A new electrocardiographic pattern indicating inferior myocardial infarction.

BACKGROUND: We identified a specific pattern that does not display contiguous ST-segment elevation (STE), indicating acute inferior myocardial infarction (MI) with concomitant critical stenoses on the other coronary arteries. We sought to define the frequency, underlying anatomic substrate, diagnostic power and prognostic implications of this pattern. METHODS: One thousand patients with a diagnosis of non-STEMI were enrolled as the study group. Within the same date range, all patients with inferior STEMI and 1000 patients, who had been excluded for MI (no-MI), were also enrolled. The coronary angiograms were reviewed by two interventional cardiologists, who were blinded to the ECGs. Echocardiographic wall motion bullseye displays and coronary angiography maps were constructed for each group. The dead or alive status was checked from the electronic national database. RESULTS: The final study population consisted 2362 patients. The prespecified ECG pattern was observed in 6.3% (61/966) of the non-STEMI cohort and 0.5% (5/1000) of no-MI patients. These patients had a larger infarct size as evidenced by 24-hour troponin levels, higher frequency of angiographic culprit lesion, and higher frequency of composite acute coronary occlusion endpoint compared to their non-STEMI counterparts. On the other hand, they had a similar in-hospital (5% vs. 4%, respectively; P = 0.675) and one-year mortality compared to the patients with inferior STEMI (11% vs. 8%, respectively; P = 0.311). CONCLUSION: We here define a new ECG pattern indicating inferior MI in patients with concomitant critical lesion(s) in coronary arteries other than the infarct-related artery. Patients with this pattern have multivessel disease and higher mortality.

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis.

BACKGROUND: The currently used scheme for the classification of infarct location and extent in anterior myocardial infarction (MI) is intuitive rather than being evidence-based, and recent evidence suggests that it may be misleading both in anatomic and prognostic sense. MATERIAL AND METHODS: Consecutive patients with the diagnosis of anterior MI were enrolled. All electrocardiograms (ECG) were first classified according to established scheme and then reassessed using newer criteria for angiographic site of occlusion. The site of left anterior descending (LAD) occlusion was determined using multiple angiographic views. Clinic, echocardiographic and angiographic outcomes were compared. RESULTS: A total of 379 anterior MI cases were enrolled, final study population consisted of 267 patients. The established scheme did not predict infarct size or adverse outcomes. Location of the myocardium subtended by the occluded coronary network did not match with the anatomic location as ECG classification implies. Many high-risk patients with proximal LAD were classified as "anteroseptal", whereas the majority of the patients labeled as "extensive anterior MI" had in fact distal occlusions. On the other hand, expert interpretation was fairly accurate in predicting adverse outcomes and the site of angiographic involvement. CONCLUSION: Classifying patients according to the established scheme neither gives prognostic information nor accurately localizes infarction. It should be regarded as obsolete and its use should be abandoned. Instead, the extent of infarction can be inferred from newer criteria provided by the angiographic correlation studies.

Predictors of In-Hospital Mortality in Patients With ST-Segment Elevation Myocardial Infarction Complicated With Cardiogenic Shock.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) complicated with cardiogenic shock (CS) remains as an unresolved condition causing high morbidity and mortality despite advances in medical treatment and coronary intervention procedures. In the current study, we evaluated the predictors of in-hospital mortality of STEMI complicated with CS. METHODS: In this retrospective study, we evaluated the predictive value of baseline characteristics, angiographic, echocardiographic and laboratory parameters on in-hospital mortality of 319 patients with STEMI complicated with CS who were treated with primary percutaneous coronary intervention. Patients were divided into two groups consisting of survivors and non-survivors during their index hospitalisation period. RESULTS: The mortality rate was found to be 61.3% in the study population. At multivariate analysis after adjustment for the parameters detected in univariate analysis, chronic renal failure, Thrombolysis In Myocardial Infarction (TIMI) post percutaneous coronary intervention (PCI) ≤2, plasma glucose and lactate level, blood urea nitrogen level, Tricuspid Annular Plane Systolic Excursion (TAPSE) and ejection fraction were independent predictors of in-hospital mortality. CONCLUSIONS: Apart from haemodynamic deterioration, angiographic, echocardiographic and laboratory parameters have an impact on in-hospital mortality in patients with STEMI complicated with CS.

