Electrocardiographic signs of the left main coronary artery disease in acute coronary syndrome
https://doi.org/10.15829/1560-4071-2020-4038
Abstract
Myocardial infarction (MI) due to the left main coronary artery (LMCA) disease is a life-threatening condition. Evaluation of ECG signs of LMCA occlusion is important because of revascularization emergency. There is no single ECG pattern for LMCA occlusion. The purpose of the present literature review is to reveal ECG potential in diagnosing LMCA occlusion in acute coronary syndrome. Variability of ECG abnormalities was noted depending on the degree of LMCA occlusion, collateral blood flow from the right coronary artery, and concomitant stenosis. ST elevation in aVR is an evident predictor of LMCA lesion. Electrophysiological mechanisms of its formation were described. Diagnostic significance of additional ECG signs of LMCA disease was presented. Diagnostic and treatment strategies for patients with ECG signs of severe LMCA disease were summarized.
About the Authors
E. S. Eniseeva
Irkutsk State Medical Academy of Postgraduate Education — Branch of Russian Medical Academy of Continuous Professional Education; Irkutsk State Medical University
Russian Federation
Competing Interests: not
Russian Federation
Competing Interests: not
K. V. Protasov
Irkutsk State Medical Academy of Postgraduate Education — Branch of Russian Medical Academy of Continuous Professional Education
Russian Federation
Competing Interests: not
Russian Federation
Competing Interests: not
G. P. Gurtovaya
Irkutsk State Medical University
Russian Federation
Competing Interests: not
Russian Federation
Competing Interests: not
References
1. Nikus K, Pahlm O, Wagner G, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. J Electrocardiol. 2010;43(2):91-103. doi:10.1016/j.jelectrocard.2009.07.009.
2. 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. Clinical Case Reports. 2017;5(12):2088-92. doi:10.1002/ccr3.1227.
3. Jakl M, Stasek J, Kala P, et al. Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram. Scand Cardiovasc J. 2014;48(1):13-19. doi:10.3109/14017431.2013.865074.
4. Édes IF, Ruzsa Z, Lux A, et al. Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations. Adv Interv Cardiol. 2018;14(3):233-39. doi:10.5114/aic.2018.78325.
5. Saed, G. Survival after acute and total occlusion of the left main coronary artery. Asian Cardiovasc Thorac Ann. 2010;18(6):599. doi:10.1177/0218492310384514.
6. Lee GK, Hsieh YP, Hsu SW, et al. Value of ST-segment change in lead aVR in diagnosing left main disease in Non-ST-elevation acute coronary syndrome – A meta-analysis. Ann Noninvasive Electrocardiol. 2019;24(6):e12692. doi:10.1111/anec.12692.
7. D’Ascenzo F, Presutti DG, Picardi E, et al. Prevalence and noninvasive predictors of left main or three-vessel coronary disease: evidence from a collaborative international meta-analysis including 22,740 patients. Heart. 2012;98:914-19. doi:10.1136/heartjnl-2011-301596.
8. Fujii T, Hasegawa M, Miyamoto J., et al. Differences in initial electrocardiographic findings between ST-elevation myocardial infarction due to left main trunk and left anterior descending artery lesions. Int J Emerg Med. 2019;12(1):12. doi:10.1186/s12245-019-0227-x.
9. Fiol M, Carrillo A, Rodríguez A, et al. Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: Differential diagnosis and clinical considerations. J Electrocardiol. 2012;45(5):487-90. doi:10.1016/j.jelectrocard.2012.05.001.
10. D’Angelo C, Zagnoni S, Gallo P, et al. Electrocardiographic changes in patients with acute myocardial infarction caused by left main trunk occlusion. J Cardiovasc Med (Hagerstown). 2018;19(8):439-45. doi:10.2459/JCM.0000000000000684.
11. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367:1287-96. doi:10.1056/NEJMoa1208410.
12. Nikus K, Järvinen O, Sclarovsky S, et al. Electrocardiographic presentation of left main disease in patients undergoing urgent or emergent coronary artery bypass grafting. Postgrad Med. 2011;123(2):42-48. doi:10.3810/pgm.2011.03.2262.
13. Tamura A. Significance of lead aVR in acute coronary syndrome. World J Cardiol. 2014;6(7):630-37. doi:10.4330/wjc.v6.i7.621.
14. Taglieri N, Marzocchi A, Saia F, et al. Short- and long-term prognostic significance of ST segment elevation in lead aVR in patients with non-ST segment elevation acute coronary syndrome. Am J Cardiol. 2011;108:21-28. doi:10.1016/j.amjcard.2011.02.341.
15. Bayes de Luna A, Fiol-Sala M. Where Is the culprit lesion? Circulation. 2016;134:1507-09. doi:10.1161/CIRCULATIONAHA.116.024761.
16. Zhao Y-T, Zhou H, Shi R, et al. Total occlusion of the left main coronary artery presenting as ST-elevation myocardial infarction. J Electrocardiol. 2018;51(3):479-80. doi:10.1016/j.jelectrocard.2017.12.040.
17. Zhou H, Zhao Y-T. Anterior ST-Segment Elevation Myocardial Infarction Without ST Elevation in Lead V1. Where Is the Culprit Lesion? Circulation. 2020;141:1351-53. doi:10.1161/CIRCULATIONAHA.120.045891.
18. Kurisu S, Inoue I, Kawagoe T, et al. Electrocardiographic prediction of short-term prognosis in patients with acute myocardial infarction associated with the left main coronary artery. J Electrocardiol. 2009;42(2):106-10. doi:10.1016/j.jelectrocard.2008.10.008.
