Predictive Value of Admission Electrocardiogram For Multivessel Disease in Acute Anterior and Anterior‐Inferior Myocardial Infarction

Background: Our aim was to investigate the correlation between admission ECG and coronary angiography findings in terms of predicting the culprit vessel responsible for the infarct or multivessel disease in acute anterior or anterior‐inferior myocardial infarction (AMI). Methods: We investigated 101 patients with a diagnosis of anterior AMI with or without ST‐segment elevation or ST‐segment depression in at least two leads in Dll, III, aVF. The patients were classified as those with vessel involvement in the left anterior descending (LAD) coronary artery and patients with multivessel disease. Vessel involvement in LAD + circumflex artery (Cx) or LAD + right coronary artery (RCA) or LAD + Cx + RCA were considered as multivessel disease. Thus, (a) anterior AMI patients with reciprocal changes in inferior leads, (b) anterior AMI patients with inferior elevations, (c) all anterior AMI patients according to the ST‐segment changes in the inferior region were analyzed according to the presence of LAD or multivesssel involvement. Results: Presence of ST‐segment depression in aVL and V6 was significantly correlated with the presence of multivessel disease in anterior AMI patients with reciprocal changes in the inferior leads (P = 0.005 and P = 0.003, respectively). No statistically significant difference between the leads were detected in terms of ST‐segment elevation in predicting vessel involvement in the two groups of anterior AMI patients with inferior elevations. When all the patients with anterior AMI were analyzed, the presence of ST‐segment depression in leads aVL, V4, V5 and V6 were significantly associated with the presence of multivessel disease (P = 0.035, P = 0.010, P = 0.011, P = 0.001, respectively). Conclusions: The presence of ST‐segment depression in anterolateral leads in the admission ECG of anterior AMI patients with reciprocal changes in inferior leads was associated with multivessel disease.     

急性前壁心肌梗死并下壁导联ST段压低与冠状动脉病变的关系

目的：观察急性前壁心肌梗死下壁导联ＳＴ段压低与冠状动脉病变的关系。方法：对６６例急性前壁心肌梗死患者均常规行冠状动脉造影术,根据常规心电图下壁导联ＳＴ段压低＞１ｍｍ分为ＳＴ段压低组（４８例）与ＳＴ段正常组（１８例）,比较分析心电图与冠状动脉造影之间的关系。结果：急性前壁心肌梗死患者２７．３％有下壁导联ＳＴ段压低,ＳＴ段压低组中冠状动脉病变支数与正常组无显著性差异（Ｐ＞０．０５）,７３．２％为左前降支（ＬＡＤ）近端病变,显著高于ＳＴ段正常组（４５．８％）。ＳＴ段压低组５５．６％伴有心电图ＳＴＩ,ａＶＬ抬高,显著高于ＳＴ段正常组（４．２％）（Ｐ＜０．０１）。结论：急性前壁心肌梗死并下壁导联ＳＴ段压低与冠状动脉病变支数无关,而与ＬＡＤ近端病变有关,可能反映高侧壁心肌缺血时的心电图对应性改变。     

急性下壁心肌梗死患者心电图胸前导联ST段改变的临床意义

目的探讨急性下壁心肌梗死患者心电图胸前导联ST段改变与冠状动脉造影(CAG)所见冠状动脉病变部位的关系及其临床意义。方法 187例急性下壁心肌梗死患者,按入院时18导心电图胸前导联ST段改变分为3组,ST段无变化组(47例),ST段抬高组(16例),ST段压低组(124例);所有患者均行CAG。结果急性下壁心肌梗死伴胸前导联ST段抬高时多为右冠状动脉(RCA)近段闭塞(14例,82.3%),尤其是伴圆锥支动脉闭塞,与RCA中远端闭塞(2例,5.9%)比较差异有统计学意义(P0.01),且14例(73.7%)伴有右心功能不全和血流动力学障碍。下壁心肌梗死胸前导联ST段压低者可见于RCA、回旋支(LCX)闭塞及RCA、LCX闭塞与前降支(LAD)、对角支(D)病变的不同组合,其中LCX闭塞伴RCA病变者多表现为朐前ST V_4～V_6的压低,RCA闭塞伴LAD近端病变多有胸前ST V_1～V_6的压低,RCA伴D病变胸前ST V_1～V_3压低,与对照组比较差异有统计学意义(P0.05)。结论急性下壁心肌梗死合并胸前导联ST段抬高表明为RCA近段或丌口闭塞且多伴右心室心肌梗死和心功能不全;下壁心肌梗死伴胸前导联ST段压低提示为多支病变,ST V_1～V_3压低多伴有对角支严重狭窄,STV_1～V_6压低多伴有前降支的严重狭窄。     

