Persistent precordial "hyperacute" T-waves signify proximal left anterior descending artery occlusion

Abstract

Persistent precordial "hyperacute" T-waves signify proximal left anterior descending artery occlusion Verouden, N.J.; Koch, K.T.; Peters, R.J.; Henriques, J.P.; Baan, J.; van der Schaaf, R.J.; Vis, M.M.; Tijssen, J.G.; Piek, J.J.; Wellens, H.J.; Wilde, A.A.; de Winter, R.J. Published in: Heart DOI:10. 1136/hrt.2009.174557 Link to publication Citation for published version (APA):Verouden, N. J., Koch, K. T., Peters, R. J., Henriques, J. P., Baan, J., van der Schaaf, R. J., ... de Winter, R. J. (2009). Persistent precordial "hyperacute" T-waves signify proximal left anterior descending artery occlusion. Heart, 95(20), 1701 -1706 . DOI: 10.1136 /hrt.2009 General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Download date: 11 May 2018Persistent precordial ''hyperacute'' T-waves signify proximal left anterior descending artery occlusion The standard 12-lead electrocardiogram (ECG) remains the most important clinical tool for the timely identification and management of patients with acute myocardial infarction. 1 Accurate recognition of characteristic changes in the pattern of the QRS-complex, ST-segments and T-waves associated with acute proximal occlusion of a large epicardial coronary artery is essential in predicting the amount of myocardium at risk and guides decisions regarding the need for immediate reperfusion therapy. [2][3][4] In the early days of reperfusion therapy, patients would only qualify for thrombolytic therapy when there was unequivocal evidence of acute transmural ischaemia with cumulative STsegment deviation of 12-15 mm present on the ECG. 5Nowadays, primary percutaneous coronary intervention (PCI) within 2 hours of first medical contact for acute transmural myocardial infarction is the preferred treatment for reperfusion. 6 According to the current guidelines, primary PCI should be performed in patients with a clinical presentation of ST-segment elevation myocardial infarction (STEMI) within 12 hours of symptom onset and persistent ST-segment elevation at the Jpoint in at least two contiguous lead with cut-offs of >2 mm in lead V2-V3 and >1 mm in the remaining leads. [7][8][9] In the region serviced by our centre, a 12-lead ECG is recorded in patients with chest pain either on admission in the referring hospital or in the ambulance. This ECG is tra...

Winter Is Coming After a Cardiac Arrest

“…In most patients, a 1-to 2-mm ST-segment elevation in the lead aVR is found. This pattern was thoroughly described by de Winter et al 2,3 in 2008, and since then several cases have been reported. In most cases, the proximal segment of the left anterior descending artery was occluded.…”

“…Some authors defend that a collateral blood supply might protect the myocardium from transmural ischemia and prevent the ST-segment elevation. However, in the article of Verouden et al, 3 in a cohort of 1890 patients with anterior ST-segment elevation myocardial infarction who were referred for primary coronary angiography and presented an occlusion of the proximal left anterior descending artery, only a few patients who also presented de Winter's pattern had Rentrop Grade 3 collateral blood supply. These authors postulated that the area of transmural ischemia was so large that no injury currents were generated toward the precordial leads but only directed upward to an aVR lead.…”

“…Another alternative explanation might be that the absence of ST-segment elevation may be related to the lack of activation of sarcolemmal ATP-sensitive potassium channels by ischemic ATP depletion, as has been shown in sarcolemmal ATP-sensitive potassium knockout animal models of acute ischemia. 2,3 In 2009, Gorgels 1 explained this pattern by changes in the subendocardial but not in the epicardial action potential, suggesting subendocardial ischemia as the underlying mechanism.…”

Total Occlusion of Anterior Descending Artery (AD) without ST-Segment Elevation: DE Winter Pattern

“…This is characterized by ST depression and T wave apical and symmetrical from V1 to V5 leads, associated or not with ST elevation at AVR, denoting total occlusion of the anterior descending artery. The recognition of this electrocardiographic pattern is fundamental, since many of these patients are classified as coronary syndrome without ST elevation delaying immediate primary reperfusion [5].…”

The Role of the ECG in Diagnosis, Risk Estimation, and Catheterization Laboratory Activation in Patients with Acute Coronary Syndromes: A Consensus Document

“…3 However, if seen in patients with typical symptoms and at a relatively slow heart rate, regional ischemia due to subtotal occlusion of the LAD or left circumflex coronary artery should be suspected. 47,48 Patients presenting with such an ECG pattern often progress to typical STEMI (Fig. 4).…”