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• W2049880706 abstract "The accuracy of the admission electrocardiogram (ECG) in predicting the site of acute coronary artery occlusion in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease is not well known. This study aimed to assess whether the presence of multivessel coronary artery disease (CAD) modifies the artery-related ST-segment changes in patients with acute coronary artery occlusion. We reviewed the admission ECG, clinical records, and coronary angiography of 289 patients with STEMI caused by acute occlusion of left anterior descending (LAD; n = 140), right (n = 118), or left circumflex (LCx; n = 31) coronary arteries. All patients underwent primary percutaneous coronary reperfusion during the first 12 hours. The magnitude and distribution of artery-related ST-segment patterns were comparable in patients with single (n = 149) and multivessel (n = 140) CAD. Occlusion of proximal (n = 55) or mid-distal (n = 85) LAD artery induced ST-segment elevation in leads V1 to V5, but only the proximal occlusion induced reciprocal ST-segment depression in leads II, III, and aVF (p <0.001). Proximal and mid-distal occlusion of right (n = 45 and 73, respectively) or LCx (n = 15 and 16) coronary artery always induced ST-segment elevation in leads II, III, and aVF and reciprocal ST-segment depression in leads V2 and V3. ST-segment elevation in lead V6 >0.1 mV predicted LCx artery occlusion. In conclusion, patients with STEMI with single or multivessel CAD have concordant artery-related ST-segment patterns on the admission ECG; in both groups, reciprocal ST-segment depression in LAD artery occlusion predicts a large infarct. Subendocardial ischemia at a distance is not a requisite for the genesis of reciprocal ST-segment changes. The accuracy of the admission electrocardiogram (ECG) in predicting the site of acute coronary artery occlusion in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease is not well known. This study aimed to assess whether the presence of multivessel coronary artery disease (CAD) modifies the artery-related ST-segment changes in patients with acute coronary artery occlusion. We reviewed the admission ECG, clinical records, and coronary angiography of 289 patients with STEMI caused by acute occlusion of left anterior descending (LAD; n = 140), right (n = 118), or left circumflex (LCx; n = 31) coronary arteries. All patients underwent primary percutaneous coronary reperfusion during the first 12 hours. The magnitude and distribution of artery-related ST-segment patterns were comparable in patients with single (n = 149) and multivessel (n = 140) CAD. Occlusion of proximal (n = 55) or mid-distal (n = 85) LAD artery induced ST-segment elevation in leads V1 to V5, but only the proximal occlusion induced reciprocal ST-segment depression in leads II, III, and aVF (p <0.001). Proximal and mid-distal occlusion of right (n = 45 and 73, respectively) or LCx (n = 15 and 16) coronary artery always induced ST-segment elevation in leads II, III, and aVF and reciprocal ST-segment depression in leads V2 and V3. ST-segment elevation in lead V6 >0.1 mV predicted LCx artery occlusion. In conclusion, patients with STEMI with single or multivessel CAD have concordant artery-related ST-segment patterns on the admission ECG; in both groups, reciprocal ST-segment depression in LAD artery occlusion predicts a large infarct. Subendocardial ischemia at a distance is not a requisite for the genesis of reciprocal ST-segment changes. The patterns of ST-segment shift are currently used to identify the infarct-related coronary artery and the level of the occlusion in patients with ST-segment elevation myocardial infarction (STEMI).1Kosuge M. Kimura K. Ishikawa T. Hongo Y. Mochida Y. Sugiyama M. Tochikubo O. New electrocardiographic criteria for predicting the site of coronary artery occlusion in inferior wall acute myocardial infarction.Am J Cardiol. 