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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 1-6

Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention


Departments of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi, India

Date of Submission22-Oct-2020
Date of Decision15-Jan-2021
Date of Acceptance15-Mar-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Tarun Kumar
Department of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_42_20

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  Abstract 


Objective: The objective was to study the role of 12-lead electrocardiogram (ECG) changes in predicting the association of severe stenosis of other coronary arteries along with infarct-related artery in patients who presented with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Materials and Methods: We studied the admission ECG, clinical records, and coronary angiography of 201 patients with STEMI who underwent primary PCI within the first 12 h of symptoms. Patients with first episode of STEMI and coronary angiogram showing coronary artery disease between January 2015 and July 2016 were included in this study. Results: Most of the patients in this study were males (82.1%). The mean age of the patients was 55.20 ± 11.79 years. Diabetic mellitus (37.8%), hypertension (37%), and smoking (49.7%) were the main risk factors. This study had 117 (58.2%) patients of anterior wall myocardial infarction (MI) (Group I) while inferior wall MI was present in 84 (41.8%) patients (Group II). In Group I, 83 (70.9%) patients had single-vessel disease (SVD) while 34 (29.1%) patients had multivessel disease (MVD). The presence of ST-segment depression ≥0.1 mV in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.001, 0.001, and 0.001, respectively). In Group II, 39 (51.3%) patients had SVD while 37 (48.7%) patients had MVD. The presence of ST-segment depression in leads aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.049, 0.001, and 0.001, respectively). Conclusion: The presence of ST-segment depression of ≥0.1 mv in leads I, aVL, and V6 on admission ECG in the setting of acute anterior wall STEMI and in leads aVL, V5, and V6 on admission ECG in the setting of acute inferior wall STEMI was associated with MVD.

Keywords: Electrocardiogram, ST-elevation myocardial infarction, percutaneous coronary intervention, reciprocal ST changes


How to cite this article:
Sharma AK, Kumar T, Dhaka MK. Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Res Cardiovasc Med 2021;10:1-6

How to cite this URL:
Sharma AK, Kumar T, Dhaka MK. Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Res Cardiovasc Med [serial online] 2021 [cited 2021 Aug 2];10:1-6. Available from: https://www.rcvmonline.com/text.asp?2021/10/1/1/319789




  Introduction Top


Acute coronary syndrome is one of the common diagnoses in hospitalized patients with chest pain. The electrocardiogram (ECG) remains a crucial tool in the identification and management of acute myocardial infarction (MI). A detailed analysis of patterns of ST-segment elevation may influence decisions regarding the use of reperfusion therapy. The early and accurate identification of the infarct-related artery (IRA) on the ECG can help predict the amount of myocardium at risk and guide decisions regarding the urgency of revascularization. There are many sets of criteria that are helpful in predicting the level of occlusion in IRA in patients with ST-elevation myocardial infarction (STEMI).[1]

In spite of all well-defined ECG-based criteria[2],[3],[4] for localization of arterial occlusion in STEMI patients, only a few studies[5],[6],[7] have been done to predict the presence of multivessel coronary artery disease in acute MI. In multivessel coronary artery disease, it is very vital to predict number of coronary arteries having severe stenosis or occlusion as the number of diseased vessels is directly correlated with myocardium at risk and outcome.

At present, there are no definite criteria for predicting stenosis of other coronary arteries in patients with STEMI. The present study is aimed to prospectively assess the role of 12-lead ECG changes in predicting the association of severe stenosis of other coronary arteries along with IRA in patients who present with STEMI undergoing primary percutaneous coronary intervention (PCI).


  Materials and Methods Top


This was a hospital-based prospective, observational study to assess the role of 12-lead ECG changes conducted between January 2015 and July 2016. The inclusion criteria were as follows: (1) age 15–80 years, (2) first episode of STEMI, (3) diagnostic angiogram showing coronary artery disease, and (4) eligible for PCI. The exclusion criteria were as follows: (1) patients not giving consent; (2) history of previous MI; (3) chronic valvular heart disease; (4) prior PCI or coronary artery bypass graft surgery; (5) patients who present with cardiogenic shock; (6) ECG showing evidence of paced rhythm, preexcitation, and intraventricular conduction defect; (7) cardiomyopathy; and (8) electrolyte imbalance. The study protocol was approved by the institutional ethics committee, and consent form was signed by each participating patient/guardian.

