Clinical Communications: Adult| Volume 64, ISSUE 2, P208-210, February 2023

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Inferior Subtle ST Elevation. Would You Activate Cardiac Catheterization Laboratory?

Published:December 26, 2022DOI:



      According to guidelines, patients with inferior myocardial infarction only qualify for emergent reperfusion if they have at least 1 mm of ST elevation in two contiguous inferior leads. Although this has remained the standard for years, acute coronary occlusion may occur in patients with nondiagnostic ST elevation. Accordingly, a paradigm change is instigated, shifting the focus to physiopathology (occlusion myocardial infarction) rather than ST criteria.

      Case Report

      A middle-aged man presented to our emergency department with chest pain and subtle nondiagnostic electrocardiography (ECG) changes in inferior leads. A careful examination of aVL to detect ST depression in this lead was the key to successfully diagnosing occlusion myocardial infarction, allowing early revascularization of an occluded right coronary artery.

      Why Should an Emergency Physician Be Aware of This?

      Accurate diagnosis of coronary occlusion by means of ECG can be challenging in certain situations, as acute myocardial ischemia may occur in patients with nondiagnostic ST elevation, especially in the inferior leads. A thorough examination of aVL searching for ST depression is essential in these situations.


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        • The GUSTO Angiographic Investigators
        The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction.
        N Engl J Med. 1993; 329: 1615-1622
        • Martin TN
        • Groenning BA
        • Murray HM
        • et al.
        ST-segment deviation analysis of the admission 12-lead electrocardiogram as an aid to early diagnosis of acute myocardial infarction with a cardiac magnetic resonance imaging gold standard.
        J Am Coll Cardiol. 2007; 50: 1021-1028
        • Aslanger EK
        • Meyers HP
        • Smith SW.
        Recognizing electrocardiographically subtle occlusion myocardial infarction and differentiating it from mimics: ten steps to or away from cath lab.
        Turk Kardiyoloji Dernegi Arsivi. 2021; 49: 488-500
        • Aslanger EK
        • Yıldırımtürk Ö
        • Şimşek B
        • et al.
        DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study).
        Int J Cardiol Heart Vasc. 2020; 30100603
        • Daly M
        • Finlay D
        • Guldenring D.
        Detection of acute coronary occlusion in patients with acute coronary syndromes presenting with isolated ST-segment depression.
        Eur Heart J Acute Cardiovasc Care. 2012; 1: 128-135
        • Miranda DF
        • Lobo AS
        • Walsh B
        • Sandoval Y
        • Smith SW.
        New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department.
        Can J Cardiol. 2018; 34: 132-145
        • Birnbaum Y
        • Sclarovsky S
        • Mager A
        • Strasberg B
        • Rechavia E.
        ST segment depression in a VL: a sensitive marker for acute inferior myocardial infarction.
        Eur Heart J. 1993; 14: 4-7
        • Bischof JE
        • Worrall C
        • Thompson P
        • Marti D
        • Smith SW.
        ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis.
        Am J Emerg Med. 2016; 34: 149-154
        • Meyers HP
        • Bracey A
        • Lee D
        • et al.
        Accuracy of OMI ECG fndings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction.
        IJC Heart Vasc. 2021; 33100767