Value of the initial electrocardiogram in assessing patients with inferior-wall acute myocardial infarction for prediction of multivessel coronary artery disease

Abstract

Patients with inferior-wall acute myocardial infarction (AMI) who have ST-segment depression in the left precordial leads (LSTD +) on the initial electrocardiogram were reported to have more diffuse coronary artery disease (CAD) than had those without this finding (LSTD −). This suggests that LSTD + patients may need extensive revascularization interventions more often than do LSTD − patients. However, this has not yet been confirmed.

To compare the coronary angiographic findings and treatment strategies for patients with inferior-wall AMI according to the LSTD pattern.

The clinical outcomes and the angiographic findings for 238 consecutive patients aged ≤ 75 years who had been admitted to our hospital between 1 February 1995 and 1 February 1997 with inferior-wall AMI were retrospectively analyzed. The patients were divided into two groups according to the pattern of precordial ST-segment depression: LSTD +, ST-segment depression in leads V4–V6; and LSTD −, absence of this finding. All patients were treated according to current practice guidelines including with thrombolysis and revascularization interventions.

The final study population included 217 patients; 83 were LSTD + and 134 were LSTD −. All underwent coronary angiography within 30 days of the infarction. Compared with LSTD − patients, LSTD + patients tended to be older (mean age 62.7 ± 11.7 versus 58.3 ± 9.6 years, P  = 0.004), and had higher incidences of hypertension (39.8 versus 24.6%, P  = 0.019) previous myocardial infarction (45.8 versus 20.1%, P  = 0.0001) and congestive heart failure (21.7 versus 3.7%, P  = 0.00008). Three-vessel CAD was much more common, and single-vessel CAD much less common, in the LSTD + than in LSTD − group (62.7 versus 13.4% and 8.4 versus 50.7%, P  < 0.00001 for both). Coronary-artery-bypass surgery and multivessel percutaneous coronary interventions (PCI) were used in treating 65.1% of the LSTD + versus only 6.0% of the LSTD − patients (P  < 0.00001), whereas single-vessel PCI was used in treating 71.6% of the LSTD − patients versus only 24.1% of the LSTD + patients (P  < 0.00001). Thus, the LSTD − pattern predicted single-vessel disease and single-vessel PCI only, whereas the LSTD + pattern was predictive of multivessel CAD and of use of coronary-artery-bypass surgery or multivessel PCI (predictive values of 94.0 and 65.1%, respectively).

Among patients with inferior-wall AMI, left precordial ST-segment depression predicts a very high prevalence of multivessel CAD and use of extensive revascularization interventions. The absence of this finding predicts nondiffuse CAD and lack of a need for extensive revascularization.