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Schmitz T, Thilo C, Linseisen J, Heier M, Peters A, Kuch B, Meisinger C. Admission ECG changes predict short term-mortality after acute myocardial infarction less reliable in patients with diabetes. Sci Rep 2021; 11:6307. [PMID: 33737645 PMCID: PMC7973741 DOI: 10.1038/s41598-021-85674-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Prior studies examined association between short-term mortality and certain changes in the admission ECG in acute myocardial infarction (AMI). Nevertheless, little is known about possible differences between patients with diabetes and without diabetes in this regard. So the aim of the study was to investigate the association between 28-day case fatality according to certain ECG changes comparing AMI cases with and without diabetes from the general population. From 2000 until 2017 a total of 9756 AMI cases was prospectively recorded in the study Area of Augsburg, Germany. Each case was assigned to one of the following groups according to admission ECG: ‘ST-elevation’, ‘ST-depression’, ‘only T-negativity’, ‘predominantly bundle branch block’, ‘unspecific changes’ and ‘normal ECG’ (the last two were put together for regression analyses). Multivariable adjusted logistic regression models were calculated to compare 28-day case-fatality between the ECG groups for the total sample and separately for diabetes and non-diabetes cases. For the non-diabetes group, the parsimonious logistic regression model revealed significantly better 28-day-outcome for the ‘normal ECG / unspecific changes’ group (OR: 0.47 [0.29–0.76]) compared to the reference group (STEMI). Contrary, in AMI cases with diabetes the category ‘normal ECG / unspecific changes’ was not significantly associated with lower short-term mortality (OR: 0.87 [0.49–1.54]). Neither of the other ECG groups was significantly associated with 28-day-mortality in the parsimonious logistic regression models. Consequently, the absence of AMI-typical changes in the admission ECG predicts favorable short-term mortality only in non-diabetic cases, but not so in patients with diabetes.
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Affiliation(s)
- Timo Schmitz
- MONIKA/KORA Myocardial Infarction Registry, University Hospital of Augsburg, Augsburg, Germany. .,Chair of Epidemiology, LMU München at UNIKA-T Augsburg, Augsburg, Germany.
| | - Christian Thilo
- Department of Cardiology, University Hospital of Augsburg, Augsburg, Germany
| | - Jakob Linseisen
- Chair of Epidemiology, LMU München at UNIKA-T Augsburg, Augsburg, Germany.,IRG Clinical Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Margit Heier
- KORA Study Centre, University Hospital of Augsburg, Augsburg, Germany.,Institute of Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Annette Peters
- Institute of Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Bernhard Kuch
- Department of Internal Medicine, Hospital Nördlingen, Nördlingen, Germany
| | - Christa Meisinger
- Chair of Epidemiology, LMU München at UNIKA-T Augsburg, Augsburg, Germany.,IRG Clinical Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany
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Al Rajoub B, Noureddine S, El Chami S, Haidar MH, Itani B, Zaiter A, Akl EA. The prognostic value of a new left bundle branch block in patients with acute myocardial infarction: A systematic review and meta-analysis. Heart Lung 2017; 46:85-91. [DOI: 10.1016/j.hrtlng.2016.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
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Xiang L, Zhong A, You T, Chen J, Xu W, Shi M. Prognostic Significance of Right Bundle Branch Block for Patients with Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Med Sci Monit 2016; 22:998-1004. [PMID: 27017617 PMCID: PMC4811299 DOI: 10.12659/msm.895687] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background The aim of the current meta-analysis was to assess the effect of right bundle branch block (RBBB) on mortality outcome in patients with acute myocardial infarction (AMI). Material/Methods Embase, PubMed, and Cochrane databases were searched through January 2015 using the keywords “RBBB”, “mortality”, “AMI”, “Coronary Heart Disease”, and “cardiovascular”. An odds ratio (OR) of RBBB on mortality endpoints was calculated using random-effects models. Results RBBB was associated with significantly increased overall mortality in patients with AMI. The OR of RBBB for deaths was 1.56 [95% confidence interval (CI), 1.44 to 1.68, p<0.001]. Moreover, RBBB showed a considerable effect on both in-hospital mortality (OR: 1.94, 95% CI: 1.60 to 2.37, p=0.002) and long-term mortality (OR: 1.49, 95% CI: 1.37 to 1.62, p<0.001). Conclusions RBBB is associated with an increased risk of all-cause mortality and indicates a poorer prognosis in patients with AMI.
