A. Lee

Recognition and management of aVR STEMI: A retrospective cohort study

Identification of ST elevation on the electrocardiogram (ECG) is the cornerstone of diagnosis of ST-elevation myocardial infarction (STEMI). While lesion localisation can usually be achieved by regional ST-elevation patterns on ECG, clinicians often neglect changes in the ST segment of lead aVR, possibly contributing to delayed recognition and poorer outcomes for these patients. This study compared the door-to-balloon time and peak troponins as a surrogate marker of infarct size for patients presenting with STEMI with STsegment elevation in aVR compared with those patients without elevation in aVR. A total of 179 patients, including 17 patients presenting with ST-elevation in aVR, were included in this study. Patients presenting with elevation in aVR had significantly longer door-to-balloon times than those patients presenting with traditional patterns of ST-elevation. There was, however, no significant difference in peak troponin as a marker of infarct size. While patients presenting with ST-elevation in lead aVR may have a delayed time to intervention, the present study does not suggest the use of aVR elevation as an indication for urgent angiography. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Vlok, R., Kempton, H., Melhuish, T., Wall, J., Lee, A. & White, L. (2018). Recognition and management of aVR STEMI: A retrospective cohort study. British Journal of Cardiology, 25 (1), 1-6. Authors Ruan Vlok, Hannah Kempton, Thomas M. Melhuish, Joshua Wall, Astin Lee, and Leigh D. White This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/5379 Log in (https://bjcardio.co.uk/wp-login.php?redirect_to=/2018/01/recognition-and-management-of-avr-stemi-aretrospective-cohort-study/) | Register (https://bjcardio.co.uk/wp-login.php?action=register) This website is intended for UK healthcare professionals only Advertisement (https://bjcardio.co.uk/wp-login.php?action=register) For UK healthcare professionals only (https://bjcardio.co.uk/) Authors: Ruan Vlok, Joshua Wall, Hannah Kempton, Thomas Melhuish, Astin Lee, Leigh White Ruan Vlok Junior Medical Officer Hannah Kempton Junior Medical Officer, and Conjoint Lecturer at University of New South Wales Thomas Melhuish Junior Medical Officer, and Conjoint Lecturer at University of New South Wales Wagga Wagga Rural Referral Hospital, Sturt Hwy and Docker St, Wagga Wagga, NSW, Australia 2650 Joshua Wall Surgical Senior Resident, Westmead Hospital Astin Lee Consultant Cardiologist, The Wollongong Hospital Leigh White Anaesthetics Registrar, Caboolture Hospital, and Associate Lecturer at Department of Medicine, University of Queensland School of Medicine, University of Wollongong, NSW, Australia Correspondence to: Dr H Kempton (hrkempton@gmail.com (mailto:hrkempton@gmail.com)) Recognition and management of aVR STEMI: a retrospective cohort study January 2018 doi:10.5837/bjc.2018.004 (http://dx.doi.org/10.5837/bjc.2018.004) Page 1 of 6 Recognition and management of aVR STEMI: a retrospective cohort study | The British J... 5/7/2018 https://bjcardio.co.uk/2018/01/recognition-and-management-of-avr-stemi-a-retrospective-co... Figure 1. ST-elevation in aVR (https://bjcardio.co.uk/wp-content/uploads/2018/01/Screen-Shot2018-01-17-at-13.34.22.png) Identification of ST elevation on the electrocardiogram (ECG) is the cornerstone of diagnosis of ST-elevation myocardial infarction (STEMI). While lesion localisation can usually be achieved by regional ST-elevation patterns on ECG, clinicians often neglect changes in the ST segment of lead aVR, possibly contributing to delayed recognition and poorer outcomes for these patients. This study compared the ‘door-to-balloon time’ and peak troponins – as a surrogate marker of infarct size – for patients presenting with STEMI with ST-segment elevation in aVR compared with those patients without elevation in aVR. A total of 179 patients, including 17 patients presenting with ST-elevation in aVR, were included in this study. Patients presenting with elevation in aVR had significantly longer door-to-balloon times than those patients presenting with ‘traditional’ patterns of ST-elevation. There was, however, no significant difference in peak troponin as a marker of infarct size. While patients presenting with ST-elevation in lead aVR may have a delayed time to intervention, the present study does not suggest the use of aVR elevation as an indication for urgent angiography. Introduction The variety of electrocardiogram (ECG) changes that occur following acute myocardial infarction (AMI), occur in concordance with coronary circulation anatomy. ST-segment elevation in lead aVR can indicate an anterior wall AMI. However, lead aVR is commonly neglected by clinicians, and as such, this may be a potential source of adverse patient outcomes. The aim of this single-centre study is to investigate how proficiently AMIs presenting with aVR ST-elevation are recognised, using ‘door-to-balloon times’ as an outcome measure in patients having primary percutaneous coronary intervention (PCI) or those having elective PCI within 24 hours of acute coronary syndrome (ACS), with significant occlusion. The secondary objective was to determine whether poor recognition translates to larger infarction using a surrogate measure of peak troponin levels compared with patients meeting standard ST-elevation myocardial infarction (STEMI) criteria. A sample ECG demonstrating elevation in aVR is shown in figure 1. Materials and methods This was a retrospective cohort study performed at a single tertiary institution, using The Wollongong Hospital (TWH) catheterisation database. Ethics approval was granted by TWH and the University of Wollongong Human Research Ethics Committee. TWH catheterisation database was searched for non-ST-elevation myocardial infarction (NSTEMI) and STEMI patients over a two-year period ending December 2013. De-identified, coded data included: ECG and basic clinical and demographic data including age, gender, family history of cardiovascular disease, smoking status, hypercholesterolaemia, hypertension and diabetes mellitus. The First published online 23rd January 2018

