Prediction of the extent and severity of left ventricular dysfunction in anterior acute myocardial infarction by the admission electrocardiogram

Clinical outcomes of ST-elevation myocardial infarction patients who present special forms of ST-segment elevation

BACKGROUND

There are several patterns of special ST-segment elevation morphology in patients with ST-elevation myocardial infarction (STEMI), but their effect on prognosis is unclear. We, therefore, investigated the mortality of patients with these patterns by comparing them to patients with typical ST-segment morphologies.

METHODS

This observational study assessed 1277 consecutive patients with STEMI. Their initial electrocardiograms were analyzed quantitatively and divided into four categories: typical (n = 1138), Tombstone (n = 62), Triangular (n = 39), and Lambda patterns (n = 38). The primary outcome was death (all causes).

RESULTS

The Triangular and Lambda pattern patients had high proportions of cardiogenic shock (15.8%, 9.7%, 66.7%, and 47.4%, P < 0.01, for typical, Tombstone, Triangular, and Lambda, respectively) and out-of-hospital cardio-pulmonary arrests (4.8%, 6.5%, 38.5%, and 26.3%, P < 0.01). They also had higher frequencies of multivessel disease (37.2%, 30.7%, 66.7%, and 55.3%, P < 0.01) and left main trunk lesion (2.8%, 0%, 35.9%, and 13.2%, P < 0.01). During a median observation period of 717 days, the mortality rates were 18.3%, 17.7%, 71.8%, and 52.6% (P < 0.01; 7.4%, 9.7%, 53.9%, and 42.1% within 30-days, P < 0.01), respectively. The hazard ratios were 1.3 (95% CI: 0.6-3.0. P = 0.51) in Tombstone, 9.6 (95% CI: 6.0-15.3, P < 0.01) in Triangular, and 6.7 (95% CI: 4.0-11.2, P < 0.01) in Lambda patterns when referenced to typical patterns.

CONCLUSION

The mortality rate in STEMI patients with Triangular and Lambda patterns was higher than that of those with typical and Tombstone patterns.

Assessment of Selected Baseline and Post-PCI Electrocardiographic Parameters as Predictors of Left Ventricular Systolic Dysfunction after a First ST-Segment Elevation Myocardial Infarction

OBJECTIVE

To assess the performance of ten electrocardiographic (ECG) parameters regarding the prediction of left ventricular systolic dysfunction (LVSD) after a first ST-segment-elevation myocardial infarction (STEMI).

METHODS

We analyzed 249 patients (74.7% males) treated with primary percutaneous coronary intervention (PCI) included into a single-center cohort study. We sought associations between baseline and post-PCI ECG parameters and the presence of LVSD (defined as left ventricular ejection fraction [LVEF] ≤ 40% on echocardiography) 6 months after STEMI.

RESULTS

Patients presenting with LVSD (n = 52) had significantly higher values of heart rate, number of leads with ST-segment elevation and pathological Q-waves, as well as total and maximal ST-segment elevation at baseline and directly after PCI compared with patients without LVSD. They also showed a significantly higher prevalence of anterior STEMI and considerably wider QRS complex after PCI, while QRS duration measurement at baseline showed no significant difference. Additionally, patients presenting with LVSD after 6 months showed markedly more severe ischemia on admission, as assessed with the Sclarovsky-Birnbaum ischemia score, smaller reciprocal ST-segment depression at baseline and less profound ST-segment resolution post PCI. In multivariate regression analysis adjusted for demographic, clinical, biochemical and angiographic variables, anterior location of STEMI (OR 17.78; 95% CI 6.45-48.96; p < 0.001), post-PCI QRS duration (OR 1.56; 95% CI 1.22-2.00; p < 0.001) expressed per increments of 10 ms and impaired post-PCI flow in the infarct-related artery (IRA; TIMI 3 vs. <3; OR 0.14; 95% CI 0.04-0.46; p = 0.001) were identified as independent predictors of LVSD (Nagelkerke's pseudo R2 for the logistic regression model = 0.462). Similarly, in multiple regression analysis, anterior location of STEMI, wider post-PCI QRS, higher baseline number of pathological Q-waves and a higher baseline Sclarovsky-Birnbaum ischemia score, together with impaired post-PCI flow in the IRA, higher values of body mass index and glucose concentration on admission were independently associated with lower values of LVEF at 6 months (corrected R2 = 0.448; p < 0.00001).

