarajan B, Balakrishnan M, Shetty R, et al. aVR ST segment elevation: acute STEMI or not? Incidence of an acute coronary occlusion. Am J Med 2019;132(5):622–30.
Yan AT, Yan RT, Kennelly BM, Anderson Jr FA, Budaj A, López-Sendón J, et al. Relationship of ST elevation in lead aVR with angiographic findings and outcome in non–ST elevation acute coronary syndromes. Am Heart J 2007;154(1):71–8.
Rathi N, Baloch MZ, Sachdewani RK, Memon F. Frequency of left main artery/three vessel disease predicted through ECG changes in patients presenting with non-ST segment acute coronary syndrome. J Liaquat Univ Med Health Sci 2016;15(2):93–7.
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