Journal of Electrocardiology 39 (2006) S68 – S72

www.elsevier.com/locate/jelectrocard

Electrocardiographic presentations of left main or severe triple vessel

disease in acute coronary syndromes—an overview
Kjell C. Nikus, MD,a,4 Markku J. Eskola, MD,a Samuel Sclarovsky, MDb
a
Heart Center, Tampere University Hospital, 33520 Tampere, Finland
b
Procardia Medical Center, Tel Aviv PC 63541, Israel
Received 18 April 2006; revised 14 May 2006; accepted 16 May 2006

Abstract The prognosis of high-risk patients with non-ST-elevation acute coronary syndrome can be improved
by invasive therapy. Taking into account the large number of patients with symptoms suggestive of
acute coronary syndrome, the heterogeneity of the population and the increased risk of events shortly
after the onset of symptoms, a strategy for initial evaluation and treatment is essential. The
electrocardiogram (ECG) is the most accessible and widely used diagnostic tool for patients with
symptoms suggestive of acute myocardial ischaemia. The ECG is almost never normal during
episodes of rest angina. A specific ECG pattern, transient ST-segment depression and negative
T waves maximally in leads V4-5, is associated to left main or severe triple vessel disease, and
should alert the treating physician to admit the patient for immediate invasive evaluation. The ECG
finding is a result of severe wide-spread subendocardial ischaemia.
D 2006 Elsevier Inc. All rights reserved.

Severe coronary artery disease typically been smaller in ST-elevation myocardial infarction
(STEMI) studies. In the Danami-2 study comparing throm-
In 99% of individuals, the left coronary artery has a short
bolytic therapy with primary percutaneous coronary inter-
common stem, the left main coronary artery (LMCA), that
vention (PCI), the proportion of triple vessel disease was 13%
bifurcates or trifurcates.1 In most individuals, the left
and 15%, and of left main disease, 3.6% and 2.3% for referral
coronary artery supplies the left ventricular (LV) anterior
vs invasive-treatment centers, respectively.4
wall, one third of the right ventricular free wall, the left and
right ventricular apex, a large part of the ventricular septum,
and one half of the posterior LV wall. Because a large part Risk stratification in ACS
of the myocardium of the left ventricle is perfused by the
Acute coronary syndrome is categorized into STEMI and
LMCA, critical stenosis or sudden obstruction of the artery
non–ST-elevation ACS consisting of the unstable angina
frequently results in rapid fatality.
(UA) and the closely related condition non-STEMI. ST-
The disease severity in coronary angiography in non–
elevation myocardial infarction (MI) results from a sudden
ST-elevation acute coronary syndrome (ACS) varies depend-
total occlusion of an epicardial coronary artery or its side
ing on the type of study and inclusion criteria. In a study from
branch. Immediate reperfusion therapy is indicated.5 Non–
the early 1980s, the proportion of triple vessel (40%) and left
ST-elevation ACS is usually caused by disruption of an
main (20%) disease was relatively high.2 In the Fragmin and
atherosclerotic plaque and a subsequent cascade of patho-
fast revascularization during InStability in Coronary artery
logic processes that decrease coronary blood flow. The
disease II study (FRISC II) comparing invasive with
patients must be evaluated rapidly. Taking into account the
noninvasive treatment, the proportion of triple vessel disease
large number of patients with symptoms suggestive of ACS,
in the 2 treatment arms was 23% and 30%, respectively, and
the heterogeneity of the population, and the increased risk of
of left main disease, 8% in both groups.3 The number of
events shortly after the onset of symptoms, a strategy for
patients with severe coronary artery disease (CAD) has
initial evaluation and treatment is essential. Markers of
elevated short-term risk of death or nonfatal MI are
4 Corresponding author. Tel.: +358 3 3116 4141; fax: +358 3 3116
accelerating symptoms within 48 hours, prolonged rest
4157. pain, heart failure, hemodynamic problems, life-threatening
E-mail address: [email protected] (K.C. Nikus). arrhythmias, electrocardiographic (ECG) changes, and
0022-0736/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jelectrocard.2006.05.023
 K.C. Nikus et al. / Journal of Electrocardiology 39 (2006) S68–S72 S69
6
elevated biochemical markers of myocardial injury. The
electrocardiogram is the most accessible and widely used
diagnostic tool for patients with symptoms suggestive of
acute myocardial ischemia.

Electrocardiographic categories in ACS

The Global Use of Strategies to Open occluded coronary
arteries IIb (GUSTO-IIb) trial comparing the efficacy of
recombinant hirudin with that of heparin encompassed the
whole spectrum of patients with ACS. Electrocardiographic
changes suggestive of ischemia were required for inclusion.
Twelve thousand one hundred twenty-four patients had their
ECG changes categorized at hospital admission. Two
thousand seven hundred twenty-three (22%) had T-wave
inversion alone, 3369 (28%) had ST-segment elevation,
4263 (35%) had ST-segment depression, and 1769 (15%)
had a combination of ST-segment elevation and depression.7
Some patients with ACS also present with a normal
finding of electrocardiogram, especially if the recording is
performed during a symptom-free interval. In the thrombol-
ysis in myocardial infarction 11B trial comparing enox-
aparin with placebo in 3910 patients with non–ST-elevation
ACS, 16.9% to 17.5% had normal findings of electro-
cardiograms at randomization. More than 70% had ST
deviation.8 In the Efficacy and Safety of Subcutaneous
Enoxaparin in Non-Q wave Coronary Events (ESSENCE)
trial comparing low–molecular weight heparin with unfrac-
tionated heparin in UA, only slightly more than 50% of
the patients had ECG changes, and about 7% showed
ST-segment elevation, 22% to 24% ST depression, and 38%
T-wave inversion.9
In patients with suspected ACS, the likelihood of
developing an MI is low (3% overall), with normal or
nonspecific findings of electrocardiograms at presentation.10
This study was, however, performed before the introduction
of sensitive biomarkers (cardiac troponin) for MI diagnosis.
The risk becomes progressively higher with T-wave
inversion (32%), ST-segment depression (48%), ST-segment
elevation (81%), and ST-segment elevation plus depression
(89%).7 ST-segment depression has been associated with
triple vessel or left main disease, and hence, there was an
unfavorable outcome.11 Patients with ST-segment depres-
sion also gain the most benefit from invasive compared with
conservative treatment.12

ST-segment depression in subendocardial MI

and ischemia
The variation in ECG presentation between patients with
ACS is partly explained by different pathophysiologic
mechanisms. Sudden and complete occlusion of a coronary
artery results in transmural ischemia confined to the region
of the heart supplied by 1 epicardial artery.13
The significance of ST-segment depression in ACS has
been the subject for debate for many decades. In 1943,
Fig. 1. A, Circumferential subendocardial ischemia in 12-lead electrocar-
Kemball Price and Janes14 described for the first time a case diogram (50 mm/s): widespread ST-segment depression maximally in chest
of subendocardial infarction. The electrocardiogram of the leads V4-5 with negative T waves, ST-segment elevation in lead aVR. B, Left
patient 3 days after an attack of chest pain lasting for 2 hours coronary angiography with very tight distal LMCA stenosis (arrow).
S70 K.C. Nikus et al. / Journal of Electrocardiology 39 (2006) S68–S72