1998; 82: 1318-1322Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Engelen D.J. Gorgels A.P. Cheriex E.C. De Muinck E.D. Ophuis A.J. Dassen W.R. Vainer J. Van Ommen V.G. Wellens H.J. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.J Am Coll Cardiol. 1999; 34: 389-395Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 3Sasaki K. Yotsukura M. Sakata K. Yoshino H. Ishikawa K. Relation of ST-segment changes in inferior leads during anterior wall acute myocardial infarction to length and occlusion site of the left anterior descending coronary artery.Am J Cardiol. 2001; 87: 1340-1345Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 4Fiol M. Cygankiewicz I. Carrillo A. Bayés-Genis A. Santoyo O. Gómez A. Bethencourt A. Bayés de Luna A. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction.Am J Cardiol. 2004; 94: 709-714Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In patients with multivessel coronary artery disease (CAD), the acute occlusion of a coronary artery may be associated with ischemia at a distance and this may modify the pattern of the ST-segment changes.5Mirvis D.M. Physiologic bases for anterior ST segment depression in patients with acute inferior wall myocardial infarction.Am Heart J. 1988; 116: 1308-1322Abstract Full Text PDF PubMed Scopus (52) Google Scholar However, the ability of the admission electrocardiogram (ECG) to predict the site of coronary occlusion in patients with STEMI with multiple CAD has not been systematically analyzed. The purpose of this study was to compare the accuracy of the admission ECG in predicting the site of coronary occlusion in patients with STEMI with single and multivessel CAD.MethodsWe reviewed the clinical records of 373 consecutive patients with STEMI submitted to primary percutaneous coronary reperfusion in our institution from October 2009 to December 2010. The diagnosis of STEMI was based on typical chest pain lasting >30 minutes associated with ST-segment elevation of >0.1 mV in at least 2 consecutive electrocardiographic leads (0.2 mV for leads V2 and V3). Patients with ST-segment changes secondary to left bundle branch block (n = 19) or artificial ventricular paced rhythm (n = 5) were excluded.Demographic, clinical, and echocardiographic data were extracted from the clinical records. The admission 12-lead ECG was recorded within the first 12 hours of the STEMI. Two independent investigators unaware of the clinical and angiographic data reviewed the electrocardiographic parameters. Positive and negative displacements of the ST segment were measured at the J-point level. Reciprocal ST-segment changes were defined as ST-segment depression of >0.1 mV in any electrocardiographic lead other than aVR (0.05 mV for V2 and V3).Primary coronary angioplasty was performed in all patients within the first 4.3 ± 3.2 hours from the onset of symptoms. Angiographic findings were evaluated by 2 independent experienced observers blinded to the clinical and electrocardiographic data. The infarct-related artery was identified by total coronary artery occlusion or angiographic evidence of an intraluminal thrombus. Flow through the culprit lesion was graded using the Thrombolysis in Myocardial Infarction trial criteria.6TIMI Study GroupThe Thrombolysis In Myocardial Infarction (TIMI) trial. Phase I findings.N Engl J Med. 1985; 312: 932-936Crossref PubMed Scopus (3467) Google Scholar Any additional coronary stenosis of >70% was considered significant.7Levine G.N. Bates E.R. Blankenship J.C. Bailey S.R. Bittl J.A. Cercek B. Chambers C.E. Ellis S.G. Guyton R.A. Hollenberg S.M. Khot U.N. Lange R.A. Mauri L. Mehran R. Moussa I.D. Mukherjee D. Nallamothu B.K. Ting H.H. