Author + information
- Ahmed Harhash1,
- Sridhar Reddy1,
- Jennifer Huang-Tsang1,
- Balaji Natarajan1,
- Mahesh Balakrishnan1,
- Ranjith Shetty1,
- Mathew Hutchinson1 and
- Karl Kern2
Prompt identification of ST-elevation myocardial infarction (STEMI) on ECG is critical as early reperfusion can be lifesaving. The ACCF/AHA guidelines established that ST elevation (STE) must be present in at least 2 contiguous leads to qualify for a diagnosis of STEMI. STE in aVR, co-existent with multi-lead ST depression (STD), was endorsed as a sign for left main (LM) or proximal LAD occlusion. Previous studies have described the association of multi-vessel disease with STD in the inferolateral leads with reciprocal STE in aVR. We sought to investigate the incidence of an acutely occluded vessel (i.e. STEMI) versus severe multi-vessel CAD without a total occlusion (i.e. NSTEMI) in patients (pts) presenting with STE-aVR.
STEMI activations between January 2014 and November 2016 were identified by retrospective chart review. Patients with admission ECG showing STE-aVR co-existent with multi-lead STD were enrolled. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Patients' demographics, presenting complaint, labs, hospital course, and in-hospital mortality were collected. Descriptive analysis was performed using STATA 12.0.
Among 604 STEMI activations, 66 pts (11%) were identified with STE-aVR. Of those, 24 (36%) presented with cardiac arrest, and 53 (80%) underwent emergent coronary angiography. Culprit coronary occlusion was identified in only 5 pts (9%). Thirty-four pts (64%) were found to have severe diffuse CAD but with distal TIMI 3 flow and 19 pts (36%) had mild or no disease. It was unclear whether the occlusion was acute or chronic in 3 pts. STE-aVR was associated with 32% in-hospital mortality, compared to only 6.2% in a 190 randomly sampled STEMIs in the same study period(p<0.001).
STE-aVR was associated with acutely thrombotic coronary occlusion in only 9% of pts. These patients had a five-fold higher in-hospital mortality compared to the overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior PCI or CABG. Urgent cardiology evaluation is warranted but routine STEMI activation based on this ECG finding alone should be reconsidered in pts presenting with critical illness.
CORONARY: Acute Coronary Syndromes