A



RAJIV GANDHI UNIVERISTY OF HEALTH SCIENCES,

KARNATAKA

Annexure- II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |Name of the candidate and address |DR. SAYD MOHAMED ALIYAS RAJEEB.K.J, |

| | |Department of General Medicine, |

| | |A.J Institute of Medical Sciences, |

| | |Kuntikana, Mangalore -575004 |

|2. |Name of institution |A.J Institute of Medical Sciences, |

| | |Kuntikana, Mangalore -575004 |

|3. |Course of study and subject |M.D General Medicine |

|4. |Date of admission |10th May, 2010 |

|5. |Title of topic: |THE ROLE OF ECG IN LOCALIZING THE CULPRIT VESSEL OCCLUSION IN ACUTE ST SEGMENT ELEVATION MYOCARDIAL |

| | |INFARCTION WITH ANGIOGRAPHIC CORRELATION |

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|6. |BRIEF RESUME OF INTENDED WORK |The Electrocardiogram remains a crucial tool in the identification and management of acute myocardial|

| |6.1 Need for study |infarction. A detailed analysis of patterns of ST-segment elevation may influence decisions regarding|

| | |the perfusion therapy5. The early and accurate identification of the infarct related artery can help|

| | |predict the amount of myocardium at risk and guide decisions regarding the urgency of |

| | |revascularization1. Electrocardiographic signs of reperfusion represent an important marker of micro |

| | |vascular blood flow and consequent prognosis. Electrocardiography reflects the physiology of |

| | |myocardium during acute ischaemia whereas the coronary angiography identifies the vessel anatomy. |

| | |This study will identify the culprit vessel from ECG in patients with acute ST elevation myocardial |

| | |infarction and correlate with coronary angiogram. |

| | |Criteria to identify the culprit vessels from ECG are |

| | |Right Coronary Artery |

| | |ST elevation in LII, III, aVF |

| | |ST elevation in LIII>LII (Right coronary artery occlusion) |

| | |ST depressionV3/ ST elevation in LIII LIII |

| | |ST depression in V1,V2,V3 |

| | |ST depressionV3/ ST elevation in LIII >1.2 (Left circumflex artery occlusion) 1 |

| | |Left anterior descending coronary artery |

| | |ST elevation in aVL and LI |

| | |ST elevation in V2,V3,V4 (Ist septal branch of Left anterior descending coronary artery) |

| | |ST elevation in V2 and isoelectric or ST depression in V3,V4,V5,V6 (Ist diagonal branch of Left |

| | |anterior descending coronary artery) |

| | |ST depression in V2 (Ist obtuse marginal branch of Left anterior descending coronary artery) |

| | |ST depression in aVL (Distal part of Left anterior descending coronary artery1. |

| |6.2 Review of literature |Peter J et al reviewed the use of electrocardiogram in acute myocardial infarction and identification|

| | |of infarct related artery, they suggested that specificity of electrocardiogram in acute myocardial |

| | |infarction is limited by large individual variations in coronary anatomy, they suggested the |

| | |following criteria for identification of culprit vessel occluded in acute ST elevation myocardial |

| | |infarction. Even though the electrocardiogram is limited by its inadequate representation of the |

| | |posterior, lateral, and apical walls of the left ventricle, it can help in identifying proximal |

| | |occlusion of the coronary arteries, which results in most extensive and most severe myocardial |

| | |infarctions. The criteria suggested by them to identify the culprit vessel in acute myocardial |

| | |infarction is as follows5 |

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| | |Right coronary artery |

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| | |ST elevation in L III > L II |

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| | |ST elevation in II , III, aVF |

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| | |Reciprocal ST depression in L I & aVL |

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| | |Left circumflex artery |

