Acute Coronary Syndrome Requiring Immediate Reperfusion

The Study
Zoni C,R et al. Proposed new classification for acute coronary syndrome: Acute coronary syndrome requiring immediate reperfusion. Catheter Cardiovascular Interv. 2023;101:1172-1181.

The use of ST elevation Myocardial Infarction (STEMI) and Non-ST elevation (NSTEMI) acute coronary syndromes (ACS), have been used to determine who goes to the cath lab.

A STEMI is a straightiforward approach to identify who needs urgent cardiac catheterisation. We know however that an acute coronary occlusion can occur in the setting of NSTEMI in approxiamately 25% of patients. This can be associated with significant MACE and mortality (1).

The OMI/NOMI classification is an important step towards recognising that ecg patterns are nor always predictive of  occlusion, however this method may not always identify all patients who may benefit for coronary reperfusion (2).

The vessels most frequently occluded and not presenting with ST elevation on ecg, were the circumflex and right coronary arteries (3).

This study reports on several patterns that were associated with acute occlusion and may benefit from acute intervention.

1.Aslanger pattern

This was a retrospective study of 966 patients that found occlusion in 54% of patients, predominantly in the circumflex artery (50%) and right coronary artery (32%). The ecg pattern is as  follows (4):

• STE in lead III, but not in other inferior leads
• STD in any of leads V4-V6, but not V2, with a positive T wave
• STE in lead V1 > STE V2

2.Isolated ST depression in V1-V4

In 1198 patients presenting with isolated ST depression in V1-V4 26% had an acute coronary occlusion, of which 48% occurred in the the circuflex and 34% in the right coronary artery (5).

3.Hyperacute T waves

This may be an early sign of STEMI in patients with ACS symptoms. Hyperacute T waves were associated with occlusion of the left anterior descending (LAD) artery (6)

4.deWinter’s Pattern

This is an ACS pattern that does not present with the classic STEMI pattern (7). There is J point ST depression, with an upsloping ST segment in V1-V6 and tall positive T waves. There may also be STE in aVR

5.Wellens Pattern

This ecg pattern, which can be biphasic or deep negative T waves in the anterior leads, describes a critical lesion, although not totally occlusive in the LAD. This can progress into a STEMI and progresses to an acute anterior infarction in 75% of cases (8).

6.STE in aVR

This may be associated with nearly total occlusion of the left Main artery when ACS is present (7).

References

1. Khan AR,  et al. Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis. Eur Heart J. 2017;38(41):3082-3089.
2. Aslanger EK, et al. Time for a new paradigm shift in myocardial infarction. Anatolian J Cardiol. 2021;25(3):156-162.
3. Krishnaswamy A, et al. Magnitude and consequences of missing the acute infarct-related circumflex artery. Am Heart J. 2009;158(5):706-712.
4. Aslanger E, et al. A new electrocardiographic pattern indicating inferior myocardial infarction. J Electrocardiol.
   2020;61:41-46.
5. Pride YB, et al. Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior ST-segment depression: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) substudy. JACC. Cardiovasc interven. 2010;3(8):806-811.
6. Zorzi A, et al. Interpretation of acute myocardial infarction with persistent ‘hyperacute T waves’ by cardiac magnetic resonance. Eurn Heart J: Acute Cardiovascr Care. 2012;1(4):344-348.
7. de Winter RJ, et al. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359(19):2071-2073.
8. Honda S, et al. Wellens’ syndrome. N Engl J Med. 2022;387(12):e25.