Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : OC11 - OC15 Full Version

Angiographic Localisation of Culprit Vessel in Non ST Elevated Acute Coronary Syndrome


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51978.15896
Chandrakanta Mishra, Archana Mishra, Biswajit Das, Ritesh Acharya, Satyanarayan Routray

1. Associate Professor, Department of Cardiology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 2. Associate Professor, Department of Physiology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 3. Associate Professor, Department of Cardiology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 4. Resident, Department of Cardiology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 5. Professor, Department of Cardiology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India.

Correspondence Address :
Dr. Ritesh Acharya,
Flat No. 404, Harihar Enclave, Goutam Nagar, Bhubaneswar, Odisha, India.
E-mail: acharyaritesh1987@gmail.com

Abstract

Introduction: Coronary Artery Disease (CAD) is a major cause of mortality and morbidity. Among Acute Coronary Syndrome (ACS), Non ST Elevated Acute Coronary Syndrome (NSTE-ACS) continues to increase. Unlike ST Elevated Myocardial Infarction (STEMI), association of ischaemic changes in Electrocardiogram (ECG) with culprit lesion localisation in NSTE-ACS has not been well reported.

Aim: To investigate the association between ECG abnormalities and angiographic localisation of culprit vessel in patients of NSTE-ACS.

Materials and Methods: This observational, prospective study was conducted in SCB Medical college and Hospital, Cuttack, Odisha, India, from December 2019 to November 2020. A total of 200 eligible patients of newly diagnosed NSTE-ACS were included. Demographic and risk factor assessment, clinical examination and routine blood investigations were done. All patients had an admission Electrocardiogram (ECG), Echocardiography (Echo) and Coronary Angiography (CAG) done within 72 hours of admission. Admission ECG was associated with CAG to assess predictive value in localisation of culprit vessel. Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Likelihood Ratio (LR), pre and post-test odds of individual ECG findings were assessed. Statistical Package for the Social Sciences (SPSS) version 24.0 was used for statistical analysis.

Results: Sensitivity, specificity, PPV, NPV, LR+, pretest odds and post-test odds of anterior wall, inferior wall, lateral wall and augmented Vector Right (aVR) group ECG changes in predicting Left Anterior Descending (LAD), Right Coronary Artery (RCA), Left Circumflex Artery (LCX) and Left main or Triple Vessel Disease (LM/TVD) as culprit artery were 75.9%, 90.5%, 91.7%, 73.1%, 7.96, 1.38 and 10.98; 69.1%, 91.5%, 87.8%, 76.9%, 8.14, 0.89 and 7.21; 64%, 93%, 87.3%, 77.4%, 9.10, 0.75 and 6.86 and 69.2%, 96.3%, 90%, 86.7%, 18.66, 0.48 and 8.98, respectively. Sensitivity, specificity, PPV and NPV of anterior and lateral, inferior and lateral and anterior and inferior wall ECG changes in predicting LAD and LCX, RCA and LCX and LAD and RCA as culprit vessels were 75.0%, 82.6%, 27.27% and 97.43%; 47.0%, 88.5%, 27.5% and 94.73% and 53.3%, 83.2%, 20.51% and 95.65%, respectively. The ECG was normal in 31% of which Myocardial Infarction with Non Obstructive Coronary Artery (MINOCA) (34%) and Single Vessel Disease (SVD) (30.6%) were prevalent. The MINOCA were mostly seen in normal ECG pattern.

Conclusion: An ECG is a moderately sensitive but highly specific parameter in predicting LAD, LCX, RCA and LM/TVD as culprit vessels in Non ST Segment Elevation Myocardial Infarction- Acute Coronary Syndromes (NSTE-ACS). Double territory ECG changes have a poor association in predicting culprit vessel. However, a good association was noted for (anterior and lateral) wall ECG changes in predicting LAD and LCX as culprit arteries.

