aVR ST Segment Elevation: Acute STEMI or NOT? Incidence of an Acute Coronary Occlusion.
Am J Med. 2019 Jan 08;:
Authors: Harhash AA, Huang JJ, Reddy S, Natarajan B, Balakrishnan M, Shetty R, Hutchinson MD, Kern KB
Abstract
BACKGROUND: Identification of ST-elevation myocardial infarction is critical as early reperfusion can save myocardium and increase survival. ST-elevation (STE) in aVR, co-existent with multi-lead 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 multi-lead ST-depression.
METHODS AND RESULTS: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multi-lead 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. Forty-seven total 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 multi-lead ST-depression was associated with 31% in-hospital mortality, compared to only 6.2% in a subgroup of 190 STEMI patients without STE-aVR (p<0.00001).
CONCLUSIONS: STE-aVR with multi-lead 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, while urgent, rather than emergent, catheterization appears to be important.
PMID: 30639554 [PubMed - as supplied by publisher]