Electrocardiographic findings

The 12-lead ECGs were recorded in emergency room at presentation. Acute STEMI was diagnosed as per the third universal definition of MI.[8] The acute MI location was determined according to the Minnesota Code as follows: anterior wall (V1 through V5), inferior wall (L2, L3, or aVF), and lateral wall (L1, aVL, or V6).[9]

The electrocardiographic criterion for the diagnosis of reciprocal ST changes was a depression of the ST segment of at least 0.1 mV in at least two leads in the wall opposite the infarction (leads I, aVL, and VI to V4 for inferior MI and leads II, III, and aVF for anterior MI). The ST-segment elevation or depression was measured 0.06 s after the nadir of the S wave, taking the TP segment as the baseline.[10]

Coronary angiography

Diagnostic coronary angiography (CAG) was carried out in all patients using the Judkins technique. A culprit artery was determined from the correlation between the ECGs and the characteristics of occlusion including occlusion due to thrombosis formation and/or ulceration with decreased contrast density.[11] Significant stenosis was defined as ≥90% luminal narrowing compared to proximal reference of normal coronary artery diameter. Two or more vessel disease was considered as multivessel disease (MVD).[12]

Statistical analysis

The results were reported as mean ± standard deviation for the quantitative variables and numbers and percentages for the categorical variables. The groups were compared using the Student's t-test for the continuous variables and the Chi-square test for the dichotomous variables. P < 0.05 was considered as statistically significant. All the statistical analyses were carried out via the Statistical Package for the Social Sciences version 20 (SPSS Inc., Chicago, IL, USA).


  Results Top


During the study period, a total of 281 patients with acute STEMI underwent primary PCI, 62 patients were excluded by exclusion criteria, and 18 patients had lateral wall MI which was not studied. Finally, a total of 201 patients were included in this study.

Demographic characteristics

A total of 201 patients of acute STEMI were studied. Their mean age was 55.20 ± 11.79 years. One hundred and sixty-five (82.1%) patients were male while 36 (17.9%) patients were female. Diabetes mellitus was present in 76 patients (37.8%) while hypertension in 75 (37.3%). One hundred (49.7%) patients were smokers. Out of 201 STEMI patients, 117 (58.2%) patients were suffering from anterior wall MI (AWMI) (Group I) while 84 (41.8%) patients from inferior wall MI (IWMI) (Group II). The baseline characteristics of patients with AWMI and IWMI are shown in [Table 1].
Table 1: Baseline characteristics of patients with anterior wall myocardial infarction and inferior wall myocardial infarction

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Relation of ST-segment depression in each of the leads with single or multivessel involvement in anterior wall myocardial infarction patients

There were 95 (81.1%) patients of AWMI with ST-segment depressions [Table 2] and [Figure 1] in the 12-lead ECG. When the patients with ST-segment depression were studied angiographically for single or multivessel involvement, 67 (70.0%) patients revealed single-vessel disease (SVD) and 28 (30.0%) patients revealed MVD. The presence of ST-segment depression of ≥0.1 mV in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.001, 0.001, and 0.001, respectively).
Table 2: Relation of ST-segment depression in each of the leads with single or multivessel involvement in anterior wall myocardial infarction patients

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Figure 1: Relation of ST-segment depression in each of the leads with single or multivessel involvement in anterior wall myocardial infarction

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When all patients with AWMI were evaluated, 83 (70.9%) patients had SVD with left anterior descending artery (LAD) involvement and 34 (29.1%) patients had MVD. When studied for ST-segment depression, the presence of ST-segment depression of ≥0.1 mV in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.035, 0.020, and 0.001, respectively).

