Identifying the culprit after a criminal event may be easy for the police.For cadiologists investigating the crime scene after a coronary event, it is a different story. (Of course, localization of IRA after a STEMI may not be really difficult.) But , when a patient is having UA and coronary artery shows multiple lesions, we do have real diagnostic issue. The general dictum could be, tightest lesion or the complex eccentric ones with thrombus is likely to be the culprit. This has important therapeutic Implication, as we are argued to address the active lesions first. The following study was done in 2009 trying to find the ARA solely by ECG features.
The conclusion was
The following ECG findings were helpful in localizing Angina related artery . ST depression in V3- V5 correlated with LAD angina .Global ST depression was highly correlated with proximal LAD or Left main disease ( 6/6 patients). ST depression in V1 –V3 was associated more commonly with dominant LCX/OM disease. ST depression in 2 ,3 , AVF , or I, AVL had no significant correlation with either RCA or LAD system.However multiple culprit lesions or diffuse inflammatory CAD should always be thought off. One more possibility is , its simply a demand ischemia or micro vascular angina were there is no true epicardial culprit lesion.
A revisit to my 2009 IHJ article.
http://indianheartjournal.com/ihj09/nov_dec_09/509-523.html
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IDENTIFYING ANGINA RELATED ARTERY (ARA) IN UNSTABLE
ANGINA /NSTEMI BY ADMISSION ECG AND ECHOCARDIOGRAPHY S.Venkatesan C.Krishnakumar .G.Gnanavelu .R.Subramanian.Geetha Subramanian B.Ramamurthy.P.Arunachalam.M.Somsundram.V.E.Thandapani.M.A.Rajasekaran. S.Murugan , Madupraphu doss ,P.Pachiappan. Madras Medical College. Chennai |
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Unstable angina( UA /NSTEMI ) constitute a heterogeneous group of patients with lesions ranging from normal coronary artery to severe multi vessel disease. Even though multiple active plaques are documented , one critical lesion would be responsible for the index episode of angina.. Contrary to STEMI there is no standard methodology to identify the Angina related artery.(ARA) in UA .We under took this analysis to find whether admission ECG with the help of echocardiography could predict the ARA in patients with UA 26 patients with UA admitted in our CCU were the subjects of study. Patients with post infarction angina, CABG , PCI , old MI , left ventricular dysfunction were excluded. All patients were treated as per institutional protocol. Echocardiogrphic analysis of wall motion defects (WMD) were documented between 2hrs and 24hours of admission .CAG was done between 24 hrs and 7 days. The coronary lesion was considered angina related if the WMD detected by echocardiography matched with the myocardial segments supplied by the arterial territory containing the lesion . After locating the ARA , the patient’s admission ECG was compared retrospectively with CAG finding to study whether it has any predictive value for identifying ARA. 6 patients who had single vessel disease the ARA localization was straight forward. (LAD -4 , LCX -1 RCA-1 ). In 2 patients there was obvious eccentric thrombus containing plaque indicating the culprit lesion . 18 had DVD or TVD with no clearcut culprit lesion. The following ECG findings were helpful in localizing ARA.ST depression in V3- V5 correlated with LAD angina .Global ST depression was highly correlated with proximal LAD or Left main disease ( 6/6 patients). ST depression in V1 –V3 was associated more commonly with dominant LCX/OM disease. ST depression in 2 ,3 , AVF , or I, AVL had no significant correlation with either RCA or LAD system. It is concluded ARA can be identified with fair degree of accuracy by admission ST segment profile. This observation differs with the existing literature which suggest little role for ECG to localize arterial lesion in UA. In patients with multivessel CAD with more than one critical lesion a combination of ECG and echo features help us to fix the angina related artery and possibly the lesion. This has important therapeutic implication. Keywords: Angina Related Artery, Unstable Angina/NSTEMI, ECG, Echocardiography. |
Postample
I am reposting this abstract again because the same paper has been plagiarised in at least two occasions and got published in predatory journals. Now, we realise Journal article shopping and trading has become a scientific scam .
Reference
This paper from Japan analysed this ARA concept in 1996 itself with SPECT Imaging