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58: e44-122Abstract Full Text Full Text PDF PubMed Scopus (1918) Google Scholar We also assessed the presence of chronic total coronary artery occlusions, the distribution of collateral vessels, and the pattern of coronary dominance. Patients were divided into 3 groups according to the infarct-related artery: left anterior descending (LAD), right, and left circumflex (LCx). In each vessel we differentiated between the proximal and mid-distal location of the occlusion taking as a reference the first diagonal branch in the LAD group, the 1/2 distance to the acute margin of the heart in cases of the right coronary artery, and the first marginal branch in the LCx group.Informed consent was obtained from each patient. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the ethics committee of our institution.Continuous variables are presented as the mean value ± SD and discrete variables as absolute value and percentage. Comparisons between continuous variables were assessed by the Student t test. Discrete variables were compared by the chi-square test. A p value <0.05 was considered statistically significant. Statistical analysis was performed using the software PASW statistics 19.0 (SPSS Inc, Chicago, Illinois).ResultsAmong the 349 initially screened patients, we further excluded 19 with normal coronary angiography, 16 with unidentifiable infarct-related artery, and 25 in whom the infarct-related artery was a secondary vessel (the diagonal branch of the LAD artery in 8 cases, the intermediate branch in 3, the posterior descending or posterolateral branches of the right coronary artery in 6, and the marginal branches of the LCx artery in 8). Thus, 289 patients were entered in the final analysis.The demographic and clinical characteristics of patients with acute occlusion of the LAD, right, or LCx arteries were comparable (Table 1). However, patients with proximal LAD artery occlusion showed the highest peak values of cardiac biomarkers and the lowest left ventricular ejection fraction (Figure 1). Fourteen patients (4.8%) died during the hospital stay (cardiogenic shock in 13 patients and lethal arrhythmia in 1) and 11 of them presented with Killip class IV on admission. The in-hospital mortality distributed comparability among the 3 study groups with no further differences between patients with single or multivessel CAD.Table 1Clinical and demographic characteristics of patients with acute occlusion of the left anterior descending (LAD), right, or left circumflex (LCx) coronary arteriesVariableCoronary Artery OccludedLAD (n = 140)Right (n = 118)LCx (n = 31)Proximal (n = 55)Mid-Distal (n = 85)Proximal (n = 45)Mid-Distal (n = 73)Proximal (n = 15)Mid-Distal (n = 16)Age (yrs)62.9 ± 16.361.9 ± 13.463.6 ± 11.961.5 ± 13.161.6 ± 15.157.3 ± 11.7Men44 (80)65 (77)37 (82)60 (82)12 (80)13 (81)Body mass index (kg/m2)27.7 ± 4.627.1 ± 3.526.8 ± 3.827.1 ± 4.028.5 ± 4.727.6 ± 5.5Hypertension30 (55)50 (59)23 (51)37 (51)9 (60)8 (50)Dyslipidemia28 (51)42 (49)21 (47)34 (47)7 (47)10 (63)Diabetes mellitus14 (26)24 (28)14 (31)15 (21)4 (27)3 (19)Current smoker26 (47)41 (48)26 (58)43 (59)6 (40)9 (56)Previous STEMI3 (6)3 (4)1 (2)7 (10)3 (20)0Previous non-STEMI03 (4)1 (2)3 (4)00Killip class I34 (62)63 (74)37 (82)62 (85)10 (67)15 (94) II13 (24)13 (15)4 (9)3 (4)2 (13)1 (6) III2 (4)5 (6)01 (1)1 (7)0 IV6 (11)4 (5)4 (9)7 (10)2 (13)0Hemoglobin (g/dl)14.0 ± 1.613.5 ± 1.813.3 ± 2.113.5 ± 1.712.8 ± 2.714.1 ± 2.2Creatinine (mg/dl)1.1 ± 0.51.0 ± 0.31.1 ± 0.61.0 ± 0.31.0 ± 0.41.1 ± 0.3Data are presented as mean ± SD or n (%), as appropriate. p Value = NS. Open table in a new tab Coronary angiography evidenced single-vessel disease in 149 patients (51%) and multiple-vessel disease in the remaining 140 patients (48%; 2-vessel in 98 patients [34%] and 3-vessel in 42 patients [14%]). The percentage of patients with multivessel CAD, chronic coronary occlusion, or coronary collaterals was homogeneously distributed among the 3 study groups (Table 2). A pattern of right coronary dominance was observed in most of the cases.Table 2Angiographic findings in patients with acute occlusion of the left anterior descending (LAD), right, or left circumflex (LCx) coronary arteriesVariableCoronary Artery OccludedLAD (n = 140)Right (n = 118)LCx (n = 31)Proximal (n = 55)Mid-Distal (n = 85)Proximal (n = 45)Mid-Distal (n = 73)Proximal (n = 15)Mid-Distal (n = 16)Number of coronary arteries narrowed 126 (47)*49 (58)*22 (49)38 (52)6 (40)8 (50) >129 (53)*36 (42)*23 (51)35 (48)9 (60)8 (50)Collateral circulation18 (33)21 (25)25 (56)33 (45)4 (27)6 (38)Chronic total occlusion6 (11)11 (13)4 (9)6 (8)2 (13)2 (13)Right coronary dominance48 (87)73 (86)43 (96)73 (100)9 (60)12 (75)Data are presented as n (%).