title: Acute coronary syndrome with a totally occluded culprit artery: relation of the ST injury vector with ST-elevation and non-ST elevation ECGs.
abstract: BACKGROUND
  In acute coronary syndrome (ACS), ST-segment elevation (STE), often associated with a completely occluded culprit artery, is an important ECG criterion for primary percutaneous coronary intervention (PCI). However, several studies showed that in ACS a completely occluded culprit artery can also occur with a non-ST-elevation (NSTE) ECG. In order to elucidate reasons for this discrepancy we examined ST injury vector orientation and magnitude in ACS patients with and without STE, all admitted for primary PCI and having a completely occluded culprit artery.
  
  
  METHODS
  We studied the ECGs of 300 ACS patients (214/86 STE/NSTE; 228/72 single/multivessel disease) who had a completely occluded culprit artery during angiography prior to primary PCI. The J+60 injury vector orientation and magnitude were computed from Frank XYZ leads derived from the 10-s standard 12-lead ECG.
  
  
  RESULTS
  Demographic and anthropomorphic characteristics of the STE and NSTE patients did not differ. STE patients had a higher rate of right coronary artery occlusions, and a lower rate of left circumflex occlusions than NSTE patients (43 vs. 31%, and 13 vs. 22%, respectively; P<0.05). Injury vector elevation and magnitude were larger in STE than in NSTE patients (32° ± 37° vs. 6° ± 39°, and 304 ± 145 μV vs. 134 ± 72 μV, respectively; P<0.0001).
  
  
  CONCLUSIONS
  STE criteria favor certain injury vector directions and larger injury vector magnitudes. Obviously, several ACS patients with complete culprit artery occlusions requiring primary PCI do not fulfill these criteria. Our study suggests that STE-NSTE-based ACS stratification needs further enhancement.
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Sumche
authors.initials: S
authors.lastname: Man
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Chinar
authors.initials: C
authors.lastname: Rahmattulla
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Arie C
authors.initials: AC
authors.lastname: Maan
authors.affiliation: Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Niek H J J
authors.initials: NH
authors.lastname: van der Putten
authors.affiliation: Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: W Arnold
authors.initials: WA
authors.lastname: Dijk
authors.affiliation: Department of Medical statistics, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Erik W
authors.initials: EW
authors.lastname: van Zwet
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Ernst E
authors.initials: EE
authors.lastname: van der Wall
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Schalij
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Anton P
authors.initials: AP
authors.lastname: Gorgels
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: c.a.swenne@lumc.nl.
authors.forename: Cees A
authors.initials: CA
authors.lastname: Swenne
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D017023:Coronary Angiography; D004562:Electrocardiography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention
keywords: Acute coronary syndrome; ECG; Occluded culprit artery