Takayasu Arteritis Presenting With Cardiac Arrest

ST-Segment Elevation in Electrocardiogram Lead aVR

BackgroundExercise-induced ST-segment elevation (STE) in lead aVR may be an important indicator of prognostically important coronary artery disease (CAD). However, the prevalence and associated clinical features of exercise-induced STE in lead aVR among consecutive patients referred for exercise stress electrocardiography (ExECG) is unknown.MethodsAll consecutive patients receiving a Bruce protocol ExECG for the diagnosis of CAD at a tertiary care academic center were included over a two-year period. Clinical characteristics, including results of coronary angiography, were compared between patients with and without exercise-induced STE in lead aVR.ResultsAmong 2227 patients undergoing ExECG, exercise-induced STE ≥1.0mm in lead aVR occurred in 3.4% of patients. Patients with STE in lead aVR had significantly lower Duke Treadmill Scores (DTS) (-0.5 vs. 7.0, p<0.01) and a higher frequency of positive test results (60.2% vs. 7.3%, p<0.01). Furthermore, patients with STE in lead aVR were more likely to undergo subsequent cardiac catheterization than those without STE in lead aVR (p<0.01, odds ratio = 4.2).ConclusionsAmong patients referred for ExECG for suspected CAD, exercise-induced STE in lead aVR was associated with a higher risk DTS, an increased likelihood of a positive ExECG, and referral for subsequent coronary angiography. These results suggest that exercise-induced STE in lead aVR may represent a useful ECG feature among patients undergoing ExECG in the risk stratification of patients.

PREVALENCE OF EXERCISE INDUCED ST-SEGMENT ELEVATION IN LEAD AVR

Exercise-Induced ST-Segment Elevation in ECG Lead aVR Is a Useful Indicator of Significant Left Main or Ostial LAD Coronary Artery Stenosis

Previous researches proved that the ST-segment elevation (STE) in lead aVR had great significance on the prediction of severe left main lesion or serious multivessel lesions. The current research is to summarize the published data and evaluate the overall association of STE in lead aVR and left main coronary artery disease (LMD) in Non-ST-elevation acute coronary syndrome. Literature searching was performed in the online database, and a systematic review was conducted based on the searched results. Meaningful STE in lead aVR was summarized and analyzed for odds ratio (OR) and 95% confidence intervals (95% CI). Twenty-seven articles were included for final data analysis. Compared with STE<0.05, STE≥0.05mV was associated with a higher incidence rate of LMD (OR=6.64, 95% CI: 4.80~9.17), and the degree of STE in lead aVR was significantly associated with LMD. Myocardial infarction was more likely to occur in patients with STE≥0.05mV than in patients with STE<0.05mV (OR=3.12, 95% CI: 1.73~5.62). The STE in lead aVR and the degree of STE are independent predictors in diagnosing LMD or myocardial infarction.

