Value of the electrocardiogram in diagnosing the number of severely narrowed coronary arteries in rest angina pectoris

doi:10.1016/0002-9149(93)90852-4

The American Journal of Cardiology

Volume 72, Issue 14, 1 November 1993, Pages 999-1003

https://doi.org/10.1016/0002-9149(93)90852-4 Get rights and content

Abstract

The aim of this study was to assess the value of the electrocardiogram recorded during chest pain for identifying high-risk patients with 3-vessel or left main stem coronary artery disease (CAD). Therefore, the number of leads with abnormal ST segments, the amount of ST-segment deviation, and specific combinations of leads with abnormal ST segments were correlated with the number of coronary arteries with proximal narrowing of >70%. Electrocardiograms recorded during chest pain were compared with one from a symptom free episode. In this retrospective analysis, 113 consecutive patients were included. One-vessel CAD was present in 47 patients, 2-vessel CAD in 22, 3-vessel CAD in 24 and left main CAD in 20. Stratification was performed according to the presence of an old myocardial infarction. The number of leads with ST-segment deviations, and the amount of ST-segment deviation in the electrocardiogram obtained during chest pain at rest showed a positive correlation with the number of diseased coronary arteries. These findings were more marked when the absolute shifts from baseline were considered, because ST-segment abnormalities could be present also in the electrocardiogram obtained during the symptom-free episode. Left main and 3-vessel CAD showed a frequent combination of leads with abnormal ST segments: ST-segment depression in leads I, II and V₄–V₆, and ST-segment elevation in lead aVR. The negative predictive and positive accuracy of this pattern were 78 and 62%, respectively. When the total amount of ST-segment changes was >12 mm, the positive predictive accuracy for 3-vessel or left main stem CAD increased to 86%. The findings show that the electrocardiogram during chest pain at rest is of great value in diagnosing the number of diseased coronary arteries in patients with rest angina.

References (22)

S. Sclarovsky et al.
Unstable angina: the significance of ST-segment elevation or depression in patients without evidence of increased myocardial oxygen demand
Am Heart J
(1986)
S. De Servi et al.
Clinical and angiographic findings in angina at rest
Am Heart J
(1986)
F.A. Shawl et al.
Effect of coronary angioplasty on electrocardiographic changes in patients with unstable angina secondary to left anterior descending coronary artery disease
J Am Coll Cardiol
(1990)
S. Sclarovsky et al.
Unstable angina pectoris evolving to acute myocardial infarction: significance of ECG changes during chest, pain
Am Heart J
(1986)
D.A. Weiner et al.
Identification of patients with left main and three vessel coronary disease with clinical and exercise test variables
Am J Cardiol
(1980)
I. Sato et al.
Improved accuracy of the exercise electrocardiogram in detection of coronary artery and three vessel coronary disease
Chest
(1988)
R. Detrano et al.
Exercise induced ST-segment depression in the diagnosis of multivessel coronary artery disease; a meta-analysis
J Am Coll Cordial
(1989)
P. Bogaty et al.
Prognosis in patients with a strongly positive exercise electrocardiogram
Am J Cardiol
(1989)
R. Detrano et al.
Exercise electrocardiography variables: a critical approach
J Am Coll Cardiol
(1986)
J. Maddahi et al.
Noninvasive identification of left main and triple vessel coronary artery disease: improved accuracy using quantitative analysis of regional myocardial stress distribution and washout of thallium-201
J Am Coll Cardiol
(1986)

P.L. McHenry et al.