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Affiliation(s)
- Li Xiang
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Anyuan Zhong
- Department of Respiration, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Tao You
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Jianchang Chen
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Weiting Xu
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Minhua Shi
- Department of Respiration, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
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Nikus K, Järvinen O, Sclarovsky S, Huhtala H, Tarkka M, Eskola M. Electrocardiographic Presentation of Left Main Disease in Patients Undergoing Urgent or Emergent Coronary Artery Bypass Grafting. Postgrad Med 2015; 123:42-8. [DOI: 10.3810/pgm.2011.03.2262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nikus KC, Sclarovsky S, Huhtala H, Niemelä K, Karhunen P, Eskola MJ. Electrocardiographic presentation of global ischemia in acute coronary syndrome predicts poor outcome. Ann Med 2012; 44:494-502. [PMID: 21679105 DOI: 10.3109/07853890.2011.585345] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Global ischemia (GI) electrocardiogram (ECG), wide-spread ST depression with inverted T waves maximally in leads V(4-5), and lead aVR ST elevation (STE), is a marker of an adverse outcome in patients with non-ST elevation acute coronary syndromes (ACS), perhaps because this pattern is indicative of left main stenosis. The prognostic value of this ECG pattern has not been established. AIMS The distribution of ECG changes and the prognostic value of the GI ECG were studied. METHODS ECGs of consecutive patients admitted with suspected ACS (n = 1,188) were classified into seven ECG categories: STE, Q waves without STE, left bundle branch block, left ventricular hypertrophy, GI ECG, other ST depression and/or T wave inversion, and other findings. RESULTS The GI ECG pattern predicted a high rate (48%) of composite end-points (mortality, re-infarction, unstable angina, resuscitation, or stroke) at 10-month follow-up compared to the other ECG categories (36%) (HR 1.78; CI 95% 1.31-2.41; P < 0.001). In multivariate analysis, the GI ECG pattern was associated with a higher rate of composite end-points (HR 1.40; CI 95% 1.02-1.91; P = 0.035). The multivariate analysis furthermore identified age, creatinine level, and diabetes as independent predictors of prognosis. CONCLUSIONS The GI ECG pattern predicted an unfavorable outcome, when compared to other ECG patterns in patients with ACS.
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Affiliation(s)
- Kjell C Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
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6
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Huvelle E, Fay R, Alla F, Cohen Solal A, Mebazaa A, Zannad F. Left bundle branch block and mortality in patients with acute heart failure syndrome: a substudy of the EFICA cohort. Eur J Heart Fail 2010; 12:156-63. [DOI: 10.1093/eurjhf/hfp180] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Etienne Huvelle
- CIC-INSEM-CHU, Nancy, Hôpital Jeanne d'Arc, BP 90303; 54201 Toul Cedex France
| | - Renaud Fay
- CIC-INSEM-CHU, Nancy, Hôpital Jeanne d'Arc, BP 90303; 54201 Toul Cedex France
| | | | - Alain Cohen Solal
- APHP, Department of Cardiology, Lariboisière Hospital; U942 Inserm, Université Paris Diderot; Paris France
| | - Alexandre Mebazaa
- APHP, Department of Anesthesiology and Critical Care Medicine, Lariboisière Hospital; U942 Inserm, Université Paris Diderot; Paris France
| | - Faiez Zannad
- CIC-INSEM-CHU, Nancy, Hôpital Jeanne d'Arc, BP 90303; 54201 Toul Cedex France
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7
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Kuch B, Heier M, von Scheidt W, Kling B, Hoermann A, Meisinger C. 20-year trends in clinical characteristics, therapy and short-term prognosis in acute myocardial infarction according to presenting electrocardiogram: the MONICA/KORA AMI Registry (1985-2004). J Intern Med 2008; 264:254-64. [PMID: 18397247 DOI: 10.1111/j.1365-2796.2008.01956.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes. BACKGROUND Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB). DESIGN AND SETTING We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088). RESULTS The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45). CONCLUSIONS Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.