Background: As acute occlusion of the left main (LM) artery causes life-threatening hemodynamic deterioration and malignant arrhythmias, resulting in an adverse outcome, a rapid diagnosis and subsequent urgent revascularization with percutaneous coronary intervention (PCI) or coronary bypass surgery is very important in this subset of patients. The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years.&#x0D; Objective: To determine the accuracy of 12-lead electrocardiography in predicting left main and/or triplevessel disease in patients with non-ST elevation acute coronary syndrome (NSTE- ACS). Methodology: This cross sectional observational study carried out among patients presenting with non-ST elevation acute coronary syndrome at Cardiac Emergency Department or CCU of BSMMU. This study was conducted from May 2017 to April 2018. A total of 36 patients meeting the eligibility criteria were consecutively included. Data collection was carried out by using a questionnaire. Informed written consent was obtained from the hospital authority. Analysis of data was finally done with Statistical Package for Social Science program 17 version of computer on the basis of different variables.&#x0D; Result: As ST-segment elevation in lead aVR is a continuous variable, a suitable cut-off for ST- elevation in lead aVR was found out for diagnosing LM and/or triple vessel disease (TVD) using ROC curve. The cut-off value was 0.75 mm which gave us an optimum sensitivity of 88.5% and a specificity of 80% with an area under the curve being 0.892(95% CI = 0.785-1.000), p &lt; 0.001. The area under the curve demonstrated that 89.2% of the LM and/or TVD were correctly diagnosed with ST elevation e” 0.75 mm in lead aVR in patients with non-ST segment elevation acute coronary syndrome. The positive predictive value was commendably high (92%) and negative predictive value was no less (72.7%) with an overall diagnostic accuracy of 86%.&#x0D; Conclusion: From the findings of the study it can be concluded that ST- segment elevation e”0.75 mm in lead aVR in patients of non-ST segment elevation acute coronary syndrome had optimum sensitivity and specificity with an appreciably high overall diagnostic accuracy. The ST- segment elevation e”0.75 mm in lead aVR in patients with non-STE-ACS can differentiate LM and/or triple vessel disease with fair degree of accuracy.&#x0D; University Heart Journal Vol. 14, No. 2, Jul 2018; 71-76

Background Atherosclerosis is the ongoing process of plaque formation involving primarily the intima of large and medium-sized arteries. The condition progresses relentlessly throughout a person’s lifetime, before finally manifesting itself as an acute ischemic event. TIMI score is a tool of 7 points for patients with NSTE-ACS to detect the risk according to the score. The term acute coronary syndrome (ACS) includes unstable angina (UA), non STsegment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Aim To investigate the added value of the presence of ST-segment elevation in lead avR on admission electrocardiogram to the (TIMI) clinical scoring system in predicting the angiographic severity of coronary artery disease in patients admitted with NSTE-ACS. Patients and Methods 150 patients with Non ST-segment elevation acute coronary syndrome was included from Cardiology Department, Ain Shams University Hospital, Cairo, Egypt. Results From those patients, 137 patients (91.3%) diagnosed by coronary angiography to have significant CAD and 93 patients (62%) had ST-Elevation in lead aVR . These 137 patients were divided into 3 groups according to TIMI risk score to 16 patients (10.6%) had low risk score, 63 patients (42.0%) had intermediate risk &amp; lastly 58 patients (38.7%) had high risk score. . Although being useful in prediction of multi-vessel &amp; LM involvement among high risk group, TIMI score failed to predict the same in intermediate &amp; low risk groups where multi-vessel involvement was found in 46 patients (30.6%) &amp; 7 patients (4.6%) of intermediate &amp; low risk groups respectively. Also LM involvement was found in 15 patients (10%) &amp; 2 patients (1.3%) of intermediate &amp; low risk groups respectively. Conclusion ST-segment elevation (STE) in lead avR had an adding predicting value in NSTEACS patients especially those with low to intermediate TIMI score. Adding the value of STE in lead aVR to TIMI risk score may improve the early stratification &amp; management of those patients at high risk coronary artery disease, with subsequent impact on morbidity &amp; mortality.

Prognostic Value of ST-Segment Elevation in Lead aVR in Patients With Type A Acute Aortic Dissection

The aVR sign characterized by ST-segment elevation in lead aVR and diffuse ST-segment depression on the electrocardiogram indicates potential life-threatening conditions. We report the case of a 53-year-old male with a history of ascending aortic replacement for acute aortic dissection, who presented to our institution in shock. The initial electrocardiogram revealed the aVR sign, consisting of ST-segment elevation in lead aVR and ST-segment depression in leads II, III, aVF, and V3-6, leading to the initiation of salvage veno-arterial extracorporeal membrane oxygenation (ECMO) due to deteriorating hemodynamics. The aVR sign resolved shortly after ECMO initiation, and hemodynamics stabilized even with reduced ECMO flow. Subsequent coronary angiography showed no impaired coronary perfusion, whereas contrast-enhanced CT revealed severe supra-valvular stenosis due to pseudoaneurysm-induced graft kinking. The patient was then managed with emergency surgery for the pseudoaneurysm. In this report, we encountered a salvaged case of critical circulatory failure presenting with the aVR sign due to severe graft kinking caused by pseudoaneurysm formation.

