Reciprocal Changes in 12-Lead Electrocardiography Can Predict Left Main Coronary Artery Lesion in Patients With Acute Myocardial Infarction

Abstract

SUMMARYAcute left main coronary artery (LMCA) occlusion may result in acute myocardial infarction (AMI) or sudden death. ST elevation in the aVR and V1 leads is reported to be valuable in recognizing LMCA occlusion. Early recognition of electrocardiogram (ECG) changes, such as reciprocal ST depression in other leads, is helpful in averting this disaster. This study aimed to determine the reciprocal ST segment depression of 12-lead ECGs associated with acute LMCA occlusion. From January 2000 to December 2004, 61 patients who underwent emergency percutaneous coronary intervention in 3 hospitals due to AMI associated with LMCA (n = 18) and a left anterior descending coronary artery (LADCA) (n = 43) proximal lesion were selected. Reciprocal ST segment depression occurred in leads aVF, V 2 , V 3 , V 4 , V 5 , and V 6 with significantly higher incidence in the LMCA group than in the LADCA group. Stepwise linear multivariate discriminant analysis indicated that ST segment depression in leads aVF, V 2 , and V 4 could distinguish the LMCA group from the LADCA group. We concluded that reciprocal ST segment depression in leads V 2 , V 4 , and aVF of a 12-lead ECG is an important predictor of acute LMCA occlusion. (Int Heart J 2006; 47: 13-20) Key words: Reciprocal change, ST segment depression, Acute left main occlusion, Acute myocardial infarction ACUTE LMCA occlusion is a serious clinical condition. Despite its low incidence, the prognosis is often poor. The condition is usually discovered too late for surgery to be initiated, therefore, vessel patency is usually obtained by percutaneous coronary intervention.1,2) Unfortunately, this modality is associated with a high mortality rate. Early recognition and faster percutaneous coronary intervention may decrease the mortality rate.

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

“…So far, only few case reports of LMT occlusion presenting as STEMI have been described. 1,4-6 True incidence is unknown because in these publications, 1,4,7,8 ACS with LMT subtotal occlusion (thrombolysis in myocardial infarction [TIMI] flow ≥ 1) or total occlusion with CC is not distinguished from total occlusion with transmural involvement and no CC (TIMI flow = 0). In this study, 7 patients with total LMT occlusion without CC evident on coronary angiography, showing a STEMI pattern in the ECG, are described.…”

ST Segment Elevation in aVR: Clinical Significance in Acute Coronary Syndrome

“…Lead aVR is electrically opposite to leads D1, D2, aVL, and V3–V6, and therefore an ST depression in these leads produces reciprocal STE-aVR; 11 in addition, lead aVR directly reflects the electrical activity of the right upper portion of the heart, including the basal portion of the interventricular septum and consequently, a transmural infarction in this area theoretically produces STE-aVR. Accordingly, STE-aVR is thought to result from either one of the two following mechanisms: diffuse antero-lateral subendocardial ischemia with reciprocal change in aVR or transmural infarction of the basal portion of the heart 11. In addition, an anatomical variant of the Purkinje fibers has been evoked3 to explain the absence of STE in anterior leads in some patients, despite transmural anterior infarction.…”

Thrombotic occlusion of the ostial left main coronary artery in a patient with acute coronary syndrome

“…Other ECG patterns caused by LMCA occlusion are anterior ST-segment elevation, ST-segment depression in the precordial leads, right bundle branch block, and ST-segment elevation in leads I and aVL. 3 Acute LMCA occlusion is a serious clinical condition. Despite its low incidence, the prognosis is often poor.…”

“…Many different ECG patterns have been described by authors, either as case reports or as small series. [1][2][3][4] Hori et al described 13 patients with acute myocardial infarction (MI) caused by total occlusion of the LMCA during a period of eight years. 1 ST elevation in lead aVR was present in 69% of patients, and five of the six non-survivors had ST-segment elevation in lead aVR as well as aVL.…”