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Affiliation(s)
- B Kuch
- I. Medizinische Klinik, Hospital of Augsburg, Teaching Hospital of the Ludwig Maximilians University München, Augsburg, Germany.
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8
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Pitsavos C, Chrysohoou C, Panagiotakos DB, Stefanadis C. Electrocardiographic findings at presentation, in relation to in-hospital mortality and 30-day outcome of patients with Acute Coronary Syndromes; The GREECS study. Int J Cardiol 2008; 123:263-70. [PMID: 17383031 DOI: 10.1016/j.ijcard.2006.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2006] [Revised: 10/15/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND We sought to evaluate the impact of initial electrocardiographic findings at presentation on in-hospital mortality and 30-day outcome of patients with acute coronary syndromes (ACS). METHODS From October 2003 to September 2004, a sample of 6 hospitals located in several urban and rural Greek regions was selected, and almost all survivors 24 h after an admission for ACS were enrolled into the study (2172 patients were included in the study; 76% were men and 24% women). ECG and biochemical indices of myocardial damage were considered in all patients. Electrocardiographic findings at presentation were categorized as ST-elevation (STE), non-STE and non-diagnostic ECG abnormalities. RESULTS Of the 2172 patients, 34% had STE, 24% had non-STE and the 32% of them had non-diagnostic ECG abnormalities. After adjusting for age, sex and various other risk factors we observed that patients with STE had 3.3 (95% CI 1.4 to 7.7) higher risk of dying during hospitalization compared to those who had non-diagnostic ECG abnormalities. Furthermore, patients with non-STE had 1.5 (95% CI 0.9 to 2.5) higher risk of having an event (death or re-hospitalization due to CVD) during the first 30-days following discharge as compared to those who had non-diagnostic ECG abnormalities. All patients presented with non-STE ACS had higher 30-day event rates. CONCLUSION Patients with STE had higher in-hospital mortality, but lower longer term event rate after ACS in our population, irrespective of age, gender and other characteristics.
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Affiliation(s)
- Christos Pitsavos
- First Cardiology Clinic, School of Medicine, University of Athens, Athens, Greece
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9
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Kuch B, von Scheidt W, Kling B, Heier M, Hoermann A, Meisinger C. Characteristics and outcome of patients with acute myocardial infarction according to presenting electrocardiogram (from the MONICA/KORA Augsburg Myocardial Infarction--Registry). Am J Cardiol 2007; 100:1056-60. [PMID: 17884361 DOI: 10.1016/j.amjcard.2007.04.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 04/25/2007] [Accepted: 04/25/2007] [Indexed: 10/23/2022]
Abstract
Acute myocardial infarctions (AMIs) are categorized according to presenting electrocardiography into ST-elevation (STE), non-STE, and bundle branch block AMIs. Data on the characteristics and risks of these categories originate mainly from voluntary registries or clinical trials and may be hampered by selection and information bias. This study evaluated these different categories, with the additional differentiation of non-STE AMIs into ST-depression (STD) AMIs and those with nonspecific electrocardiographic signs (no-ST) in an unselected cohort. From 1985 to 2004, all consecutive patients aged 25 to 74 years who were hospitalized with AMI at the study region's major clinic were registered prospectively. A total of 6,748 patients were identified, of whom 45.8% had STE, 14.0% STD, 32.4% no-ST, and 7.8% bundle branch block AMIs, respectively. There were substantial differences in medical history, presentation, and therapy among the AMI types. Even after adjusting for the latter factors, the odds ratios of 28-day case fatality compared with no-ST were 1.26 (95% confidence interval 1.01 to 1.59) for STE, 1.84 (95% confidence interval 1.39 to 2.44) for STD, and 3.18 (95% confidence interval 2.37 to 4.27) for bundle branch block. In conclusion, after considering in-hospital therapy, the difference between STE and no-ST was nonsignificant, whereas the case-fatality difference between no-ST and STD persisted, suggesting some other unknown underlying factors associated with STD.
