Patient_y_ACS_scenar..

In acute coronary syndrome scenario:
Which is the culprit artery? And Why?
Case from Raimundo Barbosa Barros MD
Coronary center Hospital de Messejana Dr. Carlos Alberto Studart Gomes
Fortaleza-Ceará-Brazil
Commentaries Andrés Ricardo Pérez-Riera MDPhD
Admission ECG June, 08, 2011 Midnight and forty-five minutes
ST elevations in the
right precordial leads
Necrosis, injury
and ischemia III
Second ECG June, 08, 2011 4 hours later after procedure
After percutaneous transluminal coronary angioplasty of the right coronary artery
COLLEAGUES OPPINION
Hello. This is not a straight-forward case. Maximal ST elevation in V2. Could be LAD or RCA.
Minimal ST elevation with inverted T in III. Inverted T in aVF. Reciprocal ST depression in I,
aVL with prominent T waves (reciprocal change of T inversion in III). If it was LAD, the artery
would extend to the inferior wall ("wrapping artery") and the lesion would be distal to LD1 In
that case one would not expect the ST elevations in the precordial leads to be highest in V1V3. Accordingly, I would expect the RCA to be the culprit artery and the occlusion to be
proximal to significant right ventricular/acute marginal branches. My guess is that it is a
rather small artery, but absence of reciprocal ST depression in V6 is, in my opinion, a bit
strange. Usually a small RCA with ST elevation (right ventricular transmural ischemia) in V1
results in reciprocal ST depression in V6. It is notable that the evolving stages of the inferior
and anterior changes are different. In III and aVF, there is evolving MI (inverted T waves), but
in V1-V4 there is hyperacute "preinfarction syndrome" (ST elevation without inverted T wave
or Q wave). At least theoretically, one would see this pattern in acute inferior STEMI, which
is subacute when a side branch has been occluded with a stent (side branch occlusion later
than the acute inferior STEMI).
Kind regards
Kjell Nikus
Tampere
Finland
Hi
Option 1: Prior occluded RCA with new proximal LAD, before 1st septal perforator.
Option 2: Proximal LAD (before 1st septal perforator) in a very large LAD that goes
around the apex.
Adrian B
Dear Andres,
This ECG is somewhat perplexing. Clearly there is an inferior myocardial infarction with Q
waves and ST elevation in lead III > lead II which suggests right coronary occlusion. The ST
elevation in V1-3 is more typical of anteroseptal injury due to proximal LAD disease. In some
cases there is a wrap around LAD that gets the inferior wall and results in inferior ST segment
elevation. Usually this occurs with an LAD lesion distal to the first diagonal with additional ST
changes in lateral precordial leads (not present in this case). I don’t think this is a wraparound LAD occlusion. I believe the ST elevation in V1-3 is an unusual manifestation of an
RV myocardial infarction – in which case I would expect additional ST elevation in the rightsided chest leads (V3R, V4R). If that is the case, then the culprit artery is a proximal RCA
occlusion.
I await the opinion of your colleagues.
Regards,
Frank Yanowitz MD
Professor of Medicine
University of Utah School of Medicine
Medical Director, ECG Department
LDS Hospital Salt Lake City, Utah
8th Ave. and C Street
Salt Lake City, Utah 84143 USA
[email protected];
[email protected]
Estimados colegas amigos mi interpretacion es: Artéria culpable es una coronária derecha
ocluida en su porcion inicial de dominante antes de la rama de VD con infarto agudo del
ventriculo derecho asociado a infarto agudo de cara inferior de VI. Porque ? por el analisis
de precordiales derechas con supradesnivel ST en VI-V2-V3.(expresion de la injuria de VD
) y de supradesnivel del segmento ST en III es expresión de injuria de cara inferior. Seria
interesante para confirmar, el registro de las precordiales derechas accesórias V3R y V4R
mas sensibles y
especificas ya que el segmento ST supradesnivelado en estas
derivaciones accesórias confirmarian lo anteriormente expuesto.
Síntesis: Infarto agudo de miocardio del ventrículo derecho asociado a infarto agudo de
miocardio inferior por oclusión de la porción proximal de la coronaria derecha.