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| | |ST elevation in L II > L III |

| | |Isoelectric ST / ST elevation in aVL |

| | |ST depression in V 1, V 2, V 3 |

| | |Left anterior descending coronary artery |

| | |ST elevation in V 2 , V 3 , V 4. |

| | |They concluded that important information to guide management and determine prognosis can be derived |

| | |from the electrocardiogram in patients with acute myocardial infarction. Electrocardiographic markers|

| | |of proximal coronary artery occlusion identify relatively large myocardial infarction that benefit |

| | |most from early and complete revascularization strategies, such as primary angioplasty5. |

| | |Y Birnbaum et al reviewed role of electrocardiogram in ST elevation acute myocardial infarction with |

| | |emphasis on prediction of infarct size, estimation of prognosis, and the correlation between various |

| | |electrocardiographic patterns and the localization of the infarct and the underlying coronary |

| | |anatomy. The ECG assessments presented in this review are identification of right ventricular |

| | |infarction accompanying acute inferior myocardial infarction, a very proximal left anterior |

| | |descending coronary artery occlusion in anterior myocardial infarction and grade III ischaemia or ST |

| | |depression in V4-V6, indicating multi vessel disease in inferior acute myocardial infarction. The |

| | |importance of identification of right ventricular infarction is that hypotension in these patients is|

| | |usually caused by inadequate filling of left ventricle by the poorly contracting right ventricle. So |

| | |therefore the treatment should be aimed at augmenting ventricular by volume expansion and avoiding |

| | |diuretics and nitrates. Another ECG assessment of importance in identification of culprit vessel in |

| | |acute ST elevation myocardial infarction is occlusion proximal left anterior descending coronary |

| | |artery. If the infarct size is proximal to the first diagonal branch of the left anterior descending |

| | |artery, a large portion of the left ventricle is at risk for infarction including the anteroseptal, |

| | |anterosuperior, anterolateral and apical regions. Such patients require urgent primary percutaneous |

| | |coronary intervention or immediate treatment with thrombolytic agent¹. |

| | |Domien J. Engelen assessed the value of the electrocardiogram as predictor of the left anterior |

| | |descending coronary artery occlusion site in relation to the first septal perforator and/or the first|

| | |diagonal branch in patients with acute anterior myocardial infarction. In anterior myocardial |

| | |infarction determination of the exact size of left anterior descending artery is important as it is |

| | |related to the extend of the myocardial extend of myocardial necrosis and prognosis. The ECG showing|

| | |the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and |

| | |exact left anterior descending artery occlusion site was determined by coronary angiography. ST |

| | |elevation in lead aVR, complete right bundle branch block, ST depression is lead V5>2.5 mm strongly |

| | |predicted left anterior descending artery occlusion proximal to the first septal perforator whereas |

| | |abnormal Q waves in V4-6 were associated with occlusion distal to first septal perforator branch of |

| | |left anterior descending artery. Abnormal Q-wave in lead aVL was associated with occlusion proximal |

| | |to first diagonal branch of left anterior descending artery whereas ST depression in aVL was |

| | |suggestive of occlusion distal to the first diagonal branch of left anterior descending artery3. |

| | |Malika Arbane et al in a prospective trial compared the magnitude and location of ST-segment |

| | |deviation seen on the admission ECG in patients with a proximal left anterior artery occlusion with |

| | |those with a mid- or distal left anterior descending total occlusion as determined by coronary |

| | |angiography performed within a few hours of onset of symptoms. Sixty six consecutive patients were |

| | |included in the study. They concluded that, in anterior acute myocardial infarction, ST elevation in |

| | |aVL and ST depression in LII, LIII, aVF predict the culprit lesion in the left anterior descending |

| | |artery proximal to the origin of the first diagonal branch, with a good specificity and positive |

| | |predictive value. Inferior ST depression is not related to remote ischemia, but represents and |

| | |electrocardiographic phenomenon reciprocal to ST elevation in aVL; this ST elevation is in aVL is |

| | |related to antero-lateral extension of the infarct secondary to first diagonal branch ischaemia. |

| | |Because inferior depression predicts a proximal left anterior descending occlusion and it is |

| | |associated with greater infarct this would explain the association of inferior ST depression with |

| | |greater infarct size, left ventricular dysfunction and poor prognosis in acute anterior myocardial |

| | |infarction8. |

| | |Abid R Assali examined whether the culprit artery in inferior wall myocardial infarction can be |

| | |predicted by the configuration of the QRS complex in lateral limb lead aVL. They identified two |

| | |patterns of the QRS complex in lateral limb lead aVL. Pattern I, S/R-wave ratio 1mm. This study showed that in |

| | |patients with inferior wall acute myocardial infarction, pattern I or the QRS complex in lead aVL is |

| | |a sensitive marker for left circumflex coronary artery obstruction. Whereas pattern II is a sensitive|

| | |and specific marker for RCA obstruction. If pattern I is not found, the chance of an obstruction in |