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Affiliation(s)
- Bernhard Kuch
- I. Med. Klinik, Hospital of Augsburg, Augsburg, Germany.
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10
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Wilson LD, Wan X, Rosenbaum DS. Cellular alternans: a mechanism linking calcium cycling proteins to cardiac arrhythmogenesis. Ann N Y Acad Sci 2007; 1080:216-34. [PMID: 17132786 DOI: 10.1196/annals.1380.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Essentially all previous research on alternans has been restricted to normal myocardium, whereas sudden cardiac death (SCD) occurs most commonly in patients with ventricular dysfunction (i.e., heart failure), which is associated with marked disruption of proteins responsible for normal calcium cycling in myocytes. Several lines of evidence from studies in normal hearts suggest a link between impaired calcium cycling which characterizes ventricular mechanical dysfunction and impaired calcium cycling that is responsible for alternans. In normal myocardium, cells which exhibit the slowest calcium cycling, and not the slowest repolarization, are most susceptible to alternans. Decreased expression of key calcium cycling proteins is observed in alternans-prone cells. Sarcoplasmic reticulum ATPase (SERCA2a) expression is decreased, suggesting a mechanism for the slower sarcoplasmic reticulum (SR) calcium reuptake observed in alternans-prone cells. In addition, diminished ryanodine receptor (RyR) function leading to abnormal calcium release from the SR is also linked to cellular alternans. Although impaired contractile function clearly predisposes to SCD, the mechanisms linking mechanical to electrophysiological dysfunction in the heart are unclear. We propose that cellular calcium alternans may be an important mechanism linking mechanical dysfunction to cardiac arrhythmogenesis.
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Affiliation(s)
- Lance D Wilson
- MetroHealth Campus, Case Western Reserve University, 2500 MetroHealth Drive, Hamann 330, Cleveland, OH 44109-1998, USA
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Stephenson K, Skali H, McMurray JJV, Velazquez EJ, Aylward PG, Kober L, Van de Werf F, White HD, Pieper KS, Califf RM, Solomon SD, Pfeffer MA. Long-term outcomes of left bundle branch block in high-risk survivors of acute myocardial infarction: The VALIANT experience. Heart Rhythm 2007; 4:308-13. [PMID: 17341394 DOI: 10.1016/j.hrthm.2006.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 11/16/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND In survivors of myocardial infarction (MI), new left bundle branch block (LBBB) is associated with adverse outcomes, but its impact is not well described in post-MI patients with left ventricular (LV) systolic dysfunction and/or heart failure (HF). OBJECTIVES The aim of this study was to determine if new LBBB is an independent predictor of long-term fatal and nonfatal outcomes in high-risk survivors of MI by reviewing data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. METHODS In VALIANT, 14,703 patients with LV systolic dysfunction and/or HF were randomized to valsartan, captopril, or both a mean of 5 days after MI. Baseline ECG data were available from 14,259 patients. We assessed the predictive value of new LBBB for death and major cardiovascular outcomes after 3 years, adjusting for multiple baseline covariates including LV ejection fraction. RESULTS At follow-up, patients with new LBBB (608 [4.2%]) compared with patients without new LBBB had more comorbidities and increased adjusted risk of death (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6), cardiovascular death (HR 1.4, 95% CI 1.2-1.7), HF (HR 1.3, 95% CI 1.1-1.6), MI (HR 1.5, 95% CI 1.2-1.9), and the composite of death, HF, or MI (HR 1.4, 95% CI 1.2-1.6). CONCLUSION In post-MI survivors with LV systolic dysfunction and/or HF, new LBBB was an independent predictor of all major adverse cardiovascular outcomes during long-term follow-up. This readily available ECG marker should be considered a major risk factor for long-term cardiovascular complications in high-risk patients after MI.