*p Value <0.05. Open table in a new tab The first ECG was recorded within 183 ± 188 minutes from the onset of symptoms. The overall pattern and distribution of the ST-segment changes induced by acute proximal or mid-distal LAD artery occlusion was comparable in patients with single or multivessel CAD (Figure 2). However, the multivessel group presented subtle differences: lower ST-segment elevation in leads I (0.01 ± 0.07 vs 0.07 ± 0.12 mV, p = 0.03) and aVL (0.03 ± 0.08 vs 0.12 ± 0.17 mV, p = 0.01) and greater ST-segment elevation in lead V1 (0.15 ± 0.13 vs 0.09 ± 0.10 mV, p = 0.05). The first septal branch was involved in 36 of the 55 patients of the proximal LAD group. These patients showed greater ST-segment depression in leads III (−0.17 ± 0.16 vs −0.06 ± 0.10 mV, p = 0.02) and aVF (−0.13 ± 0.13 vs −0.06 ± 0.09 mV, p = 0.04).Figure 2Electrocardiographic changes induced by acute occlusion of the LAD artery in patients with single and multivessel CAD. Left panels illustrate the mean ± SD values (bars) of positive and negative ST-segment displacement in patients with proximal or mid-distal LAD artery occlusion and single or multivessel CAD. Right panels illustrate 12-lead ECG of representative patients in each study group.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Proximal and mid-distal right coronary artery occlusion induced ST-segment elevation in leads II, III, and aVF, and reciprocal ST-segment depression in leads I, aVL, and V2 in patients with either single or multivessel CAD (Figure 3). In the latter cases, the reciprocal ST-segment changes extended to leads V3 and V4 (p = 0.02). The right ventricular branch was affected in 63 of the 118 patients with right coronary artery occlusion. The magnitude of ST-segment changes was comparable in patients with and without involvement of the right ventricular branch. Leads V3R and V4R were not routinely recorded.Figure 3Electrocardiographic changes induced by acute occlusion of the right coronary artery in patients with single and multivessel CAD. Left panels illustrate the mean ± SD values (bars) of positive and negative ST-segment displacement in patients with proximal or mid-distal right coronary artery occlusion and single or multivessel CAD. Right panels illustrate 12-lead ECG of representative patients in each study group.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Proximal and mid-distal LCx artery occlusion induced ST-segment elevation in leads II, III, aVF, and V6 in patients with either single or multivessel CAD (Figure 4). These changes were associated in all instances with reciprocal ST-segment depression in leads V2 and V3. Of notice, in patients with multivessel CAD, the reciprocal ST-segment depression expanded to lead V4. Compared with right coronary artery occlusion, LCx artery occlusion was associated with lower ST-segment elevation in leads II, III, and aVF (p <0.001), lower reciprocal ST-segment depression in leads I and aVL (p <0.001), and higher ST-segment elevation in lead V6 (p = 0.003) in patients with either single or multivessel CAD (Figures 3 and 4). ST-segment elevation in lead V6 predicted LCx artery occlusion with a sensitivity of 71% and a specificity of 83% in patients with single vessel disease and 63% and 82% in patients with multivessel CAD.Figure 4Electrocardiographic changes induced by acute occlusion of the LCx coronary artery in patients with single and multivessel CAD. Left panels illustrate the mean ± SD values (bars) of