Relation of ST-segment depression in each of the leads with single or multivessel involvement in inferior wall myocardial infarction patients

There were 76 (90.4%) patients of IWMI who had ST-segment depression [Table 3] and [Figure 2] in the 12-lead ECG. When these patients were studied angiographically for single (right coronary artery [RCA] or left circumflex [LCX]) or multivessel involvement, there were 39 (51.3%) patients with SVD (RCA in 30 patients and LCX in 9 patients) and 37 (48.7%) patients had MVD. The presence of ST-segment depression in leads aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.049, 0.001, and 0.001, respectively).
Table 3: Relation of reciprocal ST-segment changes in each of the leads with single or multivessel involvement in inferior wall myocardial infarction patients

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Figure 2: Relation ST-segment depression in each leads with single or multivessel involvement in inferior wall myocardial infarction

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When all patients with IWMI were evaluated, forty-four (52.3%) patients had SVD and 40 (47.7%) patients had MVD. When analyzed for ST-segment depression, the presence of ST-segment depression in aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.002, 0.010, and 0.011, respectively).


  Discussion Top


Among 201 patients, 117 (58.2%) patients were suffering from AWMI (Group 1) and 84 (41.8%) patients from IWMI (Group 2). In our study patients, 127 patients (63.2%) were having SVD while 74 (36.8%) patients were having MVD.

The mean age of all study patients was 55.20 ± 11.79 years, and it was comparable to other studies published from India, with 56.30 ± 13 years in STEMI population in CREATE registry[12] and 57 ± 12 years in the study done by Jose and Gupta.[13] In study Group I and II patients with MVD were elderly as compared to patients with SVD. Most of the patients in this study were males 165 (82.1%), which is comparable with previous studies, suggesting that CAD is predominantly a disease of men.[14],[15]

In our study, 76 (37.8%) patients were diabetic comparable to the Indian study by Nagamahesh et al.[16] (38.6%) but was higher than the reported prevalence (26.9%) in STEMI patients of CREATE registry.[17] Furthermore, a number of patients with diabetes mellitus were significantly more in patients with MVD as compared to SVD. In Group 1, 18 (52.9%) patients of MVD were diabetic as compared to 24 (28.9%) patients of SVD (P = 0.03), while in Group II, –22 (55.0%) patients of MVD were diabetic as compared to 12 (27.2%) with SVD patients (P = 0.01). These findings are similar to the study done by Gui et al.[18] in which diabetic patients had a higher incidence of triple-vessel disease (35.2%) compared to SVD (28.8%).

In this study, 75 (37.3%) patients were hypertensive. Recent, studies done by El-Menyar et al.[19] and Ali et al.[20] focused on patients with STEMI who underwent primary PCI. In these studies, previous history of hypertension was present in 30%–33% of STEMI patients. In our study, a number of patients with hypertension were significantly more common in MVD as compared to SVD. In Group I, 18 (52.9%) patients of MVD were hypertensive as compared to 25 (30.1%) patients of SVD (P = 0.03), while in Group II, 21 (52.5%) patients of MVD were hypertensive as compared to 11 (25.5%) patients of SVD (P = 0.01).

In our study, 100 (49.7%) patients were smokers, which is comparable to other studies by Sharma et al.[21] (49.3%) and Misiriya et al. (46.5%).[22] History of smoking was more in MVD as compared to SVD. In Group 1, 19 (55.8%) patients of MVD were smokers as compared to 44 (53.0%) patients of SVD (P = 0.54), while in Group II, 19 (47.5%) patients of MVD were smokers as compared to 18 (40.9%) patients of SVD (P = 0.66).

The mechanism underlying the reciprocal ST-segment depression in patients with STEMI is complex. After the early description by Little et al.,[23] two mechanisms have been considered: (1) mirror projection of the ST-segment elevation at a distance from the infarcted region[24],[25],[26] and (2) true ST-segment deviation caused by additional subendocardial ischemia at a distance from the infarction.[27],[28],[29]

IRA was attempted to be localized by using 12-lead ECG findings in various studies.[3],[4],[5],[30],[31] However, in these studies, the IRA in AWMI was a single vessel (LAD) and IRA in IWMI was either RCA or LCX. Multivessel involvement in various combinations, for example, of both LAD and LCX, or LAD and RCA, or LAD, LCX, and RCA as critical stenosis, is commonly seen in the coronary angiograms of patients with acute STEMI.

