ST‐Depression with Negative T Waves in Leads V4–V5—A Marker of Severe Coronary Artery Disease in Non‐ST Elevation Acute Coronary Syndrome: A Prospective Study of Angina at Rest,with Troponin,Clinical, Electrocardiographic,and Angiographic Correlation

Background: The significance of ST‐segment depression in acute coronary syndrome has been the subject of debate for many decades. Studies indicate that different manifestations of ST/T changes may have significantly different prognostic implications. Methods and Results: We studied the correlation of ST/T changes in 12‐lead electrocardiography recorded during pain, to clinical and angiographic findings and in‐hospital prognosis, in patients with non‐ST‐elevation acute coronary syndrome and elevated troponin levels. Fifty consecutive patients could be differentiated into two groups: (1) 25 patients with ST‐segment depression and a negative T wave maximally in leads V_4–5, (2) 25 patients with ST‐segment depression and a positive T wave in the precordial lead with maximal ST‐segment depression. Patients in group I had significantly more often left main or left main equivalent coronary artery disease; 76% versus 8% (P < 0.001), heart failure; 40% versus 4% (P = 0.005), and higher in‐hospital mortality; 24% versus 0% (P = 0.02), than patients in group II. The troponin levels did not differ significantly between the groups. Conclusions: In patients with non‐ST‐elevation acute coronary syndrome and elevated troponin levels two subgroups could be identified. Transient ST‐segment depression and a negative T wave maximally in leads V_4–5 during anginal pain predicts left main, left main equivalent, or severe three‐vessel coronary artery disease with high sensitivity and specificity. In patients with ST‐segment depression and a positive T wave, there is a high probability of one‐vessel disease.