Keywords

Coronary Angiography, Echocardiography, Electrocardiogram, Non ST elevated myocardial infarction, Unstable angina

The Coronary Artery Disease (CAD) is a major cause of mortality and morbidity across the world. In 2015, nearly 17.9 million people died of Cardiovascular Disease (CVD) representing 31% of global deaths of which an estimated 7.2 million were due to CAD (1). Coronary artery disease prevalence continues to rise in India with rapid epidemiologic transition with a projected rise in mortality in 117% and 105% men and women respectively between 1990-2020 (2).

Among Acute Coronary Syndromes (ACS), the fraction of Non ST Segment Elevation Myocardial Infarction-Acute Coronary Syndromes (NSTE-ACS) continues to increase while that of STEMI is declining (3). According to Kerala and Himachal Pradesh ACS registries, NSTE-ACS accounts for 63% and 54.5% of ACS cases, respectively (4),(5).

The standard 12 lead ECG has long been a reliable clinical tool for diagnosis and treatment of Acute Myocardial Infarction (AMI). Unlike ST Elevated Myocardial Infarction (STEMI), association of ischaemic changes in Electrocardiogram (ECG) with culprit lesion localisation in NSTE-ACS has not been well reported (6). Electrocardiogram can provide valuable information to improve clinical decision making and targeted early invasive therapy. Initial catheterisation of presumed culprit artery in NSTE-ACS would reduce the time to perfusion and can transform into mortality benefit for the patients (7).

Thus, the authors conducted, that, the present study to investigate the association between ECG abnormalities and angiographic localisation of culprit vessel in patients of NSTE-ACS.

Material and Methods

This prospective, observational study was conducted at the Department of Cardiology, SCB Medical College and Hospital, Cuttack, Odisha, India, from December 2019 to November 2020. Study was conducted as per the principles of Declaration of Helsinki and International Committee on Harmonization of Good Clinical Practice (ICH-GCP). All the research participant signed the informed consent. The study protocol was approved by the Institute Ethics Committee. Total 200 patients were included.

Inclusion criteria: All consecutive, newly diagnosed cases of NSTE-ACS admitted in the Department of Cardiology who gave written informed consent for being a participant in the study were included.

Exclusion criteria: Cases with age <18 or >80 years, previous history of ACS, angioplasty or Coronary Artery Bypass Graft (CABG), contraindications to Coronary Angiogram (CAG), CKD and allergy to iodinated compounds, lack of consent for CAG ST/T changes due to secondary causes were excluded.

Patients with presence of acute onset typical ischaemic symptoms with normal ECG or ST segment depression or T-wave inversion or flattening with rise/fall of troponin level with atleast one value above 99th percentile upper reference limit were diagnosed as Non ST Segment Elevation Myocardial Infarction- Acute Coronary Syndromes (NSTE-ACS) (3) and those with normal troponin level were classified as Unstable Angina (UA) (8).

ST segment depression ≥0.05 mV (0.5 mm) and T wave inversion ≥0.1 mV (1 mm) with prominent R wave or R/S ratio >1, in two contiguous leads, were considered significant ST/T changes.

Study Procedure

Aforementioned admission ECG changes in V1-6, I,aVL were taken as anterior wall; V5-6, I, aVL were taken as lateral wall; II, III, aVF were taken as inferior wall. When these ECG changes were noted in anterior, inferior and lateral wall, they correspond to LAD, RCA and LCX territories respectively and ST elevation in aVR with ST depression in other leads was considered as aVR group ECG changes correspond to LMCA or Triple Vessel Disease (TVD). The MINOCA was defined as patients with Acute Myocardial Infarction (AMI) with absence of obstructive disease (< 50% obstruction) on angiography in any major epicardial vessel.

A standard 12 lead ECG on admission along with echocardiography was undertaken for Regional Wall Motion Abnormality (RWMA) and LV function. Blood parameter including Troponin T (quantitative) and lipid profile were measured. Demographic variables, risk factors and ST/T changes in different wall territory on admission ECG were recorded. Detailed clinical examination and risk stratification was done. Accordingly Guideline Directed Medical Therapy (GDMT) was ensured to all.

