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Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial
H Pendell Meyers1, Alexander Bracey2, Daniel Lee3
1Department of Emergency Medicine Carolinas Medical Center Charlotte NC.
Insights
Posterior myocardial infarctions are often missed by STEMI criteria. ST-segment depression in leads V1-V4 can indicate posterior OMI, improving diagnosis and treatment for these critical cases.
Area of Science:
- Cardiology
- Diagnostic Electrocardiography
- Acute Coronary Syndromes
Background:
- Posterolateral ST-segment-elevation myocardial infarctions (OMIs) are frequently missed by standard ST-segment-elevation myocardial infarction (STEMI) criteria.
- Over 50% of patients with circumflex artery occlusion do not receive timely reperfusion, leading to increased mortality.
- ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) is a potential indicator of posterior OMI.
Purpose of the Study:
- To evaluate the utility of ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) in identifying occlusion myocardial infarctions (OMIs) of the posterolateral walls.
- To compare the diagnostic performance of STDmaxV1-4 with STEMI criteria in a high-risk acute coronary syndrome population.
- To assess the impact of STDmaxV1-4 on the timely diagnosis and treatment of OMIs.
Main Methods:
- Retrospective review of 808 patients with acute coronary syndrome.
- OMI defined by culprit lesion with TIMI flow 0-2 or TIMI 3 flow plus elevated troponin.
- ECGs interpreted blinded to outcomes; STDmaxV1-4 identified and compared with STEMI criteria.
Main Results:
- Of 265 OMIs, 108 met STEMI criteria. 118 patients (15%) had suspected ischemic STDmaxV1-4.
- STDmaxV1-4 showed 97% specificity and 37% sensitivity for OMI. It detected 99 OMIs, of which 47% also met STEMI criteria.
- Patients with STEMI-negative OMI and STDmaxV1-4 were less likely to undergo timely catheterization (46% vs. 68%).
Conclusions:
- Ischemic STDmaxV1-4 has high specificity (97%) for OMI and 96% for OMI requiring emergent PCI.
- Standard STEMI criteria missed approximately half of OMIs identified by STDmaxV1-4.
- Ischemic STDmaxV1-4 in acute coronary syndrome should be considered OMI until proven otherwise, prompting further investigation and management.
Abstract:
Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.
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