| | |the left coronary circumflex artery is very low4. |

| | |Radhakrishnan Nair et al in retrospective review applied various criteria of ECG discrimination |

| | |between right and left circumflex coronary artery occlusion in patients with acute inferior |

| | |myocardial infarction. This study confirmed the utility of four previously described parameters of |

| | |identifying the right coronary artery or the left circulflex occlusions as containing the culprit |

| | |lesion in patients with acute inferior myocardial infarction. They also found a previously unreported|

| | |parameter, the amount of ST-segment depression in lead aVR, also is an accurate predictor³. |

| | |Itzhak Herz et al attempted to predict the culprit artery by assessing the relative ST-segment |

| | |deviations in different leads during inferior wall acute myocardial infarction. All standard |

| | |admission 12 lead electrocardiograms were evaluated by 2 investigators blinded to the angiographic |

| | |findings. The magnitude of ST-segment elevation in leads II and III was compared, as was the |

| | |ST-segment depression in leads aVL and I. Coronary angiography films were reviewed by 2 investigators|

| | |who were blinded to the electrocardiographic findings. In this study they came to a conclusion that |

| | |a higher ST-segment elevation in lead III than in lead II and a deeper ST-segment depression in lead |

| | |aVL than in lead I are sensitive and specific markers for right coronary artery occlusion related |

| | |acute myocardial infarction6. |

| |6.3 Objectives of study |This study is aimed at validating the usefulness of electrocardiography in localizing the culprit |

| | |vessel in acute ST elevation myocardial infarction and correlating the findings with coronary |

| | |angiogram in order to plan early, rapid intervention and revascularization. |

|7 |MATERIALS AND METHODS: | |

| |7.1 Source of data |It will be a prospective hospital based study, comprising of patients diagnosed with acute ST |

| | |elevation myocardial infarction who undergo coronary angiogram from AJ Hospital and Research Centre, |

| | |Mangalore. |

| |7.2 Method of collection of data |Study design: Prospective observational study |

| | |Set-up: AJ Institute of Medical Sciences |

| | |AJ Hospital and Research Centre, Mangalore. |

| | Method of data collection, as well as|This study will be conducted in patients, diagnosed with acute ST elevation myocardial infarction |

| |inclusion and exclusion criteria, |will be evaluated and the ECG findings of each patient will be correlated with that of coronary |

| |parameters to be studied |angiogram in order to localize the culprit vessel involved. |

| | |Inclusion criteria |

| | |All patients |

| | |with acute myocardial infarction with chest pain lasting >30 minutes. |

| | |with ECG criteria - ST elevation > 1 mm in atleast two contiguous leads in limb leads & > 2 mm in |

| | |chest leads |

| | |who underwent coronary angiogram |

| | |Exclusion criteria |

| | |Patients with history of |

| | |Previous myocardial infarction |

| | |Prior CABG |

| | |Congenital heart disease |

| | |ECG showing features of LVH |

| | |Left BBB in baseline ECG |

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| |7.3 Does study require investigation |The following investigations will be carried out on each of the patients. |

| |or intervention to be conducted on |Level of cardiac enzymes |

| |patients or other humans or animals. |CK |

| |If so, please describe briefly |CK MB |

| | |ECG at presentation |

| | |Echocardiography |

| | |Coronary Angiography |

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| |7.4 Has Ethical clearance been | Yes |

| |obtained from your institution in case| |

| |of previous section | |

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|8. | List of references |Y Birnbaum, BJ Drew. The electrocardiogram in ST elevation acute myocardial infarction correlation |

| | |with coronary anatomy and prognosis. Post grad Medical Journal 2003; 79:490-504 |

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| | |Radhakrishnan Nair D Luke Clancy. ECG discrimination between right and left circumflex coronary |

| | |artery occlusion in patients with acute IW MI. Chest July 2002 : 122:134-139 |

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| | |Domien J Engelen, Anton P. Gorgels, Emile C.Cheriex, et al. Value of Electrocardiogram in localizing |

| | |the Occlusion site in Left Anterior Descending Coronary Artery in Acute Anterior Myocardial |

| | |Infarction. J Am coll cardiol 1999, 34 : 389- 385 |

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| | |Abid R Assali, Itzhak Herz, Mordochai Vaturi,et al. Electrocardiograhic Criteria for Predicting the |

| | |Culprit Artery in Inferior wall acute myocardial infarction. American journal of cardiology 1999 , |

| | |84 : 87-89 |

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| | |Peter j Zimebaum et al. Use of ECG in acute myocardial infarction. NEJM 2003 348:933-940 |