Patients underwent diagnostic Coronary Angiography (CAG) within 72 hours of admission depending upon the risk stratification and subject to availability of cath lab. Coronary angiography was done with Siemens Artis Zee machine via the femoral or radial route for evaluation and detection of location and severity of lesions and accordingly treatment was advised by the treating physician. Optimal angiographic views were taken to assess the lesion characteristics and quantification of diameter stenosis by Quantitative Coronary Angiography (QCA). Obstructive lesions were observed in two orthogonal views and diametric stenosis of atleast 50% were considered significant.

Culprit Lesion Determination

Patients who had Single Vessel Disease (SVD), the culprit artery localisation was straight forward. In multi vessel disease, the lesion was taken as culprit if the Regional Wall Motion Abnormality (RWMA) on echocardiography matched myocardial segments supplied by the artery containing the significant lesion or if an obvious eccentric thrombus with scalloped or overhanging edges and a narrow neck was noted (7). Thrombus was indicated by globular intraluminal mass with rounded or polypoid shape, or haziness of lesion. After locating the culprit artery, the patient’s admission ECG was compared with CAG finding to study whether it has any predictive value for identifying culprit artery.

Statistical Analysis

All the data collected were entered into the Microsoft Excel 2007 software and further analyzed in Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Chicago). All the categorical variables were expressed in terms of number/frequency and percentages. Association between two categorical variables were obtained by using Chi-square test. All the continuous variables were expressed in terms of mean and standard deviation. Significance level in comparison of means between two groups were obtained by independent sample t-test test/Mann-Whitney U test while between more than two groups were obtained by using Analysis of Variance (ANOVA). A p-value <0.05 was taken as statistically significant. Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Likelihood Ratio (LR), pretest and post-test odds of individual ECG findings were assessed.

Results

Out of 200 Non ST elevated acute coronary syndrome patients, Non ST Elevation Myocardial Infarction (NSTEMI) was 78% (n=156) and UA 22% (n=44). The mean age was 57.61±8.44 years with 69.5% (n=139) being male. Family history of CAD (44, 22%), smoking [38% (n=76)], diabetes mellitus [36.5% (n=73)], hypertension [(103, dyslipidemia [10% (n=20)] and tobacco chewing [30.5% (n=61)] were the risk factors identified. The mean BMI was 23.94±2.33 kg/m2. The ST/T changes in anterior wall, inferior wall and lateral wall were 48% (n=96), 37% (n=74) and 31.5% (n=63) respectively. aVR group ECG changes was 25% (n=50) and normal ECG in 31% (n=62) (Table/Fig 1).

Patients with ECG finding suggestive of single territory, double territory, aVR group and normal ECG were 30% (n=60), 14% (n=28), 25% (n=50) and 31% (n=62) respectively. Among single territory, anterior wall ECG changes (50%) were most common followed by inferior wall (38.5%) and lateral wall (11.5%) (Table/Fig 2).

Patients with Single Vessel Disease (SVD), Double Vessel Disease (DVD), Left Main (LM) or Triple Vessel Disease (TVD) and Myocardial Infarction with Non Obstructive Coronary Arteries (MINOCA) were 31.5% (n=63), 24% (n=48), 32.5% (n=65) and 12% (n=24) respectively. In SVD, LAD was the most common culprit artery (50%) followed by RCA (30%) and LCX (20%) respectively. In patients with DVD, lesions in LAD and LCX, LCX and RCA and LAD and RCA were almost equally distributed in 33.3%, 35.4% and 31.3% respectively (Table/Fig 3).

In patients with normal ECG, SVD, DVD, TVD and MINOCA were 30.6% (n=19), 14.5% (n=9), 20.9% (n=13) and 34% (n=21) respectively. Among SVD, LAD was the most common culprit artery 57.9% (n=11). MINOCA were mostly seen with normal ECG pattern in 87.5% (21 out of 24 patients) (Table/Fig 4).

