Prognostic role of magnetic-resonance imaging in patients with nonischemic ventricular arrhythmias

Authors: Berdibekov B.Sh., Aleksandrova S.A., Gromova O.I., Meladze M.G., Golukhova E.Z.

Company: 1 Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
2 Davydovskiy Municipal Сlinical Hospital # 23, Moscow, Russian Federation

For correspondence:  Sign in or register.

Type:  Reviews


For citation: Tret’yakova M.M., Manchurov V.N., Skrypnik D.V., Vasilieva E.Yu., Shpektor A.V. Electrocardiographic features of left main coronary artery stenosis in patients with multivessel coronary artery disease who underwent the exercise tolerance testing. Creative Cardiology. 2022; 16 (2): 226–35 (in Russ.). DOI: 10.24022/1997-3187-2022-16-2-226-235

Received / Accepted:  26.03.2022 / 24.06.2022

Keywords: exercise testing electrocardiogram left main coronary artery

Subscribe 🔒



Objective. To explore the electrocardiographic features of left main coronary artery stenosis (LMCAS) in patients with multivessel coronary artery disease who underwent the exercise tolerance testing (EST).

Material and methods. We enrolled 78 patients with suspected myocardial ischemia who underwent the standard Bruce EST followed by coronary angiography. Patients were included into the study if they had adequately performed and interpretable EST and multivessel coronary artery disease revealed by coronary angiography. According to the coronary angiography results, patients were divided into two groups: with (n =36) and without (n = 42) LMCAS. We compared the Duke index and ST segment deviations during EST between two groups.

Results. The Duke index was significantly lower in patients with LMCAS: –12.2 vs. –8.5, respectively (р = 0.006). The frequency of ST segment elevation in lead aVR was significantly higher in patients with LMCAS: 55 vs. 19%, respectively (р = 0.004). Six or more leads with ST segment depression on peak exercise observed significantly more often in patients with LMCAS: 31 vs. 2,5% (р = 0.001). The combined sign, including Duke index ≤–11 in combination with ST segment elevation ≥ 1 mm in lead aVR and/or 6 or more leads with ST segment depression was found in the group with lesions of the LMCAS and was not observed in the control group (р = 0.001; specificity 97.5%).

Conclusion. A combined sign including low Duke index in combination with ST segment elevation in lead aVR and/or 6 or more leads with ST segment depression may serve as a highly specific predictor of LMCAS in patients with multivessel coronary artery disease.


