|Year : 2021 | Volume
| Issue : 2 | Page : 70-81
The sensitivity and specificity of electrocardiogram in localizing the culprit artery with angiographic correlation in Indian patients with acute ST-segment elevation myocardial infarction
Jacob Joseph1, Jaideep C Menon2
1 Department of Cardiology, Lisie Hospital, Ernakulam, Kerala, India
2 Adult Cardiology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
|Date of Submission||14-Apr-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||03-May-2021|
Dr. Jacob Joseph
Department of Cardiology, Lisie Hospital, Lisie Hospital Road, North Kaloor, Kaloor, Ernakulam - 682 018, Kerala
Source of Support: None, Conflict of Interest: None
Background: A detailed analysis of electrocardiogram (ECG) patterns may help in the identification of the precise site and location of coronary artery occlusions and guide the selection of an appropriate clinical therapeutic strategy in patients with myocardial infarction (MI). Aim: This study was conducted to evaluate the sensitivity and specificity of prespecified ECG criteria in localizing the culprit artery in acute ST-segment elevation myocardial infarction (STEMI) and to correlate the ECG findings with coronary angiogram. Methods: Patients with acute STEMI aged ≥l8 years, diagnosed by ECG and who underwent angiography, were included for analysis. The infarct-related artery was identified with prespecified ECG criteria and the measure of agreement kappa was calculated to find the correlation between ECG findings and coronary angiogram. Results: Of 118 patients, anterior wall myocardial infarction (AWMI) was more common than inferior wall myocardial infarction (IWMI) (56% vs. 46%). In AWMI, ST-elevation ≥2.5 mm in V1 and ST-elevation in augmented Vector Left (aVL) had high sensitivity for detecting occlusion proximal to S1 and D1. High correlation with the angiogram was observed with ST-elevation in aVL, V1 for occlusion proximal to S1 and D1 (κ = 0.531; P = 0.000). In IWMI, ST-elevation in lead III > II and ST-elevation ≥1 mm in II, III, augmented Vector Foot (aVF) had maximum sensitivity in detecting occlusion in proximal and distal right coronary artery (RCA). High correlation with the angiogram was observed with ST-elevation in lead III > II (κ = 0.438; P = 0.000) and ST-coving without ST-elevation in RV4 (sensitivity = 79%, κ = 0.402; P = 0.002) for occlusion in the RCA. Ratio of S:R waves amplitude in aVL ≤3 and ST-depression ≥0.5 mm V1-V3 were 100% sensitive for occlusion in the left circumflex (LCx). Strong correlation with the angiogram was observed with ST-elevation ≥0.5 mm V7–V9 for occlusion in LCx (sensitivity = 94%, κ = 0.743; P = 0.000). Conclusion: ECG in patients with STEMI is valuable and can reliably predict the culprit artery in these patients prior to angiography.
Keywords: Anterior wall myocardial infarction, coronary angiography, electrocardiogram, inferior wall myocardial infarction, ST-elevation myocardial infarction
|How to cite this article:|
Joseph J, Menon JC. The sensitivity and specificity of electrocardiogram in localizing the culprit artery with angiographic correlation in Indian patients with acute ST-segment elevation myocardial infarction. J Indian coll cardiol 2021;11:70-81
|How to cite this URL:|
Joseph J, Menon JC. The sensitivity and specificity of electrocardiogram in localizing the culprit artery with angiographic correlation in Indian patients with acute ST-segment elevation myocardial infarction. J Indian coll cardiol [serial online] 2021 [cited 2021 Jun 13];11:70-81. Available from: https://www.joicc.org/text.asp?2021/11/2/70/315262
| Introduction|| |
The new criteria for acute myocardial infarction (AMI) as per the Fourth Universal Definition of myocardial infarction (MI) (2018) requires: (1) the presence of an acute myocardial injury with clinical evidence of acute myocardial ischemia; (2) detection of a rise and/or fall of cardiac troponin values with at least one value above the 99th percentile of upper reference limit; and (3) the presence of at least one of the following features – symptoms of myocardial ischemia; new ischemic changes on electrocardiogram (ECG); development of pathological Q waves; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology; or identification of a coronary thrombus by angiography or autopsy.
