Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: Differential diagnosis and clinical considerations

Fiol, Miquel; Carrillo, Andrés; Rodriguez, A; Pascual, Marcos; Bethencourt, Armando; Luna, Antonio

doi:10.1016/j.jelectrocard.2012.05.001

Cited by 52 publications

(52 citation statements)

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“…[6][7][8] On admission, however, the patient was hemodynamically stable, no asynergy in the anteroseptal myocardium was observed, and there was no flow limitation in the left coronary artery. We therefore could not conclude whether the initial ECG findings could be explained by ischemia in the anteroseptal myocardium.…”

Section: Discussionmentioning

confidence: 95%

“…The present case highlights the use of ischemic QRS axis deviation tendency to indicate ischemic heart disease, including left main trunk disease. [6][7][8] Further study is needed to determine the diagnostic value of this informative ECG finding, especially in cases who originally have bundle branch block or frontal plane QRS axis deviation. In our experience, however, ischemic QRS axis deviation tendency is useful to evaluate the ischemia in a case with complete right bundle branch block, where ST-segments are hard to evaluate for ischemic changes ( Figure 5).…”

Section: Discussionmentioning

confidence: 99%

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Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

et al. 2016

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SummaryA 73-year-old man was admitted to our hospital because of chest pain at rest. Electrocardiography (ECG) showed an ST-segment depression, a negative U-wave in the precordial leads, and a right axis deviation (RAD) tendency. Coronary angiography revealed occlusion of the right coronary artery. Collateral flow from the jeopardized left anterior descending artery to the posterior descending artery (PDA) was fair. After successful revascularization, improvement in the ECG findings was noted. Since blood supply to the left posterior fascicle is dependent on the PDA, the RAD tendency could be explained by the presence of a transient ischemic left posterior hemiblock. (Int Heart J 2016; 57: 363-366) Key words: Unstable angina pectoris, Electrocardiography, Cardiac conduction system, Coronary angiography, QRS axis deviation T he coronary artery feeds the cardiac conduction system.1) The left anterior fascicle receives its blood supply mainly from the left anterior descending artery (LAD), while the left posterior fascicle is perfused mainly by the posterior descending artery, which is the vessel involved in inferior myocardial ischemia in most cases. Transient ischemia can be detected through a change in the frontal plane QRS axis, 1) which can be observed during routine coronary angiography as a transient ischemic QRS axis deviation tendency during contrast agent injection.2) Compared with an ST-segment change, a transient ischemic QRS axis deviation tendency seems to be rarely appreciated in current clinical practice since the relative changes can be minute and need to be compared against a control.1) Here, we report a case of unstable angina pectoris of the inferior myocardium to highlight the usefulness of detecting a transient ischemic QRS axis deviation tendency in the diagnosis of ischemia and to identify the ischemia-related coronary artery. Case ReportA 73-year-old man with rheumatoid arthritis, diabetes mellitus, and hypertension was admitted to our hospital because of intermittent chest pain while at rest during the previous few days. On admission, his creatinine kinase (CK) level was 166 U/L (reference value < 225 U/L), CK-MB was 14 U/ L (reference value < 10 U/L), and troponin-I was 3.17 mg/L (reference value < 3.10 mg/L). Electrocardiography (ECG) showed an ST-segment depression in I, II, III, aVF, and V4-V6; ST-segment elevation in aVR; a negative U-wave in V3-V6; and the absence of an abnormal Q-wave (Figure 1). Furthermore, compared with previous ECG findings, the R-wave voltages in II and aVF had increased, the S-wave voltage in III had decreased, the R-wave voltage in aVL had decreased, and the S-wave voltage in I had increased, revealing a right axis deviation tendency during ischemia (frontal QRS axis: -7° to 22°) (Figure 2). Transthoracic echocardiography showed severe hypokinesis in the left and right ventricular inferior myocardium. A diagnosis of non-ST-segment elevation acute coronary syndrome was suspected, and emergency coronary angiography was performed. Total occlusion of the domin...