CONCLUSIONS

According to our study, baseline and post-PCI ECG parameters are of modest value for the prediction of LVSD occurrence 6 months after a first STEMI.

Prognostic value of infarct-related-lead Tpeak-Tend/QT ratio in patients with ST-segment elevation myocardial infarction

Tpeak-Tend/QT ratio (Tp-e/QT) in patients with ST-segment elevation myocardial infarction (STEMI) is reportedly associated with major adverse cardiac events (MACEs). However, Tp-e/QT measurement methods are controversial, and few studies have clarified the effect of different Tp-e/QT measures on prognosis. Our study is the first to investigate the advantages of the Tp-e/QT measured by infarct-related-lead method in predicting MACEs during hospitalization and long-term mortality in patients with STEMI. A total of 427 STEMI patients undergoing primary percutaneous coronary intervention (PCI) were included in this study. The Tp-e/QT before PCI was measured by traditional 12-lead method and infarct-related-lead method. Outcomes were tested using comparative statistics, logistic regression, receiver operating characteristic (ROC) curve and Kaplan-Meier survival analysis. There were 62 (14.5%) patients who had MACEs in-hospital. Logistic regression showed that the Tp-e/QT in infarct-related-lead was an independent predictor (p < 0.001). The area under the ROC curve (AUC) of the Tp-e/QT in infarct-related-lead was larger than that in the Tp-e/QT in traditional 12-lead (0.889 vs 0.741), and the optimal cutoff value was 0.32. The three-year survival rate of patients in the infarct-related-lead Tp-e/QT < 0.32 group was better than Tp-e/QT ≥ 0.32 group in Kaplan-Meier survival analysis (93.9 vs 87.0%). When stratified according to infarct-related arteries, the results showed that the common odds ratio of patients in Tp-e/QT ≥ 0.32 group occurred MACEs was 1.562, P = 0.038. The infarct-related-lead Tp-e/QT performed better than the traditional 12-lead Tp-e/QT in predicting poor prognosis.

Degree of ST-segment elevation in patients with STEMI reflects the acute ischemic burden and the salvage potential

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is clinically diagnosed by significant ST-segment elevation (STE) in the electrocardiogram (ECG). The importance of the sum of significant ST-segment elevation (∑STE) before primary percutaneous coronary intervention (PPCI) - considered an indicator of the degree of ischemia - is sparse. We evaluated the association of ∑STE before PPCI with respect to area at risk, infarct size and myocardial salvage.

METHODS

A total of 503 patients with STEMI and available cardiac magnetic resonance (CMR) were included. CMR was performed at day 1 (interquartile range [IQR], 1-1) and at follow-up at day 92 (IQR, 88-96). The ECG before PPCI with the most prominent STE was used for analysis.

RESULTS

∑STE divided into quartiles were progressive linearly associated with area at risk (p < 0.001), final infarct size (p < 0.001) and extent of microvascular obstruction (p < 0.001) and inverse linearly associated with final myocardial salvage (p < 0.001). Similar results were found for linear regression analyses. However, ∑STE was not associated with final myocardial salvage in patients with pre-PCI TIMI (thrombolysis in myocardial infarction) flow 0/1 (p = 0.24) in contrast to patients with pre-PCI TIMI flow 2/3 (p ≤ 0.001).

CONCLUSION

In patients with STEMI presenting within 12 h of symptom onset, the degree of STE in the ECG before PPCI is a marker of the extent of myocardium at risk that in turn affects the infarct size in patients with pre-PCI TIMI flow 0/1, whereas the degree of STE in patients with pre-PCI TIMI flow 2/3 is a marker of the extent of the myocardium at risk as well as myocardial salvage - both affecting the myocardial damage.

