RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA.

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the candidate
and address (in block letters) / DR. SYLESH KUMAR JAIN .G
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 <0.5 (Proximal right coronary artery occlusion)
ST depressionV3/ ST elevation in LIII 0.5 – 1.2 (Distal right coronary artery occlusion)2,3
Left Circumflex Artery
ST elevation in LIILIII
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 1/3, ST depression1mm. And pattern II, S/R-wave ratio>1/3, ST depression >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:
1.  This study is aimed at validating the usefulness of electrocardiography in localizing the culprit vessel in acute inferior wall myocardial infarction
2.  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 involved.informed 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:
1.  Peter j Zimebaum ,Mark E Josephson. Use of ECG in acute myocardial infarction. N Engl J Med. 2003; 348:933-40.
2.  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.
3.  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.
4.  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.
5.  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.
6.  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.
7.  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)
11.1 GUIDE / DR. T.S.SHIVANAND .
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