Reciprocal ST depression in acute myocardial infarction.

ST segment depression in leads remote from those showing ST elevation during acute myocardial infarction has been attributed to benign electrical phenomena, distant myocardial ischaemia, or extensive myocardial damage. Eighty four consecutive survivors under 55 years of age with a first transmural myocardial infarction were studied. All patients had exercise tests six weeks after infarction and coronary angiography a mean of three months after infarction. Thirty eight (75%) of the 51 inferior and 19 (58%) of the 33 anterior infarcts showed reciprocal ST depression of greater than or equal to 1 mm during the acute phase. Ten (26%) of the 38 patients with inferior infarcts and reciprocal depression had ST depression in the same leads on exercise. There was concomitant disease of the left anterior descending artery in four (40%) of these 10 patients and in five (18%) of the 28 with inferior infarcts with reciprocal depression but without ST depression in the same leads on exercise. Five (26%) of the 19 patients with anterior infarcts with associated reciprocal depression and four of the 14 without reciprocal depression had important right coronary artery disease. In patients with inferior infarction important disease of the left anterior descending artery could not be predicted by ST depression in particular lead groups. Therefore reciprocal ST depression during acute myocardial infarction does not predict concomitant disease in the coronary artery supplying the reciprocal territory.     

Reciprocal ST depression in acute myocardial infarction

ST segment depression in leads remote from those showing ST elevation during acute myocardial infarction has been attributed to benign electrical phenomena, distant myocardial ischaemia, or extensive myocardial damage. Eighty four consecutive survivors under 55 years of age with a first transmural myocardial infarction were studied. All patients had exercise tests six weeks after infarction and coronary angiography a mean of three months after infarction. Thirty eight (75%) of the 51 inferior and 19 (58%) of the 33 anterior infarcts showed reciprocal ST depression of greater than or equal to 1 mm during the acute phase. Ten (26%) of the 38 patients with inferior infarcts and reciprocal depression had ST depression in the same leads on exercise. There was concomitant disease of the left anterior descending artery in four (40%) of these 10 patients and in five (18%) of the 28 with inferior infarcts with reciprocal depression but without ST depression in the same leads on exercise. Five (26%) of the 19 patients with anterior infarcts with associated reciprocal depression and four of the 14 without reciprocal depression had important right coronary artery disease. In patients with inferior infarction important disease of the left anterior descending artery could not be predicted by ST depression in particular lead groups. Therefore reciprocal ST depression during acute myocardial infarction does not predict concomitant disease in the coronary artery supplying the reciprocal territory.     

Importance of reciprocal ST segment depression in leads V5 and V6 as an indicator of disease of the left anterior descending coronary artery in acute inferior wall myocardial infarction.