Correlation of computer-quantitated treadmill exercise electrocardiogram with arteriographic location of coronary artery disease

Am J Cordial

(1972)

Cited by (129)

Context-independent identification of myocardial ischemia in the prehospital ECG of chest pain patients
2024, Journal of Electrocardiology
Non-traumatic chest pain is a frequent reason for an urgent ambulance visit of a patient by the emergency medical services (EMS). Chest pain (or chest pain-equivalent symptoms) can be innocent, but it can also signal an acute form of severe pathology that may require prompt intervention. One of these pathologies is cardiac ischemia, resulting from a disbalance between blood supply and demand. One cause of a diminished blood supply to the heart is acute coronary syndrome (ACS, i.e., cardiac ischemia caused by a reduced blood supply to myocardial tissue due to plaque instability and thrombus formation in a coronary artery). ACS is dangerous due to the unpredictable process that drives the supply problem and the high chance of fast hemodynamic deterioration (i.e., cardiogenic shock, ventricular fibrillation). This is why an ECG is made at first medical contact in most chest pain patients to include or exclude ischemia as the cause of their complaints.
For speedy and adequate triaging and treatment, immediate assessment of this prehospital ECG is necessary, still during the ambulance ride. Human diagnostic efforts supported by automated interpretation algorithms seek to answer questions regarding the urgency level, the decision if and towards which healthcare facility the patient should be transported, and the indicated acute treatment and further diagnostics after arrival in the healthcare facility. In the case of an ACS, a catheter intervention room may be activated during the ambulance ride to facilitate the earliest possible in-hospital treatment.
Prehospital ECG assessment and the subsequent triaging decisions are complex because chest pain is not uniquely associated with ACS. The differential diagnosis includes other cardiac, pulmonary, vascular, gastrointestinal, orthopedic, and psychological conditions. Some of these conditions may also involve ECG abnormalities. In practice, only a limited fraction (order of magnitude 10%) of the patients who are urgently transported to the hospital because of chest pain are ACS patients. Given the relatively low prevalence of ACS in this patient mix, the specificity of the diagnostic ECG algorithms should be relatively high to prevent overtreatment and overflow of intervention facilities. On the other hand, only a sufficiently high sensitivity warrants adequate therapy when needed.
Here, we review how the prehospital ECG can contribute to identifying the presence of myocardial ischemia in chest pain patients. We discuss the various mechanisms of myocardial ischemia and infarction, the typical patient mix of chest pain patients, the shortcomings of the ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) ECG criteria to detect a completely occluded culprit artery, the OMI ECG criteria (including the STEMI-equivalent ECG patterns) in detecting completely occluded culprit arteries, and the promise of neural networks in recognizing ECG patterns that represent complete occlusions. We also discuss the relevance of detecting any ACS/ischemia, not necessarily caused by a total occlusion, in the prehospital ECG.
In addition, we discuss how serial prehospital ECGs can contribute to ischemia diagnosis. Finally, we discuss the diagnostic contribution of a serial comparison of the prehospital ECG with a previously made nonischemic ECG of the patient.
aVR: The forgotten lead in acute coronary syndrome: A case series
2023, Medical Journal Armed Forces India
Lead aVR is often considered as a neglected lead or forgotten lead owing to its reciprocal location to the lateral leads. However, it has diagnostic and prognostic importance in cases of acute coronary syndromes.
We present a series of four cases of acute coronary syndrome with ST elevation (STE) in aVR and critical stenosis in coronary vessels.
Patients with STE in aVR have a poor prognosis with increased morbidity not limited to increased chances of heart failure at presentation, greater hemodynamic instability, and in-hospital acute kidney injury, as well as increased mortality due to large infarction areas. Thus, early revascularization is warranted in such cases.
Emergency Department Chest Pain Patients With or Without Ongoing Pain: Characteristics, Outcome, and Diagnostic Value of the Electrocardiogram
2020, Journal of Emergency Medicine
In emergency department (ED) chest pain patients, it is believed that the diagnostic accuracy of the electrocardiogram (ECG) for acute coronary syndrome (ACS) is higher during ongoing than abated chest pain.
We compared patient characteristics and the diagnostic performance of the ECG in ED patients presenting with ongoing, vs. abated, chest pain.
