Acute myocardial infarction with significant left main coronary artery stenosis, significant 3-vessel coronary artery disease and elevated troponin-I at admission

Exercise-induced ST-segment elevation in lead aVR accompanied by ST-segment elevation in lead V1 might be a specific finding of left main coronary artery (LMCA) stenosis. Lead aVR and lead v1 ST segment elevation has been reported, during an attack of chest pain, in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4). ST-segment elevation in lead aVR in patients with angina at rest can be related to transmural ischemia of the basal part of the interventricular septum, frequently due to LMCA or multivessel coronary disease too. 3-vessel coronary artery disease (CAD) and LMCA disease show a frequent combination of leads with abnormal ST segments during chest pain with ST-segment depression in leads I II V4-V6, and ST-segment elevation in lead aVR. When ST-segment status in lead aVR combines with troponin T, ST-segment elevation in lead aVR and positive troponin T on admission are useful predictors of LMCA or 3-vessel CAD. We present a case of acute myocardial infarction with significant left main coronary artery stenosis, significant 3-vessel coronary artery disease and elevated troponin I at admission in an 83-year-old Italian woman. Also this case focuses attention on the importance of the recognition of the patterns suspected for LMCA and/or 3-vessel coronary disease.     

ECG Diagnosis and Classification of Acute Coronary Syndromes

In acute coronary syndromes, the electrocardiogram (ECG) provides important information about the presence, extent, and severity of myocardial ischemia. At times, the changes are typical and clear. In other instances, changes are subtle and might be recognized only when ECG recording is repeated after changes in the severity of symptoms. ECG interpretation is an essential part of the initial evaluation of patients with symptoms suspected to be related to myocardial ischemia, along with focused history and physical examination. Patients with ST‐segment elevation on their electrocardiogram and symptoms compatible with acute myocardial ischemia/infarction should be referred for emergent reperfusion therapy. However, it should be emphasized that a large number of patients may have ST‐elevation without having acute ST‐elevation acute coronary syndrome, while acute ongoing transmural ischemia due to an abrupt occlusion of an epicardial coronary artery may occur in patients with ST‐elevation less than the thresholds defined by the guidelines. Up‐sloping ST‐segment depression with positive T waves is increasingly recognized as a sign of regional subendocardial ischemia associated with severe obstruction of the left anterior descending coronary artery. Widespread ST‐segment depression, often associated with inverted T waves and ST‐segment elevation in lead aVR during episodes of chest pain, may represent diffuse subendocardial ischemia caused by severe coronary artery disease. In case of hemodynamic compromise, urgent coronary angiography has been increasingly recommended for these patients.     

Total occlusion of the left main coronary artery presenting as ST-elevation myocardial infarction

An ECG pattern of widespread ST depression in six or more precordial and inferior leads, accompanied by ST-segment elevation in the aVR and/or V₁ leads, is typical of the non-ST-segment elevation myocardial infarction (NSTEMI) pattern associated left main (LM) artery occlusion, but this ECG pattern is really associated with a subocclusion of the LM, or in the case that the LM was occluded with the presence of collateral circulation. There are few reports of ST-elevation myocardial infarction (STEMI) due to acute total LM occlusion. We report a case of STEMI pattern due to acute total LM occlusion.     

严重冠脉病变的心电图分析

目的分析左主干、前降支近端或三支病变冠心病心绞痛患者的心电图改变。方法13例冠脉造影诊断为左主干、前降支近端或三支病变的患者,对其静息时、心绞痛发作时心电图有无aVR、V1导联的ST段抬高及临床资料进行分析。结果胸痛发作时11例出现了aVR、V1导联典型改变,静息时2例aVR、V1导联改变。结论心电图aVR、V1导联ST段抬高,尤其STaVR〉STV1,V4～V6导联ST段下移,合并Ⅱ、Ⅲ、aVF导联或Ⅰ、Ⅱ导联ST段下移与冠脉左主干、前降支近端严重狭窄及三支病变有良好的相关性。     

Significance of lead aVR in acute coronary syndrome

The 12-lead electrocardiogram(ECG)is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome(ACS).Unlike other 11 leads,lead aVR has been long neglected until recent years.However,recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS.ST-segment elevation in lead aVR can be caused by(1)transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery;(2)transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery;and(3)reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads.On the other hand,ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions.It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction.Cardiologists should pay more attention to the tracing of lead aVR when interpreting the12-lead ECG in clinical practice.     

Concomitant left anterior descending coronary artery and right coronary artery occlusion with typical anterior ST depression and inferior ST elevation

We report the case of a 41-year-old man with acute myocardial infarction showing first ST elevation in V1-V6-DI-aVL leads followed by a typical V2-V4 ST depression (concomitant occlusion of proximal diagonal branch with an incomplete left anterior descending occlusion) and DII-DIII-aVF ST elevation. At coronary angiography, a proximal left anterior descending coronary stenosis with right coronary artery thrombosis was found.     