The purpose of this study was to determine the coronary angiographic correlations (specifically disease of the left anterior descending coronary artery) of reciprocal ST segment depression appearing during inferior acute myocardial infarction. Forty six patients (41 men and five women; mean age 56 years) were allocated into two groups based on the extent of precordial ST segment depression: widespread (V1-V6) ST depression v localised (V1-V4) ST depression. Patients with no reciprocal ST depression or patients with ST depression in V1-V4 but with ST elevation in V5 and V6 (inferolateral acute myocardial infarction) were excluded. All patients were catheterised during hospital admission for infarction. Twenty four of the 28 patients with ST depression in V1-V6 had significant lesions in the left anterior descending coronary artery whereas 16 of the 18 patients with ST depression in V1-V4 had insignificant or no lesions in the left anterior descending artery. The sensitivity, specificity, and positive and negative predictive values of widespread ST depression in predicting disease in the left anterior descending coronary artery were 92%, 80%, and 86% and 89% respectively. In patients with inferior acute myocardial infarction and precordial ST depression, the extent of ST depression is of clinical significance. Widespread (V1-V6) ST depression suggests disease of the left anterior descending coronary artery, whereas localised ST depression (V1-V4) indicates its absence.     

Importance of reciprocal ST segment depression in leads V5 and V6 as an indicator of disease of the left anterior descending coronary artery in acute inferior wall myocardial infarction

The purpose of this study was to determine the coronary angiographic correlations (specifically disease of the left anterior descending coronary artery) of reciprocal ST segment depression appearing during inferior acute myocardial infarction. Forty six patients (41 men and five women; mean age 56 years) were allocated into two groups based on the extent of precordial ST segment depression: widespread (V1-V6) ST depression v localised (V1-V4) ST depression. Patients with no reciprocal ST depression or patients with ST depression in V1-V4 but with ST elevation in V5 and V6 (inferolateral acute myocardial infarction) were excluded. All patients were catheterised during hospital admission for infarction. Twenty four of the 28 patients with ST depression in V1-V6 had significant lesions in the left anterior descending coronary artery whereas 16 of the 18 patients with ST depression in V1-V4 had insignificant or no lesions in the left anterior descending artery. The sensitivity, specificity, and positive and negative predictive values of widespread ST depression in predicting disease in the left anterior descending coronary artery were 92%, 80%, and 86% and 89% respectively. In patients with inferior acute myocardial infarction and precordial ST depression, the extent of ST depression is of clinical significance. Widespread (V1-V6) ST depression suggests disease of the left anterior descending coronary artery, whereas localised ST depression (V1-V4) indicates its absence.     

Significance of treadmill stress testing in transmural myocardial infarction: Correlation with coronary angiography

To assess the usefulness of stress testing in predicting multivesselcoronary disease and left ventricular dysfunction, 83 male patientswith a myocardial infarction one to 84 months previously werestudied. In inferior infarction (45 patients), the ST segment depressionhad a sensitivity of 91% and a specificity of 77% to detectmultivessel disease. Patients with multivessel disease had significantlylower exercise capacity and maximal heart rates. ST segmentelevation showed a poor correlation with the number of affectedvessels. In anterior infarction (38 patients), both ST segment depressionand elevation were of little value to detect multivessel disease.However, the predictive value of an exercise test without STsegment changes to exclude multivessel disease was 89%; on theother hand, patients without ST segment changes had significantlyhigher ejection fractions, exercise capacity, maximal heartrates and rate-pressure products than patients with ST segmentchanges. Patients with ST segment elevation had significantly lower ejectionfractions in both groups. The sensitivity of ST segment elevationto detect severe segmental left ventricular dysfunction was84% for anterior infarction and 54% for inferior infarction.Specificity was 84 and 85%, respectively. We conclude that: (1) exercise-induced ST segment depression is useful to predictthe extent of coronary artery disease in inferior infarction,but it is of limited value in anterior infarction, (2) exercise-induced ST segment elevation correlates well withthe presence of severe left ventricular dysfunction in bothanterior and inferior infarction, and (3) an exercise test of considerable intensity without ST segmentchanges makes the existence of multivessel coronary diseaseand/or severe left ventricular dysfunction very improbable.     