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| | |Itzhak Herz, Abid R Assali, Yehuda Adler, Alejandro solodky and Samuel Sclarovsky, New ECG criteria |

| | |for prediction of right and left coronary artery as culprit in IWMI. AMJ cardiol 1997 80: 1343-1345 |

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| | |Diagnosis of acute myocardial infarction in angiographically documented occluded infact vessel |

| | |limitations of ST Segment elevation in standard & extended ECG leads. |

| | |(Chest 2001 , 120 (5) 1540 – 1545) |

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| | |Malika Arbane et al. Prediction of site of total occlusion in the left anterior descending coronary |

| | |artery using admission ECG in anterior wall acute myocardial infarction. American journal of |

| | |cardiology 2000 , 85 : 487-491 |

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|9. |9.1 Name of Candidate: | |

| | |DR. SAYD MOHAMED ALIYAS RAJEEB.K.J |

| |9.2 Signature of candidate | |

|10. |Remarks of the guide |This study has been undertaken because of its usefulness in clinical assessment of the patient with |

| | |acute ST elevation myocardial infarction. |

|11. |Name and designation of | |

| |11.1 Guide |Dr. EVS Maben MD, |

| | |Professor and Head Of Department, |

| | |Department of General Medicine, |

| | |AJ Institute of Medical sciences, |

| | |Mangalore – 04. |

| |11.2 Signature | |

| |11.3 HEAD OF DEPARTMENT |Dr. EVS Maben MD, |

| | |Professor and Head Of Department, |

| | |Department of General Medicine, |

| | |AJ Institute of Medical sciences, |

| | |Mangalore - 04, |

| |11.4 Signature: | |

|12 |12.1 Remarks of Chairman | |

| |and principal | |

| |12.2 Signature | |

Consent for participation in research : THE ROLE OF ECG IN LOCALIZING THE CULPRIT VESSEL OCCLUSION IN ACUTE ST SEGMENT ELEVATION MI & ANGIOGRAPHIC CORRELATION

Purpose of study : This study will be done to identify culprit vessel involved in acute ST elevation Myocardial Infarction with the help of ECG and correlating the findings with coronary angiogram.

Procedure : Patients diagnosed with acute ST elevation myocardial infarction will be evaluated and the ECG findings of each patient will be correlated with that of coronary angiogram in order to localize the culprit vessel involved.

• Benefits : Early and accurate identification of infarct related artery by correlation with ECG and angiography helps to precisely predict the infarct size and amount of myocardium at risk, so as to estimate prognosis, and plan early, rapid intervention.

Alternatives : Even if a decision is taken not to participate in the study, standard care will be received.

Privacy and confidentiality : The results of the study may be published for scientific purposes and/or to scientific groups. However you will not be identified. Privacy and confidentiality of the study participants will be ensured.

Insurance policy : The AJ Institute of Medical sciences will provide, within the limitations of the laws of the State of Karnataka, facilities and medical attention to subjects who suffer injuries as a result of participating in its projects. In the even that you believe that you have suffered any physical injury as a result of participating in this study, you may contact Principal Investigator Dr.Sayd Mohamed Aliyas Rajeeb.K.J, or Dr. EVS Maben, Guide.

Financial incentive for participation : You will not receive any payment for participating in this study.

Authorization to publish results : Results of this study may be published for scientific purposes or presented to scientific groups; however, you will not be identified. No indefinable information will be used for publication or dissemination of the study finding. Only Dr. EVS Maben, guide, and Dr. Dr.Sayd Mohamed Aliyas Rajeeb.K.J, Post Graduate student in the department of The AJ Institute of Medical sciences, will have access to the data.

Contacts : If you have any questions regarding the research you may contact Dr. Ramesh Pai, Principal and Chairman of Ethical Committee, AJ Institute of Medical sciences. In the event of an emergency, you may contact Dr.Sayd Mohamed Aliyas Rajeeb.K.J, Post Graduate student in the department of The AJ Institute of Medical sciences, cell phone no. 7760063897, or Dr. EVS Maben, HOD of General Medicine, AJ Institute of Medical sciences.