[The myocardial infarction size measuring using modern methods]

An accurate quantitative assessment of myocardium necrosis area and the viable zone (stunned and hibernating) in patients with myocardial infarction is crucial for the preoperative patient selection and predicting the cardiac surgery effectiveness. Currently, researchers and clinicians are most interested in the problem of determining the viable myocardium zone. However, only the necrosis zone area directly correlates with the patients prognosis and determines the heart pathological remodeling processes. In the distant period, the data obtained can be used to predict the post-infarction period course or for analysis the relationship of the necrosis zone with arrhythmogenesis, and a number of other indicators. Thus, the necrosis zone and the viable myocardium zone are two parameters that need to be monitored in dynamics in all patients after myocardial infarction. The most accurate and reproducible method for determining the necrosis area is contrast magnetic resonance imaging of the heart, however, this technique is still inaccessible in most hospitals. In this regard, it remains relevant to estimate the necrotic myocardium area by ubiquitous non-invasive methods such as electrocardiography and echocardiography.

Long-term clinical outcomes and prognoses of ST-segment elevation myocardial infarction patients who present with tombstoning ST-segment elevation

INTRODUCTION

Although patients with tombstoning ST-segment elevation (Tomb-ST) usually have poor in-hospital and short-term survival rates, no studies have examined the long-term clinical outcomes and prognosis of ST-segment elevation myocardial infarction (STEMI) patients who have this electrocardiographic pattern. Therefore, we aimed to evaluate the long-term clinical events and mortality of such patients in this study.

METHODS

In this retrospective analysis, we included 335 consecutive patients who were diagnosed with acute anterior wall-STEMI from January 2015 to June 2018. The criteria for the definition of Tomb-ST were accepted as provided in a previous study. Endpoints of the study were the incidence of significant in-hospital and long-term major adverse clinical events (MACE) including the composite of total death, myocardial reinfarction, and hospitalizations due to heart failure.

RESULTS

Patients who presented with Tomb-ST had significantly higher in-hospital and long-term mortality (10% [n = 12 patients] vs. 2.3% [n = 5 patients]; p < 0.001and 6.5% [n = 7 patients] vs. 1.9% [n = 4 patients]; p = .04, respectively). In a multivariate traditional and penalized Cox proportional hazard regression analysis, this type of electrocardiographic pattern was found as independent predictor of long-term MACE (Odds ratio [OR]: 3.82, 95% confidence interval [CI]: 1.91-7.63, p < .001 and OR: 4.36, 95% CI: 1.97-9.66, p < .001, respectively).

CONCLUSION

In the present study, we observed that the presence of Tomb-ST might be an independent predictor of long-term MACE in STEMI patients. To the best of our knowledge, this is the first study to evaluate the long-term MACE of such patients.

Electrocardiogram to predict reperfusion success in late presenters with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

Clinical decision-making in patients with ST-segment elevation myocardial infarction (STEMI) presenting beyond 12 h of symptom onset (late presenters) is challenging. However, the electrocardiogram (ECG) may provide helpful information. We investigated the association between three ECG-scores and myocardial salvage and infarct size in late presenters treated with primary percutaneous coronary intervention (primary PCI).

METHODS

Sixty-six patients with STEMI and ongoing symptoms presenting 12-72 h after symptom onset were included. Cardiac magnetic resonance was performed at day 1 (interquartile range [IQR], 1-1) and at follow-up at day 93 (IQR, 90-98). The pre-PCI ECG was analyzed for the presence of pathological QW (early QW) as well as Anderson-Wilkins acuteness score (AW-score), the classic Sclarovsky-Birnbaum Ischemia Grading System (classic SB-IG-score) and a modified SB-IG-score including any T-wave morphologies.

RESULTS

Early QW was associated with a larger myocardium at risk (39 ± 12 versus 33 ± 12; p = 0.030) and final infarct size (20 ± 11 versus 14 ± 9; p = 0.021) as well as a numerical lower final myocardial salvage (0.52 ± 0.19 versus 0.61 ± 0.23; p = 0.09). The association with final infarct size disappeared after adjusting for myocardium at risk. An AW-score < 3 showed a trend towards a larger final infarct size (18 ± 11 versus 11 ± 11; p = 0.08) and was not associated with salvage index (0.55 ± 0.20 versus 0.65 ± 0.30; p = 0.23). The classic and modified SB-IG-score were not associated with final infarct size (modified SB-IG-score, 17 ± 10 versus 21 ± 13; p = 0.28) or final myocardial salvage (0.53 ± 0.20 versus 0.53 ± 0.26; p = 0.96).

CONCLUSION

Of three well-established ECG-scores only early QW and AW-score < 3 showed association with myocardium at risk and infarct size to some extent, but the association with myocardial salvage was weak. Hence, neither of the three investigated ECG-scores are sufficient to guide clinical decision-making in patients with STEMI and ongoing symptoms presenting beyond 12 h of symptom onset.

