Correlation of angiographic findings and right (V₁ to V₃) versus left (V₄ to V₆) precordial ST-segment depression in inferior wall acute myocardial infarction

This study assessed whether differences in the underlying mechanisms for various patterns of precordial ST-segment depression with inferior acute myocardial infarction (AMI) are associated with poorer prognoses. We studied 1,155 patients with inferior AMI who underwent thrombolysis in the Global Utilization of Streptokinase and TPA for Occluded arteries (GUSTO-1) angiographic substudy: those without precordial ST depression (n = 412; 35.7%), those with maximum ST depression in leads V₁ to V₃ (n = 547; 47.4%), and those with maximum ST depression in leads V₄ to V₆ (n = 196; 17.0%) on admission electrocardiogram. We compared the infarct-related artery, presence of left anterior descending or multivessel coronary artery disease, and left ventricular function among groups. Patients with maximum ST depression in leads V₄ to V₆ more often had 3-vessel disease (26.0%) than those without precordial ST depression (13.5%) or those with ST depression in leads V₁ to V₃ (15.7%; p = 0.002), and they had a lower ejection fraction (median 54% vs 60% and 55%, respectively; p <0.001). Patients with maximum ST depression in leads V₁ to V₃ less often had AMIs due to proximal right coronary artery obstruction (23.9%) than patients without precordial ST depression (35.2%) or those with ST depression in leads V₄ to V₆ (40.0%; p = 0.001) and had larger AMIs as estimated by peak creatine kinase. Different patterns of precordial ST depression are associated with distinctive coronary anatomy. ST depression in leads V₄ to V₆, but not V₁ to V₃, confers a greater likelihood of multivessel coronary artery disease.