Angiographic evidence that reciprocal ST-segment depression during acute myocardial infarction does not indicate remote ischemia: Analysis of 23 patients

Although reciprocal ST-segment depression from the remote noninfarcting ventricular wall during acute myocardial infarction (Ml) is a common clinical finding, the significance of this electrocardiographic pattern is unclear. Previous retrospective studies have suggested that these findings may reflect either remote wall ischemia, multivessel coronary artery disease (CAD), extensive MI or a benign electrical phenomenon. Prior studies have lacked angiographic data obtained at the time of these acute electrocardiographic changes. In this study we prospectively evaluated 23 patients with acute MI. Left ventricular wall motion, coronary anatomy and the ECG were all assessed over a short period during the acute phase of the MI. Segmental wall motion was used as a sensitive indicator of ischemia.Seventeen patients had acute anterior MI, of whom 47 % had reciprocal ST-segment depression; 6 patients had inferior MI, with 3 showing reciprocal ST depression. The mean degree of ST-segment elevation from the infarcting wall tended to be greater in patients with reciprocal ST-segment depression than in those without such reciprocal ST depression (2.8 ± 0.4 vs 1.9 ± 0.3 mm, p = 0.06). Patients with and without reciprocal ST-segment depression had similar degrees of segmental dysfunction in the infarct wall. However, no abnormalities in segmental wall motion in the remote wall were seen regardless of the presence or absence of remote wall ST-segment depression. In addition, the presence or absence of ST-segment depression did not predict the extent or degree of CAD. Finally, the magnitude of ST-segment elevation from the acutely infarcting wall correlated significantly with the degree of remote wall reciprocal ST-segment depression (r = 0.83, p < 0.01).Thus, the presence of remote wall reciprocal ST-segment depression on the ECG during the acute phase of an MI does not predict ischemia or the extent of CAD in the arteries supplying the remote noninfarcting wall. Because the reciprocal electrocardiographic changes correlate with the degree of ST-segment elevation, they probably represent a benign electrical phenomenon.     

Exercise-induced precordial ST depression in patients with prior inferior myocardial infarction with single vessel disease

We investigated the mechanisms of exercise-induced precordial ST depression in prior inferior myocardial infarction in single vessel disease, and attempted to differentiate ST depression in single vessel from multivessel disease. Subjects were categorized as; Group I (n = 18), with inferior myocardial infarction and single vessel disease without (n = 11; Ia) and with (n = 7; Ib) exercise-induced precordial ST depression and group II (n = 10), inferior myocardial infarction with multivessel disease. The subjects were examined using 12-lead exercise ECG, stress T1-201 myocardial imaging and stress radionuclide ventriculography. Compared to group Ia, exercise-induced precordial ST depression in group Ib was associated with extensive infarction extending into the inferoseptal left ventricular wall by T1-201 myocardial imaging. Worsening of septal wall motion was also more frequently observed on stress radionuclide ventriculography. For detecting multivessel disease in prior inferior myocardial infarction, exercise ECG and radionuclide ventriculography had poor specificity and predictive value compared to stress T1-201 myocardial imaging. We conclude that exercise-induced precordial ST depression observed in patients with prior inferior myocardial infarction due to single vessel disease reflects a peri-infarction ischemia in the inferoseptal wall of the left ventricle. Great caution is necessary when predicting multivessel disease in prior inferior myocardial infarction using exercise ECG. Stress T1-201 myocardial imaging is the most accurate diagnostic means for this purpose.     

急性下壁心肌梗死伴有胸前导联ST段压低的临床意义

目的 分析急性下壁心肌梗死（acute inferior myocardial infarction,AIMI）伴有胸前导联ST段压低的冠状动脉病变特点及临床意义。方法 回顾分析2006年8月～2007年8月住院的AIMI患者91例。按胸前导联ST段是否压低将患者分为4组:胸前导联ST段无压低组（n=27）;胸前导联仅V1～4 ST段压低组（n=26）;胸前导联仅V5～6 ST段压低组（n=12）;广泛胸前导联ST段压低组（n=26）。结果 AIMI伴有胸前导联V1～4 ST段压低与冠状动脉多支病变呈负相关,ORⅢ=0.38,无统计学意义;AIMI伴有胸前导联V1～6 ST段压低与冠状动脉多支病变呈正相关,ORⅣ=5.25,P<0.01,有显著统计学意义。胸前导联V1～6 ST段压低组与其他组相比较,左室射血分数（LVEF）低,差异显著（P<0.05）;该组前降支病变率高（73.1%）,但与其他3组相比无统计学差异。结论 AIMI伴有胸前导联V1～6 ST段压低提示多支病变,且心功能不全发生率高。     