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Affiliation(s)
- Kent Stephenson
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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12
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Zannad F, Huvelle E, Dickstein K, van Veldhuisen DJ, Stellbrink C, Køber L, Cazeau S, Ritter P, Maggioni AP, Ferrari R, Lechat P. Left bundle branch block as a risk factor for progression to heart failure. Eur J Heart Fail 2006; 9:7-14. [PMID: 16890486 DOI: 10.1016/j.ejheart.2006.04.011] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 12/09/2005] [Accepted: 04/25/2006] [Indexed: 12/13/2022] Open
Abstract
The prevalence of conduction disturbances, particularly left bundle branch block (LBBB), is strongly correlated with age and with the presence of cardiovascular disease. LBBB has been reported to affect approximately 25% of the heart failure (HF) population and it is likely that the deleterious role of such conduction disorders in the progression to HF has been underestimated. The purpose of this article is to review the data from the literature indicating that LBBB may have a causative role, mediated through the resulting intra-ventricular asynchrony, in the deterioration of cardiac function and the development of cardiac remodelling and HF. It also aims to address the potential for future clinical therapies for this conduction disorder.
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Affiliation(s)
- Faiez Zannad
- CIC-INSERM-CHU de Nancy, Hôpital Jeanne d'Arc, Dommartin-lès-Toul, BP 303 - 54201 Toul Cedex, France.
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13
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Goodman SG, Bozovich GE, Tan M, Dos Santos A, Gurfinkel EP, Cohen M, Langer A. The greatest benefit of enoxaparin over unfractionated heparin in acute coronary syndromes is achieved in patients presenting with ST-segment changes: the Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) Electrocardiogram Core Laboratory Substudy. Am Heart J 2006; 151:791-7. [PMID: 16569535 DOI: 10.1016/j.ahj.2005.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 08/11/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND We undertook a prospective electrocardiogram (ECG) substudy in the ESSENCE trial and hypothesized that patient subgroups with ST-segment deviation would experience greater benefit from enoxaparin, as compared with unfractionated heparin (UFH). METHODS Of the 3171 patients in the trial, 3087 had a qualifying ECG available for analysis by the core laboratory. Patients were divided into 4 mutually exclusive groups based upon the qualifying ECG: (1) ST-segment elevation, (2) ST-segment depression, (3) T-wave inversions, or (4) others. RESULTS The 30-day and 1-year primary outcomes (death, myocardial infarction, or recurrent angina) were significantly lower among patients with ST elevation or ST depression who received enoxaparin, as compared with UFH (20.8% vs 28.0%, P = .0019 and 32% vs 40.4%, P = .0011, respectively). The greatest absolute benefit of enoxaparin over UFH was seen in patients with ST depression (primary end point at 30 days, 24.6% vs 32.4%, P = .018; at 1 year, 35.5% vs 44.5%, P = .012). CONCLUSION Specific recognition of patients with ST-segment depression appears to identify those not only at high risk for adverse outcome, but also patients most likely to derive the greatest benefit from enoxaparin, as compared with UFH therapy.
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Affiliation(s)
- Shaun G Goodman
- Division of Cardiology, Canadian Heart Research Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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14
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Rathore SS, Weinfurt KP, Foody JM, Krumholz HM. Performance of the Thrombolysis in Myocardial Infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients. Am Heart J 2005; 150:402-10. [PMID: 16169316 PMCID: PMC2790534 DOI: 10.1016/j.ahj.2005.03.069] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2003] [Accepted: 03/29/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The TIMI ST-elevation myocardial infarction (STEMI) score was developed and validated in a randomized controlled trial population. We sought to assess its accuracy in a community-based cohort of elderly patients hospitalized with STEMI. METHODS We evaluated the TIMI STEMI score in 47,882 patients aged > or = 65 years hospitalized with STEMI in US hospitals from 1994 to 1996. We assessed TIMI STEMI score discrimination and calibration for 30-day mortality and compared observed and published TIMI mortality rates. RESULTS The cohort's median TIMI score was 6 (25th-75th percentile 4, 8). Thirty-day mortality rates were higher among patients with higher TIMI scores (TIMI score 2: 4.4% vs TIMI score > 8: 35.6%, P < .0001 for trend). However, the TIMI score provided only modest discrimination (c = 0.67) and calibration (goodness-of-fit P < .0001). Mortality rates for TIMI scores differed between patients who did and did not receive reperfusion therapy (P < .0001 for TIMI score x reperfusion therapy interaction). Thirty-day mortality rates in the cohort were higher than published TIMI estimates (P = .001; eg, TIMI score 2: 4.4% cohort vs 2.2% published rate). CONCLUSIONS The TIMI score provided modest prognostic discrimination and calibration among elderly patients with STEMI. Our findings highlight the difficulties in applying risk scores developed in randomized controlled trial cohorts to elderly patients.
