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Gepubliceerd in: Netherlands Heart Journal 10/2022

Open Access 10-05-2022 | Rhythm Puzzle – Answer

Electrocardiographic ST-segment elevation with prominent R waves in precordial leads

Auteurs: A. Y. Andreou, A. R. Pérez-Riera

Gepubliceerd in: Netherlands Heart Journal | Uitgave 10/2022

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Answer

Electrocardiography (ECG) during angina showed an ST-segment elevation resembling the Greek letter λ (lambda) and a striking increase in R wave amplitude (> 15 mm) in leads V2–V5 (prominent anterior QRS forces), loss of septal Q waves in V5–V6 and ST-segment elevation in II, aVF and III (Fig. 1). Emergency angiography revealed an obstructive stenosis in the proximal left anterior descending (LAD) coronary artery (Fig. 2), which was successfully treated with stenting.
ECG showed intermittent changes compatible with a conduction disturbance or block in the left septal fascicle (LSF), which is a third distinct division of the left bundle branch proceeding to the middle third of the left septal surface towards the apex [1]. Indeed, of all causes of prominent anterior QRS forces, only left septal fascicular block (LSFB) can manifest as intermittent ECG changes [1]. Durrer et al. demonstrated breakthrough activation through the LSF by using isolated, perfused human hearts, thereby for the first time proving its existence [2]. Ischaemia-induced LSFB has been associated with lesions in the proximal LAD coronary artery, the septal branches of which provide the entire blood supply of the LSF [1]. In our patient, ischaemic ST-segment elevation and LSFB were probably due to vasospasm at the site of the LAD artery lesion compromising blood flow in the first septal branch found in the immediate vicinity.
A precordial lambda-like ST-segment elevation comprises a prominent J wave merging with an elevated ST-segment and indicates an increased risk of malignant ventricular arrhythmias. ECG recognition of LSFB in acute coronary syndromes manifesting with this type of ST-segment elevation should alert physicians to the presence of a proximal LAD artery culprit lesion and prompt aggressive therapy including emergency angiography [3].

Funding

The authors received no specific funding for this work.

Conflict of interest

A.Y. Andreou and A.R. Pérez-Riera declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Literatuur
1.
go back to reference Riera PAR, Ferreira C, Ferreira Filho C, et al. Electrovectorcardiographic diagnosis of left septal fascicular block: anatomic and clinical considerations. Ann Noninvasive Electrocardiol. 2011;16:196–207. CrossRef Riera PAR, Ferreira C, Ferreira Filho C, et al. Electrovectorcardiographic diagnosis of left septal fascicular block: anatomic and clinical considerations. Ann Noninvasive Electrocardiol. 2011;16:196–207. CrossRef
2.
go back to reference Durrer D, van Dam RT, Freud GE, Janse MJ, Meijler FL, Arzbaecher RC. Total excitation of the isolated human heart. Circulation. 1970;41:899–912. CrossRef Durrer D, van Dam RT, Freud GE, Janse MJ, Meijler FL, Arzbaecher RC. Total excitation of the isolated human heart. Circulation. 1970;41:899–912. CrossRef
3.
go back to reference Sato A, Tanabe Y, Chinushi M, et al. Analysis of J waves during myocardial ischaemia. Europace. 2012;14:715–23. CrossRef Sato A, Tanabe Y, Chinushi M, et al. Analysis of J waves during myocardial ischaemia. Europace. 2012;14:715–23. CrossRef
Metagegevens
Titel
Electrocardiographic ST-segment elevation with prominent R waves in precordial leads
Auteurs
A. Y. Andreou
A. R. Pérez-Riera
Publicatiedatum
10-05-2022
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 10/2022
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-022-01696-6

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