The significance of ST‐elevation in aVL in anterolateral myocardial infarction: An assessment by cardiac magnetic resonance imaging

Allencherril, Joseph; Fakhri, Yama; Engblom, Henrik; Heiberg, Einar; Carlsson, Marcus; Dubois-Randé, J.-L.; Halvorsen, Sigrun; Hall, Trygve S.; Larsen, Alf Inge; Jensen, Svend Eggert; Arheden, Håkan; Atar, Dan; Clemmensen, Peter; Ripa, Maria Sejersten; Birnbaum, Yochai

doi:10.1111/anec.12580

Cited by 6 publications

(6 citation statements)

References 22 publications

(35 reference statements)

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“…Previous studies have already pointed out the relative competition between the reciprocal changes of ST-depression in the inferior leads induced by LAD lesions proximal to the first diagonal branch, and inferior ST-elevation accompanying wrap-around LAD artery. 23,24 When we retrospectively reviewed the incidence of this variant in segment 6 patients, an occurrence of about 19% was observed. This observation is further supported by showing the prevalence of ST-elevation in the inferior leads to be as much as 13% higher in segment 7, compared with segment 6 patients, being ‘unopposed’ by the first diagonal driven lateral ST elevations since the diagonal artery is spared.…”

Section: Discussionmentioning

confidence: 99%

Acute diagonal-induced ST-elevation myocardial infarction and electrocardiogram-guidance in the era of primary coronary intervention: New insights into an old tool

Fanne¹,

Shochat²,

Shotan³

et al. 2020

European Heart Journal. Acute Cardiovascular Care

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Background: Previous studies, published before the advent of primary reperfusion, described the electrocardiographic features of ST-segment elevation myocardial infarction (STEMI) caused by total diagonal artery occlusion, as demonstrated at pre-discharge coronary angiography. We aimed to assess the electrocardiographic and echocardiographic features in STEMI unequivocally attributed to a diagonal lesion in the era of primary coronary intervention. Methods: The electrocardiograms and echocardiograms of patients sustaining STEMI caused by diagonal artery involvement were compared with those of patients with STEMI attributed to proximal or mid left anterior descending artery (LAD) lesions. ST-segment deviations were measured at four different points in each lead and analyzed against TIMI flow and SNuH score. The electrocardiographic and echocardiographic features of each group were mapped. Results: In contrast to previous studies claiming an ever-present incidence of at least 1-mm ST-segment elevation in leads I and aVL with diagonal STEMI, we report 86% of any ST-elevation in leads I, aVL and V2 (64-71% for ST-elevation >1 mm). Both higher SNuH score and pre-intervention TIMI flow were associated with larger lateral ST-elevations (85.7% and 86.4-95.5%, respectively). Higher prevalence of ST-depression in the inferior leads reflecting reciprocal changes was observed in patients with diagonal-induced STEMI (57-76% vs. 24-51% in LAD obstructions, p <0.05). Conclusion: The most sensitive and predictive sign for acute ischemia was any degree of ST-deviation measured 1 mm beyond the J point. ST-elevations in I, aVL and V 2 , sparing V 3-V 5 , strongly favor isolated diagonal lesion. Proximal LAD lesion lacking ST-segment elevations in leads I and aVL is primarily due to wraparound LAD anatomy.

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Section: Discussionmentioning

confidence: 99%

Acute diagonal-induced ST-elevation myocardial infarction and electrocardiogram-guidance in the era of primary coronary intervention: New insights into an old tool

Fanne¹,

Shochat²,

Shotan³

et al. 2020

European Heart Journal. Acute Cardiovascular Care

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“…This is thought to be a result of the ischemia at the inferior wall due to the occlusion of a wrapped LAD that canceled the ST‐segment elevation in lateral leads as suggested by Sasaki et al (). Allencherril et al () reported that the concomitant apical inferior ischemia attenuated ST elevation in lead aVL using cardiac magnetic resonance imaging. The present study referred to the report by Sasaki et al (), and their report had a great contribution to establish our diagnostic flow.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic flowchart to estimate the morphology of left descending artery lesions by initial electrocardiogram in ST‐elevation myocardial infarction