Saludos
Juan José Sirena
----------------------------------------------------------------------------------------------------------------------------------
Dear colleagues and friends my interpretation is: proximal dominat right coronary
artery oclussion before the right ventricular branches of the right ventricle: acute
right ventricular myocardial infarction associated with inferior AMI of LV. Why?
Because right precordial leads ST segment elevation is expression of RV injury.
The ST segmente elevation in III is expression of injury in inferior wall. It would be
interesting to confirm with the registration of accessories right precordial leads
V4R and V3R. These leads are more sensitive and specifics. ST segment
elevation in theses leads would confirm the above mentioned.
Synthesis: Acute myocardial infarction of the right ventricle associated with
inferior myocardial infarction of LV by dominant proximal right coronary artery
oclussion.
Greetings Juan José Sirena MD Santiago del Estero Argentine
Mis queridos amigos del forum en relación a la arteria responsable es una arteria derecha
muy corta con una obstrucción proximal a la marginal derecha larga. Este patrón,
corresponde a una coronaria derecha pequeña y marginal larga. Esta es a la anatomia
clásica de los canes.
Porque coronaria derecha corta?: porque la unica derivación comprometida en la
pared inferior es III (sin afectar II).
Porque proximal ? porque V1 esta involucrada.
Porque larga? Porque V2 ,V3 estan involucradas que el septo izquiero alto y medio estan
irrigada por la marginal derecha porque V1 ,no es mas alta que V2 ya que el centro de la
isquemia en el septo derecho, expresada en V1 ?
porque V1 esta atenuada, porque V6 derecha esta con isquemia y ST/T el;evado ( 2 areas
electricamente opuestas con isquemia la altura del los ST-T se atenuan o concelan (
yo prefiero llamarla atenuada porque se que el ST ,tendria que ser mas elevado que V2 , y
este concepto es importante cuando decimos que cuanto mas elevado el segmento ST-T
mayor la isquemia.
En este ECG ocurre algo no usual: III se encuentra en la tercera etapa de reperfusión , es
decir con onda Q, segmento ST elevado y onda T invertida, talvez por haverse realizado
angioplastia, pero la marginal larga sigue obstruida, o por que no se vio que la arteria
estaba obstruida en la entrada, y el hemodinamista no vio el ECG , y no se abrió, Esto
evolucionará con infarto septal derecho e izquierdo, que a veces complica con ruptura
septal en su evolución. Con mi amigo Kjellnikus del hospital Universitario de Tampere ,
Finlandia hemos publicados mas de 20 trabajos de investigación accesibles en Google.
Nosotros hemos encontrado casos similares a este
Un frateral abrazo a todos los foristas
Samuel Sclarovsky
FINAL DIAGNOSIS
1)Right ventricular acute MI
2)Inferior acute MI of LV
Proximal RCA obstruction: Pseudo anteroseptal AMI It led to acute isolated right ventricular
ischaemia with ST elevations in the right precordial leads (V1-V3, V3R and V4R) on the
ECG. The ECG pattern of pure right ventricular ischaemia can be seen when an isolated
occlusion of a large right ventricular branch occurs, for example as a complication of
percutaneous transluminal coronary angioplasty1;2.
The prognosis of acute inferior myocardial infarction is worse when it is complicated
by right ventricular infarction. ST elevation in the right precordial leads is one of the
reliable methods for detecting acute right ventricular infarction. ST elevation in lead
V4R during acute inferior myocardial infarction predicts right ventricular systolic
dysfunction3.
In right ventricular infarction, the currents of injury usually occur simultaneously in the
right ventricular free wall and left ventricular inferior wall, and then are electrically
opposed to each other4.
1.
2.
3.
4.
van der Bolt CL, Vermeersch PH, Plokker HW Isolated acute occlusion of a large right ventricular branch of the right
coronary artery following coronary balloon angioplasty. The only true 'model' to study ECG changes in acute, isolated
right ventricular infarction. Eur Heart J. 1996 Feb;17:247-50.
Logeart D, Himbert D, Cohen-Solal A. ST-segment elevation in precordial leads: anterior or right ventricular myocardial
infarction? Chest. 2001 Jan;119:290-292.
Yoshino H, Udagawa H, Shimizu H, et al. ST-segment elevation in right precordial leads implies depressed right
ventricular function after acute inferior myocardial infarction. Am Heart J. 1998 Apr;135:689-695.
