Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA.

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |Name of the candidate |DR. SYLESH KUMAR JAIN .G |

| |and address (in block letters) |POST GRADUATE STUDENT |

| | |DEPARTMENT OF GENERAL MEDICINE |

| | |SSIMS & RC, DAVANGERE |

| | |KARNATAKA. |

|2. |Name of the institution |S. S. INSTITUTE OF MEDICAL SCIENCES AND RESEARCH CENTRE |

| | |DAVANGERE-577005. |

| | |KARNATAKA. |

|3. |Course of study and subject |POST GRADUATE DEGREE, |

| | |M.D. GENERAL MEDICINE. |

|4. |Date of admission to course |03.05.2012 |

|5. |Title of the topic |“A STUDY ON THE ROLE OF ECG CHANGES IN LOCALIZING THE CULPRIT VESSEL IN ACUTE |

| | |INFERIOR WALL MYOCARDIAL INFARCTION WITH ANGIOGRAPHIC CORELLATION IN A TERTIARY CARE |

| | |HOSPITAL.” |

| 6. |BRIEF RESUME OF THE INTENDED WORK: |

| |6.1 Need for the study: |

| |The Electrocardiogram remains a crucial tool in the identification and management of acute myocardial infarction. A detailed analysis of patterns of |

| |ST-segment elevation in inferior wall myocardial infarction may influence decisions regarding the perfusion therapy.1 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 |

| |revascularization.2 |

| | |

| |Electrocardiography reflects the physiology of myocardium during acute ischaemia whereas the coronary angiography identifies the vessel anatomy. The |

| |present study will identify the culprit vessel from ECG in patients with acute inferior wall 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. |

| |And electrocardiogram finding will be correlated with coronary angiogram. |

| | |

| |6.2 Review of literature: |

| |Y Birnbaum et al reviewed role of electrocardiogram in ST elevation acute inferior wall 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. 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 agent. . By reflecting the pathophysiology of the myocardium during acute ischaemia, the ECG conveys information unique from that of |

| |coronary angiography and provides important information to guide clinical decision-making.2 |

| | |

| |Moazzam Ali Naqvi et al have predicted through a number of researchers by using different electrocardiographical criteria to predict the culprit vessel |

| |in acute inferior wall myocardial infarction (MI) cases. Therefore, the determination of infarct related artery in AMI is extremely important with regard|

| |to prediction of potential complications, furthermore, predicting the probable site of occlusion within RCA is worthwhile because proximal occlusions are|

| |likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Our study aimed at evaluating the ECG criteria to |

| |predict the proximity of lesion in the right coronary artery (RCA) in acute inferior wall MI cases. The Objectives were to predict the presence of a |

| |proximal lesion in right coronary artery by severity of ST segment elevation in inferior ECG leads.4 |

| | |

| |Elhan hakki kazazi et al reviewed that despite the fact that left main lesion was similar in the two types of myocardial infarction, the number of |

| |involved coronary arteries was significantly higher in the inferior myocardial infarction patients. It has been suggested that each site of acute |

| |myocardial infarction has relatively specific mechanisms so that predominant pathophysiology in inferior infarction |

| |33.2% of anterior wall myocardial infarction patients and 19.6% of inferior wall patients had single vessel disease. We also found that 72.0% of inferior|

| |wall myocardial infarction patients had multi-vessel coronary artery disease. Results were obtained based on our angiographic database and maybe the |

| |patients with inferior wall myocardial infarction who underwent angiography had high risk features and did not include all the inferior myocardial |

| |infarction population. 5 |

| | |

| |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 inferior wall 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 inferior wall 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 inferior wall myocardial infarction.1 |

| | |

| |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 low.6 |

| | |

| |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 predictor.7 |

| | |

| |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 infarction.3 |

| | |

| |6.3 Objectives of the study: |

| |This study is aimed at validating the usefulness of electrocardiography in localizing the culprit vessel in acute inferior wall myocardial infarction |

| |Correlating the findings with coronary angiogram. |

| |7. Materials and methods: |

| |7.1 Source of data: |

| |Patients diagnosed with acute inferior wall myocardial infarction who undergo coronary angiogram from S.S Institute of Medical Sciences and Research |