MI is categorized into ST-segment elevation myocardial infarction (STEMI) and non-STEMI based on ECG. The STEMI rates in developing countries like India have been reported to be high, as are the associated morbidity and mortality estimates. Approximately 3 million new STEMI cases are reported every year in India. The 30-day mortality rates have also been found to be high among patients with STEMI in India compared to developed countries. Another key finding is that STEMI presents at a very young age (on an average 10 years earlier) in Indian patients as compared to patients in the West., The management of STEMI also poses a substantial economic burden in India. The World Health Organization estimated a loss of $237 billion of Indian economy, attributed to productivity loss and health-care expenditure on cardiovascular diseases during the year 2005–2015.
ECG, along with clinical presentation, is the most widely used ancillary tool for the initial assessment of patients presenting with symptoms of acute coronary s (ACS). The amplitude and/or extent of ST-segment deviation in ECG in patients with STEMI may provide valuable information about the location and extent of acute myocardial injury, which may further help optimize treatment decisions in these patients., The localization of the culprit vessel may also help predict the immediate and 30-day possible outcomes and complications.,, Studies have revealed that the detection of involvement of the left main artery and the proximal left anterior descending (LAD) artery as well as multivessel disease by analyzing the ECG patterns may facilitate better risk stratification and help accurately predict the prognosis.[9.10] This can further guide treatment decisions regarding early perfusion, emergency coronary artery bypass graft surgery, or hemodynamic support with an intra-aortic balloon pump.,,, Furthermore, detection of occlusion in the proximal right coronary artery (RCA) by ECG may be useful as it may help predict the plausibility of the risk of hypotension or bradyarrhythmias during reperfusion., Therefore, prompt diagnosis of culprit artery based on ECG patterns may help facilitate the triage of STEMI patients to the hospitals' percutaneous coronary intervention setting within the recommended time interval of 120 min from diagnosis, which may in turn help improve prognosis and reduce hospital stay and mortality in these patients.,,
The American College of Cardiology, the American Heart Association (AHA), and the European Society of Cardiology recommend conducting a 12-lead ECG recording at the point of first medical contact with a maximum target delay of 10 min (Class 1, Level B) in patients with STEMI, along with the interpretation of the ECG by an experienced physician., Furthermore, early ECG, especially prehospital ECG, has been recommended by the guidelines to decrease door-to-drug time and door-to-balloon time in patients with STEMI.
Various studies have analyzed the role of ECG in identifying the culprit vessel in MI, and the results have been contradictory. Rao et al. observed that ECG criteria are not the substitute of invasive procedure for differentiating the culprit artery in AMI; however, they provide an economical, reliable, and faster method of differentiating infarct-related artery in acute inferior MI. Similarly, Waduud et al. in their retrospective study found that in patients presenting with a suspected ACS, it is possible to identify the LAD artery and RCA as the culprit artery using ECG criteria with a reasonable degree of sensitivity (>70%) and specificity (>90%). Further, careful interpretation of the ECG has been found to be a reliable tool for the identification of the culprit vessel in STEMI associated with multivessel disease, thus allowing to choose the appropriate reperfusion strategy. Hebbal et al., in their study, assessing prognostic importance of lead augmented vector right and leads V7–V9 found that lead aVR ST-deviation and lead V7 ST-deviation helped predict STEMI patients at high risk; patients with aVR ST-depression had higher mortality compared to aVR ST-elevation because of larger myocardial involvement.
On the other hand, few studies reported that ECG may not be able to always identify the infarct-related artery. Zhang et al. observed that coronary collateral vessels can mislead judgments of the infarct related artery by ECG. Early repolarization syndrome and anatomic variation of the coronary artery or heart or small branch occlusion can be identified as infarct by ECG. Tahvanainen et al. reported the following factors associated with failure of ECG to identify the culprit artery in patients with inferior STEMI: left coronary artery dominance, multivessel disease, and absence of ECG signs of the proximal culprit lesion.
Coronary angiography is another diagnostic modality, which is considered as the gold standard for identifying the infarct-related artery in STEMI. While ECG signifies the electrophysiology of the myocardium during acute ischemia, coronary angiography helps identify the vessel anatomy.
Considering the aforementioned literature views, the aim of this study is to describe the sensitivity and specificity of prespecified ECG criteria in localizing the culprit artery in patients with acute STEMI and to correlate the ECG findings with a coronary angiogram, thereby validating the usefulness of electrocardiography in localizing the culprit vessel in acute STEMI.
| Methods|| |
This cross-sectional study was carried out at the Department of Cardiology, Lisie Medical Institutions, Kochi, Kerala, India. Data from the medical records of the below-mentioned eligible patients were collected from December 2017 to December 2018:
- Both men and women ≥18 years of age who presented to the cardiac intensive care unit with STEMI in the last 24 h with persistent ST-elevation
- Patients presenting with chest pain lasting more than 20 min, having a new ST-elevation in at least 2 contiguous leads with ST-elevation ≥2.5 mm in men <40 years, ≥2 mm in men >40 years, or ≥l5 mm in women in leads V2–V3 and/or >l mm in the other leads (in the absence of the left ventricular hypertrophy or LBBB).