急性下壁心肌梗死胸前导联ST段压低与冠状动脉病变的关系及临床意义探讨

目的 :探讨急性下壁心肌梗死胸前导联ST段压低与冠状动脉病变的关系及临床意义。方法 :回顾分析 2 0 0 0年 7月至 2 0 0 2年 5月住院的首次急性下壁心肌梗死患者 6 0例。按胸前导联ST段压低范围将患者分为 4组 :无胸前导联ST段压低组 (Ⅰ组 ,n =2 2 ) ;胸前导联V1～ 3ST段压低组 (Ⅱ组 ,n =12 ) ;胸前导联V4～ 6 ST段压低组 (Ⅲ组 ,n =12 ) ;胸前导联V1～ 6 ST段压低组 (Ⅳ组 ,n =14 )。分析内容包括冠心病危险因素、心电图、心肌酶谱、心脏彩超、冠状动脉造影以及心肌梗死的并发症。结果 :左前降支 (LAD)病变发生率在Ⅰ与Ⅲ、Ⅳ各组分别为 4 7 1%、6 0 %、72 7% (P >0 0 5 ) ,而在Ⅱ组仅为 9 1% ,与Ⅰ组比较 ,Ⅱ组的LAD病变发生率低 (P <0 0 5 ) ,但Ⅰ组LAD病变程度较轻 ,>90 %狭窄者仅占 12 5 % ,而Ⅲ、Ⅳ组分别占 83 3%、87 5 % (P <0 0 5 ) ;回旋支 (LCX)病变在Ⅰ、Ⅱ、Ⅲ、Ⅳ组分别占 17 6 %、4 5 5 %、6 0 %、6 3 6 % ,与Ⅰ组比较 ,Ⅲ、Ⅳ各组的LCX病变发生率较高 (P <0 0 5 ) ,且Ⅳ组多支病变比例较高 (P <0 0 5 ) ;左室射血分数 (LVEF)在Ⅰ、Ⅱ、Ⅲ、Ⅳ组分别为 0 6 3± 0 0 5、0 6 2± 0 0 6、0 5 5± 0 10、0 5 1± 0 13,与Ⅰ组相比 ,Ⅳ组的LVEF较低 (P <0 0 5 ) ;低血压状?     

急性下壁心肌梗死心电图胸前导联V1-3 ST段抬高的临床意义

目的 探讨急性下壁心肌梗死患者心电图胸前导联ST段抬高与冠状动脉造影所示冠状动脉病变的关系及其临床意义.方法 187例急性下壁心肌梗死患者,按入院时18导心电图胸前导联ST段改变分为2组,ST段抬高组（16例）和非ST段压低组（171例）.所有患者均行冠状动脉造影术,病变适合行经皮腔冠状动脉成型术并检测B型钠尿肽（BNP）.结果 急性下壁心肌梗死伴胸前导联ST段抬高时多为右冠状动脉近段闭塞,尤其是圆锥支闭塞（P＜0.01）,且伴有右心功能不全和血流动力学障碍,与下壁右室心梗相比BNP差异有统计学意义（P＜0.01）.结论 急性下壁心肌梗死合并胸前导联ST抬高表明为右冠状动脉近段或开口闭塞且多伴右室心肌梗死和心功能不全.     