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

et al. 2016

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“…In such patients, the ECG may normalize or show diffuse T wave inversion after resolution of symptoms. However, most patients with acute total occlusion of the left main coronary artery who arrive alive to the hospital have ST elevation [ 19 ]. Moreover, a similar ECG pattern may be seen in patients with hypertensive heart disease or cardiomyopathy.…”

Section: Diffuse St Depression In the Inferior And Anterolateral Leadmentioning

confidence: 93%

The Electrocardiogram in Coronary Artery Disease

Birnbaum

Wilson

Nikus

2015

Coronary Artery Disease

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The fi rst human electrocardiogram (ECG) was performed by AD Waller in 1887. Willem Einthoven was the fi rst one to use the term ECG in 1901 and named the waves P, Q, R, S and T. The ECG remains a major non-invasive cardiac imaging tool. In the last 30 years newer and more direct imaging modalities, such as echocardiography, nuclear scanning, cardiac computerized tomography (CT) and magnetic resonance imaging (MRI) have been developed, adding to the information gained from the ECG in the assessment of the heart in various stable conditions. Yet, due to its wide availability, low-cost and rapid interpretation, the ECG remains the most commonly used and, perhaps most important of available cardiovascular diagnostic tools; especially for rapid assessment of patients with symptoms compatible with acute coronary syndromes (ACS) and/or arrhythmia. The Electrocardiogram in Coronary AbstractThe electrocardiogram (ECG) remains the most commonly used and, perhaps most important of available cardiovascular diagnostic tools; especially for rapid assessment of patients with symptoms compatible with acute coronary syndromes (ACS) and/or arrhythmia. ST elevation is thought to represent transmural ischemia due to thrombotic occlusion of an epicardial artery. Emergent reperfusion therapy by primary percutaneous intervention (PCI) or thrombolytic therapy is usually indicated. In contrast, patients without ST segment elevation are treated conservatively in the initial stages. However, the distinction between ST elevation myocardial infarction (STEMI) and non ST elevation ACS (NSTE-ACS) is not always clear. Many patients with compatible symptoms have ST elevation not due to "transmural ischemia". On the other hand, occasionally, patients may have acute ischemia due to complete occlusion of an epicardial artery, but their ECG may show minor degree of ST elevation. Moreover, certain distinct ECG patterns have been described in patients presenting without ST elevation that are associated with higher risk. Recognition of these specifi c patterns of NSTE-ACS, as well as common patterns suggesting non-ischemic ST elevation is crucial.

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“…Right bundle branch block (RBBB) may present an rS pattern with notched S wave in lead V 1 (atypical RBBB) . However, RBBB is often seen in patients with acute coronary syndrome (ACS) and as a transient phenomenon in acute pulmonary embolism (APE) . In the context of ACS, the presence of new RBBB provides prognostic information .…”

Section: Introductionmentioning

confidence: 99%

Electrocardiographic Findings in Accessory Right Precordial Leads in Adults and Seniors with Notched S Waves in Lead V₁—A Preliminary Study

Zhong-qun

Nikus

Pérez‐Riera

et al. 2013

Noninvasive Electrocardiol

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Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: Differential diagnosis and clinical considerations

Cited by 52 publications

References 12 publications

Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

The Electrocardiogram in Coronary Artery Disease

Electrocardiographic Findings in Accessory Right Precordial Leads in Adults and Seniors with Notched S Waves in Lead V₁—A Preliminary Study

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Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: Differential diagnosis and clinical considerations

Cited by 52 publications

References 12 publications

Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

Transient Ischemic Right Axis Deviation Tendency of the Frontal Plane QRS Axis in a Case of Inferior Myocardial Ischemia

The Electrocardiogram in Coronary Artery Disease

Electrocardiographic Findings in Accessory Right Precordial Leads in Adults and Seniors with Notched S Waves in Lead V1—A Preliminary Study

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Electrocardiographic Findings in Accessory Right Precordial Leads in Adults and Seniors with Notched S Waves in Lead V₁—A Preliminary Study