ST segment elevation in COVID-19-related pulmonary embolism.

Background: Long-term survival after out-of-hospital cardiac arrest (OHCA) has improved in the last decade with special focus on the post cardiac arrest syndrome. Therapeutic hypothermia and percutaneous coronary intervention (PCI) are the two most important in-hospital interventions. International guidelines recommend aggressive use of coronary angiography in patients with ST segment elevation myocardial infarction (STEMI), but it is not clear if also patients without ST elevation should undergo early coronary angiography (ECA). The aim of the study was to document outcome in all OHCA patients of cardiac etiology, with special focus on angiographic findings and survival among patients with or without ST segment elevation. Methods: All patients admitted to our hospital after primary resuscitated OHCA are registered in our Post-resuscitation care registry. Electrocardiogram (ECG), coronary angiographic findings and overall survival of patients admitted in 2008 with cardiac etiology were investigated retrospectively by reviewing medical charts. Patients were classified according to the presence of ST segment elevation on post-resuscitation ECG or not. Results: Altogether 62 patients were included. ST elevation was present in 33 (53%) patients in whom all underwent ECA, 24 (73%) had an acute coronary occlusion, 5 (15%) had old occlusions, 17 (51%) had multivessel disease, and 29 (88%) received PCI. Among the 29 (47%) patients without ST elevation, 24 (83%) underwent ECA, of whom 5 (17%) had an acute coronary occlusion, 12 (50%) had old occlusions, 18 (75%) had multivessel disease, and 12 (38%) received PCI. In total, 60% of the patients were treated with therapeutic hypothermia with no difference between the two groups. Overall survival was 64% and 59% in patients with and without ST elevation, respectively (ns). Conclusion: Overall survival after OHCA of cardiac etiology was good, with no difference between patients with or without ST segment elevation. The presence of ST elevation on ECG was highly associated with the presence of an acute coronary occlusion, but a substantial proportion of patients without ST elevation also had coronary occlusions treated by PCI and more studies are warranted to determine whether all patients should undergo ECA.

• Several cardiovascular/hemostatic disturbances haves been reported in patients with COVID-19, but the real frequency and their potential association with the pathogenic mechanisms of SARS-CoV-19 still remain to be defined. • We investigated the relative frequency of acute coronary syndrome, deep venous thrombosis, pulmonary embolism, stroke and upper gastrointestinal bleeding in COVID patents attending emergency departments (EDs), before hospitalization and compared them with frequencies in the general ED population attending 50 Spanish EDs. • We found that the risk of pulmonary embolism is clearly increased in COVID patients, with an OR of 4.53 with respect to non-COVID patients (95% confidence interval 4.03- 5.10). Additionally, the diagnosis of pulmonary embolism was 2 fold more frequent among ED comers in 2020 compared to 2019, suggesting a SARS-CoV-2 role in such increment of cases.. The remaining entities studied were not found to be unequivocally increased in the present study and need further investigation.

ST-segment elevation on a post-cardiac arrest electrocardiogram (ECG) is traditionally viewed as a hallmark of acute coronary occlusion. However, this finding can also arise from non-coronary etiologies like massive pulmonary embolism (PE), creating a high-stakes diagnostic dilemma. An 83-year-old woman hospitalized for trauma developed cardiac arrest with pulseless electrical activity (PEA). Immediate post-resuscitation ECG showed marked ST-segment elevation in leads V1-V4, II, III, and aVF, suggesting extensive myocardial infarction. A point-of-care echocardiogram showed severe right ventricular dilation, raising the suspicion of PE, which was confirmed by computed tomography. Fortuitously, a Holter monitor was attached, capturing the sequence of ECG changes before and after the onset of PE. It revealed that ST-segment elevation appeared after the onset of cardiac arrest and gradually decreased thereafter. The patient was successfully treated with anticoagulation. This case suggests that post-arrest ST-segment elevation in PE may reflect dynamic right ventricular strain and supply-demand mismatch, rather than fixed coronary occlusion.Recognizing the "dynamic" nature of these ECG changes, alongside rapid echocardiographic assessment, is essential to avoid unnecessary emergent coronary angiography and ensure timely treatment for PE.

