Electrocardiographic prediction of multivessel disease in ST-Elevation myocardial infarction: A validation of standard criteria and identification of novel patterns

OBJECTIVE: To assess the value of the admission electrocardiogram (ECG) in predicting multivessel coronary artery disease (MVD) in patients with ST-elevation myocardial infarction (STEMI) and to identify novel predictive patterns. METHODS: This was a single-center, retrospective observational study of 169 STEMI patients who underwent coronary angiography. Two cardiologists, blinded to angiographic findings, reviewed admission ECGs to identify the culprit artery and predict MVD using pre-specified criteria. Diagnostic accuracy metrics were calculated, and associations between ECG findings and MVD were assessed. RESULTS: MVD was present in 81 (48%) patients. While the ECG identified the culprit artery with 97% accuracy, its sensitivity for predicting MVD using standard criteria was low (21.0%), though specificity was high (94.3%). However, in inferior STEMI, ST depression in aVR was significantly associated with MVD (p=0.010; OR 4.2). In anterior STEMI, the absence of limb lead changes was a highly specific predictor of MVD (p=0.009; OR 13.3; Spec 98.4%). CONCLUSIONS: While the admission ECG is highly accurate for culprit artery localization, its sensitivity for MVD is low. ST depression in aVR in inferior STEMI and the absence of limb lead changes in anterior STEMI are novel, highly specific predictors of MVD that can enhance early risk stratification.