Anterolateral ST segment depression in acute inferior myocardial infarction: angiographic and clinical implications

We examined the relationship between coronary anatomy and anterolateral ST segment depression during inferior acute myocardial infarction (AMI) in 84 consecutive survivors of inferior AMI, who underwent prospective coronary angiography a median time of 2 weeks after AMI. Multivessel disease was defined as two or more significantly (greater than 70%) stenosed vessels. A QRS scoring system was used to estimate myocardial infarct size. Patients with ST depression had more multivessel disease compared to patients with no ST depression (53% vs 6%, p less than 0.01), more left anterior descending stenoses (36% vs 10% p less than 0.05), and higher QRS scores (5.8 +/- 3.2 vs 2.6 +/- 1.8, p less than 0.01) indicating larger infarcts. Patients with ST depression and one-vessel disease (47%) still had higher QRS scores compared to patients with no ST depression (4.8 +/- 2.9 vs 2.6 +/- 1.8, p less than 0.001) and had an increased prevalence of infarct-related vessels with a terminal branch supplying the left ventricular lateral wall or apex. We conclude that anterolateral ST depression during inferior AMI may indicate the presence of additionally stenosed vessels or that the infarct-related vessel has a large vascular territory. The absence of ST depression virtually precludes multivessel disease.     

Inferior ST segment depression during acute anterior myocardial infarction: clinical and angiographic correlations

This study was performed to determine whether inferior ST segment depression during early stages of acute transmural anterior myocardial infarction identifies patients with multivessel coronary artery disease and additional inferior ischemia. Coronary and left ventricular angiography were performed within 3.4 months in 33 patients with acute transmural anterior infarction. Initial electrocardiograms, 2 to 5 hours after onset of chest pain, revealed significant ST segment depression (greater than or equal to 0.1 mV) in at least two of leads II, III and a VF in 15 patients (45%) (group B); in 18 patients (group A) this finding was absent. Compared with group A, patients in group B had greater anterior ST elevation (1.2 versus 0.7 mV, p less than 0.025); higher serum peak creatine kinase (2,475 versus 1,147 IU/liter, p less than 0.005); higher Killip scores (2.1 versus 1.3, p less than 0.001); more in-hospital complications (60 versus 17%, p less than 0.05); lower mean left ventricular ejection fraction (34 versus 55%, p less than 0.001); more frequent regional left ventricular dysfunction in anterolateral (91 versus 44%, p less than 0.05), posterolateral (36 versus 0%, p less than 0.05) and inferior (100 versus 6%, p less than 0.005) regions; greater wall motion abnormality scores (10.0 versus 5.5, p less than 0.005); higher frequency of concomitant left circumflex or right coronary artery disease, or both (80 versus 28%, p less than 0.01); more frequent postinfarction angina (100 versus 39%, p less than 0.001) and lower New York Heart Association functional classification scores (1.7 versus 2.4, p less than 0.05) at 6 month follow-up. The time course of inferior ST depression differed from that of anterior ST elevation. Thus, inferior ST depression was maximal in the first 48 hours and decreased (p less than 0.05) thereafter. In contrast, ST elevation in leads V1 to V6 and I appeared to decrease (p = NS) between days 4 and 7. However, inferior ST depression "mirrored" ST elevation in lead aVL, which also decreased (p less than 0.05) after 48 hours. Thus, inferior ST depression during anterior infarction is associated with more extensive infarction, greater morbidity and higher frequency of multivessel coronary disease. Such inferior ST depression might reflect not only "reciprocal change," but also ischemia in adjacent lateral and remote inferior regions.     

Significance of reciprocal ST depression in acute myocardial infarction: a study of 258 patients treated by thrombolysis.