急性冠脉综合征三支病变患者心电图表现

目的 研究急性冠脉综合征(ACS)三支病变患者心电图表现.方法 241例冠状动脉(冠脉)造影明确的ACS分成非ST段抬高型急性冠脉综合征(NSTE-ACS)(n=173)与急性ST段抬高型心肌梗死(STEMI)(n=68)两种群体,比较各群体中三支病变与非三支病变患者心电图指标.结果 NSTEMI-ACS三支病变与左主...     

Wellens' syndrome and other electrocardiographic changes in a patient with a left anterior descending artery subocclusion associated with a left main coronary artery subocclusion

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Patients with unstable angina have a higher incidence of left main coronary artery (LMCA) and proximal left anterior descending (LAD) coronary artery disease compared to patients with stable angina pectoris. In 1982, Wellens and colleagues described two electrocardiographic patterns that were predictive of critical narrowing of the proximal LAD artery, and were subsequently termed Wellens' syndrome. The criteria were: a) prior history of chest pain, b) little or no cardiac enzyme elevation, c) no pathologic precordial ST segment elevation, d) no loss of precordial R waves, and e) biphasic T waves in leads V2 and V3, or asymmetric, often deeply inverted T waves in leads V2 and V3. The ECG changes are best recognized outside the episode of anginal pain. Lead aVR and lead v1 ST segment elevation, during chest pain, has been reported in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4).We present a case of changing axis deviation in a 37-year-old Italian man with a LAD coronary artery subocclusion associated with a LMCA subocclusion. This case focuses attention on the importance of the recognition of the patterns suspected for LAD coronary artery disease or for LMCA disease.     

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

Acute left main coronary artery (LMCA) occlusion may result in acute myocardial infarction (AMI) or sudden death. ST elevation in the aVR and V1 leads is reported to be valuable in recognizing LMCA occlusion. Early recognition of electrocardiogram (ECG) changes, such as reciprocal ST depression in other leads, is helpful in averting this disaster. This study aimed to determine the reciprocal ST segment depression of 12-lead ECGs associated with acute LMCA occlusion. From January 2000 to December 2004, 61 patients who underwent emergency percutaneous coronary intervention in 3 hospitals due to AMI associated with LMCA (n = 18) and a left anterior descending coronary artery (LADCA) (n = 43) proximal lesion were selected. Reciprocal ST segment depression occurred in leads aVF, V(2), V(3), V(4), V(5), and V(6) with significantly higher incidence in the LMCA group than in the LADCA group. Stepwise linear multivariate discriminant analysis indicated that ST segment depression in leads aVF, V(2), and V(4) could distinguish the LMCA group from the LADCA group. We concluded that reciprocal ST segment depression in leads V(2), V(4), and aVF of a 12-lead ECG is an important predictor of acute LMCA occlusion.     

Comparison of ST-segment deviation to scintigraphically quantified myocardial ischemia during acute coronary occlusion induced by percutaneous transluminal coronary angioplasty

This study compared ST-segment changes during acute coronary artery occlusion with measurements of ischemia by myocardial scintigraphy. Forty patients who were referred for elective prolonged percutaneous transluminal coronary angioplasty underwent 12-lead electrocardiographic recording before the procedure (baseline) and continuously during the entire balloon inflation (occlusion). For each patient, the summed ST-segment deviation was calculated as the maximal absolute difference, elevation or depression, between baseline and occlusion recordings in all 12 leads. Each patient underwent 2 myocardial scintigraphies, 1 with technetium-99m sestamibi injected during the balloon inflation and 1 on the following day as a control study. Ischemia that was induced by balloon occlusion was quantified in terms of extent and severity. Results for the entire study group showed that summed ST deviation correlated with extent (r = 0.59, p < 0.0001) and severity (r = 0.61, p < 0.0001) of ischemia. The location of maximal ST deviation differed for the 3 arteries. For occlusion of the left anterior descending artery, maximal ST deviation was elevated in lead V3. For occlusion of the left circumflex artery, maximal ST deviation was depressed in lead V2. Occlusion of the right coronary artery caused ST elevation in lead III and ST depression in lead V2. In conclusion, this study demonstrated a significant correlation between summed ST deviation and myocardial ischemia during coronary occlusion that is induced by percutaneous transluminal coronary angioplasty.     