Patients who were excluded included those having STEMI but did not undergo coronary angiogram and patients with LBBB in baseline ECG, paced rhythm, pericarditis, myocarditis, Brugada syndrome, stress cardiomyopathy, early repolarization syndrome, or hyperkalemia.
Patients were evaluated on the basis of clinical presentation and a 12-lead ECG at the time of admission. A detailed history of chest pain was collected along with the demographic profile (age, gender), other relevant medical history, and risk factor profile (smoking, diabetes, and hypertension). Suspected culprit vessel was identified based on the ECG changes in various leads, and patients were classified into the inferior wall myocardial infarction (IWMI) and anterior wall myocardial infarction (AWMI) categories. All patients were continuously monitored with the standard coronary care unit protocols. Once feasible, a coronary angiogram was performed. Thereafter, the suspected culprit vessel was correlated with the angiogram.
All data obtained are presented as mean ± standard deviation. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of individual ECG parameters were calculated. The ECG findings in the patients were correlated with angiogram using a measure of agreement kappa. A P < 0.05 was considered statistically significant.
| Results|| |
Demographics and clinical presentation
Of the 118 patients with STEMI (92 men and 26 women), 36.4% were in the age range of 51–60 years. The mean age was 58.46 ± 10 years. A total of 86 patients presented within 6 h of chest pain. The most common risk factor was diabetes mellitus (45.8%), followed by smoking (39.8%) and hypertension (36.4%). History of exertional angina was present in 36.4% of patients. Anterior wall MI was observed in 54.2% and IWMI in 45.8% of patients. The detailed demographics and clinical characteristics are shown in [Table 1].
Electrocardiogram patterns for detecting occlusions in anterior wall myocardial infarction
A total of 64 patients presented with AWMI involving LAD vessel that is divided into Sl and Dl. While occlusion proximal to S1 and D1 was noted in 50% of AWMI patients, the corresponding estimates for occlusion proximal to S1 and distal to D1, distal to S1 and proximal to D1, and distal to S1 and D1 were 20.3%, 7.8%, and 21.9%, respectively. Seven patterns of ECG were considered in localizing an occlusion proximal to S1 and D1. Among these 7 patterns, the most common pattern was ST-elevation in V1, which was seen in about 76.5% of patients. Four ECG patterns were identified for occlusion proximal to S1 and distal to D1, among which the commonest one was complete right bundle branch block (RBBB) which was noted in 17.2% of patients. Four ECG patterns helped identify occlusions distal to Sl and proximal to Dl, of which ST-elevation aVL and ST-depression III > II were the most common patterns noted in 48% and 41% of patients, respectively. For detecting occlusions distal to S1 and D1, four ECG patterns were considered, of which the most common patterns noted were ST-elevation in V3-V6 and Q wave in V4–V6 in 34% and 11% of patients, respectively [Table 2].
|Table 2: Electrocardiogram variables considered for detecting occlusion in the left anterior descending vessel|
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Electrocardiogram patterns for detecting occlusions in inferior wall myocardial infarction
Inferior wall MI involving RCA and left circumflex (LCx) was presented in 54 patients. While occlusions proximal and distal to RCA were noted in 44% and 26% of patients, occlusions in LCx were noted in 30% of patients. A total of eight ECG patterns were considered in localizing an occlusion proximal to RCA, and the most common patterns noted were ST-elevation ≥l mm in II, III, aVF, ST-depression 1 mm in LI, aVL (aVL > I), each in 90.7% of patients and ST-elevation in LIII > II in 74% of patients. Six ECG patterns helped detect occlusions distal to RCA. Similar to occlusion proximal to RCA, the most common patterns noted in occlusion distal to RCA were ST-elevation ≥l mm in II, III, aVF in 90.7% of patients followed by ST-elevation in LIII > II in 75.9% of patients. Seven ECG patterns were considered for identifying occlusions in LCx; S/R wave ratio aVL ≤3 followed by ST-depression in V1 is the most common patterns noted in 96.3% and 78% of patients, respectively [Table 3].
|Table 3: Electrocardiogram variables considered for detecting occlusion in the right coronary artery and left circumflex vessels|
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Diagnostic value of electrocardiogram patterns for detecting occlusion in the left anterior descending artery
The sensitivity, specificity, PPV, and NPV for each of the ECG criteria for detecting occlusion in LAD artery proximal to S1 and D1, proximal to S1 and distal to D1, distal to S1 and proximal to D1, and distal to S1 and D1 are shown in [Table 4]a,[Table 4]d.