showed ST-segment depression and T-wave inversion in the Sclarovsky et al26 studied 32 consecutive patients who
extremity lead I and chest lead IV. The ECG changes almost had horizontal or downward-sloping ST-segment depres-
completely resolved during follow-up. Autopsy showed sion greater than 2 mm in the precordial leads. A peaked
severe multivessel disease and a large sheetlike subendo- T wave was observed in 21 patients, whereas 11 patients
cardial infarct. The next year, Bayley et al15 described the showed negative T waves in addition to ST-segment
correlation between ST-segment depression and subendo- depression at presentation. The groups did not differ in
cardial infarction. He called the phenomenon of downward baseline demographic parameters, and the incidence of
displacements of the RS-T junction in all the limb leads and acute MI was similar. In the group with negative T waves,
in the chest lead as injury against the rule, and he the in-hospital mortality was 27%, whereas none of the
speculated that this ECG finding would result when necrosis patients with positive T waves died in the hospital. Of
is more intense at the endocardial than at the epicardial patients who had coronary angiography, 7 of 10 patients of
aspects of the ventricular walls. In 1950, Levine and Ford16 those with negative T waves had significant left main
described cases with subendocardial circumferential MI. disease and 2 of 10 had triple vessel disease. In the group
Anatomic endocardial lesions were correlated to ECG with positive T waves, 4 of 21 (19%) had triple vessel and
changes in 6 patients with left main or severe 3-vessel none had significant left main disease. The authors
CAD. The ECG changes consisted of widespread ST- concluded that ischemic ST depression associated with
segment depression, often associated with widespread peaked negative T waves should raise suspicion of multi-
inversion of the T wave. These findings have later been vessel or left main disease.
confirmed by other groups of investigators.17-20 Cook et al21 Nikus et al27 prospectively studied 50 patients with a
stated that ST-segment depression and T-wave inversion non–ST-elevation ACS, elevated troponin levels, a heart rate
might occur in transient subendocardial ischemia. They of 100 beats/min or less, and transient ischemic changes—
published detailed anatomic studies of large and small ST-segment depression or T-wave inversion recorded during
subendocardial infarcts, correlating to premortal ECG anginal pain. No patients presented with isolated T-wave
changes. Despite the works of these legendary groups of inversion. The patients were divided into 2 groups: 1 group
investigators, no new progress in the topic appeared during with ST-segment depression and negative T waves maxi-
the following years. The medical communities did not mally in leads V4-5 and 1 with a positive T wave in the
accept the concepts, probably because it was not possible to precordial lead with maximal ST-segment depression.
reproduce circumferential ischemia in the experimental Patients with negative T waves were older and had more
laboratory (Fig. 1). Levine stated: bNature can fulfill the often previous angina pectoris, but the troponin levels did
conditions of this experiment much more readily than can not differ significantly between the groups. Of patients with
the physiologist.Q16 negative T waves, 76% had left main or left main
Atie et al22 studied 127 consecutive patients with angio- equivalent disease, and the rest (24%) had severe triple
graphically proven LMCA disease. Eighty-two patients vessel disease defined as significant or total occlusion in
(65%) had UA. During chest pain, all patients had an the proximal or mid segment of all 3 main epicardial
abnormal finding of electrocardiogram, the most frequent coronary arteries. In-hospital mortality was 24% in the
pattern being ST-segment depression in leads V3-5 (maxi- group with negative T waves. Patients with a positive
mally in lead V4) and ST-segment elevation in leads V1 and T wave had 1-vessel disease in 56%, nonsevere triple vessel
aVR. Outside an episode of chest pain, the ST segment was disease in 20%, and left main disease in 8%, and no patient
normal in 50 patients (38%), and both the ST segment and the died in the hospital. In addition, clinical heart failure and
T wave were normal in 33 patients (25%). subnormal ejection fraction were more frequent in those
Kosuge et al23 retrospectively studied 310 patients with with negative T waves, 40% vs 4% and 42% vs 8%,
ACS to find the predictors of severe CAD. In multivariate respectively. Severe angiographic CAD could be predicted
analysis, the ST-segment elevation of 0.5 mm or greater in with positive and negative predictive values of 100% and
lead aVR was the strongest predictor of LMCA or triple 92%, respectively. The ECG pattern of transient ST-seg-
vessel disease, followed by troponin T. ment depression and negative T waves maximally in leads
V4-5 has been described as acute circumferential subendo-
cardial ischemia.28
The significance of T-wave direction in cases with
ST-segment depression
Pathophysiology of ST-segment depression in the
In the mid-1970s, investigators in Europe investigated
precordial leads
the mechanisms of rest angina, spontaneous or induced by
ergonovine maleate.24,25 They found that subtotal occlusion Extensive ischemia, for example, caused by sudden
of the left anterior descending coronary artery produced an obstruction of the LMCA, impairs the relaxation of the left
ST-segment depression in leads V2-4. When the artery was ventricle.29 The resulting increase in LV end-diastolic
totally occluded, they noted an ST-segment elevation in pressure (LVEDP) induces severe subendocardial ischemia.
these leads. It could be speculated that in some patients, Aroesty et al30 performed a hemodynamic monitoring
regional nontransmural ischemia could manifest as during atrial pacing in 22 patients with CAD. Eleven
ST depression in the same leads that show an injury current patients demonstrated a nonischemic response without chest
(ST elevation) when the artery becomes totally occluded. pain, significant ECG changes, or rise in LVEDP. According
 K.C. Nikus et al. / Journal of Electrocardiology 39 (2006) S68–S72 S71