The sensitivity, specificity, PPV, NPV, LR+, pretest odds and post-test odds of anterior wall, inferior wall, lateral wall and aVR group ECG changes in predicting LAD, as culprit artery were 75.9%, 90.5%, 91.7%, 73.1%, 7.96, 1.38 and 10.98; RCA as culprit artery were 69.1%, 91.5%, 87.8%, 76.9%, 8.14, 0.89 and 7.21; LCX as a culprit artery were 64%, 93%, 87.3%, 77.4%, 9.10, 0.75 and 6.86 and LM/TVD as culprit artery were 69.2%, 96.3%,90%, 86.7%, 18.66, 0.48 and 8.98 respectively. Sensitivity, specificity, PPV and NPV of anterior and lateral, inferior and lateral and anterior and inferior wall ECG changes in predicting LAD and LCX, as culprit vessels were 75.0%, 82.6%, 27.27% and 97.43%; RCA and LCX as culprit vessels were 47.0%, 88.5%, 27.5% and 94.73% and LAD and RCA as culprit vessels were 53.3%, 83.2%, 20.51% and 95.65% respectively (Table/Fig 5).

Discussion

In the present study, authors assessed the validity of ECG changes in predicting the culprit artery compared to the gold standard i.e. coronary angiography in patients with NSTE-ACS.

The mean age was 57.62±8.45 years and was nearly 10 years earlier than that reported in Western studies (9),(10),(11). A male preponderance was observed that is probably due to the gender bias and atypical presentation in females, as shown in INTERHEART study and its South Asian cohort 76% and 85% respectively (12),(13). Risk factor profiles of our NSTE-ACS patients was similar to the CREATE registry (14) and NE registry (15). Tobacco chewing as a risk factor in 1/3rd of present study cases should be noted with a caution considering the large prevalence of tobacco chewing in our part of the country. The NSTE-ACS was more prevalent compared to unstable angina (78% vs 22%) similar to previous studies (15),(16). It could be due to the increased reliance on highly sensitive biomarkers of myocardial necrosis.

In the present study, anterior wall (48%) ECG changes were most common followed by inferior wall (37%), lateral wall (31.5%) and aVR group ECG changes (25%) similar to 3D-EINSTEIN study (16) and Sanaani A et al., (6). The ECG was normal in 31% similar to 3D-EINSTEIN study (16). In these patients, MINOCA (34%) and SVD (30.4%) were most prevalent, which is similar to Hiremath RG et al., (17) (25% and 37.5%), Teixeira R et al., (18) (26.2% and 32.7%) and Moustafa A et al., (19) (23.4% and 53.2%). LAD (57.9%) was the most common culprit vessel in normal ECG group similar to Moustafa A et al., (19) (55.6%).

On the basis of coronary angiogram, LM/TVD (32.5%) was most prevalent followed by SVD (31.5%), DVD (24%) and MINOCA (12%), as seen in Sidhu NS et al., (20) study in 37.7%, 32.2%, 16.7% and 18.9% patients respectively. However, contrasting to the present observation, Desai AP and Bhagarhatta R, (21), Iqbal F and Barkataki JC, (15) and Moustafa A et al., (19) reported, SVD as most common culprit vessel affecting 47.6%, 35.3% and 53.4% patients respectively. Overall, LAD (58%) was the most common culprit vessel followed by RCA (47%), LCX (43%) and LMCA/TVD (32.5%) similar to the observations reported by Sharma R et al., (13), Moustafa A et al., (19) and Deora S et al., (22). Among SVD, LAD (50%) was the most common culprit vessel similar to Desai AP and Bhagarhatta R, (21) and Sanaani A et al., (6) study.