QRS complex distortion (Grade 3 ischaemia) as a predictor of myocardial damage assessed by cardiac magnetic resonance imaging and clinical prognosis in patients with ST-elevation myocardial infarction

AIMS

Distortion of the terminal portion of the QRS complex (so-called Grade 3 ischaemia, G3I) has been associated with adverse outcomes in ST-elevation myocardial infarction (STEMI) populations. However, the correlation of G3I with infarct size and microvascular injury as defined by cardiac magnetic resonance (CMR) is not well defined. Aim of this study was to assess the relation of G3I with myocardial damage as assessed by CMR and clinical outcomes in STEMI patients.

METHODS AND RESULTS

We analysed the ECGs of 572 consecutive STEMI patients regarding the presence or absence of G3I. CMR was performed within 1 week after infarction for comprehensive assessment of myocardial damage using a standardized protocol. The primary clinical endpoint was major adverse cardiac events (MACE) within 12 months after infarction. G3I was present in 186 (32%) patients. The presence of G3I was associated with larger infarct size (P = 0.01), the presence of late microvascular obstruction (P = 0.05), the presence of intramyocardial haemorrhage (P = 0.04), and impaired myocardial salvage (P = 0.01). G3I was associated with a higher incidence of MACE (P = 0.01) and was identified as an independent predictor of MACE in Cox regression analysis (HR 2.19; 95% CI 1.10 to 4.38, P = 0.03).

CONCLUSION

This largest study to date correlating G3I on the admission ECG with CMR markers of myocardial damage demonstrates that G3I is significantly associated with infarct size, impaired myocardial salvage, and reperfusion injury in a reperfused STEMI population. Moreover, G3I was independently associated with MACE. CLINICALTRIALS.GOV: NCT00712101.

Utility of CMR Markers of Myocardial Injury in Predicting LV Functional Recovery: Results from PROTECTION AMI CMR Sub-study

BACKGROUND

Adverse left ventricular (LV) remodelling following acute ST-segment elevation myocardial infarction (STEMI) has prognostic importance. We aimed to predict 90-day left ventricular (LV) function following acute STEMI using variables from clinical presentation, biomarkers, and cardiovascular magnetic resonance imaging (CMR).

METHODS

Consecutive patients undergoing primary percutaneous coronary intervention for anterior STEMI as part of the Selective Inhibition of Delta-protein Kinase C for the Reduction of Infarct Size in Acute Myocardial Infarction (PROTECTION-AMI) trial were enrolled into the CMR sub-study at selected sites. CMR was performed at baseline (days 3 to 5) and 90 days and used to evaluate infarct size, myocardial salvage index, infarct heterogeneity, microvascular obstruction and global LV function. Biochemical markers including creatinine kinase area under the curve (CK AUC), peak CK, peak CK-myocardial band (CK-MB) and AUC, and troponin I were collected at specific time-points.

RESULTS

Ninety-six patients were enrolled in the CMR sub study and 85 completed the 90-day follow-up, across 24 centres worldwide. LV ejection fraction (EF) was 56% (46-63%) at baseline and 60% (49-67%) at 90 days (p<0.001). Infarct size had moderate inverse correlation with 90-day EF (Spearman's rho=-0.7, p < 0.001) and had the strongest correlation when compared to myocardial salvage index (Spearman's rho=0.5, p=0.001), infarct heterogeneity (Spearman's rho=-0.4, p=0.02 or microvascular obstruction (Spearman's rho=-0.4, p<0.001). All biochemical markers had similar moderate relationship to LVEF at 90 days (Spearman's rho -0.6 to -0.8, p=0.001). In a multivariable model, only baseline LVEF, CMR infarct size and infarct heterogeneity independently predicted 90-day LVEF.

CONCLUSION

This study reports findings of a combined CMR protocol (including myocardial oedema imaging) in a multi-centre, multi-vendor setting. We found infarct size, infarct heterogeneity and myocardial salvage index correlated favourably with 90-day LVEF, however only the former two were independently predictive.