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Affiliation(s)
- Saif S. Rathore
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Kevin P. Weinfurt
- Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - JoAnne M. Foody
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
- Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn
- Qualidigm, Middletown, Conn
- Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Conn
- Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Conn
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15
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Guerrero M, Harjai K, Stone GW, Brodie B, Cox D, Boura J, Grines L, O'Neill W, Grines C. Comparison of the prognostic effect of left versus right versus no bundle branch block on presenting electrocardiogram in acute myocardial infarction patients treated with primary angioplasty in the primary angioplasty in myocardial infarction trials. Am J Cardiol 2005; 96:482-8. [PMID: 16098297 DOI: 10.1016/j.amjcard.2005.04.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 04/08/2005] [Accepted: 04/08/2005] [Indexed: 11/28/2022]
Abstract
The presence of bundle branch block (BBB) has been associated with poor outcomes in patients who have acute myocardial infarction. Whether this is true in the angioplasty era is not known. We sought to evaluate the outcome of patients with acute myocardial infarction and BBB who were treated with primary angioplasty. We evaluated 3,053 patients who underwent emergency catheterization in the PAMI trials. Patients who had left BBB (n = 48, 1.6%) on presenting electrocardiogram were compared with patients who had right BBB (n = 95, 3.1%) or no BBB (n = 2,910, 95.3%). Patients who had BBB were older and more frequently had diabetes mellitus, peripheral vascular disease, and previous coronary artery bypass grafting. They had lower ejection fraction and more multivessel disease. There were no significant differences in door-to-balloon time, final Thrombolysis In Myocardial Infarction flow grade or stent use. In-hospital major adverse cardiac events (death, ischemic target vessel revascularization, and reinfarction) were higher in patients who had BBB due primarily to increased in-hospital death (left BBB 14.6%, right BBB 7.4%, no BBB 2.8%, p < 0.0001). In multivariate logistic regression analysis, left BBB was an independent predictor of in-hospital death (odds ratio 5.53, 95% confidence interval 1.89 to 16.1, p = 0.002). In conclusion, patients who have acute myocardial infarction and BBB have increased co-morbidities and higher mortality rates despite treatment with primary angioplasty. Despite early identification of multivessel disease with triage to angioplasty or coronary artery bypass grafting, if necessary, similar treatment times, and final Thrombolysis In Myocardial Infarction grade 3 flow, the presence of left BBB on admission electrocardiogram in patients who have acute myocardial infarction is an independent predictor of in-hospital mortality. Because 85% of deaths in patients who have left BBB occur within the first week, these patients should be recognized early and receive prompt and aggressive treatment.
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Pitta SR, Grzybowski M, Welch RD, Frederick PD, Wahl R, Zalenski RJ. ST-segment depression on the initial electrocardiogram in acute myocardial infarction-prognostic significance and its effect on short-term mortality: A report from the National Registry of Myocardial Infarction (NRMI-2, 3, 4). Am J Cardiol 2005; 95:843-8. [PMID: 15781012 DOI: 10.1016/j.amjcard.2004.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2004] [Revised: 12/01/2004] [Accepted: 12/01/2004] [Indexed: 11/28/2022]
Abstract
This study analyzed 255,256 patients who had acute myocardial infarction and were enrolled in the National Registry of Myocardial Infarction 2, 3, and 4 (1994 to 2002). The objective was to determine in-hospital mortality rate among patients who had ST-segment depression on the initial electrocardiogram. Patients who had ST-segment depression had an in-hospital mortality rate (15.8%) similar to that of patients who had ST-segment elevation or left bundle branch block (15.5%). After adjusting for observed differences, ST-segment depression was associated with only a slightly lower odds ratio (0.91) of mortality compared with ST-segment elevation or left bundle branch block.