Proximal to S1 and D1
For the detection of occlusion proximal to S1 and D1 in LAD artery, while ST-elevation ≥2.5 mm in Vl had the highest sensitivity (90.6%) followed by ST-elevation in aVL, V1 (87.5%) and ST-depression ≥1 mm II, III, aVF (78%), ST-depression in V5 had 100% specificity, followed by ST-elevation aVR and complete RBBB, which had 97% and 90.6% specificities, respectively [Table 4]a.
Proximal to S1 and distal to D1
ST-elevation in aVL and complete RBBB had 31% sensitivity and 15.4% sensitivity, respectively, for the detection of occlusion proximal to S1 and distal to D1. The corresponding specificities were 96% and 82%, respectively; ST-elevation in aVR and ST-depression in V5 also had a high sensitivity of 90% [Table 4]b.
Distal to S1 and proximal to D1
While ST-depression in III >II had maximum sensitivity (100%) followed by ST-elevation in aVL (80%), Q wave in V4–V6 and Q wave in augmented Vector Left (a VL) had 83% and 56% specificity, respectively, for detecting occlusion distal to S1 and proximal to D1 [Table 4]c.
Distal to S1 and D1
Only ST-elevation in V3–V6 had a high sensitivity of 78.6%, followed by ST-elevation in II, III, aVF (28.6%), ST-depression in aVL (21%) and Q wave in V4–V6 (21%) for detecting occlusion distal to S1 and D1. The corresponding specificities were 54%, 94%, 90%, and 84%, respectively.
Diagnostic value of electrocardiogram patterns for detecting occlusion in right coronary artery
Proximal to right coronary artery
While both ST-elevation ≥1 mm in II, III, aVF, and ST-elevation in LIII > II had maximum sensitivity of 100% followed by ST-depression > 1 mm in L1, aVL (96%) and RV4-T wave upright (83%), ST-elevation in V1, S/R wave ratio of aVL > 3, and ST-elevation ≥ 1 mm in V4R had specificity of 97%, 93%, and 77%, respectively [Table 5]a.
Distal to right coronary artery
Similar to occlusion in the proximal segment, ST-elevation ≥1 mm in II, III, aVF and ST-elevation in LIII >II had 100% sensitivity followed by ST-coving without ST-elevation in RV4 (78.5%). S/R wave ratio of aVL >3 had maximum specificity (100%) followed by ST-depression V3/ST-elevation LIII 0.5–1.2 (82.5%) and ST-coving without ST-elevation in RV4 (70%) [Table 5]b.
Diagnostic value of electrocardiogram patterns for detecting occlusion in the left circumflex artery
While S/R wave ratio of aVL ≤ 3 and ST-depression ≥0.5 mm in V1–V3 had 100% sensitivity followed by ST-elevation ≥0.5 mm in V7–V9 (94%), ST-elevation in LII >III and isoelectric or ST-elevation in L1 and aVL had 100% specificity followed by ST-depression in V3/ST-elevation in LIII >1.2 (95%) and RV4 inverted T wave (89.5%). The corresponding PPV, NPV, and accuracy values are shown in [Table 6].
|Table 6: Diagnostic value of electrocardiogram patterns for detecting occlusion in the left circumflex|
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Correlation between electrocardiogram and coronary angiogram for detecting occlusion in the left anterior descending artery
For detecting occlusion proximal to S1 and D1, ST-elevation in aVL and Vl had the maximum and a statistically significant correlation (κ = 0.531; P = 0.000) followed by ST-depression ≥1 mm II, III, aVF (κ = 0.375; P = 0.002), while complete RBBB has the least correlation (κ = 0.156; P = 0.098) with the coronary angiogram [Table 7]a.