19. Birnbaum GD, Birnbaum I, Birnbaum Y. Twenty years of ECG grading of the severity of ischemia. J Electrocardiol. 2014.47:546-55. doi:10.1016/j.jelectrocard.2014.02.003.
20. Kosuge M, Ebina T, Hibi K, et al. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol. 2011;107:495-500. doi:10.1016/j.amjcard.2010.10.005.
21. Alherbish A, Westerhout CM, Fu Y, et al. The forgotten lead: does aVR ST-deviation add insight into the outcomes of ST-elevation myocardial infarction patients? Am Heart J. 2013;166:333-39. doi:10.1016/j.ahj.2013.05.018.
22. Lipinski MJ, Mattu A, Brady WJ. Evolving Electrocardiographic Indications for Emergent Reperfusion. Cardiol Clin. 2018;36(1):13-26. doi:10.1016/j.ccl.2017.08.002.
23. Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012;30:994-1000. doi:10.1016/j.ajem.2011.04.025.
24. Sadowski M, Gutkowski W, Raczyński G, et al. Acute myocardial infarction due to left main coronary artery disease in men and women: does ST-segment elevation matter? Arch Med Sci 2015;11(6):1197-204. doi:10.5114/aoms.2015.56345.
25. Zhan ZQ, Nikus K, Birnbaum Y. Different ECG patterns of left main coronary artery occlusion signifying varying degrees of ischemic severity. J Electrocardiol. 2020;60:12-14. doi:10.1016/j.jelectrocard.2020.02.010.
26. Baiocco E, Compagnucci P, Contadini D. Does EKG Favor a Correct Localization of the Ischemic Areas? In: Capucci A, ed. New Concepts in ECG Interpretation. Springer, Cham, 2019:85–97. ISBN 978-3-319-91676-7.
27. Aygul N, Salamov E, Dogan U, et al. Acute occlusion of the left main trunk presenting as ST-elevation acute coronary syndrome. J Electrocardiol. 2010;43:76-78. doi:10.1016/j.jelectrocard.2009.07.008.
28. Patanè S, Marte F, Sturiale M, et al. Acute myocardial infarction with significant left main coronary artery stenosis, significant 3-vessel coronary artery disease and elevated troponin-I at admission. Int J Cardiol. 2011;153(1):e1-e2. doi:10.1016/j.ijcard.2009.03.061.
29. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362-e425. doi:10.1161/CIR.0b013e3182742cf6.
30. Ibanez B, James S, Agewall S, 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(2):119-77. doi:10.1093/eurheartj/ehx393.
31. Gibbs MA, Leedekerken JB, Littmann L. Evolution of our understanding of the aVR sign. J Electrocardiol. 2019;56:121-24. doi:10.1016/j.jelectrocard.2019.07.014.
32. Kireyev D, Arkhipov MV, Zador ST, et al. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-80. doi:10.1111/j.1542-474X.2010.00359.x.
33. Brenes-Salazar JA. ST-segment elevation in lead aVR a visual reminder of potential catastrophe. JAMA Intern Med. 2018;178(6):847-48. doi:10.1001/jamainternmed.2018.0928.
34. Ducas R, Ariyarajah V, Philipp R, et al. The presence of ST-elevation in lead aVR predicts significant left main coronary artery stenosis in cardiogenic shock resulting from myocardial infarction: The Manitoba cardiogenic shock registry. Int J Cardiol. 2013;166(2):465-68. doi:10.1016/j.ijcard.2011.11.003.
35. Wong C-K, Gao W, Stewart RA, et al. The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction. Eur Heart J. 2012;33(3):384-92. doi:10.1093/eurheartj/ ehr301.
36. Daly MJ, Adgey JA, Harbinson MT. Improved detection of acute myocardial infarction in patients with chest pain and significant left main stem coronary stenosis. QJM. 2012;105(2):127-35. doi:10.1093/qjmed/hcr134.
37. Yu X, Zheng J-Y, Zhu G-P. Successful treatment of left main coronary artery total occlusion combined with cardiogenic shock. J Int Med Res. 2019;47(8):3940-45. dx.doi.org/10.1177/0300060519860681.
38. Fern NS, Mattu A. ECG Surprise Attack!: Chest Pain and the “Forgotten Lead”. In: Kaide C, San Miguel C, ed. Case Studies in Emergency Medicine. Springer, Cham, 2020:133-46. ISBN 978-3-030-22445-5.
39. Harhash AA, Huang JJ, Reddy S, et al. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. Am J Med. 2019;132(5):622-30. doi:10.1016/j.amjmed.2018.12.021.
40. Misumida N, Kobayashi A, Fox JT, et al. Predictive Value of ST‐Segment Elevation in Lead aVR for Left Main and/or Three‐Vessel Disease in Non‐ST‐Segment Elevation Myocardial Infarction. Ann Noninvasive Electrocardiol. 2016;21(1):91–97. doi:10.1111/anec.12272.
41. Knotts RJ, Wilson JM, Kim E, et al. Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol. 2013;46(3):240-48. doi:10.1016/j.jelectrocard.2012.12.016.
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For citations:
Eniseeva E.S., Protasov K.V., Gurtovaya G.P. Electrocardiographic signs of the left main coronary artery disease in acute coronary syndrome. Russian Journal of Cardiology. 2020;25(12):4038. (In Russ.) https://doi.org/10.15829/1560-4071-2020-4038
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