Inferior ST-segment elevation as a diagnostic pitfall in proximal LAD occlusion: insights from a wrapped left
Yu-Sha Zhang1,2, Jin-Qian Cao1,3, Ya-Xin Liao1
1Department of Cardiology, Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, 410011, China.
Insights
Anatomical variants can mislead electrocardiogram (ECG) findings in ST-elevation myocardial infarction (STEMI). This case highlights dynamic ECG changes that initially suggested inferior STEMI but were caused by a left anterior descending artery occlusion.
Area of Science:
- Cardiology
- Medical Diagnostics
Background:
- Electrocardiogram (ECG) is generally reliable for localizing the infarct-related artery in ST-segment elevation myocardial infarction (STEMI).
- Coronary anatomical variants and dynamic ischemic processes can lead to atypical or misleading initial ECG patterns.
- Accurate localization is crucial for timely reperfusion therapy in STEMI.
Purpose of the Study:
- To describe a unique clinical presentation of acute myocardial infarction (AMI) with an unusual coronary anatomy.
- To illustrate a dynamic electrocardiographic phenomenon that can complicate STEMI diagnosis.
- To emphasize the importance of recognizing atypical ECG manifestations in AMI.
Main Methods:
- Case report detailing a patient with isolated inferior ST-segment elevation on initial ECG.
- Coronary angiography performed to identify the culprit lesion.
- Serial ECG monitoring to observe dynamic changes post-reperfusion.
- Anatomical assessment of coronary artery variants, including a wrapped left anterior descending artery.
Main Results:
- Initial ECG showed inferior ST-segment elevation, suggesting inferior STEMI.
- Coronary angiography revealed proximal left anterior descending artery occlusion, not an inferior vessel.
- A wrapped left anterior descending artery was found to supply the inferior wall.
- Serial ECGs demonstrated resolution of inferior changes post-reperfusion, followed by anterior changes, indicating a dynamic process.
Conclusions:
- This case underscores the potential for coronary anatomical variations to cause diagnostic challenges in STEMI.
- Dynamic ECG evolution, rather than simultaneous multiterritory involvement, was observed.
- Clinicians must be aware of such dynamic ECG phenomena to prevent diagnostic delays in high-risk STEMI patients.
Background:
Electrocardiographic localization of the infarct-related artery in ST-segment elevation myocardial infarction is generally reliable; however, coronary anatomical variants and dynamic ischemic processes may result in misleading initial ECG patterns.
Case Presentation:
We describe a clinical scenario in which isolated inferior ST-segment elevation was the initial ECG manifestation of acute myocardial infarction, while coronary angiography revealed complete occlusion of the proximal left anterior descending artery. Subsequent angiography demonstrated a wrapped left anterior descending artery extending beyond the apex and supplying the inferior wall. Serial electrocardiograms showed a sequential evolution, with resolution of inferior ST-segment elevation after reperfusion followed by the emergence of anterior changes, rather than simultaneous multiterritory involvement.
Conclusion:
Awareness of this dynamic ECG phenomenon is essential to avoid diagnostic delay in high-risk presentations.