For detecting occlusion proximal to S1 and distal to D1, the maximum correlation was observed with ST-depression in aVL (κ = 0.336; P = 0.003) and the least correlation with ST-depression in V5 (κ = −0.127; P = 0.240) [Table 7]b. None of the ECG patterns for detecting occlusion distal to S1 and proximal to D1 had a significant correlation with angiogram. For detecting occlusion distal to S1 and D1, the maximum correlation was observed with ST-elevation in II, III, aVF (κ = 0.275; P = 0.017) and least correlation with Q wave in V4–V6 (κ = 0.059; P = 0.634) [Table 7]c and [Table 7]d.
Correlation between electrocardiogram and coronary angiogram for detecting occlusion in the proximal right coronary artery
While the maximum correlation was observed with ST-elevation in LIII > II (κ = 0.438; P = 0.000), followed by V4R-T wave upright (κ = 0.386; P = 0.003) and ST-elevation ≥1 mm V4R (κ = 0.354; P = 0.009), least correlation was observed with ST-elevation ≥0.5 mm V7–V9 (κ = −0.382; P = 0.005) and ST-depression ≥0.5 mm V1–V3 (κ = −0.379; P = 0.004) [Table 8]a.
Correlation between electrocardiogram and coronary angiogram for detecting occlusion in the distal right coronary artery
The maximum correlation was observed with ST-coving without ST-elevation in RV4 (κ = 0.402; P = 0.002). The least correlation was observed with ST-elevation ≥0.5 mm V7–V9 (κ = −0.191; P = 0.122) [Table 8]b.
Correlation between electrocardiogram and coronary angiogram for detecting occlusion in the left circumflex artery
While isoelectric or ST-elevation in L1 and aVL (κ = 0.580) followed by ST-depression in V1 (κ = 0.523), RV4 inverted T wave (κ = 0.502) and ST-elevation in LII ≥III (κ = 0.449) had maximum correlation, all statistically significant (P = 0.000), ST-depression ≥0.5 mm in V1–V3 (κ = 0.032; P = 0.350) and S/R wave ratio of aVL ≤3 (κ = 0.094; P = 0.256) had least correlation [Table 9].
|Table 9: Correlation of electrocardiogram with angiogram in detecting occlusion in left circumflex|
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| Discussion|| |
In the present cross-sectional study, we successfully determined various ECG criteria for the diagnosis of the infarct-related artery and prediction of the site of occlusion in patients with STEMI and correlated the results with angiographic findings. Further, we have calculated Cohen's kappa (k) along with the estimation of validity, which predicted a fair to substantial agreement between ECG and coronary angiogram for localizing the culprit artery in STEMI patients with reliable correlation.
The incidence of CAD in our study was four times higher in males (78%) than in females (22%). Similar gender distribution was found in the study by Rao et al. (73% males and 27% females) and Bhat et al. (82% males and 18% females)., Further, in the Kerala ACS registry, only 25% of patients diagnosed with STEMI were noted to be females. The mean age of patients in our study was 58.46 ± 10 years. Majority of our study population (37%) were in the age range of 51–60 years followed by 31% in the age range of 61–70 years. The INTER-HEART study also reported a similar mean age of 57 years in ACS patients in Southeast Asia and Japan. In another study conducted in North-East India, patients with STEMI had a mean age of 55.8 years.
Among the risk factors documented in our study, diabetes mellitus was found to be most common, accounting for 45.8% followed by smoking in 39.8%, hypertension in 36.4%, and dyslipidemia in 24.6%. The INTERHEART-South Asia study identified eight coronary risk factors: abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low fruit and vegetable consumption, and lack of physical activity, which accounted for 89% of all acute MI cases in Indians., Similar to our study, diabetes mellitus followed by hypertension and hyperlipidemia were found to be the common risk factors by Kiani et al. In another cross-sectional study in India involving 100 STEMI patients, diabetes (33%), hypertension (40%), and smoking (30%) were noted to be the most common risk factors. The high prevalence of comorbid risk factors in Indian CAD patients could be the rationale for STEMI presentation at a young age. In this context, it may be pertinent to mention that the mean age noted in our study was 5–10 years lower than that noted in the Western population.,,
Among the 118 patients included in our study, 54% of patients had AWMI in the LAD artery, and 46% of patients had IWMI involving RCA and LCx artery. Further, most of the population had occlusion proximal to S1 and D1 in the LAD artery (50%). This distribution is similar to the distribution reported by Rao et al. Out of 126 patients in the focus study, 55% of patients had AWMI involving the LAD artery with more than 50% detected with occlusion proximal to S1 and D1. Similarly, Gosh et al. reported 52% of patients with occlusion in LAD artery and 48% in the RCA artery.
