aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion
Ahmed A Harhash1, Jennifer J Huang1, Sridhar Reddy1
1University of Arizona Sarver Heart Center, Tucson.
Insights
ST elevation in lead aVR with ST depression indicates acute coronary occlusion, but this study found it rarely leads to emergent revascularization. While associated with higher mortality, urgent catheterization is recommended over emergent activation for STEMI.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Electrocardiography
Background:
- ST elevation myocardial infarction (STEMI) identification is crucial for timely reperfusion and improved survival.
- ST elevation in lead aVR (STE-aVR) with multilead ST depression was previously linked to left main or proximal LAD coronary artery occlusion.
- This study aimed to determine the incidence of acute coronary occlusion in patients presenting with STE-aVR and multilead ST depression.
Purpose of the Study:
- To investigate the frequency of acute coronary occlusion in patients with STE-aVR and multilead ST depression.
- To assess the clinical outcomes and mortality associated with this ECG finding.
- To evaluate the necessity of routine STEMI activation for emergent revascularization in these patients.
Main Methods:
- Retrospective analysis of 847 STEMI activations from January 2014 to April 2018.
- Blind analysis of electrocardiograms (ECGs) and coronary angiograms by experienced cardiologists.
- Identification of 99 patients (12%) with STE-aVR and multilead ST depression.
Main Results:
- Only 10% of patients with STE-aVR and multilead ST depression had acute coronary occlusion, none involving the left main or LAD.
- Severe coronary disease was present in 59% of patients, but most had preserved distal flow.
- In-hospital mortality was significantly higher (31%) in patients with STE-aVR and multilead ST depression compared to those without (6.2%).
Conclusions:
- STE-aVR with multilead ST depression is infrequently associated with acute coronary occlusion requiring emergent revascularization.
- Routine STEMI activation for emergent revascularization based solely on STE-aVR is not warranted.
- Urgent, rather than emergent, cardiac catheterization may be more appropriate for patients presenting with STE-aVR and multilead ST depression.
Background:
Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression.
Methods:
STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression.
Results:
Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001).
Conclusions:
STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.
More Related Videos
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:26Acute Coronary Syndrome V: Nursing Management
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:30Acute Pharyngitis
Acute pharyngitis is the inflammation of the back of the throat (pharynx), commonly resulting in a sore throat. It is a frequently encountered condition that prompts individuals to seek medical advice.
Classification
Acute pharyngitis can be categorized based on its underlying cause: