Influence of the Extent of Coronary Atherosclerotic Disease on ST-Segment Changes Induced by ST Elevation Myocardial Infarction

Abstract

The accuracy of the admission electrocardiogram (ECG) in predicting the site of acute coronary artery occlusion in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease is not well known. This study aimed to assess whether the presence of multivessel coronary artery disease (CAD) modifies the artery-related ST-segment changes in patients with acute coronary artery occlusion. We reviewed the admission ECG, clinical records, and coronary angiography of 289 patients with STEMI caused by acute occlusion of left anterior descending (LAD; n = 140), right (n = 118), or left circumflex (LCx; n = 31) coronary arteries. All patients underwent primary percutaneous coronary reperfusion during the first 12 hours. The magnitude and distribution of artery-related ST-segment patterns were comparable in patients with single (n = 149) and multivessel (n = 140) CAD. Occlusion of proximal (n = 55) or mid-distal (n = 85) LAD artery induced ST-segment elevation in leads V1 to V5, but only the proximal occlusion induced reciprocal ST-segment depression in leads II, III, and aVF (p <0.001). Proximal and mid-distal occlusion of right (n = 45 and 73, respectively) or LCx (n = 15 and 16) coronary artery always induced ST-segment elevation in leads II, III, and aVF and reciprocal ST-segment depression in leads V2 and V3. ST-segment elevation in lead V6 >0.1 mV predicted LCx artery occlusion. In conclusion, patients with STEMI with single or multivessel CAD have concordant artery-related ST-segment patterns on the admission ECG; in both groups, reciprocal ST-segment depression in LAD artery occlusion predicts a large infarct. Subendocardial ischemia at a distance is not a requisite for the genesis of reciprocal ST-segment changes.

Electrocardiographic prediction of lateral involvement in acute non-anterior wall myocardial infarction

“…Also, combining a gain of R-and loss of S-wave in V 1 in one variable seems to be a suitable measurement of the extent of R-waves, since acute ST-segment changes affect the height of R as well as the depth of S. In the clinical setting, lateral wall infarction is specifically due to Cx occlusion. The strong correlation of ST-segment elevation in V 6 in the small group of Cx occlusion and R/S ratio in V 1 was expected considering its laterally located supply area, and is in accordance with earlier studies investigating V 6 ST-segment elevation in single vessel Cx occlusion [16]. However, the correlation between ST-segment elevation in V 6 and R/S ratio in V 1 needs further testing because of underrepresentation of Cx occlusions in STEMI populations.…”

ST-Segment Elevation in the Right Precordial Leads in Patients with Acute Anterior Myocardial Infarction

“…Concurrent RV infarction and anterior STEMI may occur in both proximal and distal LAD occlusions. Prior studies have explained some ECG patterns in patients with anterior STEMI that predict the location of LAD occlusion (5,6,17). However, with regard to our findings, this is not true for leads V3R/ V4R.…”

“…Electrocardiography (ECG), which is a noninvasive and fast method to evaluate patients with suspected coronary disease, may provide valuable information about the location of occlusion in LAD artery. Most studies, which have suggested predictive ECG patterns, however, have not included the leads V3R and V4R in their evaluations (4)(5)(6).…”

ST-segment depression resolution predicts infarct size and reperfusion injury in ST-elevation myocardial infarction

“…However, the underlying mechanism of concomitant ST-segment depression and particularly its resolution after PCI in patients with STEMI is highly controversial. It has been speculated that reciprocal ST-segment depression may reflect a more extensive infarction,4 17 18 additional ischaemia beyond the infarct zone,18–21 more diffuse coronary artery disease6 22 or simply a benign mirror projection of the ST-segment elevation without significant clinical relevance 23 24…”