In anterior wall STEMI, the importance of proximal LAD lesions on prognosis is proved beyond doubt. It is obvious that the ability to predict LAD proximal occlusion with the initial ECG is crucial, as well as the presence of MVD along with LAD occlusion.

A significant correlation was found between ST-segment changes and multivessel involvement with AWMI in this study. Ninety-five (81.1%) patients of AWMI had ST-segment depression and were studied angiographically for LAD or multivessel involvement. There were 67 (70.5%) patients with single vessel (LAD) and 28 (29.5%) patients with MVD. The presence of ST-segment depression in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.001, 0.001, and 0.001, respectively, in these three leads).

When all patients (117) with AWMI were evaluated, 83 (70.9%) patients had LAD involvement and 34 (29.1%) had MVD. When studied for ST depression, the presence of ST-segment depression in I, aVL, and V6 was found statistically significantly associated with MVD (P = 0.035, 0.020, and 0.001, respectively, in these leads).

A previous study done by Kürüm et al.[32] to investigate the correlation between admission ECG and CAG findings in patients with acute anterior or anterior-inferior MI found that the presence of reciprocal ST-segment depression in aVL and V6 was significantly correlated with the presence of MVD in anterior STEMI patients (P = 0.005 and 0.003, respectively).

Another study done by Knour[33] to investigate the significance of reciprocal ST-segment depression in 100 patients of anterior wall STEMI found a higher incidence of MVD as compared to SVD in patients with reciprocal ST depression (80.5% vs. 49.2%, P < 0.001).

A significant correlation was also found between ST-segment changes and multivessel involvement with IWMI in this study. Seventy-six (90.4%) patients of IWMI had ST changes and were studied angiographically for single (RCA or LCX) or multivessel involvement. There were 39 (51.3%) patients with single vessel and 37 (48.7%) patients with MVD. The presence of ST-segment depression in leads aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.049, P = 0.001, and P = 0.001, respectively, in these three leads).

When all 84 patients of IWMI were evaluated, 44 (52.3%) patients had SVD and 40 (47.7%) patients had MVD. When analyzed for ST depression, the presence of ST-segment depression in aVL, V5, and V6 was found statistically significantly associated with MVD (P = 0.002, 0.010, and 0.011, respectively, in these three leads).

A previous study done by Hossain et al.[34] to correlate between ST-depression in ECG on admission and severity of coronary lesion in angiogram in 93 patients with acute inferior MI found that left precordial ST depression (lead V4–V6) correlates with multivessel CAD. MVD patients had double-vessel disease in 38.5% (P = 0.007) of patients and triple-vessel disease in 30.8% (P = 0.014).

Birnbaum et al.[6] studied the correlation of angiographic findings and right (V1–V3) versus left (V4–V6) precordial ST-segment depression in 1155 patients with acute IWMI and found that patients with maximum ST depression in leads V4–V6 more often had three-vessel disease (26.0%) than those without precordial ST depression (13.5%) or those with ST depression in leads V1–V3 (15.7%) (P = 0.002).

Limitations

Sample size was small. The higher percentage of males in our study is another limitation of this study. True usefulness of these criteria needs to be corroborated in a larger study to develop an ECG algorithm for predicting multivessel coronary artery disease in acute MI patients.


  Conclusion Top


The presence of ST-segment depression of ≥0.1 mv in leads I, aVL, and V6 on admission ECG in the setting of acute anterior wall STEMI and in leads aVL, V5, and V6 on admission ECG in the setting of acute inferior wall STEMI was associated with MVD.

Ethical clearance

IEC- 1-40/86/2013/IEC/PGIMER-RMLH/0300 Dated-14/11/2013.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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