Circumflex artery related myocardial infarction: Less reperfusion therapy and large infarct size

Electrocardiographic features of patients with COVID-19: One year of unexpected manifestations

To evaluate, in patients with chest pain, the diagnostic value of ST elevation (STE) in lead aVR during stress testing prior to (99m) Tc-sestamibi scanning correlating ischaemic territory with angiographic findings. Consecutive patients attending for (99m) Tc-sestamibi myocardial perfusion imaging (MPI) completed a treadmill protocol. Peak exercise ECGs were coded. STE >or=0.05 mV in lead aVR was considered significant. Gated perfusion images and findings at angiography were assessed. STE in lead aVR occurred in 25% (138/557) of the patients. More patients with STE in aVR had a reversible defect on imaging compared with those who had no STE in aVR (41%, 56/138 vs 27%, 114/419, p=0.003). Defects indicating a left anterior descending artery (LAD) culprit lesion were more common in the STE in aVR group (20%, 27/138 vs 9%, 39/419, p=0.001). There was a trend towards coronary artery stenosis (>70%) in a double vessel distribution involving the LAD in those patients who had STE in aVR compared with those who did not (22%, 8/37 vs 5%, 4/77, p=0.06). Logistic regression analysis demonstrated that STE in aVR (OR 1.36, p=0.233) is not an independent predictor of inducible abnormality when adjusted for STD >0.1 mV (OR 1.69, p=0.026). However, using anterior wall defect as an end-point, STE in aVR (OR 2.77, p=0.008) was a predictor even after adjustment for STD (OR 1.43, p=0.281). STE in lead aVR during exercise does not diagnose more inducible abnormalities than STD alone. However, unlike STD, which is not predictive of a territory of ischaemia, STE in aVR may indicate an anterior wall defect.

Seventy-eight consecutive survivors of a first acute anterior Q wave myocardial infarction (AMI) underwent two-dimensional echocardiography (2D echo), colour Doppler echo and radionuclide angiography (RNA) for the diagnosis of left ventricular (LV) anteroapical aneurysm, in order to study the relationship of this complication to precordial ST segment elevation in these patients. The ST elevation (mm) in lead V2, the maximum ST elevation in V1-V6 and the sum of ST elevation in V1 to V6 were calculated. LV aneurysm was present in 19 patients by 2D echo, of whom 12 had a paradoxical systolic flow pattern (red and outward towards the transducer) at the apex. There was no difference between the mean ST elevation in V2 or the maximum ST elevation in V1-V6 in patients with and without an aneurysm, although the sum of ST elevations in V1 to V6 was higher in the former group (P < 0.01). ST elevation of patients with and without paradoxical systolic flow also did not differ significantly. Wall motion abnormality (akinesis and dyskinesis) by 2D echo in the anterior wall was seen in 74% of patients with and 36% of patients without an aneurysm (P < 0.005), and in the septal region in 63% and 47% of respective patients (P-NS). There was no difference between the magnitude of ST elevation in subgroups of patients with ejection fraction (EF) < or = 30% to > or = 40%, but the mean EF of patients with (23 +/- 2.1%) and without a LV aneurysm (34 +/- 1.3%) differed (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Elevation of ST segment in leads V3R/ V4R, which is commonly encountered in right ventricular 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. We aimed to investigate the prognostic value of ST segment elevation in leads V3R/V4R in patients with first acute anterior myocardial infarction. Prospective cohort study. Right precordial leads V3R/V4R were recorded in 111 patients admitted with first time anterior myocardial infarction. Patients were allocated into two groups based on the presence or absence of ST elevation in leads V3R/V4R. Demographic, biochemical and echocardiographic data, as well as the angiographic information, were recorded. In-hospital and 3 month mortality, and major adverse cardiac events (MACE), death, heart failure and ventricular dysrhythmia were also compared. ST elevation in lead V3R or V4R was present 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 patients with elevation vs. 53.8% of patients without elevation, p=0.22). Post-myocardial infarction complications, mortality and major adverse cardiac events were similar in the two groups. Left ventricular ejection fraction (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]. Although ST elevation in V3R/V4R can be present in patients with left anterior descending artery 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 issue needs further investigation.