Your decision whether or not to participate in the study will not affect the standard care during your current of future relations with the hospital. You are free to discontinue the study at any time and for any reason.

Statement of consent

I volunteer and consent to participate in the study. I have read the consent or it has been read to me. The study has been fully explained to me and I may ask queries at any time.

___________________________________________________ Date:

Signature of left thumb impression of Patient

___________________________________________________ Date:

Signature of investigator/Designee obtaining informed consent

___________________________________________________ Date:

Signature (Witness)

Time plan

TITLE : THE ROLE OF ECG IN LOCALIZING THE CULPRIT VESSEL OCCLUSION IN ACUTE ST ELEVATION MYOCARDIAL INFARCTION WITH ANGIOGRAPHIC CORRELATION.

|PHASE |TIME PERIOD |OUTLINE OF PLAN |

|I |August 2010 to October 2010 |Identification of the problem |

| | |Review of Literature |

| | |Development of proforma |

| | |Conducting pilot study |

| | |Submission of synopsis |

|II |November 2010 to November 2011 |Enrollment |

| | |Data collection |

| | |Follow up |

|III |December 2011 to July 2012 |Analysis of collected data |

|IV |July 2012 to November 2012 |Discussion |

| | |Publication |

THE ROLE OF ECG IN LOCALIZING THE CULPRIT VESSEL OCCLUSION IN ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION WITH ANGIOGRAPHIC CORRELATION

Proforma:

Case no. : O.P. No. / I.P. No.

Name : Dept / Ward

Age : Sex : Unit:

Address : Date of Admission :

Occupation :

Religion : Date of discharge

Socio-economic status : Upper class / Middle Class / Lower class

HISTORY:

I. PRESENTING COMPLAINTS : DURATION

✓ Duration of chest pain

✓ Nausea / Vomiting / Sweating

✓ Giddiness / syncope

✓ Dyspnoea

✓ Palpitation

II. RISK FACTORS : DURATION

• H/O angina

• Diabetes Mellitus

• Hypertension

• Hypercholesterolemia

• Family h/o CAD

• Smoking / alcohol

GENERAL PHYSICAL EXAMINATION :

Built and Nourishment

Pallor /Clubbing / Cyanosis /Oedema

J.V.P.

Blood pressure

SYSTEMIC EXAMINATION :

I. CARDIOVASCULAR SYSTEM:

Examination of arterial system

Pulse :

Radial pulse : Rate : Rhythm : Volume :

Vessel wall condition

Carotid Pulse : Character : Volume :

Peripheral pulses – Normal / Reduced / Absent

Radio – Femoral delay :

Examination of venous system :

Jugular venous pulsation : Normal / Raised

Jugular venous pressure : in cms above sternal angle

Examination of precordium

Inspection :

Shape of the chest :

Precordial Prominence, Pectus excavatum / carinatum/ Kyphosis / Scoliosis

Absent / Present

Apex Location :

Precordial Pulsation : Absent / Present Location :

Parasternal Heave : Absent / Present

Neck / Epigastric Pulsations

Other Findings

Palpation : Apex position / Non-position / Normal / Tapping / Hyperdynamic /

Heaving Diffuse / Other types

Parasternal heave : Absent / if present Grade

Any palpable sound Thrill : Absent Present

Other findings

Percussion : Left Border of the Heart

Right Border of the Heart

Base of the Heart

Auscultation :

Heart sounds : Bradycardia Absent / Present

Mitral Area :

Aortic area :

Pulmonary Area :

Tricuspid Area :

Other Areas :

Any other auscultatory findings:

CLINICAL DIAGNOSIS :

INVESTIGATIONS:

Levels of cardiac enzymes

CK CK MB

ECG : 12 Lead Report -

a. Rate

b. Rhythm

c. QRS Axis and morphology,

d. P Wave

e. PR Interval

f. Q Wave

g. ST Segment

h. T wave

i. U wave

j. Low voltage complexes : Absent / Present

k. Other Findings

Echocardiogram:

|Myocardial wall thickness (mm) | |

|IVS Diastole | |

|Systole | |

|LVPW Diastole | |

|Systole | |

|Systolic Functions | |

|FS % | |

|EF% | |

|Chamber Size (cm) | |

|LA | |

|LV ED | |

|ES | |

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Coronary Angiography

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