OBJECTIVE--To investigate the clinical significance of reciprocal ST depression on the presenting electrocardiogram in patients with acute myocardial infarction treated by thrombolysis. DESIGN--A prospective cohort analytical study. SETTING--A London district general hospital. SUBJECTS--Two hundred and fifty eight consecutive patients with acute myocardial infarction treated with thrombolysis. INTERVENTIONS--All patients underwent treadmill stress testing after a mean (SEM) of 10 (3) days; 200 patients (78%) were referred for coronary arteriography at 30 (16) days. MAIN OUTCOME MEASURES--Relation between reciprocal ST depression at presentation and several endpoints: time from start of chest pain to hospital presentation, electrocardiographic changes during early treadmill stress testing, presence of multivessel coronary disease, and clinical outcome in terms of recurrent ischaemic events (death, reinfarction, and unstable angina) during a 10 (range six to 12) month follow up. RESULTS--Presentation was generally early, but in this group of patients reciprocal ST depression was significantly related to the time from the start of symptoms, those with reciprocal change presenting on average one hour earlier than those without. Although reciprocal change on the presenting electrocardiogram was weakly associated with ST depression on treadmill stress testing, it was not indicative of remote ischaemia as a result of multivessel coronary disease or high grade collateralisation of the infarct related artery. There was no association between reciprocal change and the incidence of recurrent ischaemic events. CONCLUSION--Reciprocal ST depression on the presenting electrocardiogram seems to be a benign electrical phenomenon related to the time from the start of symptoms. It does not necessarily predict an adverse prognosis in patients treated by thrombolysis.     

Angiographic correlates of anterior ST segment depression in acute inferior wall myocardial infarction.

This study was conducted prospectively to assess the correlation between the pattern of anterior ST segment depression on the admission electrocardiogram and the in-hospital morbidity and mortality in patients with acute inferior wall myocardial infarction. Coronary angiography was also done to assess its correlation, if any, with pattern of anterior ST segment depression. Our study cohort comprised of 165 consecutive patients with acute inferior wall myocardial infarction divided into four groups based on admission electrocardiogram. Group I (n = 33): patients with no anterior ST segment depression; group II (n = 16): patients with ST segment depression in leads V1-V3; group III (n = 71): patients with ST segment depression in leads V4-V6, I and aVF, and; group IV (n = 45): patients with ST segment depression in all anterior leads (V1-V6, I, aVL). The outcomes were analysed in terms of high grade atrioventricular block, Killip class II or higher failure, and in-hospital mortality. Coronary angiography was performed to analyse coronary anatomy. Group IV patients had increased incidence of complete heart block (37.8% vs 15.2% in the total group) (p < 0.001) and increased mortality (11.1% vs 4.2% in the total group) (p < 0.05). This group also had greater incidence of triple vessel disease (76.7%) (p < 0.001). Group II patients had greater incidence of double vessel disease (88.9%) (p < 0.05) and had no triple vessel disease. Group III patients had double vessel disease (76.5%) (p < 0.05) or triple vessel disease (23.5%) (p = NS) and no single vessel disease. Coronary angiography in group II showed greater incidence of involvement of left circumflex artery and right coronary artery while in group III there was left anterior descending artery and right coronary artery disease. We conclude that patients with anterior ST segment depression in group III and group IV categories are in high risk subset with acute inferior wall myocardial infarction.     

An analysis of ST segment shift in procordial leads in patients with acute inferior myocardiac infarction with and without right ventricular infarction]

ST segment change in procordial leads was analysed in 58 patients with acute inferior myocardial infarction (IMI). ST segment depression in V2 lead was negatively correlated with ST segment elevation in a VF lead in patients with IMI. ST segment depression in V2 lead was not observed when IMI was accompanied by right ventricular infarction. It indicates that ST segment depression in procordial leads was the reciprocal change of ST segment elevation in inferior leads. The direction and amplitude of ST segment shift in procordial leads may be affected by the presence of right ventricular infarction (RVI). The ratio of ST V2/ST aVF less than 0.5 may suggest a diagnosis of IMI with accompanying RVI.     