Electrocardiographic prediction of the site of lesion in the anterior descending artery in acute myocardial infarction

INTRODUCTION AND OBJECTIVES: The goal of this study was to analyze the value of electrocardiography in predicting the site of the lesion in the left anterior descending coronary artery, in relation to the first septal and the first diagonal branches, in patients with acute anterior myocardial infarction. METHOD: Ninety consecutive patients who were admitted to the coronary unit with acute anterior myocardial infarction from July 1998 to May 2000 were studied retrospectively. The electrocardiographic changes were analyzed and correlated with the site of the lesion in the anterior descending artery, as determined by coronary angiography. RESULTS: The most useful parameters in predicting the site of the lesion in the left anterior descending coronary artery in acute anterior myocardial infarction are: 1) For lesions proximal to the first septal branch, ST-segment elevation in aVR (p < 0.001) and the absence of Q wave in V4-V6 (p = 0.01). 2) For lesions proximal to the first diagonal branch, abnormal Q wave in aVL (p = 0.01) and ST depression in III (p = 0.05). 3) For lesions proximal to both the first septal and first diagonal branches, ST elevation in aVR (p < 0.001), abnormal Q wave in aVL (p = 0.02), and absence of Q wave in V4-V6 (p = 0.01). 4) For lesions distal to both the first septal and first diagonal branches, abnormal Q wave in V4-V6 (p = 0.001) and absence of ST depression in III (p < 0.001). CONCLUSIONS: In acute anterior myocardial infarction, electrocardiography is useful for predicting the site of the lesion in the left anterior descending coronary artery in relation to the first septal and the first diagonal branches.     

The De Winter‐like electrocardiogram pattern associated with multi‐vessel disease

BackgroundThe de Winter ECG pattern was described by upsloping ST‐segment depression in leads V1‐V6, tall and symmetrical T waves in precordial leads. The ECG pattern is regarded to be associated with occlusion of the left anterior descending (LAD) artery.MethodsOne patient with de Winter ECG pattern was included. The 12‐lead ECG of patients with chest pain showed upsloping ST‐segment depression up to 3 mm at the J point in leads V2‐V6; tall symmetrical T waves in leads V2‐V4; 1mm J point elevation in lead aVR; ST‐segment depression 1mm in I, aVL leads and inverted T waves in the inferior leads. The ECG was showed the de Winter pattern.ResultsThe ECG was showed the de Winter pattern. CAG was performed, which showed the normal left main; 60%‐80% LAD stenosis; 50%‐60% ostial right coronary artery(RCA) stenosis; and 90% stenosis of the vessel at middle segment. Both proximal and middle RCA vascular lesions were dilated and successfully inserted with drug‐eluting stents, respectively.ConclusionOur case the ECG was showed horizontal ST depression with tall T waves in leads V2‐V4 (maximal ST depression in lead V4) while only ST depression in leads V5‐V6, which may result from multivessel disease.     

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.

OBJECTIVES: The study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI). BACKGROUND: In anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis. METHODS: One hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography. RESULTS: ST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively). CONCLUSIONS: In anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.     

常规心电图对急性前壁心肌梗死时前降支闭塞部位预测价值的临床研究

目的探讨急性前壁心肌梗死时的常规心电图（ECG）对前降支（LAD）闭塞部位的预测价值。方法根据冠状动脉造影的结果，以第一间隔支（S1）为标志将患者分为S1近端病变（PS）组（61例）和S1远端病变（DS）组（40例）。分别测量常规ECG12导联ST段的偏移程度及出现的频率，以计算、比较两组之间的差异及其对近、远段病变部位的预测性诊断价值。结果（1）各导联诊断LAD近端病变的敏感性和特异性分别为：aVR导联ST段抬高为43％和85％（P=0．004）；aVL导联ST段抬高≥1．5mm为16％和97％（P=0．031）；Ⅱ导联ST段下移≥1．0mm为39％和85％（P=0．009）；Ⅲ导联ST段下移≥2．0mm为23％和98％（P=0．005）；aVF导联ST段下移≥1．0mm为38％和88％（P=0．006）；V5导联ST段下移为20％和86％（P=0．037）；aVR导联ST段抬高同时伴V5导联ST段下移为18％和100％（P=0．005）；aVR导联ST段抬高同时伴V6导联ST段下移为30％和93％（P=0．008）；（2）各导联诊断LAD远端病变的敏感性和特异性分别为：Ⅲ导联ST段居于等电位线或抬高为53％和90％（P=0．000）；V5导联ST段抬高≥1．5mm为50％和82％（P=0．001）；（3）近、远端患者的梗死面积和心功能水平未见明显差异。结论（1）aVR导联ST段抬高同时出现V5、V6导联ST段下移；下壁导联Ⅱ、Ⅲ、aVF导联ST段明显下移（Ⅱ，aVF导联ST段下移≥1．0mm，STⅢ下移≥2．0mm）以及Ⅰ，aVL导联ST段抬高，尤其是aVL导联ST段抬高≥1．5mm均提示LAD近端病变。（2）下壁导联（尤其是Ⅲ导联）ST段居于等电位线或升高，V5导联ST段抬高≥1．5mm均提示LAD远端病变。     