Novel ECG changes in acute coronary syndromes. Would improvement in the recognition of 'STEMI-equivalents' affect time until reperfusion?

Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24xa0h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed ‘STEMI-equivalents’, have been described as a way of identifying this subgroup. The aim of this study was to determine whether patients with STEMI-equivalent ECG changes experience similar degrees of myocardial damage, and would thus benefit from urgent PCI. Cardiac catheterisation databases at The Wollongong Hospital were searched for STEMI, and NSTEMI patients with complete occlusion of the culprit vessel, between January 2011 and December 2013. A total of 1429 patients underwent angiography during this time period. Of these, 220 were eligible for ECG analysis. We found 10–25% of NSTEMIs with ‘STEMI equivalent’ ECG changes correlated with complete vessel occlusion on angiography. These patients demonstrated equivalent initial troponin readings. Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.

Recognition and management of posterior myocardial infarction: a retrospective cohort study

Characteristic electrocardiogram (ECG) features of posterior myocardial infarction (PMI) do not include typical ST-segment elevation and, therefore, carries the risk of delayed diagnosis and management. The aim of this study was to investigate how well PMIs are recognised and whether a lack of recognition translates to a larger infarction. This was a retrospective cohort study of patients sourced from a cardiac catheterisation database. Based on ECG analysis, patients included in this study included those meeting PMI criteria and those meeting ST-elevation myocardial infarction (STEMI) criteria as the control group. Door-to-balloon times were used as an outcome measure for differences in recognition between PMIs and other STEMIs. Troponin was used as a surrogate marker to measure degree of myocardial damage. There were 14 patients meeting PMI criteria and 162 meeting STEMI criteria. PMI patients had significantly longer door-to-balloon times. There was no statistically significant difference between PMI and STEMI group initial troponins t(169)=1.05, p=0.30, or peak 24-hour troponins t(174)=-1.73, p=0.09. In conclusion, using door-to-balloon times as a marker for recognition, this study illustrated that patients suffering PMI experience delayed recognition and management compared with non-PMI STEMIs. This did not, however, result in a significantly larger size of infarction as shown by peak troponin levels.