Correlation of remote ST segment depression and coronary anatomy during acute coronary occlusion

BACKGROUND: The appearance of remote ST segment depression (RSTD) on an electrocardiogram (ECG) is associated with more extensive infarction and a worse clinical outcome than when RSTD is absent. OBJECTIVE: To determine whether RSTD predicts coronary anatomy during acute coronary occlusion. It was hypothesized that RSTD is associated with the occlusion of a proximal lesion, an extensive artery and an artery without distal collateralization. PATIENTS AND METHODS: In 113 consecutive patients with single vessel disease undergoing percutaneous transluminal coronary angioplasty (PTCA), 12-lead ECGs (recorded at baseline and during balloon inflation) and angiographical data were analyzed independently. Patients with ST segment elevation in the primary territory and RSTD (greater than 1 mm ST depression at 80 ms after the J point) (group A) were compared with patients without RSTD (group B). Proximal lesions were defined as lesions located in the segments proximal to the acute marginal branch, first diagonal artery or first obtuse marginal branch. An extensive right coronary artery (RCA) was one that supplied the posterolateral wall; an extensive left anterior descending (LAD) artery was one that supplied the inferoapical wall; and an extensive circumflex artery was one that supplied the posterior descending artery. RESULTS: Fifty-four patients (48%) had PTCA of the proximal vessels, 43 patients (38%) had extensive target vessels and 11 patients (9.7%) had collaterals. Target vessels included 33% in RCA, 44% in LAD artery and 23% in circumflex artery. Forty-five patients (40%) developed RSTD during balloon inflation (group A). Patients in group A were more likely to have extensive vessels on the angiogram than those in group B (group A 49%, group B 31%; P=0.05). None of the patients in group A had collaterals to the culprit artery, while 16% of patients in group B did (P=0.003). The two groups were not significantly different with respect to the number of proximal lesions (group A 58%, group B 42%; P=0.08). Analysis performed according to the target artery revealed that RSTD was associated with occlusion of an extensive RCA during RCA occlusion (extensive RCA in group A 100%, group B 57%; P=0.006). For the LAD artery, RSTD was associated with proximal lesions (group A 74%, group B 41%; P=0.02) and absence of collaterals (group A 100%, group B 74%; P=0.01). CONCLUSIONS: During acute coronary occlusion, the presence of RSTD on 12-lead ECG was specific for the absence of collaterals. The presence of RSTD during RCA occlusion was strongly associated with an extensive RCA, suggestive of posterolateral wall ischemia. During LAD artery occlusion, the presence of RSTD was associated with proximal occlusion, which resulted in ischemia of the LAD artery and the major diagonal artery territories.     

Reciprocal ST change in acute myocardial infarction: assessment by electrocardiography and echocardiography

To evaluate the incidence, time course and significance of reciprocal change, 25 consecutive patients admitted with their first acute transmural myocardial infarction were studied with serial electrocardiography and two-dimensional echocardiography. Reciprocal change was noted in all patients with inferior infarction (mean maximal ST segment depression 3.53 +/- 1.97 mm) and 70% of patients with anterior infarction (mean maximal ST depression 1.45 +/- 0.8 mm, p = 0.001). When initially present, reciprocal change had resolved within 24 hours in 59% of patients. The sum of reciprocal ST depression correlated with the sum of ST elevation in anterior (r = 0.92, p less than 0.001) and inferior (r = 0.55, p = 0.035) infarction, and this relation persisted when maximal ST depression and elevation were considered. Echocardiographic evidence of contraction abnormalities in areas of the left ventricle remote from the infarction was seen in 45% of patients. However, its presence did not correlate with the presence of reciprocal change. Although reciprocal change progressively diminished on serial electrocardiograms (maximal ST depression 2.73 +/- 1.77 mm at 19 hours after onset of symptoms; 1.0 +/- 0.92 mm at 2 to 3 days; and 0.22 +/- 0.26 mm at 7 to 10 days; p less than 0.05), the corresponding serial echocardiograms showed no change in the function of the remote wall (remote wall motion index 1.87 +/- 0.65, 1.81 +/- 0.62, 1.86 +/- 0.47, respectively, p = NS). These data, therefore, do not support the hypothesis that reciprocal ST depressions during early acute transmural myocardial infarction reflect remote ischemia. Rather, these changes are influenced by factors determining the degree of acute ST elevation, previously shown to include infarct size, shape, location, transmurality and duration.