Electrocardiographic prediction of the culprit vessel in inferior myocardial infarction with multivessel coronary disease

BACKGROUND: Numerous electrocardiographic (ECG) criteria have been reported to predict the culprit artery in cases of inferior myocardial infarction (MI). This study aimed to identify the most reliable predictive criteria and assess their applicability in a cohort of patients with multivessel coronary disease. METHODS: This cross-sectional study included patients with inferior MI who underwent primary percutaneous coronary intervention between January 2019 and August 2024 at Gia Dinh Hospital. We evaluated 43 previously reported ECG criteria, algorithms, and scoring systems to determine whether the culprit artery was the right coronary artery (RCA) or the left circumflex artery (LCx). Subgroup analyses were performed based on the extent of coronary artery stenosis to assess the predictive value of ECG in multivessel coronary disease. RESULTS: We evaluated 431 inferior MI patients with an average age of 62.1 ± 12.2 years, with men comprising 76.1 %. There were 63 (14.6 %) patients with one-vessel coronary disease, 136 (31.6 %) with two-vessel coronary disease, and 232 (53.8 %) with three-vessel coronary disease. The ST elevation (STE) in lead III greater than in lead II was identified as the best predictor of RCA as the culprit artery, demonstrating a sensitivity of 92 %, specificity of 67 %, positive predictive value of 94 %, negative predictive value of 59 %, accuracy of 88 %, and an area under the curve (AUC) of 0.8 (95 % CI 0.74-0.85) with p < 0.001. When analyzing the multivessel coronary disease subgroup, the STE III > II criterion maintained its strong predictive ability, with a sensitivity of 92 %, a positive predictive value of 95 %, AUC of 0.8 (95 % CI 0.74-0.87) and p < 0.001. CONCLUSIONS: The criterion of STE III > II remains a robust predictor for identifying the culprit artery in inferior MI, regardless of the presence of multivessel coronary disease.