Predicting the culprit artery in acute ST-elevation myocardial infarction and introducing a new algorithm to predict infarct-related artery in inferior ST-elevation myocardial infarction: correlation with coronary anatomy in the HAAMU Trial
Introduction
Without doubt, the electrocardiogram (ECG) is the most useful and feasible tool for the initial evaluation, early risk stratification, triage, and guidance of therapy in patients with a suspicion of an acute ischemic event.1 Especially in ST-elevation acute coronary syndrome, the ECG from the acute phase contains important information about the site and size of the area at risk, aiding in selection of appropriate therapy for the individual patient.2, 3, 4 Use of the ECG to predict the culprit artery and even the location of the culprit lesion within the infarct-related artery could provide clinically important information to augment clinical decision making and tailor reperfusion therapy.5, 6 Electrocardiogram-based individual risk stratification has been proposed as an alternative to the recently adopted “trauma center” treatment algorithm for urgent transport of practically all patients with ST-elevation myocardial infarction (STEMI) to invasive centers for primary percutaneous coronary intervention (PCI) on a 24/7 basis. Especially in geographic regions with long transport distances, “optimized” ECG analysis, including estimation of size of the area-at-risk and the severity of the ischemic process complemented with data on clinical findings, should be considered as an important part of the decision-making process.7
In most cases of anterior STEMI, the left anterior descending coronary artery (LAD) is the culprit artery. However, in inferoposterior STEMI, reflected on the ECG as ST elevation in leads II, III, and aVF, both the right coronary artery (RCA) and the left circumflex coronary artery (LCx) may be the culprit artery. Different ECG criteria based on the analysis of ST elevation and ST depression in different leads, including lead V4R, have been suggested to predict the culprit artery.8, 9, 10, 11, 12, 13, 14 Recently, Fiol et al15 proposed a sequential ECG algorithm based on ST changes in different leads with high sensitivity, specificity, and predictive value to predict the culprit artery in cases of an evolving inferoposterior STEMI.
The aims of this study, where patients with STEMI had both standard 12-lead ECG and coronary angiography in the acute phase (within 3 hours), were 2-fold. First, the LAD, LCx, or RCA was predicted as the culprit artery by predefined ECG criteria. Second, from a subpopulation with ST elevations in the inferior extremity leads (II, III, aVF), a new algorithm for predicting the culprit artery in inferior STEMI was compared with a previously published algorithm.
Section snippets
Patient population
The HAAMU (Helsinki Area AMi—treatment re-evalUation) Trial was a nonrandomized prospective trial of patients with acute STEMI comparing 3 treatment strategies: prehospital thrombolysis with coronary angiography within 3 hours, abciximab-facilitated primary PCI, or prehospital thrombolysis with coronary angiography on clinical grounds. The allocation of treatment strategy was predefined according to the area where the patient was first encountered by emergency service personnel. Study inclusion
Results
Angiographically, the infarct-related artery was the LAD in 42%, the RCA in 45%, the LCx in 10%, and the left main/multivessel disease in 2%. In 1%, the culprit artery could not be defined. The distribution of ECG-defined culprit artery (n = 187) was as follows: the LAD in 42%, the RCA in 47%, the LCx in 9%, and nonspecific in 2%. The sensitivity, specificity, and predictive values of the prespecified ECG criteria to predict angiographically defined culprit artery are listed in Table 1. All 3
Discussion
To our knowledge, this represents the first prospective study of patients with STEMI to predict the angiographic culprit artery by the ECG findings, where the ECG recordings and the coronary angiographies were performed in close temporal relationship (<3 hours) and where the patients represented “all-comers.” The study showed that the culprit artery can be predicted from the 12-lead ECG with a high degree of accuracy, even when patients with multivessel disease, and with ECG confounders, such
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Authors Tierala and Nikus have contributed equally to the manuscript.