Diversity of electrocardiographic patterns in left main culprit acute ST-elevation myocardial infarction
B Rai1, M Yildiz1, S Bergstedt2
1The Christ Hospital Health System, The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH.
Insights
Electrocardiogram (ECG) patterns in ST-elevation myocardial infarction (STEMI) with left main (LM) culprits are not well understood. A ST-elevation (STE) ECG pattern better identifies occlusive LM flow and is linked to worse outcomes.
Area of Science:
- Cardiology
- Emergency Medicine
- Internal Medicine
Background:
- Clinical implications of diverse electrocardiographic (ECG) findings in acute ST-elevation myocardial infarction (STEMI) patients with left main (LM) culprit are not well understood.
- Left main coronary artery (LMCA) involvement in STEMI is associated with high mortality.
Purpose of the Study:
- To investigate the diagnostic utility of different electrocardiographic (ECG) patterns in identifying left main (LM) culprit acute myocardial infarction (AMI).
- To assess the association between ECG findings and in-hospital adverse outcomes in patients with LM culprit STEMI.
Main Methods:
- A multicenter database of 12,403 STEMI patients was analyzed, identifying 68 (0.5%) with unprotected LM culprits.
- Activating ECGs (aECG) were classified into three patterns: Non-ST-elevation (NSTE), ST-elevation (STE), or Atypical.
- Clinical outcomes including cardiac arrest, shock, and death were compared between occlusive and sub-occlusive LM culprits and across ECG patterns.
Main Results:
- Worse in-hospital adverse outcomes (cardiac arrest, shock, death) were observed in patients with occlusive LM culprit compared to sub-occlusive LM culprit.
- Both NSTE-type and STE-type aECG patterns were found in a minority of patients, limiting their diagnostic utility for LM culprit AMI (aggregate sensitivity: 41%; specificity: 71%).
- A STE-type aECG was more frequently associated with LM occlusion (71%) compared to NSTE- or Atypical-type patterns (19%; P = .001) and linked to higher adverse in-hospital events.
Conclusions:
- Previously reported archetypal ECG patterns for LM culprit MI have limited diagnostic utility due to their infrequent observation.
- A STE-type aECG pattern more accurately detected occlusive LM coronary flow and was associated with worse in-hospital outcomes in STEMI patients.
- These findings highlight the importance of considering specific ECG patterns in STEMI patients with suspected LM involvement to predict adverse outcomes.
Background:
The clinical implications of diverse electrocardiographic (ECG) findings in acute ST-elevation myocardial infarction (STEMI) patients with left main (LM) culprit are not well understood.
Methods:
Using the multicenter Midwest STEMI consortium database of 12,403 patients, we identified 68 (0.5%) with unprotected LM culprits. The activating ECGs (aECG) were classified into three patterns: a) Non-ST-elevation (NSTE); b) ST-elevation (STE); or c) Atypical.
Results:
The median age was 68 (IQ percentile: 58-83) years, 67% were male. LM occlusion (TIMI flow: 0-1) was observed in 20 (29%) and sub-occlusive LM (TIMI flow: 2-3) in 48 (71%) patients. Worse in-hospital adverse outcomes (cardiac arrest: 50% vs 18%, P = .016; shock: 75% vs 36%, P = .007; and death, 75% vs 44%, P = .03) occurred among patients with an occlusive versus sub-occlusive LM culprit, respectively. Both a NSTE-type (n = 14; 20.5%) and STE-type (n = 14; 20.5%) aECG pattern were observed in the minority of patients limiting the diagnostic utility for identifying the presence of LM culprit acute myocardial infarction (aggregate sensitivity: 41%; specificity: 71%). A STE-type aECG was more frequently associated with LM occlusion (n = 10/14; 71%) compared with either a NSTE- or Atypical-type ECG pattern (10/54; 19%; P = .001; aggregate sensitivity: 50%, specificity: 92%) and higher adverse in-hospital cardiac events.
Conclusion:
Previously reported archetypal ECG patterns associated with LM culprit MI were observed in a minority of patients, limiting their diagnostic utility. A STE-type pattern more accurately detected the presence of occlusive LM coronary flow and was associated with worse in-hospital outcomes.
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