ACUTE ST SEGMENT ELEVATION IN A PATIENT WITH MASSIVE PULMONARY EMBOLISM MIMICKING ACUTE LEFT MAIN CORONARY ARTERY OBSTRUCTION

Right Ventricular Infarction

The significance of ST segment elevation in dobutamine stress echocardiography (DSE) remains controversial. In patients with prior Q wave myocardial infarction (MI), it may reflect myocardial ischemia, contractile reserve in the infarct-related area, or dyskinesia of the infarcted areas of myocardium. In the nonpost-MI population, it has been attributed to vasospasm or strongly associated with coronary artery disease and ischemia. We hypothesized that ST segment elevation in the absence of inducible ischemia or prior MI is related to the presence of left ventricular hypertrophy (LVH). During DSE, dobutamine was infused from 5 microg/kg/min up to a maximum of 50 microg/kg/min. Echocardiographic images were obtained at baseline, low dose, peak dose, and recovery. Ischemia was defined as either the development of a new wall-motion abnormality or worsening wall motion at peak dose. We reviewed 682 consecutive DSE tests and found ST elevation in 42 patients (incidence = 6.1%). After excluding two patients for > 10% uninterpretable echocardiographic segments, the study population consisted of 40 patients. In 25 patients with ST elevation and without echocardiographic evidence for dobutamine-induced ischemia, 21 (84%) patients had LVH (P = 0.001). In 15 patients with inducible ischemia, only 4 (27%) patients had LVH. No other significant differences were found except that prior MI was more common in the inducible ischemia group. In the subgroup of 18 patients without prior MI, no inducible ischemia was found in 15 (83%). LVH was present in 14 (93%) of these 15 patients (P < 0.005), and all 14 had a normal baseline left ventricular ejection fraction. None of the three patients in the nonpost-MI subgroup with inducible ischemia had LVH. The 22 patients with prior MI had no significant association with LVH (P = 0.39). We conclude that ST segment elevation during DSE can occur without echocardiographic evidence for ischemia and is associated with LVH in the nonpost-MI population. This ST elevation may be related to transient electrocardiographic repolarization changes in the hypertrophied ventricle in the presence of altered loading conditions and/or altered catecholamine influences rather than true ischemia.

Pulmonary thromboembolism (PTE) is a major cause of cardiovascular mortality that can present with nonspecific symptoms leading to delay in diagnosis and initiation of therapy. The electrocardiogram (ECG) is one of the first examinations to be performed in cases of suspected PTE. ECG abnormalities can be seen, varying from the typical S1Q3T3 pattern to non specific changes. However, only very rarely does a PTE produce an ECG pattern mimicking ST-segment elevation myocardial infarction. We present a case with resuscitated out-of-hospital cardiac arrest showing a ST-segment elevation in leads V1-V4. Coronary angiography showed coronary arteries without lesions and pulmonary angiography showed a massive PTE. We describe the changes of the ECG and the importance of the recognition of ST-segment elevation in right precordial leads as a sign of massive PTE.

Acute pulmonary embolism with ST-segment elevation in the inferior leads

The Diagnosis

To test the hypothesis that Qr in V(1)is a predictor of pulmonary embolism, right ventricular strain, and adverse clinical outcome. ECG's from 151 patients with suspected pulmonary embolism were blindly interpreted by two observers. Echocardiography, troponin I, and pro-brain natriuretic peptide levels were obtained in 75 patients with pulmonary embolism. Qr in V(1)(14 vs 0 in controls; p<0.0001) and ST elevation in V(1)> or =1 mV (15 vs 1 in controls; p=0.0002) were more frequently present in patients with pulmonary embolism. Sensitivity and specificity of Qr in V(1)and T wave inversion in V(2)for predicting right ventricular dysfunction were 31/97% and 45/94%, respectively. Three of five patients who died in-hospital and 11 of 20 patients with a complicated course, presented with Qr in V(1). After adjustment for right ventricular strain including ECG, echocardiography, pro-brain natriuretic peptide and troponin I levels, Qr in V(1)(OR 8.7, 95%CI 1.4-56.7; p=0.02) remained an independent predictor of adverse outcome. Among the ECG signs seen in patients with acute pulmonary embolism, Qr in V(1)is closely related to the presence of right ventricular dysfunction, and is an independent predictor of adverse clinical outcome.