Bedside ECG Markers of Adverse Risk in ACS


Dr. Ramon F. Abarquez, Jr. has been one of the most prolific consultant writers of H&L and its sister publication, Vital Signs. Highly esteemed in the medical community, he is the founding president of Philippine Society of Hypertension and a past president of the Philippine College of Physicians

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For the percutaneous coronary intervention (PCI) groups, the in-hospital mortality rate was higher in patients with ST segment elevation than in patients with no ST segment changes (15.4 percent vs 1.2 percent, p <0.001).

For group fibrinolysis, the in-hospital mortality rates were 33.3 percent, 12.9 percent, and 0 percent, in patients with ST segment elevation, ST segment depression, and no ST changes, respectively (p = 0.006).

For the optimal medical treatment (OMT) group, the in hospital mortality rate was higher in patients with ST elevation (STE) (32 percent) than in patients with ST segment depression (12.5 percent) and patients with no ST segment changes (2 percent, p = 0.006). Logistic regression analysis found that female gender, diabetes, hypertension, lower ejection fraction, and cardiogenic shock on admission were independent predictors of ST segment elevation. ST segment changes in lead aVR, which occurred in approximately half of inferior wall STEMI patients with poorer prognosis regardless of reperfusion treatment. (Kukla, Kardiol Pol. 2012;70(2):111-8)

RV culprit lesion

Right ventricular infarction (RVI) during inferior myocardial infarction (MI) is readily diagnosed when STE is recorded in lead V4R. But, STE in RVI may be misinterpreted as anterior MI. An inferior-right ventricular (RV) MI due to occlusion of a dominant right coronary artery had STE in the inferior, all precordial and right chest leads. RV dilation due to acute ischemic insult caused STE in leads V1-V4 despite the dominant opponent inferior and posterolateral left ventricular injury current. Awareness of RV dilation can avoid misinterpretation as a sign of anterior MI and proper management. (Andreou, J Cardiovasc Med (Hagerstown). 2010 Nov;11(11):843-7)

Although oxygen demand/supply of the right is lower than that of the left ventricle, due to the smaller muscular mass, despite good prognosis, sudden death and cardiac rupture have been reported. Dome-like and decreasing STE from V1 to V3 leads; rapid ST segment normalization and no Q wave evolution from V1 to V3 leads, either accompanied or not by modest ST segment elevation in III (but not aVF) evolving in no Q wave; STE in right-sided leads, absence of STD in aVL; absent concomitant STE in all inferior leads (II, III, aVF), may prevent erroneous management of right ventricular infarction if confused with left ventricular infarction. Right ventricular function evaluation by echocardiography and MRI can be useful.. (Iannetta, J Cardiovasc Med (Hagerstown). 2013 Oct;14(10):740-4)

Circadian PWV and LA profile

Increased ambulatory arterial stiffness index might be related with impaired left atrial function in hypertensive diabetic patients with no previous history of cardiovascular disease. Inclusion criteria: > 130/ > 80 mm Hg, absence of secondary causes of hypertension, whereas exclusion criteria: LVEF <50 percent, history of significant coronary artery disease, chronic renal failure, atrial fibrillation/ flutter, second or third-degree atrioventricular block, moderate to severe valvular heart disease, history of cerebrovascular disease, non-dipper hypertensive pattern and sleep apnea. among 121 hypertensive DM patients.

Ambulatory arterial stiffness index (AASI) was calculated as 1 minus the regression slope of diastolic BP plotted against systolic BP obtained through individual 24-h ABPM. Multiple linear regression analysis showed that ambulatory arterial stiffness index was independently associated with peak left atrial strain rate during ventricular systole (SR-LAs) (p<0.001). In hypertensive diabetic patients, increased ambulatory arterial stiffness index is associated with impaired left atrial functions, independent of left ventricular diastolic dysfunction. (Kalaycioglu, Anatol J Cardiol. 2015 Oct;15(10):807-13) ST changes in aVR, RV infarct and LA dysfunction are bedside markers of adverse risk in ACS.