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aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion

Published:January 09, 2019DOI:https://doi.org/10.1016/j.amjmed.2018.12.021

      Abstract

      Background

      Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression.

      Methods

      STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression.

      Results

      Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001).

      Conclusions

      STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

      Keywords

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      References

        • O'Gara PT
        • Kushner FG
        • Ascheim DD
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 127: e362-e425https://doi.org/10.1161/CIR.0b013e3182742cf6
        • Engelen DJ
        • Gorgels AP
        • Cheriex EC
        • et al.
        Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.
        J Am Coll Cardiol. 1999; 34: 389-395https://doi.org/10.1016/S0735-1097(99)00197-7
        • Yamaji H
        • Iwasaki K
        • Kusachi S
        • et al.
        Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography: ST segment elevation in lead aVR with less ST segment elevation in lead V1.
        J Am Coll Cardiol. 2001; 38: 1348-1354https://doi.org/10.1016/S0735-1097(01)01563-7
        • Tamura A
        Significance of lead aVR in acute coronary syndrome.
        World J Cardiol. 2014; 6: 630https://doi.org/10.4330/wjc.v6.i7.621
        • Zimetbaum PJ
        • Josephson ME
        Use of the electrocardiogram in acute myocardial infarction.
        N Engl J Med. 2003; 348: 933-940https://doi.org/10.1056/NEJMra022700
        • Barrabés 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: 814-819https://doi.org/10.1161/01.CIR.0000084553.92734.83
        • Yan AT
        • Yan RT
        • Kennelly BM
        • 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: 71-78https://doi.org/10.1016/j.ahj.2007.03.037
        • Gorgels AP
        • Vos MA
        • Mulleneers R
        • de Zwaan C
        • Bär FW
        • Wellens HJ
        Value of the electrocardiogram in diagnosing the number of severely narrowed coronary arteries in rest angina pectoris.
        Am J Cardiol. 1993; 72: 999-1003https://doi.org/10.1016/0002-9149(93)90852-4
        • Kühl JT
        • Berg RM
        Utility of lead aVR for identifying the culprit lesion in acute myocardial infarction.
        Ann Noninvasive Electrocardiol. 2009; 14: 219-225https://doi.org/10.111/j.1542-474x.2009.00300.x
        • DeWood MA
        • Spores J
        • Notske R
        • et a l
        Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction.
        N Engl J Med. 1980 Oct 16; 303: 897-902
        • Wong SC
        • Sanborn T
        • Sleeper LA
        • et al.
        Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry.
        J Am Coll Cardiol. 2000; 36: 1077-1083https://doi.org/10.1016/S0735-1097 (00)00873-1
        • Karwowski J
        • Gierlotka M
        • Gąsior M
        • et al
        Relationship between an infarct related artery, acute total coronary occlusion, and mortality in patients with ST segment and non ST segment myocardial infarction.
        Pol Arch Intern Med. 2017; 127: 401-411https://doi.org/10.20452/pamw.4018
        • Steg PG
        • James SK
        • Atar D
        • 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: 2569-2619
        • Amsterdam EA
        • Wenger NK
        • Brindis RG
        • et al.
        2014 ACC/AHA guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 130: e344-e426https://doi.org/10.1161/CIR.0000000000000134