In total, 1132 unselected ED chest pain patients were analyzed. The patient characteristics and diagnostic accuracy for index visit ACS of the emergency physicians’ interpretation of the ECG was compared in patients with and without ongoing chest pain. Logistic regression analysis was performed to control for possible confounders.
Patients with abated chest pain (n = 508) were older, had more comorbidities, and had double the risk of index visit ACS (15%) and major adverse cardiac events (MACE) at 30 days (15.6%) compared with patients with ongoing pain (n = 631; ACS 7.3%, 30-day MACE 7.4%). Sensitivity of the ECG for ACS was 24% in patients with ongoing pain and 35% in those without, specificity was 97% in both groups, negative predictive value was 94% and 89%, respectively, and positive likelihood ratio 10.6 and 7.8, respectively. When the diagnostic performance was controlled for confounders, there was no significant difference between the groups.
Our results indicate that ED chest pain patients with ongoing pain at arrival are younger, healthier, and have less ACS and 30-day MACE than patients with abated pain, but that there is no difference in the diagnostic accuracy of the ECG for ACS between the two groups.
Coronary artery calcification as a novel predictive marker of unstable coronary lesion in survivors of out-of-hospital cardiac arrest without ST-segment elevation
2020, Resuscitation
Acute myocardial infarction (AMI) is the leading cause of out-of-hospital cardiac arrest (OHCA). A highly predictive marker is needed to identify AMI in survivors of OHCA without ST-segment elevation because the appropriate indication for emergency coronary artery angiography in patients without ST-segment segment elevation has not been determined. Accordingly, the aim of this study was to elucidate the clinical significance of coronary artery calcification in identifying survivors of OHCA without ST-segment elevation who could benefit from emergency coronary artery angiography.
Survivors of OHCA without ST-segment elevation with no obvious extra-cardiac cause who underwent emergency computed tomography and coronary artery angiography were enrolled. Unstable coronary lesion was diagnosed using coronary artery angiography, and presence of coronary artery calcification and coronary artery calcium score were evaluated by non-contrast, non-electrocardiography gated computed tomography.
Thirty of 100 consecutive survivors of OHCA were diagnosed to have unstable coronary lesion. Sensitivity and specificity of coronary artery calcification in identifying unstable coronary lesion were 87% and 60%, respectively. Multivariate logistic regression analysis revealed that coronary artery calcification was an independent predictor of unstable coronary lesion (odds ratio: 7.28, 95% confidence interval: 2.00–26.56, p < 0.001).
Evaluation of coronary artery calcification by computed tomography is useful in identifying patients with unstable coronary lesion who could benefit from emergency coronary artery angiography among survivors of OHCA without ST-segment elevation on post-resuscitation electrocardiography.
Non–ST-Elevation Myocardial Infarction-Like Syndrome in Scombroid Tuna Fish Poisoning
2019, American Journal of Cardiology
Mistreated fish products ingestion can lead to a histaminergic illness known as Scombroid Syndrome (SS). The disease usually causes cutaneous rash, stomach cramps, nausea, vomiting, breathing disorder and further histamine-related symptoms. To date, however, SS has been disregarded among the potential triggers of acute coronary syndrome (ACS), in spite of prior published occasional case reports. In the present study we describe 3 consecutive patients presenting with signs and symptoms of ACS associated to SS. Two men and a woman with no history of coronary artery disease and food allergy were studied. Clinical characteristics, electrocardiographic presentation and outcomes are described. Non–ST-elevation myocardial infarction-like pattern was observed in all patients. The 2 men underwent unremarkable coronary angiography, whereas the woman was just monitored at emergency department. All individuals had uneventful follow-up. The present study confirms non–ST-elevation myocardial infarction-like ACS as a possible histaminergic toxic, not allergic, epiphenomenon of mistreated raw tuna fish ingestion, likely due to transient epicardial and/or microvascular coronary vasospasm.
aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion
2019, American Journal of Medicine
Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression.
STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression.
Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001).
STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

View all citing articles on Scopus

View full text

Value of the electrocardiogram in diagnosing the number of severely narrowed coronary arteries in rest angina pectoris

Abstract

Am Heart J

Am Heart J

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Chest

J Am Coll Cordial

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cordial