positive and negative ST-segment displacement in patients with proximal or mid-distal LCx artery occlusion and single or multivessel CAD. Right panels illustrate 12-lead ECG of representative patients in each study group.View Large Image Figure ViewerDownload Hi-res image Download (PPT)DiscussionThis study shows that the pattern of combined elevation and depression of the ST segment that predicts the site of coronary occlusion in patients with acute STEMI is not essentially modified by the extent of the underlying atherosclerotic CAD, and only subtle differences were detected in some particular leads. Indeed, compared with patients with single CAD, those with multivessel impairment showed lesser ST-segment elevation in leads I and aVL after proximal LAD artery occlusion, and they presented reciprocal ST-segment depression in lead V4 after right or LCx artery occlusion. Although we cannot establish the mechanism of these differences, patients with STEMI with multivessel CAD may develop additional subendocardial ischemia at a distance from the infarction and this could magnify the reciprocal ST-segment changes and also counteract the ST-segment elevation in the opposite infarcted region. Indeed, patients with STEMI with >85% stenosis of coronary vessels opposed to the infarct-related artery, and thus prone to develop subendocardial ischemia at a distance, showed a more marked reciprocal ST-segment depression pattern.8Kyriakidis M. Antonopoulos A. Barbetseas J. Aspiotis N. Georgiakodis F. Sfikakis P. Toutouzas P. Correlation of reciprocal ST-segment depression after acute myocardial infarction with coronary angiographic findings.Int J Cardiol. 1992; 36: 163-168Abstract Full Text PDF PubMed Scopus (12) Google Scholar Likewise, transmural ischemia in opposite regions may attenuate the reciprocal ST-segment changes.3Sasaki K. Yotsukura M. Sakata K. Yoshino H. Ishikawa K. Relation of ST-segment changes in inferior leads during anterior wall acute myocardial infarction to length and occlusion site of the left anterior descending coronary artery.Am J Cardiol. 2001; 87: 1340-1345Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 9Lew A.S. Hod H. Cercek B. Shah P.K. Ganz W. Inferior ST segment changes during acute anterior myocardial infarction: a marker of the presence or absence of concomitant inferior wall ischemia.J Am Coll Cardiol. 1987; 10: 519-526Abstract Full Text PDF PubMed Scopus (49) Google ScholarThe presence of reciprocal ST-segment depression in electrocardiographic leads overlying nonischemic regions was reported in early studies on acute myocardial ischemia.10Pardee H.E. An electrocardiographic sign of coronary artery obstruction.Arch Intern Med. 1920; 26: 244-257Crossref Scopus (128) Google Scholar, 11Wolferth C.C. Bellet S. Livezey M.M. Murphy F.D. Negative displacement of the RS-T segment in the electrocardiogram and its relationships to positive displacement: an experimental study.Am Heart J. 1945; 29: 220-245Abstract Full Text PDF Scopus (41) Google Scholar, 12Alzamora-Castro V. Battilana G. Abugattas R. The electrical manifestations observed in damaged or injured cardiac muscle. An experimental study.Am Heart J. 1957; 54: 254-263Abstract Full Text PDF PubMed Scopus (5) Google Scholar, 13Camara E.J. Chandra N. Ouyang P. Gottlieb S.H. Shapiro E.P. Reciprocal ST change in acute myocardial infarction: assessment by electrocardiography and echocardiography.J Am Coll Cardiol. 1983; 2: 251-257Abstract Full Text PDF PubMed Scopus (56) Google Scholar Our study further shows that the reciprocal ST-segment pattern is present in all patients with STEMI with right or LCx artery occlusion independently of the level of vessel occlusion. Moreover, in patients with LAD artery occlusion, the reciprocal changes were only observed when the occlusion affected the proximal but not the mid-distal segment. Thus, the presence of reciprocal ST-segment depression in patients with LAD artery occlusion predicts extensive infarction as has been previously appreciated in the early14Tamura A. Kataoka H. Mikuriya I. Nasu M. Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction.Eur Heart J. 1995; 16: 1795-1799PubMed Google Scholar, 15Fiol M. Carrillo A. Cygankiewicz I. Velasco J. Riera M. Bayés-Genis A. Gómez A. Peral V. Bethencourt A. Goldwasser D. Molina F. Bayés de Luna A. A new electrocardiographic algorithm to locate the occlusion in left anterior descending coronary artery.Clin Cardiol. 2009; 32: E1-E6Crossref PubMed Scopus (22) Google Scholar and subacute phases2Engelen D.J. Gorgels A.P. Cheriex E.C. De Muinck E.D. Ophuis A.J. Dassen W.R. Vainer J. Van Ommen V.G. Wellens H.J. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.J Am Coll Cardiol. 1999; 34: 389-395Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 16Birnbaum Y. Solodky A. Herz I. Kusniec J. Rechavia E. Sulkes J. Sklarovsky S. Implications of inferior ST-segment depression in acute anterior myocardial infarction: electrocardiographic and angiographic correlation.Am Heart J. 1994; 127: 1467-1473Abstract Full Text PDF PubMed Scopus (48) Google Scholar of STEMI.Patients with right or LCx artery occlusion can indistinctly present ST-segment elevation in leads II, III, and aVF. Thus, several differential electrocardiographic criteria have been reported: (1) ST-segment elevation in lead III > lead II suggesting right coronary artery occlusion with a sensitivity of 88% and specificity of 69%4Fiol M. Cygankiewicz I. Carrillo A. Bayés-Genis A. Santoyo O. Gómez A. Bethencourt A. Bayés de Luna A. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction.Am J Cardiol. 2004; 94: 709-714Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar; (2) ST-segment depression in lead I suggesting right coronary artery occlusion, with a 92% sensitivity and 77% specificity4Fiol M. Cygankiewicz I. Carrillo A. Bayés-Genis A. Santoyo O. Gómez A. Bethencourt A. Bayés de Luna A. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction.Am J Cardiol. 2004; 94: 709-714Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar; and (3) A ratio of ST-segment depression in leads V1 to V3/ST-segment elevation in leads II, III, aVF4Fiol M. Cygankiewicz I. Carrillo A. Bayés-Genis A. Santoyo O. Gómez A. Bethencourt A. Bayés de Luna A. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction.Am J Cardiol. 2004; 94: 709-714Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar or V3/III1Kosuge M. Kimura K. Ishikawa T. Hongo Y. Mochida Y. Sugiyama M. Tochikubo O. New electrocardiographic criteria for predicting the site of coronary artery occlusion in inferior wall acute myocardial infarction.Am J Cardiol. 1998; 82: 1318-1322Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar <1, implying right coronary artery occlusion, and >1 suggesting LCx artery occlusion with 94% sensitivity and 61% specificity.4Fiol M. Cygankiewicz I. Carrillo A. Bayés-Genis A. Santoyo O. Gómez A. Bethencourt A. Bayés de Luna A. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction.Am J Cardiol. 2004; 94: 709-714Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In our patients, we found lower predictive values: 72% sensitivity and 73% specificity for criteria 1, 54% and 73% for criteria 2, and 88% and 57% for criteria 3, respectively. As a novel finding, we observed that ST-segment elevation >0.1 mV in lead V6 suggested LCx artery occlusion with 71% sensitivity and 83% specificity.Elevation of the ST segment in STEMI is caused by injury currents coursing between the normal and the ischemic myocardial regions.17Janse M.J. Cinca J. Moréna H. Fiolet J.W. Kléber A.G. de Vries G.P. Becker A.E. Durrer D. The “border zone” in myocardial ischemia. 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• W2049880706 title "Influence of the Extent of Coronary Atherosclerotic Disease on ST-Segment Changes Induced by ST Elevation Myocardial Infarction" @default.
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