Kataoka H, Kanzaki K, Mikuriya Y. Marked ST-segment elevation in the precordial and inferior leads in right ventricular
myocardial infarction: a case report. J Cardiol. 1988 Jun;18:541-551.
RIGHT VENTRICULAR ACUTE MI
Right Ventricle irrigation1
1. Inferior and posterior walls: The PDA of the RCA.
2. Lateral wall: A. Mg
3. Anterior wall: Conus artery of the RCA and the moderator branch artery form LAD
Proximal RCA occlusions result in larger RV infarctions2
LCX occlusion eventually RV infarction
The classic clinical triad of RV acute MI includes3
1) Distended neck veins
2) Clear lung fields
3) Hypotension
1.
2.
3.
Forman MB, Goodin J, Phelan B. Electrocardiographic changes associated with isolated right ventricular infarction. J
Am Coll Cardiol. Sep 1984;4(3):640-643.
Giannitsis E, Potratz J, Wiegand U. Impact of early accelerated dose tissue plasminogen activator on in- hospital
patency of the infarcted vessel in patients with acute right ventricular infarction. Heart. Jun 1997;77:512-516.
Mavric Z, Zaputovic L, Matana A. Prognostic significance of complete atrioventricular block in patients with acute
inferior myocardial infarction with and without right ventricular involvement. Am Heart J. Apr 1990;119:823-828.
RV IRRIGATION
The different segments of the right ventricular chamber are irrigated in this way:
1)
2)
3)
4)
5)
RV free wall: RCA truncus, except the anterior edge;
RV lateral wall: acute marginal branch (Ac Mg) or ramus marginalis dexter;
RV anterior surface: right ventricular branch of the RCA;
RCA cone branch: part of the septum;
Posterior descending: (in 86% of the cases, RCA branch): RV posterior wall. In
14% of the cases, the PD is the branch of the Cx.
Note: in a small percentage of cases, the branches of the anterior descending
artery (ADA) irrigate part of the RV. This happens with prolonged ADA, called type
IV ADA, which surround the tip.
Right ventricle irrigation.
RIGHT VENTRICULAR MYOCARDIAL
INFARCTION (RVMI)
CLINICAL CHARACTERIZATION
Typical precordial pain that lasts, associated with characteristic signs of right ventricular
failure:
1)
2)
3)
4)
5)
Low blood pressure (BP below 90 mmHg) or shock;
Jugular vein and liver congestion with clean lungs;
Fourth noise with right ventricular gallop that increases with inspiration;
Possible presence of Kussmaul’s sign: jugular distension at deep inspiration;
Paradoxical pulse.
It is seen in patients who suffered acute infarction in the inferior, (24%) infero-dorsal, inferolatero-dorsal or strictly posterior wall, and when present, it increases hospital mortality very
much. Thus, hospital mortality by inferior infarction associated to RVMI is 27%; while when
isolated is only 7%. There are rare cases of severe isolated RVMI by proximal injury of the
RCA with no signs of infarction in the LV inferior wall.
Clinical characteristics of right ventricle infarction.
ELECTROCARDIOGRAPHY
All patients with inferior wall MI should have a right-sided precordial leads.
ST-segment elevation in lead V4R is the single most powerful predictor of RVMI, The ST-segment
elevation is transient, disappearing in < 10 hours following its onset in half of patients. The following
table demonstrates the sensitivity and specificity of > 1 mm of ST-segment elevation in V1, V3R,
and V4 R1.
LEADS
SENSITIVITY(%)
SPECIFICITY(%)
V1
28
92
V3R
69
97
V4R
93
95
Isolated RVMI is extremely rare and may be interpreted erroneously as LV anteroseptal
infarction on ECG because of ST-segment elevation in leads V1 -V42;3.
The mean ST-segment lesion vector in RVMI usually is directed anteriorly and to the
right: >100°.
1.
2.
3.
Roth A, Miller HI, Kaluski E. Early thrombolytic therapy does not enhance the recovery of the right ventricle in patients
with acute inferior myocardial infarction and predominant right ventricular involvement. Cardiology. 1990;77(1):40-9.
Schuler G, Hofmann M, Schwarz F. Effect of successful thrombolytic therapy on right ventricular function in acute
inferior wall myocardial infarction. Am J Cardiol. Nov 1 1984;54:951-957.