Fujii

Hasegawa

Nakamura

et al. 2019

Noninvasive Electrocardiol

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Background ST‐segment deviations in an initial 12‐lead electrocardiogram provide anatomical information in ST‐elevation myocardial infarction (STEMI). A diagnostic flowchart was formulated to estimate the anatomical characteristics of a culprit left anterior descending artery (LAD). Methods The present study analyzed 252 STEMI patients whose culprit lesions were confirmed to be LAD as an observational study. LAD morphology, wrapped ( n = 26) or not ( n = 226), and the positional relationship to first diagonal branch ( n = 162 in proximal, n = 90 in distal lesions) were assessed. Their ST‐segment deviations and such anatomical characteristics were examined. Results Reciprocal ST depression in nonwrapped LAD was frequent in patients without diagonal branch flow (49.3%–18.8% in II, p < .01; 66.4%–36.3% in III, p < .01; 63.7%–30.0% in aVF, p < .01). ST elevation in inferior leads was the characteristics of wrapped LAD but was not the case in patients without diagonal flow (50%–0% in II, 60%–0% in III, and 60%–0% in aVF). ST elevation in lateral leads to the diagonal branch in nonwrapped LAD is more frequent for proximal than distal lesions (36.3% vs. 15.0% in I, p < .01; 50.7% vs. 16.3% in aVL, p < .01), but this was not observed for wrapped LAD (18.8% vs. 20.0% in I, p = .72; 31.3% vs. 10.0% in aVL, p = .21). Positive and negative predictive values for the diagnostic accuracy of suggested diagnostic flow based on the above results were 0.794 and 0.478, respectively. Conclusions Our suggested diagnostic flowchart provides enough diagnostic accuracy to estimate culprit morphology.

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“…On the contrary, proximal LAD occlusion frequently displays ST-segment elevation in leads V 1 to V 4 and ST-segment depression in V 5 and V 6 , due to a ST vector directed to dominant basal segments, which is incorrectly classified as "anteroseptal" MI in the older scheme (Allencherril et al, 2018a(Allencherril et al, , 2018bBandeali et al, 2012;Bayés de Luna, 2012;Huang, Tran, Jneid, Wilson, & Birnbaum, 2011 be misinterpreted as small infarcts caused by distal occlusion of a short LAD (Sasaki et al, 2001). For example, a distal LAD occlusion or an occlusion proximal to D1 generally causes ST-vector to be directed anterolaterally, which results in ST-segment elevation in leads V 1 through V 6 .…”

Section: Anterolateral (Ste V 2 -V 6 ) (N = 14)mentioning

confidence: 99%

“…In this situation, ECG is labeled as "extensive anterior" MI by the older scheme, but instead, the occluded coronary network deprives apical or anterolateral region of blood supply. On the contrary, proximal LAD occlusion frequently displays ST-segment elevation in leads V 1 to V 4 and ST-segment depression in V 5 and V 6 , due to a ST vector directed to dominant basal segments, which is incorrectly classified as "anteroseptal" MI in the older scheme (Allencherril et al, 2018a(Allencherril et al, , 2018bBandeali et al, 2012;Bayés de Luna, 2012;Huang, Tran, Jneid, Wilson, & Birnbaum, 2011). However, a complex interaction with reciprocal changes and be misinterpreted as small infarcts caused by distal occlusion of a short LAD (Sasaki et al, 2001).…”

Section: Proximal Lad Occlusion (N = 93)mentioning

confidence: 99%

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis

Bozbeyoğlu

Aslanger

Yıldırımtürk

et al. 2019

Noninvasive Electrocardiol

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Background:The currently used scheme for the classification of infarct location and extent in anterior myocardial infarction (MI) is intuitive rather than being evidencebased, and recent evidence suggests that it may be misleading both in anatomic and prognostic sense. Material and Methods:Consecutive patients with the diagnosis of anterior MI were enrolled. All electrocardiograms (ECG) were first classified according to established scheme and then reassessed using newer criteria for angiographic site of occlusion.The site of left anterior descending (LAD) occlusion was determined using multiple angiographic views. Clinic, echocardiographic and angiographic outcomes were compared.Results: A total of 379 anterior MI cases were enrolled, final study population consisted of 267 patients. The established scheme did not predict infarct size or adverse outcomes. Location of the myocardium subtended by the occluded coronary network did not match with the anatomic location as ECG classification implies. Many high-risk patients with proximal LAD were classified as "anteroseptal", whereas the majority of the patients labeled as "extensive anterior MI" had in fact distal occlusions. On the other hand, expert interpretation was fairly accurate in predicting adverse outcomes and the site of angiographic involvement. Conclusion:Classifying patients according to the established scheme neither gives prognostic information nor accurately localizes infarction. It should be regarded as obsolete and its use should be abandoned. Instead, the extent of infarction can be inferred from newer criteria provided by the angiographic correlation studies.

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The significance of ST‐elevation in aVL in anterolateral myocardial infarction: An assessment by cardiac magnetic resonance imaging

Abstract: Patients with anterior STEMI and concomitant STE in aVL have less MaR in the apical inferior segment and more MaR in the basal anterior segment.

Cited by 6 publications

References 22 publications

Acute diagonal-induced ST-elevation myocardial infarction and electrocardiogram-guidance in the era of primary coronary intervention: New insights into an old tool

Acute diagonal-induced ST-elevation myocardial infarction and electrocardiogram-guidance in the era of primary coronary intervention: New insights into an old tool

Diagnostic flowchart to estimate the morphology of left descending artery lesions by initial electrocardiogram in ST‐elevation myocardial infarction

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis

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