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Affiliation(s)
- Sridevi R Pitta
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA
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James S. Coagulation, inflammation and myocardial dysfunction in unstable coronary artery disease and the influence of glycoprotein IIb/IIIa inhibition and low molecular weight heparin. Ups J Med Sci 2004; 109:71-122. [PMID: 15259448 DOI: 10.3109/2000-1967-101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patients with unstable coronary artery disease (CAD) have an increased risk of subsequent myocardial infarction and death. This study evaluated the safety and efficacy of treatment with glycoprotein IIb/IIIa inhibition in addition to aspirin, low molecular-weight heparin and its influence on coagulation and inflammation. Also, early and differentiated risk assessment utilising markers of inflammation, myocardial damage and dysfunction were evaluated. The Global Utilisation of Strategies To open Occluded arteries-IV (GUSTO-IV) trial randomised 7800 patients with unstable CAD to 24 or 48 hours infusion of abciximab or placebo in addition to routine treatment with aspirin and heparin or dalteparin. Baseline levels of creatinine, C-reactive protein (CRP), troponin T (TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were analysed. At selected sites, all patients received subcutaneous dalteparin (n=974), in stead of heparin infusion (n=6826). In a sub-population of dalteparin treated patients (n=404), serial measurements of markers of coagulation, fibrinolysis and inflammation were also performed. Addition of abciximab to dalteparin as the primary treatment of unstable CAD was not associated with any significant reduction in cardiac events but a doubled risk of bleedings. The combination of abciximab with dalteparin seemed as safe when used with heparin. Despite full dose dalteparin and aspirin there was a simultaneous activation of the inflammation, coagulation and fibrinolysis systems without any influence of the abciximab treatment. Elevated levels of CRP, TnT, and NT-proBNP and reduced creatinine clearance were independently related to short and long-term mortality. The best prediction of high and low risk was provided by a combination of NT-proBNP and creatinine clearance. Any detectable elevation of TnT and reduced creatinine clearance, but neither elevation of CRP nor NT-proBNP, were also independently associated to a raised risk of subsequent myocardial infarction.
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Affiliation(s)
- Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University Hospital, Uppsala, Sweden.
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Gula LJ, Dick A, Massel D. Diagnosing acute myocardial infarction in the setting of left bundle branch block: prevalence and observer variability from a large community study. Coron Artery Dis 2003; 14:387-93. [PMID: 12878904 DOI: 10.1097/01.mca.0000085135.16622.e8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the known benefit of thrombolysis it remains under-utilized among eligible patients with acute myocardial infarction (AMI) and left bundle branch block (LBBB). We sought to determine the test characteristics and observer reliability of well-known criteria for the diagnosis of AMI when LBBB is present on the electrocardiogram (ECG). METHODS Four hundred and fourteen ECGs with LBBB from a large cohort of AMI patients (7.4% of the total) and 85 ECGs with LBBB not in the setting of acute coronary syndromes were interpreted for the presence of the Sgarbossa criteria. RESULTS Agreement for the various Sgarbossa criteria ranged from only fair to moderate. The three-way comparison kappa values were significantly better for ST depression than for both discordant (P<0.001) and concordant (P=0.001) ST-segment elevation. Concordant ST-segment elevation [6.3%, 95% confidence interval (CI) 4.3-9.1%] and depression (3.1%, 95% CI 1.8-5.4%) were infrequently seen in the setting of AMI and rarely seen otherwise. Discordant ST-segment elevation was seen more frequently (19.0%, 95% CI 15.5-23.1%). Concordant ST elevation and ST depression in V1-V3 were highly specific, but insensitive, for the diagnosis of AMI. The presence of discordant ST elevation was neither sensitive nor specific. CONCLUSION The low prevalence, poor sensitivity and marked observer variability make the Sgarbossa criteria for AMI in the setting of LBBB less than adequate. Although use of these criteria would be an advance over contemporary practice, it would still fall short among this high-risk subset.