In patients with LAD as culprit artery (n=116), anterior wall ECG changes were seen in 75.9% (n=88). Sensitivity, specificity, PPV and NPV of anterior wall ECG changes predicting LAD as culprit artery were 75.9%, 90.5%, 91.7% and 73.1% respectively. This was similar to that reported by Desai AP and Bhagarhatta R, (21), who observed 73.60%, 93.50%, 90%, 81.80%; Khanra D et al., (16) who observed 72.41%, 90%, 89.36%, 73.77% and Sanaani A et al., (6) who found 90.9%, 98.5%, 96.77%, 95.77% respectively.

In patients with RCA as culprit artery (n=94), inferior wall ECG changes were present in 69.1% (n=65). Sensitivity, specificity, PPV and NPV of inferior wall ECG changes predicting significant RCA as culprit artery were 69.1%, 91.5%, 87.8% and 76.9% respectively, similar to that reported by Desai AP and Bhagarhatta R, (21) was 63.10%, 93.70%, 90.50%, 72.70% and Khanra D et al., (16) was 51.42%, 84.93%, 62.06%, 78.48% and Sanaani A et al., (6) was 93.33%, 90.80%, 63.63%, 98.75% respectively.

In patients with LCX as culprit artery (n=86), lateral wall ECG changes were present in 64% (n=55). Sensitivity, specificity, PPV and NPV of lateral wall ECG changes predicting significant LCX as culprit artery were 64.0%, 93.0%, 87.3% and 77.4% respectively similar to that reported by Desai AP and Bhagarhatta R, (21) was 63.10%, 93.70%, 90.50%, 72.70% and by Khanra D et al., (16) was 28.57%, 91.78%, 62.5%, 72.80% respectively (21).

In patients with LMCA/TVD as the culprit artery (n=65), aVR group ECG changes were present in 69.2% (n=45). Sensitivity, specificity, PPV and NPV of aVR group ECG changes predicting significant LMCA/TVD lesion were 69.2%, 96.3%, 90.0% and 86.7% respectively similar to that reported by Desai AP and Bhagarhatta R, which was 66.60%, 98.50%, 91.40% and 92.50% respectively (21).

The present study established ECG as a moderately sensitive but highly specific parameter in predicting LAD, LCX, RCA and LM/TVD as culprit vessels in NSTE-ACS. ECG changes predicting LAD (75.9%) as culprit artery were most sensitive followed by LM/TVD (69.2%), RCA (69.1%) and LCX (64%) whereas prediction of LM/TVD (96.3%) as culprit artery was most specific followed by LCX (93%), RCA (91.5%) and LAD (90.5%). Double territory ECG changes have a poor association in predicting culprit vessel in view of poor positive predictive value. However, a good association was noted for anterior and lateral wall ECG changes in predicting LAD and LCX as culprit arteries with a sensitivity, specificity and NPV of 75%, 82.6% and 97.43% respectively. The moderate sensitivity of ECG for localisation of culprit arteries in present study could be due to individual variation in coronary anatomy, presence of collateral circulation, left ventricular hypertrophy and inadequate representation of posterior wall.

Limitation(s)

Some of the limitations of present study were small sample size, single centre study, inter-observer variation in analysis of ECG, Echo and CAG. The observer performing the CAG was not being blinded to the ECG and Echo findings which could have resulted in some bias in reporting.

Conclusion

Admission ECG as a modality in predicting culprit artery in Non ST Elevated Acute Coronary Syndrome has acceptable validity. Compared to double territory lesion, single coronary involvement can be predicted in a better way using ECG in NSTE-ACS. Larger scale studies on a more diverse population could further establish its role in efficient management of NSTE-ACS.

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DOI and Others

DOI: 10.7860/JCDR/2022/51978.15896

Date of Submission: Aug 18, 2021
Date of Peer Review: Nov 06, 2021
Date of Acceptance: Dec 02, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 19, 2021
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• iThenticate Software: Dec 28, 2021 (16%)

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