Usefulness of the electrocardiogram in predicting the occlusion site in acute anterior myocardial infarction with isolated disease of the left anterior descending coronary artery

INTRODUCTION AND OBJECTIVES: In acute anterior myocardial infarction (AMI), the site of occlusion in the left anterior descending coronary artery (LAD) is related to the extension of myocardial necrosis and the prognosis. The aim of this study was to assess the value of the electrocardiogram (ECG) as a predictor of the LAD occlusion site in patients with anterior AMI. METHODS: Forty-five consecutive patients with a first anterior AMI and isolated disease of the LAD were included. We evaluated retrospectively the ECG with the most pronounced ST-segment changes before fibrinolysis and correlated the findings with the site of LAD occlusion in angiography before hospital discharge in relation to the first dominant septal and first diagonal branch: first septal affected (S), first diagonal affected (D), both affected (S + D), or neither affected were considered. RESULTS: ST depression in leads II, III, or aVF strongly predicted proximal LAD occlusion in S + D, S, and D (p = 0,003, p = 0,04, and p = 0,02, respectively). ST elevation in leads II, III, or aVF was observed only in the presence of wrap-around LAD and was related with occlusion distal to the first diagonal branch. ST elevation > or = 3 mm in lead V1 was a specific predictor of occlusion proximal to first septal (S, p = 0,01). ST elevation in aVR was associated with proximal LAD occlusion in S + D and S (p = 0,03 and p = 0,03, respectively) and absence of coronary collateral circulation. CONCLUSIONS: In anterior AMI and isolated LAD disease, the ECG can be useful in predicting the LAD occlusion site in relation to its major side branches.     

Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease

BackgroundThe electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary artery anatomy.MethodsWe describe the ECG findings in 2 cases of proximal left anterior descending (LAD) artery occlusion in ST-elevation myocardial infarction (STEMI) associated with 3-vessel coronary artery disease.ResultsBoth patients had atypical ECG patterns of ST-segment elevation in leads V₂, I, and aVL and ST-segment depression with positive T waves suggestive of extensive subendocardial ischemia in leads II, III, aVF, and V₃ through V₆; acute proximal LAD occlusion and concomitant 3-vessel coronary artery disease were observed angiographically.ConclusionElectrocardiographic changes in proximal LAD STEMI may be modified by the presence of significant atherosclerotic disease elsewhere in the coronary vasculature. Recognition of this ECG pattern may aid the clinician in the rapid identification of high-risk STEMI.     

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.     

11例急性单纯后壁心肌梗死心电图及梗死相关动脉特点分析

目的 分析急性单纯后壁心肌梗死（不包括同时合并下壁及右室心肌梗死）的心电图及冠状动脉造影特点。方法 总结自2001年至2006年门、急诊收治的急性单纯后壁心肌梗死患者11例,随访心电图特点,并行冠状动脉造影确定梗死相关动脉。结果 11例患者除了V7-V9导联ST段有典型的弓背向上抬高1．0—2．0mm外,9例（81．8％）V1-V2导联R／S≥1,5例（45．5％）V1-V4导联ST段压低1．0—2．0mm,4例（36．4％）Ⅰ、aVL导联ST段抬高0．5-1．5mm,5例（45．5％）V5-V6导联ST段抬高0．5—1．5mm。冠状动脉造影显示梗死相关动脉均为左回旋支（LCX）。梗死部位1例在第一钝缘支（OM1）发出前,为95％管状狭窄;6例（54．5％）在OM1发出后,其中4例为100％闭塞,1例为99％次全闭塞,1例为90％长段狭窄;4例（36．4％）在OM1,其中2例为100％闭塞,1例为99％次全闭塞,1例为95％局限性狭窄。单支病变3例（27．3％）,合并左前降支（LAD）病变4例（36．4％）,合并右冠状动脉（RCA）病变2例（18．2％）,同时合并LAD及RCA病变2例（18．2％）。结论12导联心电图,如有V1-V2导联R／S≥1,V1-V4导联ST段压低等特点时,结合临床与心肌酶学改变,高度怀疑急性后壁心肌梗死,需做后壁导联和冠状动脉造影加以证实,而梗死相关动脉多为左回旋支。     

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.     

aVR 导联 ST 段改变对不同冠脉血管病变的诊断及鉴别诊断意义

冠状动脉左主干及其主要分支病变均可引起心电图 aVR 导联 ST 段的抬高或压低,但不同血管病变所致心肌缺血或梗死的危险分层及临床预后却相差甚远,因此对不同冠脉血管病变的诊断及鉴别诊断非常重要。这其中 aVR 导联 ST 段的改变具有重要的临床意义,其诊断及鉴别诊断价值高于其他任何单一或多个导联。本文就 aVR 导联 ST 段的抬高或压低对不同冠脉血管病变的诊断及鉴别诊断意义、诊断标准及国外近年来的研究进展进行综述。