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Affiliation(s)
- Lorne J Gula
- Department of Medicine, University of Western Ontario, London, Canada
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20
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Rathore SS, Weinfurt KP, Gross CP, Krumholz HM. Validity of a simple ST-elevation acute myocardial infarction risk index: are randomized trial prognostic estimates generalizable to elderly patients? Circulation 2003; 107:811-6. [PMID: 12591749 DOI: 10.1161/01.cir.0000049743.45748.02] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Risk-stratification scores derived from randomized clinical trial (RCT) data should be evaluated in community-based populations. A simple risk-stratification index for patients with ST-segment elevation myocardial infarction derived from an RCT population was recently proposed, but it has not been validated in a community-based cohort. METHODS AND RESULTS We evaluated the simple risk index using data from 49 711 patients > or =65 years of age hospitalized with ST-elevation myocardial infarction. We evaluated the distribution of patients in the 5 simple risk index groups, compared observed and published 30-day mortality rates, and assessed the score's discrimination and calibration. The simple risk index provided poor discrimination (c=0.62) and calibration (goodness of fit P<0.001) for survival at 30 days. Risk score distribution was skewed, because two thirds (66.1%) of all patients were classified in the highest-risk group, whereas fewer than 11.0% were classified in the 3 lowest-risk groups. Thirty-day mortality estimates were lower than those observed in the cohort (risk group 2 to 5: 1.9% to 17.4% versus 5.3% to 27.9%). Risk index discrimination, calibration, score distribution, and mortality estimates were worse among patients who did not receive acute reperfusion therapy than among those who did. CONCLUSIONS The limited performance of the simple risk index highlights the limitations of applying prognostic models derived in RCT populations to the general population of patients 65 years and older. Prognostic scores must be validated in community-based cohorts before integration into clinical practice.
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Affiliation(s)
- Saif S Rathore
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn, USA
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Aviles JM, Whelan SE, Hernke DA, Williams BA, Kenny KE, O'Fallon WM, Kopecky SL. Intercessory prayer and cardiovascular disease progression in a coronary care unit population: a randomized controlled trial. Mayo Clin Proc 2001; 76:1192-8. [PMID: 11761499 DOI: 10.4065/76.12.1192] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the effect of intercessory prayer, a widely practiced complementary therapy, on cardiovascular disease progression after hospital discharge. PATIENTS AND METHODS In this randomized controlled trial conducted between 1997 and 1999, a total of 799 coronary care unit patients were randomized at hospital discharge to the intercessory prayer group or to the control group. Intercessory prayer, ie, prayer by 1 or more persons on behalf of another, was administered at least once a week for 26 weeks by 5 intercessors per patient. The primary end point after 26 weeks was any of the following: death, cardiac arrest, rehospitalization for cardiovascular disease, coronary revascularization, or an emergency department visit for cardiovascular disease. Patients were divided into a high-risk group based on the presence of any of 5 risk factors (age = or >70 years, diabetes mellitus, prior myocardial infarction, cerebrovascular disease, or peripheral vascular disease) or a low-risk group (absence of risk factors) for subsequent primary events. RESULTS At 26 weeks, a primary end point had occurred in 25.6% of the intercessory prayer group and 29.3% of the control group (odds ratio [OR], 0.83 [95% confidence interval (CI), 0.60-1.14]; P=.25). Among high-risk patients, 31.0% in the prayer group vs 33.3% in the control group (OR, 0.90 [95% CI, 0.60-1.34]; P=.60) experienced a primary end point. Among low-risk patients, a primary end point occurred in 17.0% in the prayer group vs 24.1% in the control group (OR, 0.65 [95% CI, 0.20-1.36]; P=.12). CONCLUSIONS As delivered in this study, intercessory prayer had no significant effect on medical outcomes after hospitalization in a coronary care unit.
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Affiliation(s)
- J M Aviles
- Mayo Physician Alliance for Clinical Trials Coordinating Center, Mayo Clinic, Rochester, Minn. 55902, USA
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