Diffuse St Depression With St Elevation Avr In Acute Coronary Syndrome And Its Association With Significant Left Main
Salman Ahmed1, Shehzad Khatti1, Ghazanfar Ali Shah1
1National Institute of Cardiovascular Diseases, Tando Muhammad Khan.
Insights
Global ST depression and ST elevation in aVR indicate widespread ischemia, but have low probability for left main stem disease. Risk factors and ECG characteristics improve diagnostic accuracy for significant coronary artery disease.
Area of Science:
- Cardiology
- Electrocardiography
- Ischemic Heart Disease
Background:
- Global ST depression with ST elevation in lead aVR is a recognized sign of widespread sub-endocardial ischemia.
- This ECG pattern has been historically linked to left main (LM) stem or three-vessel disease (3VD), though findings vary across studies.
Purpose of the Study:
- To investigate the association between specific ECG findings (global ST depression and ST elevation in aVR) and the presence of significant left main stem disease and/or significant three-vessel disease in patients with acute coronary syndrome.
Main Methods:
- A prospective observational study was conducted at a tertiary cardiac center.
- Included patients with acute coronary syndrome (ACS) exhibiting global ST depression (≥0.5 mV in ≥8 leads) and ST elevation in aVR (≥0.5 mV).
- All included patients underwent coronary angiography.
Main Results:
- Out of 404 patients, 67% had significant LM stem or 3VD, 3VD was present in 55%, and significant LM stem disease in 29%.
- Risk factors like diabetes, hypertension, and smoking were associated with increased probability of these ECG findings.
- Increased magnitude of ST elevation in aVR and higher TIMI scores improved the sensitivity for detecting significant LM stem disease and 3VD.
Conclusions:
- The combination of global ST depression and ST elevation in aVR in ACS patients has a low probability for significant LM stem disease but an intermediate probability for significant 3VD.
- The diagnostic utility of these ECG findings is enhanced by considering patient risk factors (diabetes, hypertension, smoking), the magnitude of ST elevation in aVR, and the TIMI score.
Background:
: Global ST depression in 8 or more leads along with ST elevation in aVR has been considered as hallmark of widespread sub-endocardial ischemia. It has been associated with left main (LM) stem or three vessel disease (3VD). But different studies have shown different results. We collected data from patients to see association of these ECG changes with significant LM stem disease and/or significant (3VD).
Methods:
TIt was a prospective observational study performed at tertiary care cardiac center. All patients with acute coronary syndrome (ACS) having global ST depression and ST Elevation in aVR (that is ST depression of at least 0.5 mv in ≥8 leads along with ST elevation in aVR of at least 0.5 mv) and have undergone coronary angiogram were included.
Results:
Our study included 404 patients with above mentioned ECG findings. We observed significant LM stem or significant 3VD in 67% (n=274), 3VD in 55% (n=222) and significant LM stem in only 29% (n=118). Risk factors like diabetes, hypertension and smoking increase probability of these ECG changes up to 40.4%, 32.1% and 33.3% for significant LM stem disease and 62.7%, 57.1% and 57.5% for significant 3VD. Magnitude of ST elevation in aVR leads ≥1 mm increase sensitivity for LM stem disease 35% and for 3VD up to 60.4% and TIMI score ≥4 up to 36.7% for significant LM stem disease and 62.5% for significant 3VD.
Conclusions:
: Global ST depression along with ST elevation in aVR in patients with ACS has low probability for significant LM stem intermediate probability for significant 3VD. Factors like presence of diabetes, hypertension, smoking, magnitude of ST elevation in aVR, and TIMI score improves its diagnostic yield.
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