Leili POURAFKARİ, Arezou TAJLİL, Nader D NADER, Saeid JOUDİ, Babak KAZEMİ, Samad GHAFFARİ

ST-Segment Elevation in the Right Precordial Leads in Patients with Acute Anterior Myocardial Infarction

Background: Elevation of ST segment in leads V3R/V4R, which is commonly encountered in right ventricu-lar myocardial infarction, may also occur in patients with anterior ST elevation myocardial infarction (STEMI). However, the clinical impact of this finding in the setting of anterior myocardial infarction is not well understood. Aims: We aimed to investigate the prognostic value of ST segment elevation in leads V3R/V4R in patients with first acute anterior myocardial infarction. Study Design: Prospective cohort study.Methods: Right precordial leads V3R/V4R were re-corded in 111 patients admitted with first time anterior myocardial infarction. Patients were allocated into two groups based on the presence or absence of ST eleva-tion in leads V3R/V4R. Demographic, biochemical and echocardiographic data, as well as the angiographic in-formation, were recorded. In-hospital and 3 month mor-tality, and major adverse cardiac events (MACE), death, heart failure and ventricular dysrhythmia were also com-pared. Results: ST elevation in lead V3R or V4R was pres-ent in 72 out of 111 patients (64.9%). Involvement of the proximal part of the left anterior descending (LAD) artery was not different in the two groups (44.4% of pa-tients with elevation vs. 53.8% of patients without el-evation, p=0.22). Post-myocardial infarction complica-tions, mortality and major adverse cardiac events were similar in the two groups. Left ventricular ejection frac-tion (LVEF) was significantly lower in patients with ST elevation in V3R/V4R (35 %±8 vs. 38 %±8, p=0.02). Twenty three out of 111 patients (20.7%) developed heart failure, which was similar in the two groups [16 (22.2%) of patients with ST elevation vs. 7 (17.9%) of patients without ST elevation, p=0.39].Conclusion: Although ST elevation in V3R/V4R can be present in patients with left anterior descending ar-tery occlusion, it does not seem to predict the prognosis. Lower left ventricular ejection fraction in this group may play a role in the long-term prognosis; however, this is-sue needs further investigation

PDF

___

Yip HK, Chen MC, Wu CJ, Chang HW, Yu TH, Yeh KH, et al. Acute myocardial infarction with simultaneous ST-segment ele- vation in the precordial and inferior leads: evaluation of anatomic lesions and clinical implications. Chest 2003;123:1170-80.
Zimetbaum PJ, Josephson ME. Use of the Electrocardiogram in Acute Myocardial Infarction. N Eng J Med 2003;348:933-40.
Elsman P, van 't Hof AWJ, Hoorntje JCA, de Boer M-J, Borm GF, Suryapranata H, et al. Effect of Coronary Occlusion Site on Angiographic and Clinical Outcome in Acute Myocardial In- farction Patients Treated With Early Coronary Intervention. Am J Cardiol 2006;97:1137-41.
Eskola MJ, Nikus KC, Holmvang L, Sclarovsky S, Tilsted HH, Huhtala H, et al. Value of the 12-lead electrocardiogram to de- fine the level of obstruction in acute anterior wall myocardial infarction: Correlation to coronary angiography and clinical out- come in the DANAMI-2 trial. Int J Cardiol 2009;131:378-83.
Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Oude Ophuis AJ, Dassen WR, et al. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coro- nary artery in acute anterior myocardial infarction. J Am Col Cardiol 1999;34:389-95.
Noriega FJ, Vives-Borrás M, Solé-González E, García-Picart J, Arzamendi D, Cinca J. Influence of the Extent of Coronary Ath- erosclerotic Disease on ST-Segment Changes Induced by ST El- evation Myocardial Infarction. Am J Cardiol 2014;113:757-64.
Logeart D, Himbert D, Cohen-Solal A. St-segment elevation in precordial leads* : Anterior or right ventricular myocardial in- farction? Chest 2001;119:290-2.
Inohara T, Kohsaka S, Fukuda K, Menon V. The challenges in the management of right ventricular infarction. Eur Heart J Acute Cardiovasc Care 2013;2:226-34.
Ondrus T, Kanovsky J, Novotny T, Andrsova I, Spinar J, Kala P. Right ventricular myocardial infarction: From pathophysiology to prognosis. Exp Clin Cardiol 2013;18:27-30.
Zalenski RJ, Rydman RJ, Sloan EP, Hahn K, Cooke D, Tucker J, et al. ST segment elevation and the prediction of hospital life- threatening complications: the role of right ventricular and pos- terior leads. J Electrocardiol 1998;(Suppl 31):164-71.
Walker LA, Buttrick PM. The right ventricle: biologic insights and response to disease: updated. Cur Cardiol Rev 2013;9:73-81.
Barsheshet A, Hod H, Oieru D, Goldenberg I, Sandach A, Beigel R, et al. Right precordial lead (V4R) ST-segment elevation is associated with worse prognosis in patients with acute anterior myocardial infarction. J Am Coll Cardiol 2011;58:548-9.
Bodi V, Sanchis J, Mainar L, Chorro FJ, Nunez J, Monmeneu JV, et al. Right ventricular involvement in anterior myocardial infarc- tion: a translational approach. Cardiovasc Res 2010;87:601-8.
Zhong-qun Z, Wei W, Chong-quan W, Shu-yi D, Chao-rong H, Jun-feng W. Acute anterior wall myocardial infarction en- tailing ST-segment elevation in lead V3R, V1 or a VR: elec- trocardiographic and angiographic correlations. J Electrocardiol 2008;41:329-34.
Tahirkheli NK, Edwards WD, Nishimura RA, Holmes DR, Jr. Right ventricular infarction associated with anteroseptal myo- cardial infarction: a clinicopathologic study of nine cases. Car- diovasc Path 2000;9:175-9.
Haddad F, Doyle R, Murphy DJ, Hunt SA. Right Ventricular Function in Cardiovascular Disease, Part II: Pathophysiology, Clinical Importance, and Management of Right Ventricular Fail- ure. Circulation 2008;117:1717-31.
Meissner A, Trappe HJ, de Boer MJ, Gorgels AP, Wellens HJ. The value of the ECG for decision-making at first medi- cal contact in the patient with acute chest pain. Neth Heart J 2010;18:301-6.
O'Rourke RA, Dell'Italia LJ. Diagnosis and management of right ventricular myocardial infarction. Curr Probl Cardiol 2004;29:6-47.
Stebbins A, Mehta RH, Armstrong PW, Lee KL, Hamm C, Van de Werf F, et al; Assessment of Pexelizumab in Acute Myocardi- al Infarction (APEX AMI Investigators). A Model for Predicting Mortality in Acute ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Re- sults From the Assessment of Pexelizumab in Acute Myocardial Infarction Trial. Circ Cardiovasc Interv 2010;3:414-22.
Masci PG, Ganame J, Francone M, Desmet W, Lorenzoni V, Ia- cucci I, et al. Relationship between location and size of myocar- dial infarction and their reciprocal influences on post-infarction left ventricular remodelling. Eur Heart J 2011;32:1640-8.
Ben-Gal T, Sclarovsky S, Herz I, Strasberg B, Zlotikamien B, Sulkes J, et al. Importance of the conal branch of the right coronary artery in patients with acute anterior wall myocardial infarction: electrocardiographic and angiographic correlation. J Am Coll Cardiol 1997;29:506-11.