A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation.

BACKGROUND: It may sometimes be difficult to differentiate subtle ST-segment elevation (STE) due to anterior myocardial infarction (MI) from benign variant (BV) STE. Recently, two related formulas were proposed for this purpose. However, they have never been tested in an external population. MATERIALS AND METHODS: Consecutive patients from May 2017 to January 2018, who were admitted with the diagnosis of acute anterior STEMI, were enrolled. Electrocardiograms were systematically reviewed and only subtle ones were included. First 200 consecutive patients with noncardiac chest pain were also enrolled as a control group. Relevant electrocardiographic parameters were measured. RESULTS: A total of 379 anterior MI and 200 BV-STE cases were enrolled during study period. A total of 241 patients in STEMI group were excluded for not matching subtleness criteria, four patients in control group were also excluded because of prior left-anterior descending artery intervention. The three-variable formula, with recommended cut-point of 23.5, had a sensitivity, specificity, and diagnostic accuracy of 73.9%, 86.7%, and 81.4%, respectively. The four-variable formula, with the published cut-point of 18.2, had a sensitivity, specificity, and diagnostic accuracy of 83.3%, 87.7%, and 85.9%, respectively. CONCLUSION: Three- and four-variable formulas with recommended cutoffs have a reasonable sensitivity, specificity, and diagnostic accuracy in differentiating subtle STEMI with BV-STE. Although both perform well, the four-variable formula has a higher sensitivity, specificity, and diagnostic accuracy and should be preferred.

An algorithm for the differentiation of the infarct territory in difficult to discern electrocardiograms.

BACKGROUND: In a minority of the patients presenting with ST-segment elevation (STE) myocardial infarction (MI), electrocardiogram (ECG) may show a balanced STE in both anterior and inferior lead groups and may cause diagnostic confusion about involved myocardial territory. In this study, we sought ECG clues which may facilitate discriminating (1) MI location and then (2) culprit artery in patients with difficult-to-discern ECGs. MATERIAL AND METHODS: Consecutive patients with the diagnosis of STEMI were scanned and patients with ECGs displaying both anterior and inferior STE were enrolled. ECGs with obvious ST elevation in either lead group and reciprocal ST-segment depression were excluded. Predictive power of several ECG variables has been analyzed and an algorithm has been constructed. RESULTS: A total of 959 STEMI cases were scanned, the final study population was consisted of 114 patients. Our algorithm for locating MI territory had a sensitivity, specificity, positive and negative predictive value of 72.1%, 92.5%, 91.7% and 74.2% for inferior versus anterior location, respectively (P < 0.001, φ = 0.652). As anterior MI was strictly reserved for left anterior descending (LAD) artery occlusion, these diagnostic values were also valid for discriminating circumflex artery [Cx]/right coronary artery [RCA] versus LAD as the culprit artery. In patients classified as having inferior MI, an STE in lead III greater than STE in lead II favored RCA over Cx as the culprit artery with a sensitivity, specificity, positive and negative predictive value of 97%, 46.6%, 80% and 87.5%, respectively (P < 0.001; φ = 0.544). CONCLUSION: Our algorithm can be used in difficult-to-discern ECGs for defining involved myocardial territory and culprit artery.

Fragmented QRS on Admission Electrocardiography Predicts Long-Term Mortality in Patients with Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Early diagnosis and identification of high-risk non-ST elevation myocardial infarction (NSTEMI) is an important issue. Fragmented QRS (fQRS) complexes are defined as various RSR' patterns on 12-lead resting electrocardiography (ECG). Previous studies revealed that fQRS is related with increased ventricular arrhythmias and cardiovascular mortality. The relation between fQRS and mortality in acute coronary syndromes, mitral valve disease severity and structural heart disease has been shown in different studies. The aim of this study was to investigate relation between fQRS and long-term cardiovascular mortality in NSTEMI patients. METHODS: Patients who admitted to our emergency unit and diagnosed NSTEMI between 2012 and 2013, 433 patients were included prospectively. fQRS complexes determined in 85 patients. Patients were divided into two groups according to fQRS existence. All patients evaluated for their clinical, laboratory, electrocardiographic, and echocardiographic characteristics. Angiographic features of 315 patients who underwent coronary angiography was also recorded. In-hospital, 30-day and 12-month mortality was compared between these groups. RESULTS: Demographic characteristics and cardiovascular risk factors were similar in both groups except hyperlipidemia. GRACE risk score was higher in patients with fQRS and positively correlated with existence of fQRS. In hospital and 30-days mortality were similar but late mortality was higher in fQRS group. Predictors of late mortality were found to be age, heart rate, male sex in addition to fQRS. CONCLUSION: We found a relation between fQRS and late mortality. Fragmented QRS may be seen as a cautionary signal for extensive myocardial damage and thereby increased long-term mortality for patients with NSTEMI.

Assessment of 25-Hydroxyvitamin D Levels in Patients with Resistant Hypertension.

OBJECTIVE: To investigate the possible correlation between serum 25-hydroxyvitamin D levels and resistant hypertension (RH). SUBJECTS AND METHODS: Patients who had undergone ambulatory blood pressure measurements (ABPM) during outpatient controls were enrolled. Fifty subjects with RH, 50 with controlled hypertension (CHT) and 50 normotensive subjects (NT) were included in the study. RH was defined as 'suboptimal blood pressure control despite using 3 antihypertensive agents including a diuretic or need for 4 or more drugs to control blood pressure'. The 25-hydroxyvitamin D and parathormone levels were compared between the groups. Pearson's correlation coefficient test was applied to assess the correlation between 25-hydroxyvitamin D levels and office blood pressure (BP) and ABPM. Logistic regression analysis was used to determine the independent correlates of RH. RESULTS: The 25-hydroxyvitamin D level was significantly lower in the RH group (17.02 ± 5.4 ng/ml) compared to the CHT (24.9 ± 4.8 ng/ml) and NT groups (28.0 ± 5.7 ng/ml, p < 0.001). In univariate correlation analysis, 25-hydroxyvitamin D levels had a significant negative correlation with office systolic BP (r = -0.329, p < 0.001), office diastolic BP (r = -0.395, p < 0.001), systolic ambulatory BP (r = -0.844, p = 0.004), and diastolic ambulatory BP (r = -0.567, p = 0.005). ROC analysis revealed that 25-hydroxyvitamin D levels <21.50 ng/ml predicted the presence of RH with a sensitivity of 78% and a specificity of 79% (AUC = 0.89, 95% CI 0.83-0.94). In the multivariate logistic regression analysis, 25-hydroxyvitamin D level was independently correlated with the presence of RH (ß 0.660, 95% CI 0.572-0.760, p < 0.001). CONCLUSION: There was an independent correlation between lower 25-hydroxyvitamin D levels and presence of RH.

Left Ventricular Perforation Due to Radiofrequency Catheter Ablation for Incessant Ventricular Tachycardia in a Post-Myocardial Infarction Patient.

Left ventricular (LV) myocardial perforation is a rare complication following ventricular tachycardia (VT) ablation with radiofrequency (RF); this complication should be diagnosed and treated promptly. LV free wall rupture after elective RF ablation for sustained VT refractory to medical treatment is rarely reported in the medical literature. Herein we discuss an interesting case which contributes to the ongoing literature, regarding a patient who developed LV perforation due to RF ablation for VT which was resistant to pharmacotherapy and repeated cardioversion attempts after acute myocardial infarction.

Acute myocardial infarction with concomitant pulmonary embolism as a result of patent foramen ovale.

Acute myocardial infarction (MI) and pulmonary embolism canal one lead to life-threatening conditions such as sudden cardiac death and congestive heart failure. We discuss a case of a 74-year-old man presented to the emergency department with acute dyspnea and chest pain. Acute anterior MI and pulmonary embolism concomitantly were diagnosed. Primary percutaneous coronary intervention performed because of preliminary acute anterior MI diagnosis. Transthoracic echocardiography was performed to determine further complications caused by acute MI because patient had a continuous tachycardia and dyspnea although hemodynamically stable. Transthoracic echocardiography revealed a thrombus that was stuck into the patent foramen ovale with parts in right and left atria. Anticoagulation therapy was started; neither fibrinolytic therapy nor operation was performed because of low survey expectations of the patient's recently diagnosed primary disease stage IV lung cancer. Patient was discharged on his 20th day with oral anticoagulation and antiagregant therapy.

Aortic root abscess complicated by fistulization in a young patient with bicuspid aortic valve.

Aortic root abscess is a relatively common complication of aortic valve endocarditis. However, aortic root abscess and formation of a fistula from the aortic root to the right ventricular outflow tract in the setting of a native bicuspid aortic valve (BAV) is a rare event. We present consecutive echocardiographic images of unruptured periaortic abscess and fistulization of it to the right ventricle in 24 hours, in a patient with BAV and fever of unexplained origin.

Effect of acute kidney injury on long-term mortality in patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention in a high-volume tertiary center.

OBJECTIVE: Acute kidney injury (AKI) is a reflection of both renal and cardiac reserve in patients with ST-segment elevation myocardial infarction (STEMI), but there is a lack of evidence related to the effect of AKI on long-term mortality in patients with STEMI. This study was an investigation of the prognostic value of AKI for long-term mortality in patients with STEMI complicated by cardiogenic shock (CS) and primary percutaneous coronary intervention (PPCI). METHODS: This retrospective analysis evaluated the long-term prognostic impact of AKI on 492 patients with STEMI complicated by CS who were treated with PPCI. AKI was defined as ≥0.3mg/dL increase in serum creatinine within 48 hours or a ≥50% increase in serum creatinine in 7 days, or a reduction in urine output (documented oliguria of less than 0.5mL/kg per hour >6 hours. Patients were grouped according to the incidence of AKI and long-term mortality was compared. Cox regression analysis was used to determine independent prognostic factors of long-term mortality. RESULTS: In Cox regression analysis, the age- and sex- adjusted hazard ratios (HRs) were higher for all-cause mortality in patients with AKI. [HR: 4.556; 95% confidence interval: (CI) 2.370-8.759]. After adjustment for confounding variables, the relative risk was greater for patients with AKI in comparison with patients without AKI (HR: 2.207; 95% CI: 1.150-4.739). Age (HR: 1.060, 95% CI: 1.027-1.094; p<0.001), left ventricular ejection fraction (HR: 0.952, 95% CI: 0.916-0.989; p=0.012), blood urea nitrogen level (HR: 1.019, 95% CI: 1.005-1.034; p=0.010), and AKI (HR: 2.244, 95% CI: 1.077-4.676; p=0.031) were found to be independent factors to determine long-term mortality. CONCLUSION: The results of this study demonstrated that AKI was an independent prognostic factor for long-term mortality among patients with STEMI complicated by CS and treated with PPCI.

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study).

BACKGROUND: Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. METHODS: A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database. RESULTS: In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality. CONCLUSIONS: We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).

Does electrocardiogram help in identifying the culprit artery when angiogram shows both right and circumflex artery disease in inferior myocardial infarction?

OBJECTIVE: In a subgroup of patients with inferior myocardial infarction (MI), both the right coronary artery (RCA) and circumflex coronary artery (Cx) show potentially culprit lesions, and angiography may be insufficient to determine which artery is responsible for the clinical presentation. Although many electrocardiographic (ECG) algorithms have been proposed for identifying the infarct-related artery in patients with inferior MI, it is unclear whether the current algorithms have the discriminative power to identify the real culprit artery in these patients. METHODS: The patients with the diagnosis of acute inferior MI and underwent coronary angiography were enrolled in the study. The prediction of the infarct-related artery was attempted from the admission ECG using published algorithms and criteria. For the angiographic definition of the infarct-related artery, multiple criteria were used. RESULTS: Total 417 inferior MI cases were enrolled during the study period; the final patient population comprised of 318 patients. Forty-five patients (14.2%) had both RCA and Cx lesions on coronary angiography. Although several criteria and algorithms are able to identify the infarct-related artery in the general inferior MI population, they lose their strength in patients with both RCA and Cx lesions. Only the Aslanger-Bozbeyoglu criterion emerges as a more powerful diagnostic test with a sensitivity, specificity, and c-statistic of 80%, 48%, and 0.650, respectively for the whole population (p<0.001) and 81%, 58%, and 0.709, respectively, for patients with both RCA and Cx lesions (p=0.019). CONCLUSION: The Aslanger-Bozbeyoglu criterion is not only helpful in differentiating the infarct territory in combined inferior and anterior ST-segment elevation as previously shown, but also valuable in identifying the infarct-related artery in patients with inferior STEMI with critical lesions in both the RCA and the Cx. (Anatol J Cardiol 2020; 23: 318-23).

Hair whitening and obesity are independently related to ascending aorta dilatation in young-middle aged men.

OBJECTIVE: Hair whitening (HW) is strongly linked with aging. Ascending aortic dilation (AAD) and HW share common etiologic factors. We investigated the association of HW with ascending aortic diameters. METHODS: Our study included 93 male subjects aged below 50 years. All patients underwent echocardiography to measure ascending aortic diameter, in addition to routine biochemistry tests, physical examination, and thorough medical history. HW score (HWS) was defined according to the percentage of white hair (HWS 1: <25%; HWS 2: 25-50%; HWS 3: 50-75%; and HWS 4: 75-100). RESULTS: Patients with highest HWS were older and had a higher percentage of hypertension (HT) and family history of HW. Moreover, this subgroup had increased ascending aortic diameter, higher serum uric acid, and lower total bilirubin concentrations. Multivariate analyses including age, HT, height, waist circumference, c-reactive protein, and family history of HW identified body weight and HWS as the independent predictors of ascending aortic diameter. CONCLUSION: An independent association between the degree of HW and AAD exists in middle-aged men, which may depend on coexisting factors that enhance both pathologies rather than causality. We think that oxidative stress may be one of these stressors.

Is the inferior ST-segment elevation in anterior myocardial infarction reliable in prediction of wrap-around left anterior descending artery occlusion?

OBJECTIVE: In a subgroup of patients with the anterior wall myocardial infarction (MI), the electrocardiogram (ECG) records a concomitant inferior ST-segment elevation (STE), which is generally explained by a 'wrap-around' left anterior descending (LAD) artery occlusion. However, recent evidence indicates that this may be due to a distal LAD occlusion, which may be irrelevant to the LAD length. We investigated the relationship between inferior ST-T changes in anterior MI and the presence of a wrap-around LAD. METHODS: Consecutive patients diagnosed with anterior MI due to an acute LAD occlusion were enrolled into the study. All ECGs were measured manually by a cardiologist, who was blinded to the angiographic outcomes. The site of the LAD occlusion was determined using multiple angiographic views. A wrap-around LAD was defined as a LAD artery from a post-reperfusion coronary angiogram that perfused at least one-fourth of the inferior wall of the left ventricle in the right anterior oblique projection. RESULTS: A total of 379 anterior MI cases were enrolled, and the final study population consisted of 259 patients. The presence of a wrap-around LAD was more frequent in patients presenting with inferior STE compared with patients without inferior STE (62.1% vs. 30.4%, p=0.001), however, this relationship was weak (φ=0.211). Inferior STE was more frequent in distal occlusions (22.9% vs. 4.3%, p<0.001), which showed a stronger relationship (φ=0.285). The polarity of the T-wave in lead III did not give any clues about the LAD anatomy. CONCLUSION: Contrary to the popular acceptance, our results indicate that a wrap-around LAD cannot be reliably diagnosed by ECG.

Outcomes of survivors of ST-segment elevation myocardial infarction complicated by out-of-hospital cardiac arrest: a single-center surveillance study.

OBJECTIVE: The aim of the present study was to evaluate in-hospital and long-term outcomes of ST-segment elevation myocardial infarction (STEMI) survivors who experienced out-of-hospital cardiac arrest (OHCA) and underwent primary percutaneous coronary intervention (PCI) at a high-volume center within the STEMI network. METHODS: The records of 2681 consecutive STEMI patients who underwent primary PCI between January 2009 and December 2014 at a single center in the STEMI network were retrospectively analyzed. Patients with STEMI complicated by OHCA were compared with a reference group of STEMI patients who did not experience OHCA. RESULTS: Compared with STEMI survivors without OHCA (n=2587, 96.5%), the frequency of anterior myocardial infarction, duration of hospitalization, rate of in-hospital major adverse cardiovascular and cerebrovascular events, and the incidence of ischemic cerebrovascular disease and major bleeding during in-hospital follow-up were significantly greater in those with OHCA (n=94, 3.5%). The distribution of age and gender was similar between the 2 groups. The primary PCI success rate was high and was similar in both groups. In-hospital mortality was significantly higher (18.1% vs. 1.5%; p<0.001) and survival at the 12th and 60th months was lower (74.5% vs. 96.5%; p<0.001 and 71.3% vs. 93.7%; p<0.001) in STEMI survivors with OHCA. OHCA was an independent predictor for in-hospital mortality (Odds ratio [OR]: 3.413; 95% confidence interval [CI]: 1.534-7.597; p=0.003) and all-cause mortality at 60 months (OR: 3.285; 95% CI: 2.020-5.340; p<0.001). CONCLUSION: Mortality was high in patients with STEMI complicated by OHCA, even though PCI was performed with the same success rate seen in patients without OHCA.

Predictive value of SYNTAX score II for clinical outcomes in cardiogenic shock underwent primary percutaneous coronary intervention; a pilot study.

SYNTAX Score II (SSII) connects clinical variables with coronary anatomy. We investigated the prognostic value of SSII in patients with ST segment elevated myocardial infarction (STEMI) complicated with cardiogenic shock treated with primary percutaneous coronary intervention (PPCI). In this retrospective analysis, we evaluated the in-hospital prognostic impact of SSII on 492 patients with STEMI complicated with cardiogenic shock treated with PPCI. Patients were stratified by tertiles of SSII, in-hospital clinical outcomes were compared between those groups. In-hospital univariate analysis revealed higher rates of in-hospital death for patients with SSII in tertile 3, as compared to patients with SSII in tertile 1 (OR 17.4, 95% CI 10.0-30.2, p < 0.001). After adjustment for confounding baseline variables, SSII in tertile 3 was associated with 6.2-fold hazard of in-hospital death (OR 6.2, 95% CI 2.6-14.1, p < 0.001). SSII in patients with STEMI complicated with cardiogenic shock treated with PPCI provide an independent prognostic marker of in-hospital outcomes. Our data suggests SSII to be a simple, feasible and clinically applicable tool for rapid risk stratification in patients with STEMI complicated with cardiogenic shock treated with PPCI.

A Simplified Formula Discriminating Subtle Anterior Wall Myocardial Infarction from Normal Variant ST-Segment Elevation.

Benign variant (BV) ST-segment elevation (STE) is present in anterior chest leads in most individuals and may cause diagnostic confusion in patients presenting with chest pain. Recently, 2 regression formulas were proposed for differentiation of BV-STE from anterior ST-elevation myocardial infarction (MI) on the electrocardiogram, computation of which is heavily device-dependent. We hypothesized that a simpler visual-assessment-based formula, namely (R-wave amplitude in lead V4 + QRS amplitude in V2) - (QT interval in millimeters + STE60 in V3), will be noninferior to these formulas. Consecutive cases of proven left anterior descending occlusion were reviewed, and those with obvious ST elevation MI were excluded. First 200 consecutive patients with noncardiac chest pain and BV-STE were also enrolled as a control group. Relevant electrocardiographic parameters were measured. There were 138 anterior MI and 196 BV-STE cases. Our simple formula was superior to the 3- and noninferior to the 4-variable formulas. This new practical formula had an excellent area-under curve of 0.963 (95% confidence interval, 0.946 to 0.980, p<0.001). It also had a sensitivity, specificity and diagnostic accuracy of 86.9%, 92.3%, and 90.1%, respectively. In conclusion, a simple visual assessment-based formula can reliably differentiate STE MI from BV-STE. Also, our results emphasize that focusing only on STE for diagnosing acute coronary occlusion is extremely insensitive and even puts the term "STEMI" itself into question.