The American Heart Association, American College of Cardiology Foundation (ACCF), and the Heart Rhythm Society (HRS) recommendations for the standardization and interpretation of ECG have outlined specific ECG criteria for detecting occlusions in the LAD artery. These include: (1) when ST-elevation is in leads I and aVL, as well as in leads V1–V4 and sometimes in V6, and ST-depression is in leads II, III, and aVF, the automated interpretation should suggest an extensive AWMI due to occlusion of the proximal portion of the LAD; (2) when ST-elevation is in leads V3-V6 and ST-depression is not in leads II, III, and aVF, the automated interpretation should suggest AWMI due to the occlusion of the mid or distal portion of the LAD.
In our study, patients with AWMI, different ECG criteria were used to identify the culprit artery. Seven criteria were used for localizing the culprit vessel proximal to S1 and D1; ST-elevation ≥2.5 mm in Vl was the most sensitive (90.63%), while ST-depression in V5 was associated with maximum specificity. These results are consistent with the study by Salunke and Khyalappa in which maximum sensitivity and specificity were noted with ST-elevation ≥2.5 mm in Vl and ST-depression in V5, respectively. Further, the specificity of >90% for complete RBBB noted in our study was also in line with the observation by Salunke and Khyalappa. According to Engelen et al., ST-elevation in lead aVR, complete RBBB, ST-depression in lead V5 and ST-elevation in Vl l2.5 mm strongly predict LAD occlusion proximal to Sl. These findings correlate with our study, which observed that ST-depression >l mm in inferior leads help predict occlusion proximal to Sl and Dl. We found the highest correlation for ST-elevation in aVL and Vl, with Cohen's kappa 0.53 (P < 0.001), suggesting moderate agreement between ECG and coronary angiogram.
Of the four criteria used in detecting occlusion proximal to S1 and distal to D1, ST-depression in aVL had high specificity and low sensitivity which is in line with the findings by Bhat et al. However, high sensitivity and low specificity in ST-elevation in leads V1–V4 in our study were contrary to the moderate sensitivity and high specificity noted by Bhat et al. In our study, Cohen's kappa was high for ST-depression in aVL (κ = 0.33, P = 0.003), indicating a fair agreement between ECG and coronary angiogram. However, we could not find any studies reporting similar correlation in the literature.
In detecting occlusion distal to S1 and proximal to D1, while maximum sensitivity was noted with ST-depression in III > II, high specificity was noted with Q wave in leads V4–V6. However, the Cohens kappa was found to be low in all the ECG patterns, indicating a poor association with the angiogram. The proportion of patients having this type of occlusion is very less in the current study, which might explain the poor validation of the ECG.
In our study, the presence of Q waves in leads V4–V6 had high specificity for detecting occlusion distal to S1, and ST-depression in lead aVL has high specificity for detecting occlusion distal to D1. The measure of agreement kappa was 0.27 and 0.2l, both P < 0.05 for ST-elevation in inferior leads and ST-elevation in V3–V6, respectively, implying a fair agreement with the angiogram. In line with our study, Engelen et al. also reported that ST-depression in aVL and Q wave in leads V4–V6 was highly specific in predicting an occlusion distal to D1.
According to the AHA/ACCF/HRS recommendations, IWMI that results in ST-elevation in only leads II, III, and aVF may be the result of occlusion of either the RCA or the LCx. Greater ST-elevation in lead III as compared to lead II is often associated with RCA occlusion. Further, lead V4R is of great value in diagnosing right ventricular involvement in the setting of an inferior wall infarction and in making the distinction between RCA and LCx occlusion and between proximal and distal RCA occlusion.
In the current study, ST-elevation >l mm in leads II, III, and aVF and ST-elevation in III >II were the most common variables used for detecting an occlusion in proximal and distal RCA. Both these patterns were 100% sensitive in our study. Similarly, Salunke and Khyalappa and Gaude et al. noted ST-elevation III >II was 100% sensitive in diagnosing occlusions in the RCA., Further, the high sensitivity and low specificity of ST-depression >l mm in lead I, aVL were consistent with the findings by Almansori et al. ST coving without ST-elevation in V4R and ST-depression in V3/ST-elevation in lead III 0.5–1.2 have been considered specific to distal RCA occlusion in the literature., In our study, while ST-elevation in lead III >II followed by upright T wave in V4R and ST-elevation >l mm in V4R had the highest correlation with the angiogram in detecting an occlusion in the proximal RCA, ST-coving without ST-elevation in V4R had the highest correlation in detection occlusion in the distal RCA. All were statistically significant indicating modest agreement with the angiogram.
The AHA/ACCF/HRS guidelines state that occlusion in LCx is associated with ST-depression in leads V1, V2, and V3 or ST-elevation in lead II >III and maybe isoelectric or ST-elevation in leads 1 and aVL. ST-elevation in lead II ≥III and isoelectric or ST-elevation in lead I and aVL patterns had maximum specificity in the present study. Salunke and Khyalappa also reported 100% specificity, while Rao et al. reported 96% of specificity for these ECG patterns in predicting LCx occlusion., Multiple studies recommended routine recording of posterior leads V7, V8, and V9 in all patients admitted to the hospital with an acute IWMI., The ST-elevation in these variables is frequently associated with occlusion of the LCx artery. The study had both high sensitivity and specificity for ST-elevation in V7–V9 with substantial agreement between ECG and coronary angiogram. We also found a fair agreement for isoelectric or ST-elevation in L1 and aVL, ST-depression in V1, RV4 inverted T wave, and ST-elevation in LII levati. All were statistically significant with P < 0.05. However, literature is sparse to support this finding.
The study has few limitations which include a single-center, observational study design with small sample size. Most of the patients who presented to our coronary care unit with angina and persistent ST-elevation had a late presentation of up to 24 h. Since they were included in the study, we have missed the early evolution of ECG patterns.
| Conclusion|| |
The present study demonstrates that ECG is valuable not only for determining early reperfusion therapy but also for providing information regarding the location and extent of acute myocardial injury in patients with STEMI prior to angiography. In AWMI, ECG is more reliable for detecting occlusion proximal to S1 and D1 and in IWMI it can be reliably used in detecting occlusions either in RCA or LCx. Further, the ECG patterns in the proximal coronary artery occlusion reflect relatively large MIs that will benefit with early and complete revascularization strategies such as angioplasty.
We would like to thank BioQuest Solutions Pvt Ltd., for data management, analysis, and providing editorial services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al
. Fourth universal definition of myocardial infarction (2018). Glob Heart 2018;13:305-38.
Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, et al
. ST-segment elevation myocardial infarction. Nat Rev Dis Primers 2019;5:39.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al
. Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
ICMR. In Report. Final STEMI Workshop. Available from: http://icmr.nic.in
. [Last accessed on 2020 Mar 14].
Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, et al
. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J 2017;69 Suppl 1:S63-97.
Almansori M, Armstrong P, Fu Y, Kaul P. Electrocardiographic identification of the culprit coronary artery in inferior wall ST elevation myocardial infarction. Can J Cardiol 2010;26:293-6.
Salunke KK, Khyalappa RJ. Role of electrocardiogram in identification of culprit vessel occlusion in acute ST elevation myocardial infarction in relation to coronary angiography. J Clin Prev Cardiol 2017;6:128-32. [Full text]
Shinde RS, Hiremath MS, Makhale CN, Durairaj M. Images in cardiology. ECG showing features of total left main coronary artery occlusion. Heart 2006;92:670.
Neeland IJ, Sulistio MS, Stoller DA, de Lemos JA, Atkins JM, McGuire DK. Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease. J Electrocardiol 2012;45:272-6.
Fukaya H, Oikawa J, Hirasawa S, Shimohama T, Tojo T, Niwano S, et al
. Acute myocardial infarction involving double vessel total occlusion of the left anterior descending and left circumflex arteries: A case report. J Cardiol Cases 2011;4:e1-4.
Kanic V, Vokac D, Granda S. Acute total occlusion of the left main coronary artery treated with percutaneous intervention and simultaneous implantation of intra-aortic balloon pump. Clin Case Rep 2017;5:2088-92.
Koh MS, Lee JH, Jeong JW, Chung JY. Features of electrocardiogram in patients with stenosis of the proximal right coronary artery. Korean J Intern Med 2017;32:277-85.
Lin Y, Yao Z, Yin H, Ma M, Cheng L, Cao M, et al
. Reperfusion-induced hypotension during primary percutaneous coronary intervention after acute myocardial infarction. Int J Clin Exp Med 2017;10:1330-4.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al
. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
O'Gara PT, Kushner FG, Ascheim DD, Casey Jr ED, Chung MK, de Lemos DA, et al
. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:485-510.
Ting HH, Krumholz HM, Bradley EH, Cone DC, Curtis JP, Drew BJ, et al
. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: A scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation 2008;118:1066-79.
Rao MG, Kumar RS, Nallamaddi N. The rote of ECG in localizing the culprit vessel occlusion in acute ST segment elevation myocardial infarction with angiographic correlation. J Evid Based Med Health 2015;2:8877-85.
Waduud MA, Clark EN, Payne A, Berry C, Sejersten M, Clemmensen P, et al
. Location of the culprit artery in acute myocardial infarction using the ECG. Comput Cardiol 2011;38:417-20.
Slavich G, Spedicato L, Poli S, Sappa R, Piccoli G. ECG and ST-elevation myocardial infarction in multivessel coronary disease. G Ital Cardiol (Rome) 2010;11:910-4.
Hebbal VP, Setty HS, Sathvik CM, Patil V, Sahoo S, Manjunath CN, et al
. Acute ST- segment elevation myocardial infarction: The prognostic importance of lead augmented vector right and leads V (7)-V (9). J Nat Sci Biol Med 2017;8:104-9.
Zhang XJ, Yan HB, Zheng B, Song L, Wang J, Chi YP. Reasons for failed electrocardiographic identification of the infarct-related artery in patients with ST-elevation acute myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi 2010;38:914-7.
Tahvanainen M, Nikus KC, Holmvang L, Clemmensen P, Sclarovsky S, Birnbaum Y, et al
. Factors associated with failure to identify the culprit artery by the electrocardiogram in inferior ST-elevation myocardial infarction. J Electrocardiol 2011;44:495-501.
Birnbaum Y, Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: Correlation with coronary anatomy and prognosis. Postgrad Med J 2003;79:490-504.
Bhatt P, Parikh P, Patel A, Parikh R, Patel A, Mehta JL, et al
. Unique aspects of coronary artery disease in Indian Women. Cardiovasc Drugs Ther 2015;29:369-76.
Patel A, Vishwanathan S, Nair T, Bahuleyan CG, Jayaprakash VL, Baldridge A, et al
. Sex differences in the presentation, diagnosis, and management of acute coronary syndromes: Findings from the Kerala-India ACS registry. Glob Heart 2015;10:273-80.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al
. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937-52.
Iqbal F, Barkataki JC. Spectrum of acute coronary syndrome in North Eastern India – A study from a major center. Indian Heart J 2016;68:128-31.
Kiani F, Hesabi N, Arbabisarjou A. Assessment of risk factors in patients with myocardial infarction. Glob J Health Sci 2015;8:255-62.
Chakraborty S, Majumder B, Sarkar D, Chatterjee S. A Simple Non-invasive ECG Technique to Localize Culprit Vessel Occlusion Site in ST-Elevation Myocardial Infarction (STEMI) Patients. J Clin Exp Cardiol 2017;8:1-6.
Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, et al
. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23:1190-201.
Rogers WJ, Canto JG, Barron HV, Boscarino JA, Shoultz DA, Every NR. Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. Investigators in the National Registry of Myocardial Infarction. J Am Coll Cardiol 2000;35:371-9.
Steg PG, Goldberg RJ, Gore JM, Fox KA, Eagle KA, Flather MD, et al
. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 2002;90:358-63.
Gosh B, Indurkar M, Jain MK. ECG: A Simple Noninvasive Tool to Localize Culprit Vessel Occlusion Site in Acute STEMI. Indian J Clin Pract 2013;23:590-5.
Wagner GS, Macfarlane P, Wellens H, Josephson M, Gorgels A, Mirvis DM, et al
. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: Part VI: Acute ischemia/infarction: A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;53:1003-11.
Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Ophuis AJ, Dassen WR, et al
. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. J Am Coll Cardiol 1999;34:389-95.
Bhat S, Kumar D, Parimoo A. Use of electrocardiography in identification of culprit vessel and localising the lesion in acute myocardial infarction with angiographic correlation. Global Journal of Medical Research 2019;19:1-6.
Gaude RP, Gautam DK, Jain D, Singh GP, Das P, Choudhury AK, et al
. Study of coronary angiographic correlation with electrocardiography in patients of acute coronary syndrome-ST-elevation myocardial infarction. Heart India 2018;6:115-22. [Full text]
Pradhan D, Jian S, Shrestha R, Gupta M, Karkl S, Fei LX, et al
. Clinical significance of ST segment elevation in posterior leads V7, V8 and V9 in patients with acute inferior wall myocardial infarction. J Cardiovasc Dis Diagn 2013;1:1-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]