| |Centre, Davangere. |

| |7.2 Method of collection of data: (including sampling procedure if any): |

| |Patients diagnosed with acute inferior wall myocardial infarction in SSIMS& RC, 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 rmed written consent is obtained prior to investigations.|

| |Study design: |

| |A hospital-based, descriptive, study. |

| |STATATICAL ANALYSIS: |

| |The data will be shown in terms of numbers and percentages, sensitivity, specificity, positive predictive value and negative predictive value will be |

| |calculated to study the efficiency of the test. |

| | |

| |Study period: |

| |12-18 months. |

| |Inclusion criteria: |

| |All patients |

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

| |With ECG criteria – ST segment 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 |

| | |

| |7.3 Does the study require any investigatons or interventions to be conducted on patients or other humans or animals? If so, please describe briefly: |

| |ECG & Coronary Angiography |

| |7.4 Has ethical clearance been obtained from your institution in case of 7.3 Yes |

| | |

| |8. LIST OF REFERENCES: |

| |Peter j Zimebaum ,Mark E Josephson. Use of ECG in acute myocardial infarction. N Engl J Med. 2003; 348:933-40. |

| | |

| |Y Birnbaum, BJ Drew. The electrocardiogram in ST elevation acute myocardial infarction correlation with coronary anatomy and prognosis. Postgrad Medical |

| |Journal. 2003; 79:490-504. |

| | |

| |Itzhak Herz, Abid R Assali, Yehuda Adler, Alejandro solodky , Samuel Sclarovsky, New ECG criteria for prediction of right and left coronary artery as |

| |culprit in IWMI. AMJ cardiol . 1997; 80: 1343-345. |

| | |

| |Moazzam Ali Naqvi ,Muzaffer Ali, Fuad Hakeem, Arslan Masood,Zubair Akram.Correlation of severity of st segment elevation in acute inferior wall |

| |myocardial infarction with the proximity of right coronary artery disease. J Ayub Med Coll Abbottabad 2008;20(4):82-85. |

| | |

| | |

| |Elham H K et al. Comparing angiography features of inferior versus anterior myocardial infarction regarding severity and extension in a cohort of Iranian|

| |patients. J Res Med Sci. 2011 April; 16(4): 484–489. |

| | |

| | |

| |Abid R Assali, Itzhak Herz, Mordochai Vaturi,et al. Electrocardiograhic Criteria for Predicting the Culprit Artery in Inferior wall acute myocardial |

| |infarction. AMJ cardiol. 1999 ; 84 : 87-89. |

| | |

| | |

| |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. |

| | |

| | |

|9 | SIGNATURE OF THE CANDIDATE | |

|10 | REMARKS OF THE GUIDE |Acute IWMI is one of the common condition which we come |

| | |across in this hospital . and this event can often be |

| | |associated with significant left ventricular dysfunction , |

| | |which cannot be explained such cases have reciprocal ST |

| | |changes in anterior chest leads which can be probable true |

| | |ischemic changes and hence complications can be anticipated|

| | |and prognosis can be assessed at admission. All the |

| | |investigation needed for the study are done in our institute|

| | |hence study has been recommended . |

|11 | NAME AND DESIGNATION OF: (IN BLOCK LETTERS) | DR. T.S.SHIVANAND . |

| |11.1 GUIDE |PROFESSOR |

| | |DEPT OF MEDICINE |

| | |SSIMS&RC |

| | |DAVANGERE. |

| | 11.2 SIGNATURE (GUIDE) | |

| | 11.3 CO-GUIDE |DR. SREENIVASA.B |

| | |CARDIOLOGIST |

| | |SSIMS&RC |

| | |DAVANGERE. |

| | 11.4 SIGNATURE (Co –GUIDE) | |

| | 11.5 HEAD OF THE DEPARTMENT |DR. S.SREEPADA BHAT |

| | |PROF AND HOD |

| | |DEPT OF GENERAL MEDICINE |

| | |SSIMS&RC |

| | |DAVANAGERE. |

| | | |

| |11.6 SIGNATURE: | |

|12 |12.1 REMARKS OF THE CHAIRMAN | |

| |AND PRINCIPAL | |

| | | |

| |12.2 SIGNATURE | |

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