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