1. avr prest elevation avrand diffuse st depression in precordial leads as a predictor left main...

8/10/2019 1. AVR PreST elevation aVRand diffuse ST depression in precordial leads as a predictor Left Main Coronary Artery Stenosis (LMCS) in Cardiogenic shock

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ST elevation aVR and diffuse ST depression in precordial

leads as a predictor Left Main Coronary Artery Stenosis

(LMCS) in Cardiogenic shock

Andri Octavallen, Hafifa Rahma, Ferry Limantara1,Dwiwardoyo, Bobi Prabowo2

1Emergency Medicine Postgraduate Programme, Faculty of Medicine, Universitas Brawijaya, Indonesia

2Department of Emergency Medicine, Faculty of Medicine, Universitas Brawijaya, Indonesia


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Introduction

Cardiogenic Shock complicated 7-10% of myocardial infaction withmortality rate 70-80%.

Left main coronary artery supplied 75% of left ventricular myocardialmass.

ST segmen elevation in aVR (STE-aVR) has been associated with leftmain artery coronary stenosis(LMCS), proximal LAD or 3-vessel

disease.

The typical ECG for left main occulusion is a wide spread ST segmen depressionmaximally in lead V4-V6 with inverted T wave and ST segmen elevation in lead

aVR


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CASE REPORT


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Case 1

A 58-years-old woman presented to the ERcomplaining of chest pain since 4 hours ago

The patient also noted the onset of nausea, vomitingand cold sweat

She denied cough,fevers,shortness of breath andcardiac history

She has history of hypertension and DM Vital signs were notable for pulse of 80 beats/min, BP

of unpalpable and respiratory rate of 24 breaths/min

Passed away 3 hours later


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Results

An initial 12-leads EKG was obtained thatdemonstrated : There is ST elevasion in aVR There is ST depression with negative T waves in leads

I, II, III, aVF and V4-V6 RBBB complete

Cardiac marker : Troponin I : 0,3 g/L (N < 1,0) CK-NAC : 313 U/L (N : 16,5-48,5) CKMB : 55 U/L (N : 7-25)


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EKG Case 1


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EKG Case 1.cont

Right wall


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Case 2

A 60-years-old man presented to the ERcomplaining of chest pain since 8 hours ago

The patient also noted the onset of nausea,vomiting and cold sweat

She denied cough,fevers,shortness of breathcardiac history and hypertension

She has history of DM and heavy smoker Vital signs were notable for pulse of 105beats/min, BP of 60/palpable and respiratory rateof 18 breaths/min


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Results

An initial 12-leads EKG was obtained thatdemonstrated : There is ST elevasion in aVR There is ST depression with negative T waves in leads

I, II, III, aVF and V1-V6 RBBB complete

Cardiac marker : Troponin T : 2000 ng/ml (N < 0,05) CK : 2996 U/L (N : 30-180) CKMB : 55 U/L (N : 10-16)


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ECG Case 2


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Case 3 A 59-years-old man presented to the ER complaining of

chest pain since a half hours ago

The patient also noted cold sweat

She denied cough, nausea, vomiting, fevers, shortnessof breath

She has history of hypertension, DM and cardiac

history Vital signs were notable for pulse of 103 beats/min, BP

of 95/73 and respiratory rate of 24 breaths/min

Passed away an hour later


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Results

An initial 12-leads EKG was obtained thatdemonstrated : There is ST elevasion in aVR

There is ST depression with negative T waves in leads V1-V6 There is ST depression I, II, III, aVF RBBB complete

Cardiac marker : Troponin I : 0,4 g/L (N < 1,0) CK-NAC : 160 U/L (N : 16,5-48,5) CKMB : 24 U/L (N : 7-25)


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ECG Case 3


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DISCUSSION


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The Hallmark of acute injury

ST segment elevation

Accompanied by reciprocal ST

segment depression

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. Cardiac

Electrophysiology: From Cell to Bedside. Sixth ed.


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Lead aVR

Positive pole is oriented to the rightupper side of the heart

Usually gives a mirror image of theleads oriented leftward

it is often ignoredBARRABS, J. A.,et al. 2003. Myocardial Infarction Prognostic Value of Lead aVR in Patients With a First Non-ST-Segment ElevationAcute. Circulation American Heart Association.


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ST-segment elevation in lead aVR

STE- aVR + Other repolarization changes

Associated with severe coronary artery lesionsin patients with unstable angina or STEMI

BARRABS, J. A.,et al. 2003. Myocardial Infarction Prognostic Value of Lead aVR in Patients With a First Non-ST-Segment

Elevation Acute. Circulation American Heart Association.


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ROBERT J. KNOTTS, et al. 2013 Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due toleft main coronary artery disease?Journal of Electrocardiology, 46, 240248.

STE-aVR +

LMCA stenosis

Anterior

Lateral

Inferior

ST depresion

in lead

Extensive

CAD

Pooreroutcome

Wall motionabnormal

Outcome


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aVR elevation

1. ST segment elevation in aVR and/or V12. ST-segment depression 0.1 mV in 8

limb leads

3. But are otherwise unremarkable

ROBERT J. KNOTTS, et al. 2013 Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemiadue to left main coronary artery disease?Journal of Electrocardiology, 46, 240248.

Ischemia due to

3-Vessel dis., Proximal LAD or LMCA obstruction


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Left Main Coronary Artery

LMCA occlusion/stenosis should be

suspected when RBBB and other featuresof very Proximal LAD occlusion areassociated with signs of severe

posterobasal ischemia.

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute CoronarySyndrome. Cardiac Electrophysiology: From Cell to Bedside. Sixth ed.


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Vektor

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. Cardiac

Electrophysiology: From Cell to Bedside. Sixth ed

Posterobasalventricel

Resip

rocal

Resip

rocal


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Vektorcont

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. CardiacElectrophysiology: From Cell to Bedside. Sixth ed.

Posterobasalventricel


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Conclusions

Lead aVR contains important short-term prognostic information inpatients with NSTEMI


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Conclusions..cont

Cardiogenic shock due to NSTEMI

with STE-aVR and diffuse STdepression especially in precordial

leads must be assumed as LMCS

because its rapid clinicaldeterioration


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1. avr prest elevation avrand diffuse st depression in precordial leads as a predictor left main...

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