to the pressure-volume curves, both LV contractility and aVR than patients with anterior MI without significant left
distensibility increased. The remaining 11 patients exhibited main disease. The authors speculated that the ECG pattern
an ischemic response with angina pectoris symptoms, was caused by transmural ischemia of the basal part of the
greater than 1-mm ST-segment depression on the electro- septum. Their speculation, that the reason for less
cardiogram, and greater than 5-mm Hg increase in LVEDP. ST elevation in lead V1 than in lead aVR is counterbalance
In these patients, LV diastolic distensibility decreased before in lead V1 of electrical forces from both the anterior and
a drop in systolic function. Visner et al31 induced global LV posterior wall, was supported by an editorial in the same
ischemia in conscious dogs by hydraulic constriction of the article by Gorgels et al.35 An alternative explanation for the
LMCA. This resulted in a significant decrease in the ECG pattern has been proposed by another group of
endocardial-to-epicardial flow ratio and a significant in- investigators.36 They have pointed out that lead aVR records
crease of end-diastolic LV transmural pressure. They a mirror image of leads V5 and V6. Hence, if there is an
concluded that changes in regional diastolic mechanics are ST-segment depression in the lateral precordial leads, lead
the direct result of ischemia. aVR will almost exclusively show ST-segment elevation.
Carlens et al32 compared LV hemodynamics during Lead aVR has a unique position by blookingQ into the
exercise in 2 groups of patients with angina, 1 with and LV cavity from the right shoulder. This phenomenon
1 without ST-segment depression in the exercise test. The was described already in 1950 by Yu and Stewart.20 They
highest load during the symptom-limited exercise test and wrote: bSince this lead reflects the intracavitary potential
the heart rate on that load did not differ between the groups. variations, it is conceivable that a lesion in the sub-
They noted that the LVEDP rose to a significantly higher endocardial layer of the myocardium would produce
value (40 vs 32 mm Hg) in the group with ST-segment RS-T elevation in lead aVR.Q In the abovementioned
depression. They speculated that sufficiently elevated prospective study of Nikus et al,27 all patients (no patients
LVEDP causes global subendocardial ischemia. had total LMCA occlusion) with ST-segment depression
with accompanying T-wave inversion maximally in leads
V4-5 had an ST-segment elevation of 0.5 mm or greater in
Sudden total occlusion of the LMCA
lead aVR. Also in 2 case reports with left main obstruction
There is no general agreement on the typical ECG pattern by an intimal flap in type A aortic dissection, the same ECG
of sudden total occlusion of the LMCA. Many different changes, widespread ST-depression with ST-elevation
ECG patterns have been described by authors, either as case in lead aVR, were reported.37,38 The same ECG pattern is
reports or as small series. There may be many reasons for seen in various clinical situations associated with an
the diverging opinions about the issue. Many patients either increased LVEDP, such as rest angina with sinus tachycar-
suffer sudden death before even having an electrocardio- dia,39 and chronic MI with restrictive remodeling,40 and in
gram or develop a hemodynamic catastrophe while in the exercise tests.41
hospital, for example, during a PCI procedure, without time Other ECG patterns caused by LMCA occlusion are
for ECG recording. Some authors link together cases with anterior ST-segment elevation, ST-segment depression in the
subtotal and total occlusion, although the ECG pattern may precordial leads, right bundle-branch block, and ST-segment
be different if there is some residual flow in the left coronary elevation in leads I and aVL.42
artery compared with sudden total occlusion. Variation in
coronary anatomy, left, right, or balanced dominance,
Conclusions
should have influence on the ECG changes, as should the
existence of collateral flow from the right coronary artery. The prognosis of high-risk patients with non–ST-
Finally, the dynamic nature of ACS may result in ECG elevation ACS can be improved by invasive therapy. The
patterns changing within minutes. For example, an occlu- electrocardiogram is the most accessible and widely used
sion of the proximal left anterior descending while recording diagnostic tool for patients with symptoms suggestive of
the electrocardiogram before angiography may be followed acute myocardial ischemia. The finding of electrocardio-
by thrombus propagation to the LMCA observed in gram is almost never normal during episodes of rest angina.
coronary angiography. A specific ECG pattern, transient ST-segment depression
Hori et al33 described 13 patients with acute MI caused and negative T waves maximally in leads V4-5, is associated
by total occlusion of the LMCA during 8 years. ST elevation to the left main or severe triple vessel disease and should
in lead aVR was present in 69% of patients, and 5 of alert the treating physician to admit the patient for
6 nonsurvivors had ST-segment elevation in both leads aVR immediate invasive evaluation. The ECG finding is a result
and aVL. In a descriptive study of 16 patients by Yamaji of severe widespread subendocardial ischemia.
et al,34 ST-segment elevation in lead aVR with less elevation
in lead V1 proved to be an important predictor of left main
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