  1. Zimmern S.H., Rogers W.J., Bream P.R., Chaitman B.R., Bourassa M.G., Davis K.A. et al. Total occlusion of the left main coronary artery: The Coronary Artery Surgery Study (CASS) experience. Am. J. Cardiol. 1982; 49 (8): 2003–10. DOI: 10.1016/0002-9149(82)90222-3
  2. Patel N., De Maria G.L., Kassimis G., Rahimi K., Bennett D., Ludman P., Banning A.P. Outcomes after emergency percutaneous coronary intervention in patients with unprotected left main stem occlusion: the BCIS national audit of percutaneous coronary intervention 6-year experience. JACC Cardiovasc. Interv. 2014; 7 (9): 969–80. DOI: 10.1016/j.jcin.2014.04.011
  3. Édes I.F., Ruzsa Z., Gellér L., Molnár L., Nowotta F., Kerülő M.C. et al. Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations. Postepy Kardiol. Interwencyjnej. 2018; 14 (3): 233–9. DOI: 10.5114/aic.2018.78325
  4. Manchurov V.N., Martynova M.M., Oskanov M.B., Anisimov K.V., Skrypnik D.V., Vasilieva E.Yu., Shpektor A.V. Endovascular treatment in patients with acute left main coronary artery occlusion. Russian Journal of Endovascular Surgery. 2019; 6 (2): 126–32 (in Russ.). DOI: 10.24183/2409- 4080-2019-6-2-126-132
  5. Sokolov M.S., Sapina A.I., Nazarov A.V., Skrypnik D.V., Vasilieva E.Yu., Shpektor A.V. Acute left main coronary artery occlusion. Clinical case. International Journal of Interventional Cardioangiology. 2011; 24: 110–1 (in Russ.).
  6. Skrypnik D.V., Nazarov A.V., Sokolov M.S., Vasilieva E.Yu., Shpektor A.V. Intracoronary thrombolysis in a patient with acute massive thrombosis of the coronary artery during emergency percutaneous coronary intervention. International Journal of Interventional Cardioangiology. 2011; 24: 108–9 (in Russ.).
  7. Neumann F.-J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019; 40 (2): 87–165. DOI: 10.1093/eurheartj/ehy394 8. Gaitonde R.S., Sharma N., Ali-Hasan S., Miller J.M., Jayachandran J.V., Kalaria V.G. Prediction of significant left main coronary artery stenosis by the 12-lead electrocardiogram in patients with rest angina pectoris and the withholding of clopidogrel therapy. Am. J. Cardiol. 2003; 92: 846–8. DOI: 10.1016/S0002-9149(03)00898-1
  8. Members T.F., Montalescot G., Sechtem U., Achenbach S., Andreotti F., Arden C. et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur. Heart J. 2013; 34 (38): 2949– 3003. DOI: 10.1093/eurheartj/eht296
  9. Mark D.B., Shaw L., Harrell F.E., Hlatky M.A., Lee K.L., Bengtson J.R., Pryor D.B. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N. Eng. J. Med. 1991; 325 (12): 849–53. DOI: 10.1056/nejm 199109193251204
  10. Rostoff P., Wnuk M., Piwowarska W. Clinical significance of exerciseinduced ST-segment elevation in lead aVR and V1 in patients with chronic stable angina pectoris and strongly positive exercise test results [article in Polish]. Polskie Archiwum Medycyny. Wewnetrznej 2005; 114: 1180–9.
  11. Tuna Katırcıba¸sı M., Tolga Koçum H., Tekin A., Erol T., Tekin G., Baltalı M., Müderrisoˇglu H. Exercise-induced ST-segment elevation in leads aVR and V1 for the prediction of left main disease. Int. J. Cardiol. 2008; 128 (2): 240–3. DOI: 10.1016/j.ijcard.2007.05.022
  12. Uthamalingam Sh., Zheng H., Leavitt M., Pomerantsev E., Ahmado I., Gurm G.S., Gewirtz H. Exercise-induced ST-segment elevation in ECG lead aVR is a useful indicator of significant left main or Ostial LAD Coronary Artery Stenosis. JACC: cardiovascular imaging. 2011; 4 (2): 176–86. DOI: 10.1016/j.jcmg.2010.11.014
  13. Ghaffari S., Asadzadeh R., Tajlil A., Mohammadalian A., Pourafkari L. Predictive value of exercise stress test–induced ST–segment changes in leads V1 and avR in determining angiographic coronary involvement. Ann. Noninvasive Electrocardiol. 2016; 22 (1): 1–12. DOI: 10.1111/anec.12370
  14. Michaelides A.P., Psomadaki Z.D., Aigyptiadou M.-N.K., Richter D.J., Andrikopoulos G.K., Dilaveris P.E. et al. Significance of exerciseinduced ST changes in leads aVR, V5, and V1. Discrimination of patients with single- or multivessel coronary artery disease. Clin. Cardiol. 2003; 26 (5): 226–30. DOI: 10.1002/clc.4960260506
  15. Michaelides A.P., Psomadaki Z.D., Richter D.J., Dilaveris P.E., Andrikopoulos G.K., Stefanadis C. et al. Significance of exercise-induced simultaneous ST-segment changes in lead aVR and V5. Int. J. Cardiol. 1999; 71 (1): 49–56. DOI: 10.1016/s0167-5273(99)00115-1
  16. Ostovan M.A., Zolghadrasli A.A. Exercise-induced ST-segment elevation in lead aVR as a predictor of LCx stenosis. Iran. Red. Crescent Med. J. 2011; 13 (12): 901–2.
  17. Gibbons R.J., Balady G.J., Bricker T.J., Chaitman B.R., Fletcher G.F., Froelicher V.F. et al. ACC/AHA 2002 guideline update for exercise testing. Circulation. 2002; 106 (14): 1883–92. DOI: 10.1161/01.cir.0000034670.06526.15
  18. Mark D.B., Hlatky M.A., Harrell F.E., Lee K.L., Califf R.M., Pryor D.B. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann. Intern. Med. 1987; 106 (6): 793–800. DOI: 10.7326/0003-4819-106-6-793
  19. Neill J., Shannon H.J., Morton A., Muir A.R., Harbinson M., Adgey J.A. ST segment elevation in lead aVR during exercise testing is associated with LAD stenosis. Eur. J. Nucl. Med. Mol. Imaging. 2007; 34 (3): 338–45. DOI: 10.1007/s00259-006- 0188-1
  20. Russo G., Ravenna S.E., De Vita A., Aurigemma C., Lamendola P., Lanza G.A., Crea F. Exercise test predictors of severe coronary artery disease: role of ST-segment elevation in lead aVR. Clin. Cardiol. 2017; 40 (2): 102–8. DOI: 10.1002/clc.22637
  21. McKinney J., Pitcher I., Fordyce C.B., Yousefi M., Yeo T.J., Ignaszewski A. et al. Prevalence and associated clinical characteristics of exercise-induced ST-segment elevation in lead aVR. PLoS ONE. 2016; 11 (7): e0160185. DOI: 10.1371/journal. pone.0160185

About Authors

  • Mariya M. Tret’yakova, Postgraduate, Cardiologist; ORCID
  • Vladimir N. Manchurov, Cand. Med. Sci., Assistant Professor, Endovascular Surgeon; ORCID
  • Dmitriy V. Skrypnik, Dr. Med. Sci., Chief of Chair, Head of Department; ORCID
  • Elena Yu. Vasilieva, Dr. Med. Sci., Professor, Head of Laboratory; ORCID
  • Aleksander V. Shpektor, Dr. Med. Sci., Professor, Corresponding Member of RAS, Honorary Chief of Chair; ORCID

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery