Cardiology

ECG: A Simple Noninvasive Tool to Localize Culprit

Vessel Occlusion Site in Acute STEMI
Biplab Ghosh*, Manoj Indurkar**, Mahendra Kumar Jain

Abstract
Introduction: Various electrocardiogram (ECG) patterns can determine the site of occlusion in culprit coronary artery in
ST-elevation myocardial infarction (STEMI) and the size of the myocardium that is jeopardized. Objectives: The aim of this study
was to assess diagnostic accuracy of the ECG localization of culprit vessel occlusion site as compared to coronary angiographic
findings. Material and methods: ECG criteria for localization of culprit vessel occlusion site were specified and patients with
STEMI (n = 21) were divided into three groups: Groups I, II and III, according to the localization of culprit vessel occlusion site
in left anterior descending (LAD), right coronary artery (RCA) and left circumflex (LCx) coronary arteries, respectively. Group I
was further divided into four subgroups: Ia, Ib, Ic and Ib+c according to whether occlusion in LAD was proximal to both first
septal (S1) and first diagonal (D1) branches, distal to S1 but proximal to D1 branches, distal to both S1 and D1 branches or distal
to S1 branch, respectively. Group II was further divided into two subgroups: IIa and IIb according to whether occlusion in RCA
was proximal or distal to RV branch, respectively. The results of coronary angiograms were compared with those predicted by
ECG. Results: The positive predictive accuracy (PPA) and negative predictive accuracy (NPA) of ECG criteria for LAD, RCA and
LCx coronary arteries were 90.91% and 100%, 90% and 100%, and undetermined and 90.48%, respectively. Among subgroups,
the sensitivity of ECG criteria was maximum for groups Ib+c and IIb (100%) followed by Group IIa (71.43%), Group Ic (50%),
Group Ia (42.86%) and least for Group Ib (0%). The specificity was maximum for Groups Ia and IIa (92.86%) followed by
Group Ib (90%), Group IIb (89.47%), Group Ic (78.95%) and Group Ib+c (77.78%) in that order. The PPA and NPA for Groups Ia,
Ib, Ic, Ib+c, IIa and IIb were 75% and 76.47%, 0% and 94.74%, 20% and 93.75%, 42.86% and 100%, 83.33% and 86.67% and 50%
and 100%, respectively. Conclusion: The present study demonstrates that ECG is an easily and widely available inexpensive
tool to localize site of occlusion in culprit vessel in acute STEMI.

Keywords: Culprit vessels, STEMI, ECG, coronary angiography

he standard 12 lead electrocardiogram (ECG)

has long been a reliable clinical tool for diagnosis
of acute myocardial infarction (AMI). Specific
ECG patterns for the site of occlusion in culprit
coronary artery has been well-recognized.1 Larger the
area at risk, more aggressive should be the attempt to
restore or improve perfusion of that area.
Objectives
The aim of this study was to amalgamate various ECG
criteria for localization of culprit vessel occlusion site
*Senior Resident
Dept. of Nephrology, Institute of Medical Sciences
Banaras Hindu University, Varanasi, Uttar Pradesh
**Associate Professor
Professor
Dept. of Medicine, Shyam Shah Medical College
Rewa, Madhya Pradesh
Address for correspondence
Dr Biplab Ghosh
Senior resident
Dept. of Nephrology, Institute of Medical Sciences
Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
E-mail: dr.biplabghosh@gmail.com

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Indian Journal of Clinical Practice, Vol. 23, No. 10 March 2013

and to assess its diagnostic accuracy as compared to

follow-up coronary angiographic findings.
Material and Methods
The present study was carried out on patients admitted
with AMI after application of the following exclusion
criteria: Patients with history of previous myocardial
infarction and previous coronary artery bypass graft
(CABG) surgery; ECG evidence of left bundle branch
block (LBBB), pre-excitation and paced rhythm. Written
informed consent was obtained from each patient. AMI
was diagnosed as per standard criteria.1 A detailed
history and physical examination was carried out. ECG
was recorded on admission and then 90 minutes and
three hours after completion of thrombolysis, and if
thrombolysis was not done, at four hours and 24 hours
after admission. Besides these ECG was also recorded
whenever symptoms and clinical situations demanded so.
In inferior wall, AMI right sided leads and posterior
leads were also recorded. Patients were referred to
other hospitals for coronary angiography and the
results were noted on subsequent follow-up. A lesion

cardiology
ECG Criteria to Identify Site of Occlusion in LAD (in
AWMI)
Criteria
1. Any one or more of the following
i. Complete RBBB
ii. ST V1 > 2.5 mm
iii. ST aVR
iv. ST V5
v. New onset LAHB
2. Q in aVL
3. Any one or more of the following

Occlusion site
Proximal to S1

i. ST II 1.0 mm
ii. Maximum ST appeared in V2
4. Q in V5
5. ST aVL
6. No ST III

Proximal to D1
Proximal to S1
and/or D1

Distal to S1
Distal to D1
Distal to S1 and/or D1

Group Ia had criteria 1, 2 and 3; Group Ib had criteria 2 and 4 without

1 and 5; Group Ic had criteria 4, 5, and 6; Group Ib+c was the
combination of Group Ib and Ic.

ECG Criteria to Identify whether Site of Occlusion is in

RCA or LCx (in IWMI)
Criteria
*1. ST III > ST II
*2. ST aVL > ST I
*3. ST V3/ST III ratio
4. Lead V4R
5. ST V1-V2

6. Max ST V2-V3
7. ST V7-V9

RCA
Present
Present

LCx
Absent
Absent

<1.2
T-wave upright

>1.2
Inverted
T-wave
Present

Absent (present in
occlusion of dominant
RCA causing posterior
wall MI)
Absent
Absent (present if RCA
dominant)

Present
Present

*In case of discrepancy between criteria 1, 2 and 3, the localization

was done as per criteria 1 and 2 rather than 3. Criteria 5 to 7 were
used mainly for supportive evidence.

ECG Criteria for Site of Occlusion in RCA

Criteria
V4R
ST V1
ST VR > ST in
V1-V3
Ratio of ST V3/ST
III
AV nodal block
Atrial infarction

Proximal to RV
branch
ST 1 mm
Present
Present

Distal to RV
branch
No ST
Absent
Absent

< 0.5

>0.5, but <1.2

Present
Present

Absent
Absent

was considered to be the culprit when it occluded

or severely narrowed the artery and was ulcerated
and/or contained thrombus. The results of coronary
angiograms were compared with that predicted by
ECG.
Patients were divided into three groups: Groups I,
II and III according to the localization of occlusion
site in left anterior descending (LAD), right coronary
artery (RCA) and left circumflex (LCx) coronary
arteries, respectively. Group I was further divided
into four subgroups: Ia, Ib, Ic and Ib+c according to
whether occlusion in LAD was proximal to both first
septal (S1) and first diagonal (D1) branches, distal to
S1 but proximal to D1 branch, distal to both S1 and
D1 branches or distal to S1 branch (irrespective of D1
branch), respectively. Group II was further divided
into two subgroups: IIa and IIb according to whether
occlusion in RCA was proximal or distal to right
ventricular (RV) branch, respectively.
Results
Demographic and clinical parameters of all 21 patients
are shown in Table 1. According to ECG criteria,
Groups I, II, III, Ia, Ib, Ic, IIa and IIb had 11 (52.38%),
10 (47.62%), 0 (0.0%), 4 (19.05%), 2 (9.52%), 5 (23.81%),
6 (28.57%) and 4 (19.05%) patients, respectively. The
mean left ventricular ejection fraction (LVEF) in Groups
Ia, Ib, Ic, IIa and IIb were 35.25%, 34.0%, 42.2%, 42.6%
and 55.2%, respectively. Lowest LVEF was noted in two
diabetic patients (22% and 24%). ECG criteria correlated
with coronary angiography fully in 11 patients (52.38%)
and partially in eight patients (38.10%) but not at all in
two patients (9.52%). Angiography revealed occlusion
of LCx in two patients who were misclassified by ECG
in Groups Ia and IIa. Out of the eight patients in whom
ECG correlated partially, seven had involvement of the
same coronary artery but at a proximal location from
that predicted by ECG and one had occlusion more
distally. Correlation of ECG criteria with coronary
angiography is shown in Table 2. The sensitivity of
ECG to identify culprit vessel in AMI was 100% for
both LAD coronary artery and RCA but 0% for LCx
coronary artery. The specificity was maximum for
LCx coronary artery (100%) followed by that for
RCA (91.67%) and LAD coronary artery (90.91%).
The positive predictive accuracy (PPA) and negative
predictive accuracy (NPA) for LAD, RCA and LCx
coronary arteries were 90.91% and 100%, 90% and
100%, and undetermined and 90.48%, respectively. The
sensitivity of ECG criteria to further localize the site of
occlusion in a culprit vessel in AMI was maximum for

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591

cardiology
which is the terminal portion of a wraparound LAD.

Table 1. Demographic, Clinical and Laboratory

Parameters (n = 21)
Characteristic

Number (%)

Age, mean SD (years)

55.09 10.08

Current smoker
BMI SD

9 (42.86%)

(kg/m2)

22.56 3.54

Diabetes mellitus (DM)

2 (9.52%)

Hypertension (HT)

6 (28.57%)

Family history of DM, HT and/or IHD

7 (33.33%)

No past and/or family history of DM, HT

11 (52.38%)

Presented < 3 hours of chest pain onset

8 (38.10%)

Presented >12 hours of chest pain onset

7 (33.33%)

Thrombolytic therapy given

8 (38.10%)

Single vessel disease

13 (61.90%)

Double vessel disease

4 (19.05%)

Triple vessel disease

4 (19.05%)

Groups Ib+c and IIb (100% each) followed by Group

IIa (71.43%), Group Ic (50%), Group Ia (42.86%) and
least for Group Ib (0%). The specificity was maximum
for Groups Ia and IIa (92.86% each) followed by Group
Ib (90%), Group IIb (89.47%), Group Ic (78.95%) and
Group Ib+c (77.78%) in that order. The PPA and NPA for
Group Ia, Ib, Ic, Ib+c, IIa and IIb were 75% and 76.47%,
0% and 94.74%, 20% and 93.75%, 42.86% and 100%,
83.33% and 86.67% and 50% and 100%, respectively.
Discussion
In anterior wall myocardial infarction (AWMI), the
occlusion is nearly always in the LAD coronary artery.
With inferior wall myocardial infarction (IWMI),
however, either the RCA or the LCx coronary artery
may contain the culprit lesion.1 Rarely, acute IWMI
may result from occlusion of the recurrent LAD branch,

In AWMI, ST-segment elevation in leads V1, V2 and

V3 indicates occlusion of the LAD coronary artery.
ST-segment elevation in these three leads and in lead
aVL in association with ST-segment depression of
>1 mm in leads II, III and aVF indicates proximal
occlusion of the LAD artery. In this case, the ST-segment
vector is directed upward, toward leads V1, aVL, aVR
and away from the inferior leads. ST-segment elevation
in leads V1, V2 and V3 without significant inferior
ST-segment depression suggests occlusion of the LAD
artery after the origin of the first diagonal branch.
ST-segment elevation in leads V1, V2 and V3 with
elevation in the inferior leads suggests occlusion of
the LAD artery distal to the origin of the first diagonal
branch, in a vessel that wraps around to supply the
inferoapical region of the left ventricle. New right
bundle-branch block (RBBB) with a Q-wave preceding
the R-wave in lead V1 is a specific but insensitive marker
of proximal occlusion of the LAD artery in association
with anteroseptal myocardial infarction.1
In IWMI, several ECG criteria identify RCA or LCx as
the artery containing the culprit lesion. Each of these
criteria is based on one of two anatomic facts.2 First, the
myocardial distribution of the RCA is slightly rightward
in the frontal plane, and consequently the current of
injury resulting from its occlusion will be reflected more
in lead III than lead II and ST will be more in lead aVL
than in lead I. Conversely, the distribution of the LCx
is slightly leftward in the frontal plane, and the current
of injury from its closure will be seen more in lead II
than lead III. Similarly, the current of injury with RCA
occlusion is more or less perpendicular to the axis of
lead aVR, whereas the current of injury resulting from
occlusion of the LCx has a mean vector that forms an
obtuse angle with the axis of aVR. Therefore, significant

Table 2. Correlation of ECG Criteria with Coronary Angiography

Groups by ECG

Sensitivity (%)

Specificity (%)

PPA (%)

NPA (%)

42.86

92.86

75.00

76.47

Ib

0.00

90.00

0.00

94.74

Ic

50.00

78.95

20.00

93.75

Ib+c

100.00

77.78

42.86

100.00

100.00

90.91

90.91

100.00

IIa

71.43

92.86

83.33

86.67

IIb

100.00

89.47

50.00

100.00

II

100.00

91.67

90.00

100.00

III

0.00

100.00

90.48

Ia

NPA: Negative predictive accuracy; PPA: Positive predictive accuracy.

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Indian Journal of Clinical Practice, Vol. 23, No. 10 March 2013

cardiology
ST-segment depression in aVR is more likely to occur
with LCx occlusion. An injury vector leftward enough
to cause ST-segment elevation in lead I is common with
LCx occlusion, but rare with RCA occlusion. Second,
the RCA provides almost all of the blood supply to the
right ventricle, which is rightward as well as anterior
to left ventricle. When the RCA is occluded proximal
to one or more of its major RV branches, ST-segment
elevation is likely to be seen in lead V4R. Similarly,
the ST-segment in lead V1 (V2R) may be elevated
even when the more leftward precordial leads show
ST-segment depression due to the posterior injury
that so frequently accompanies acute IWMI. Evidence
of acute RV infarction is important, not only because
it identifies the RCA as harboring the culprit lesion,
but especially because it predicts a greatly increased
morbidity and mortality. Consequently, right precordial
leads or at least lead V4R should be recorded in all
patients with acute IWMI. ST-segment depression in V1
and V2 indicates posterior injury and is typical of LCx
occlusion.
Mortality and morbidity in part are determined by the
location of the occlusion. For example, in patients with
inferior MI who have RV infarction, the culprit artery
virtually always is the RCA. Such patients, including
those in whom ECG evidence of RV MI is masked, are
at increased risk for death, shock and arrhythmias,
including atrioventricular block.2 Thus, identifying the
culprit artery in acute IWMI helps define those in whom
aggressive reperfusion strategies are likely to yield
most benefit. Coronary arteriography is the best means
of determining the culprit artery in acute IWMI. When
both the RCA and LCx are severely diseased, however,
deciding which one is the culprit can be difficult and
having an independent predictor of the culprit artery,
such as the ECG, can be very helpful.
Engelen et al in a study of patients with AWMI showed
that for different ECG criteria we used in our study to
localize LAD occlusion proximal to S1 and/or D1 (i.e.,
patients in group Ia and Ib in the present study), the
sensitivity, specificity, PPA and NPA varied from 12% to
44%, 85 to 100%, 67 to 100% and 61 to 70%, respectively.3
Similar figures for ECG criteria to localize occlusion
in LAD distal to S1 and/or D1 (i.e., patients in Group
Ib and Ic in the present study) were 22-41%, 86-95%,
77-92% and 46-53%, respectively.
In a study by Herz et al in patients with inferior wall
AMI, the sensitivity to localize RCA occlusion varied
from 55% to 94%.4 The specificity, PPA and NPA varied
from 71% to 100%, 88% to 100% and 29% to 75%,
respectively. The sensitivity, specificity, PPA and NPA

for LCx coronary artery were 88%, 100%, 100% and

97%, respectively.4 Kosuge et al studied the criteria of
ratio of ST V3/ST III in patients with acute IWMI
and found the sensitivity, specificity, PPA and NPA
for RCA occlusion proximal to RV branch to be 91%,
91%, 88% and 93%, respectively.5 The similar figure for
RCA occlusion distal to RV branch were 84%, 93%, 91%
and 88% and those for LCx coronary artery occlusion
were 84%, 95%, 73% and 98%, respectively.5 Nair et al
found that quantifying ST-segment depression in lead
aVR distinguished a culprit LCx (1 mm) from a culprit
RCA (<1 mm or no depression) as well or better than
other criteria and the importance of lead V4R has been
investigated by many authors.6,7 Diagnostic accuracy of
different ECG criteria in different studies are given in
Tables 3 and 4.
The ECG criteria used in these previous studies were
combined and used in the present study. The findings
in the present study were in agreement with those of the
study by Engelen et al except for the higher sensitivity
and NPA and lower specificity and PPA in Group Ib+c.
The results were similar to that of the study by Herz et al
except for the lower sensitivity for LCx and greater
NPA for RCA in the present study. The present series
also agreed with the findings by Kosuge et al except
for the lower sensitivity and lower NPA in Group IIa,
and higher sensitivity and NPA as well as lower PPA
in Group IIb.
The lower specificity and PPA in Group Ib+c (distal to
S1 branch occlusion of LAD) in the present study was
because of the fact that ECG was false positive for five
patients in that group with four of them having severe
degree of occlusion proximally in LAD (three had single
vessel disease) and one had LCx disease by coronary
arteriogram (CART). As pre-existing severe stenosis in
these patients could have made collateral circulation
to develop adequately so as to minimize the amount
of myocardium jeopardized even when the occlusion
was in the proximal segment of LAD, ECG might have
falsely mimicked that of distal LAD occlusion. The
lower PPA in Group IIb in the present study might be
because of the same reason as two of the four patients
in that group had occlusion more proximally. The small
sample size could be the possible explanation for lower
sensitivity in Group III, which inherently also has a
low sensitivity due to inability of ECG to localize LCx
coronary artery occlusion as posterior and lateral wall
supplied by the artery is poorly represented in the
standard surface ECG.
When patients were divided into six subgroups, ECG
did not correlate fully with CART in 10 patients all of

Indian Journal of Clinical Practice, Vol. 23, No. 10 March 2013

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cardiology
Table 3. Diagnostic Accuracy of Different ECG Criteria in AWMI (Engelen et al3)
IRA

ECG criteria

Sensitivity

LAD distal to S1

NPA

ST aVR*

43

95

86

70

36

100

100

68

ST III 1.0 mm

60

71

60

71

ST III 2.5 mm

33

97

88

67

ST aVF 1.0 mm

52

84

71

71

ST aVF 2.0 mm

26

97

85

64

cRBBB*

14

100

100

62

ST V5 1.0 mm*

17

98

88

62

ST V1 2.5 mm*

12

100

100

61

ST II 1.0 mm*

34

98

93

68

ST III 1.0 mm

66

75

64

76

ST III 2.5 mm

32

95

81

67

ST aVF 1.0 mm

54

85

71

72

ST aVF 2.0 mm

27

97

85

66

Q aVL*

44

85

67

69

Absence of ST II

67

74

78

62

Absence of ST III*

34

86

77

49

Absence of ST aVF

45

90

87

54

Q V6

17

100

100

47

Q V 5*
Q V4

LAD distal to D1

PPA

ST II 1.0 mm*

LAD proximal to S1

LAD proximal to D1

Specificity

24

93

82

47

55

69

71

53

Absence of ST II

66

73

78

60

Absence of ST III*

41

95

92

53

Absence of ST aVF

44

90

87

53

STaVL*

22

95

87

46

*Criteria used in the present study; AWMI: Anterior wall myocardial infarction; IRA: Infarct related artery; NPA: Negative predictive accuracy,
PPA: Positive predictive accuracy, ST: ST-segment elevation; ST: ST-segment depression.

Table 4. Diagnostic Accuracy of Different ECG Criteria in IWMI in Different Studies

Studies
Herz et

al4

Kosuge et

al5

Verouden et al8
Verouden et

al8

Zimetbaum et al9

ECG criteria

IRA

Sensitivity

Specificity

PPA

NPA

Various criteria

RCA

55-94

71-100

88-100

29-75

LCx

88

100

100

97

RCA proximal to
RV branch (<0.5)

91

91

88

93

RCA distal to RV
branch (>0.5, <1.2)

84

93

91

88

LCx (>1.2)

84

95

73

98

RCA

70

72

Ratio of ST V3/ST III

ST III >II, STI or aVL >1 mm

Above + ST deviation >18.5 mm

RCA

90

ST in III>II and I and/or aVL <-1 mm

RCA

70

72

90

39

Chia et al10

ST in III>II and any ST in I

RCA

76

66

89

42

Bairey et al11

ST in I

RCA

79

61

89

44

Bairey et al11

ST in aVL

RCA

95

24

82

56

IRA: Infarct related artery; IWMI: Inferior wall myocardial infarction; NPA: Negative predictive accuracy; PPA: Positive predictive accuracy,
ST: ST-segment elevation; ST: ST-segment depression.

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Indian Journal of Clinical Practice, Vol. 23, No. 10 March 2013

cardiology
whom had severe degree of obstruction. Among them
one each was in Group Ia and IIa, two each in Group
Ib and IIb and four in Group Ic. One patient each from
Group Ia and IIa had occlusion in LCx coronary artery,
which were not diagnosed by ECG, which is a known
poor tool to diagnose such occlusion. One patient in
Group Ib had more distal occlusion in LAD coronary
artery (i.e., Group Ic by CART). Though, the occlusion
was in distal LAD, he had diseased posterior descending
artery (PDA) and thus the amount of myocardium
jeopardized might have been substantial by virtue of
the severity of disease in other artery and hence less
chance of good collateral circulation. Rest of the seven
patients had more proximal lesion by CART but in the
same artery as predicted by ECG. The more proximal
lesions in these cases were of severe degree and all
patients had single vessel disease. Thus, the possible
collateral circulation that might have developed long
before the AMI in such cases could have led to better
myocardial salvage in spite of a proximal lesion giving
rise to false ECG diagnosis of distal lesion.
Conclusion
The present study demonstrates that ECG is an easily
and widely available inexpensive tool to localize site of
occlusion in culprit vessel in acute STEMI.

Limitation
The present study has two major limitations. Its sample
size is small and coronary angiography was not done
immediately on presentation but at a later date in
other referral centers. Sometimes it becomes difficult to
incriminate a lesion as the culprit one if angiography is
done later in the course especially if there is multivessel
disease or thrombolytic therapy has been given.

2. Fiol M, Cygankiewicz I, Carrillo A, Bays-Genis A,

Santoyo O, Gmez A, et al. 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(6):709-14.
3. Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Ophuis
AJ, Dassen WR, et al. 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(2):389-95.
4. Herz I, Assali AR, Adler Y, Solodky A, Sclarovsky S. New
electrocardiographic criteria for predicting either the right
or left circumflex artery as the culprit coronary artery in
inferior wall acute myocardial infarction. Am J Cardiol
1997;80(10):1343-5.
5. Kosuge M, Kimura K, Ishikawa T, Hongo Y, Mochida Y,
Sugiyama M, et al. New electrocardiographic criteria
for predicting the site of coronary artery occlusion in
inferior wall acute myocardial infarction. Am J Cardiol
1998;82(11):1318-22.
6. Nair R, Glancy DL. ECG discrimination between right and
left circumflex coronary arterial occlusion in patients with
acute inferior myocardial infarction: value of old criteria
and use of lead aVR. Chest 2002;122(1):134-9.
7. Wellens HJ. The ECG in localizing the culprit lesion in
acute inferior myocardial infarction: a plea for lead V4R?
Europace 2009;11(11):1421-2.
8. Verouden NJ, Barwari K, Koch KT, Henriques JP, Baan J,
van der Schaaf RJ, et al. Distinguishing the right coronary
artery from the left circumflex coronary artery as the
infarct-related artery in patients undergoing primary
percutaneous coronary intervention for acute inferior
myocardial infarction. Europace 2009;11(11):1517-21.
9. Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med
2003;348(10):933-40.

References

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II/III ratio and ST deviation in lead I for identifying the
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cardiogram in acute myocardial infarction. In: Hursts the
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