A 54-year-old man with dyslipidemia had smoked 1 pack of cigarettes per day for many years and recently had been experiencing chest pain on exertion and at rest. He came to the hospital because of a more severe episode of chest pain, and an electrocardiogram was recorded (Figure). He was on no medication. Figure Electrocardiogram recorded on admission. The rhythm is sinus arrhythmia at a rate of 99 beats/min. Striking ST-segment depression is present in all leads except aVR, aVL, and V1, and in each of those three leads there is ST-segment elevation, most marked ... Patients with ischemic symptoms at rest and ST-segment depression in 8 or more leads with reciprocal ST-segment elevation in leads aVR and V1 have a 70% likelihood of having severe left main or three-vessel coronary arterial narrowing (1, 2). Because the injury current caused by diffuse subendocardial ischemia engendered by severe left main coronary arterial narrowing is directed away from the left ventricular cavity and directly toward lead aVR, when ST elevation in aVR exceeds ST elevation in V1, the left main is likely the culprit artery (3). Furthermore, the magnitude of ST-segment elevation in lead aVR correlates directly with mortality in patients with their first acute non–ST-segment-elevation myocardial infarct (4). In patients with occlusion of the left main coronary artery, ST-segment elevation in both aVR and aVL (Figure) predicts increased mortality (5). Thus, our patient had electrocardiographic features suggesting left main coronary arterial disease and a poor prognosis. An increased serum troponin concentration (peak 0.58 ng/mL; reference, <0.05) and recurrent chest pain after coming to the hospital also indicated a high risk for an adverse outcome (6), and because high-risk patients benefit from an early invasive strategy (7, 8), he underwent cardiac catheterization and angiography. His left ventricular pressure was 140/12 mm Hg, and left ventriculography showed a normal-sized ventricle with anteroapical hypokinesis, an ejection fraction of 50%, and no mitral regurgitation. Coronary arteriography revealed a 95% narrowing of the distal left main coronary artery, luminal irregularities in the left anterior descending coronary artery, a 50% stenosis in the left circumflex coronary artery, and a 60% to 70% narrowing in the mid portion of the right coronary artery, which gave collaterals to the left anterior descending artery. An abdominal aortogram showed a 50% narrowing of the ostium of the right renal artery, complete occlusion of the proximal portion of the left common iliac artery with bridging collaterals, 75% narrowing of the proximal right common iliac artery by a complex plaque, and 70% narrowing at the ostium of the right internal iliac artery. The left subclavian artery had luminal irregularities, and the left internal mammary artery was free of disease. Balloon dilation and placement of a 10 mm × 4 cm stent completely eliminated the stenosis in the right common iliac artery, and through it a 40 cc intraaortic balloon was placed and pumping was begun. The following day the patient underwent three-vessel coronary arterial bypass grafting using the left internal mammary artery to the left anterior descending coronary artery and saphenous vein grafts to the first obtuse marginal branch of the left circumflex coronary artery and the posterior descending branch of the right coronary artery. The patient had an uneventful postoperative course and was discharged on the fourth postoperative day on metoprolol, simvastatin, and aspirin.

A young 18-year-old female patient with exertional angina and claudication of the upper limbs was subjected to angiography. Bruits were auscultated over the bilateral renal arteries, right subclavian and right...

Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course (L-ACAOS-IM) can cause syncope, sometimes as a prodrome of lethal events, including sudden cardiac death, in young athletes. The detailed mechanism of syncope in patients with L-ACAOS-IM is still unclear. This case report describes a 17-year-old boy who presented to the hospital because of syncope following chest pain with increasing frequency during exercise, such as playing soccer and running. In a treadmill exercise test, a decrease in blood pressure was seen (from 99/56 mm Hg to 68/38 mm Hg); chest pain and faintness accompanied by ST-segment elevation in lead aVR and ST-segment depression at other leads on electrocardiography were noted. These findings and symptoms disappeared spontaneously within a few minutes while clinicians prepared for emergency medications. Coronary computed tomography angiography (CCTA) showed that the origin of the left coronary artery (LCA) was the opposite sinus of Valsalva, and the course of the LCA was through the aortic wall toward the left coronary sinus. He was diagnosed with L-ACAOS-IM. After surgical treatment by unroofing the intramural part of the LCA and reconstructing a neo-ostium, he no longer experienced syncope during exercise. This case suggests that low cardiac output caused by myocardial ischemia, not life-threatening arrythmia, is a main mechanism of syncope in patients with L-ACAOS-IM. Consideration should be given to performing CCTA before an exercise stress test for young patients with syncope and chest pain to avoid the risk of severe myocardial ischemia.

Introduction The use of ST-segment elevation (STE) in lead aVR in addition to thrombolysis in myocardial infarction (TIMI) risk score may improve the early risk stratification and the management of patients at high-risk coronary artery disease, with subsequent effect on morbidity and mortality. Patients and methods A total of 65 patients who underwent coronary angiograms in Sohag Heart Specialized Center in the period between September 2013 and March 2014 were the participants of the study. All patients were subjected to full history taking, clinical evaluation, laboratory investigations, ECGs, TIMI scoring, and coronary angiography by femoral approach. Results Of the 65 patients, 59 patients were found to have significant coronary artery disease with 39 of them had STE in aVR lead, and none of the normal coronary angiography (CA) cases had STE in this lead. Of the 39 with STE-aVR, 13 patients had left main disease and 30 of them had multivessel disease. ST-aVR was elevated in 17 cases with low or intermediate risk according to TIMI score (9.1 and 55% of both groups, respectively), and was normal in three (12%) of the patients with high-risk TIMI score. Thus, STE-aVR could predict another 28.8% of high-risk cases that would not be detected by TIMI. Conclusion STE in lead aVR has a diagnostic and prognostic value in patients with non-STE acute coronary syndrome and may provide an additional prognostic value to the conventional cardiovascular risk factors, particularly in patients from the TIMI low-risk and intermediate-risk groups.

The significance of electrocardiographic changes during exercise tolerance testing for distinguishing occluded artery is not well known. We tried to determine the role of ST elevation in leads aVR and V1 during exercise in detecting stenosis of left main coronary artery and proximal left anterior descending artery. ST segment changes during exercise in 230 patients, who underwent diagnostic angiography, were documented. The association of ST elevation in lead aVR, V1 , leads aVR + V1 , and STE in leads aVR + V1 with ST depression in other leads with pattern of coronary stenosis were investigated. Left main and proximal left anterior artery stenosis were more common in patients with ST elevation in lead aVR (P < 0.001 for both). Similar association was found in the presence of ST elevation in lead V1 . The presence of ST elevation ≥1 mm in lead aVR had a sensitivity of 100% and 94.3% for detecting left main and left anterior descending artery stenosis, respectively. The specificity was 33.5% and 26.6%, respectively. ST elevation in leads aVR + V1 had a sensitivity of 74.4% and 65.9% and a specificity of 68.5% and 64.4% for detecting left main and left anterior descending arteries stenosis, respectively. ST elevation in lead aVR is highly sensitive for left main and proximal left anterior descending artery lesions. Using ST elevation in lead V1 in addition to lead aVR as a positive finding increases the specificity with a further decrease in sensitivity.

Utility of Exercise-Induced ST-Segment Elevation in Lead aVR for Detecting Left Main or Proximal Left Anterior Descending Disease