Sharpe
DN,
Botvinick
EH,
Shames
DM.
The
noninvasive
diagnosis
of
right
ventricular
infarction. Circulation. Mar 1978;57:483-490.
ISOLATED RIGHT VENTRICULAR INFARCTION
DI
aVR
V1
V1
V4
DII
aVL
V3R
V2
V5
DIII
aVF
V4R
V3
V6
Isolated right ventricular infarction without left ventricle involvement, subepicardial injury current recorded in V1,V3R and V4R.
Typical ECG of right ventricle infarction (very rare and isolated).
ISOLATED RIGHT VENTRICULAR INFARCTION
MODIFICATIONS IN ACCESSORY RIGHT PRECORDIAL LEADS
RV
NECROSIS
V4R
V3R
V6
RV
V5
V1
V2
V3
V4
Precordial leads in right ventricle infarction. Value of accessory precordial leads (V3R and V4R).
ISOLATED RIGHT VENTRICULAR INFARCTION
LEFT SAGITTAL VIEW
V4R
Z
V3R
Y
aVF
Electro-anatomical correlation of an isolated right ventricle infarction, in a left sagittal view.
ISOLATED RV
INFARCTION (EXCEPTIONAL)
VIEW IN THE MINOR AXIS
V3R
IT MAY CAUSE ST SEGMENT
ELEVATION IN V1-V4
CAUSING CONFUSION WITH
LV ANTERO-SEPTAL
INFARCTION.
RV INFARCTION ASSOCIATED
TO INFERIOR INFARCTION
VIEW IN THE MINOR AXIS
V3R
Y
aVF
Y
aVF
Electro-anatomical differences in isolated RV infarction and associated with
diaphragmatic infarction of the left ventricle
DIFFERENCES BETWEEN ISOLATED INFERIOR
INFARCTION AND ASSOCIATED TO RIGHT
VENTRICULAR INFARCTION
ISOLATED INFERIOR
INFARCTION
INFERIOR INFARCTION
ASSOCIATED TO RIGHT
VENTRICULAR
INFARCTION
No
Frequent
Negative
Positive
High degree of AV
block
13%
48%
ST segment elevation
from V4R to V6R
Absent
Present
Signs of right heart
failure
Kussmaul’s sign
Braat SH, et al. Am Heart J. 1984;107: 1183-1187
Comparative table between isolated inferior infarction and the one associated with right
ventricle infarction.
ECG CRITERIA FOR RV AMI DIAGNOSIS
ƒ
Rhythm: frequent atrial fibrillation, flutter, changing
pacemaker, and junctional rhythm by associated atrial
infarction (1/3 of patients present concomitant atrial
infarction).
ƒ
P wave: there may be RAE pattern as a consequence
of increase of right atrial pressure by increase of RV
final diastolic pressure.
ƒ
PR or PQ interval: Displacement of this interval (depression or elevation), which
represents part of the atrial ST(STa) segment only ostensive when associate with
AV block as a consequence of atrial infarction.
Electrocardiographic criteria of right ventricle infarction.
ECG CRITERIA FOR RV AMI DIAGNOSIS
ƒST segment: transitory ST segment elevation of 1 mm (0.1 mV)
or more in at least one of the right precordial leads V3R, V4R V5R
V6R. The sensitivity of the ST elevation sign in V4R is 100% and
specificity is 70%. The right precordial leads should always be
mapped in patients with diaphragmatic infarction and suggestive
clinical symptoms.
Generally, this infarction is associated with LV inferior wall
infarction.
Electrocardiographic criteria of right ventricle infarction.
AMI consequence of proximal RCA occlusion complicated with sinus bradicardia,
first-degree AV block and RV envolvement: ST segment elevation followed by
positive T wave in V4R
ST segment depression
SIII>SII
MIRROR IMAGE OF V7, V8 AND V9
ST segment elevation in inferior leads
V4R
ST-segment elevation in lead V4R is the single most powerful predictor of RVMI
AMI consequence of proximal occlusion RCA complicated with 2:1 AV block and
right ventricular envolvement: ST segment elevation in V4R followed by positive T
wave
P
P
P
P
P
P
V4R
Third degree AV block consequence of AMI by obstruction of RCA. QRS complexes
are narrow indicating suprahisian block.