The relationship between grade of ischemia, success of reperfusion, and type of thrombolytic regimen

BACKGROUND

This study was aimed to determine whether the grade of ischemia can predict the success of reperfusion in patients treated with thrombolytic therapy (TT) for ST elevation myocardial infarction (STEMI).

MATERIAL AND METHODS

We enrolled 229 consecutive patients with diagnosis of STEMI and receiving TT. Patients were divided into 2 groups--grade 2 ischemia (GI2) and grade 3 ischemia (GI3)--according to initial electrocardiogram (ECG). As TT, fibrin-specific (tissue plasminogen activator (t-PA)) or non-fibrin-specific (streptokinase (SKZ)) regimens were used. Successful reperfusion was defined as >50% resolution of the maximal ST segment on 90-min ECG. We tried to evaluate whether the grade of ischemia could predict the success of reperfusion and if there were any differences in terms of successful reperfusion between different thrombolytic regimens.

RESULTS

The successful reperfusion rate was significantly higher in GI2 than GI3 (82.4% vs. 64.4% respectively, p=0.002). The success rate was lowest at anterior GI3 (55.8%). Although there was no significant difference between thrombolytic regimens in all groups (p=0.77), t-Pa was superior to SKZ in anterior GI3 (63,6% vs. 30%, p=0.061). In addition, in multivariate analysis, GI and infarct localization were found as independent predictors for successful reperfusion with TT (p=0.006 and p=0.042, respectively).

CONCLUSIONS

In the current study, we found that GI2 is an independent predictor for successful reperfusion in STEMI treated with TT. Fibrin specific regime should be preferred in anterior GI3.

The Predictive Value of Fragmented QRS and QRS Distortion for High-Risk Patients with STEMI and for the Reperfusion Success

BACKGROUND

QRS fragmentation (fQRS) and QRS distortion were separately shown to be related to increased cardiovascular mortality and morbidity. To our knowledge, no study so far evaluated both parameters together in ST segment elevation myocardial infarction (STEMI). The main goal of our study is to find out if fQRS and QRS distortion can help us to determine high-risk STEMI patients, and the success of reperfusion.

METHODS

Two hundred forty-eight eligible patients with acute STEMI that underwent coronary angiography consecutively between January 1, 2009, and July 1, 2011, were enrolled in this study. Twelve-lead electrocardiography (ECG) of the patients taken in the first 48 hours were analyzed. Patients with fQRS formed group 1, without fQRS formed group 2; with QRS distortion formed group 3, and without QRS distortion formed group 4.

RESULTS

Group 1 have lower left ventricular ejection fraction (LVEF; P < 0.001), higher maximum troponin levels (P < 0.001), lower ST segment resolution (P < 0.001), more frequent proximal lesions (P < 0.001) when compared to group 2. Similar findings were observed in group 3 in comparison to group 4. Group 1 had also more frequent three vessels disease (P < 0.001), and higher rates of failed thrombolysis (P < 0.001). In-hospital mortality was found to be higher in group 1 and group 3.

CONCLUSION

fQRS and QRS distortion may be useful for identifying patients at higher cardiac risk. fQRS can foresee thrombolytic therapy failure and three vessels disease whereas QRS distortion does not possess such quality. These findings may guide the physician deciding initial treatment modality in STEMI.

Twenty years of ECG grading of the severity of ischemia

Shortly following an occlusion of an epicardial coronary artery, changes in the surface electrocardiogram (ECG) can be detected. Initially, T waves in leads with their positive poles facing the ischemic zone become positive, tall and symmetrical. Later, ST segment elevation (STE) becomes apparent. If ischemia continues, changes in the terminal portion of the QRS may also be detected. The changes in the terminal portion of the QRS are believed to be caused by prolongation of the electrical conduction in the ischemic zone and reflect severe ischemia due to lack of protection by preconditioning or collateral circulation. Several groups have shown that patients with the QRS changes of grade 3 ischemia have higher mortality, higher incidence of reinfarction and heart failure than patients presenting with only the T and ST changes of grade 2 ischemia, despite equal success in recanalizing the epicardial coronary artery by either thrombolytic therapy or primary percutaneous coronary intervention. Grade 3 ischemia is associated with more rapid progression of necrosis and larger final infarct size. Further studies are needed to better understand the underlying mechanisms that determine the severity of ischemia and how we should use this method based on the standard 12 lead ECG to implement clinical therapeutic decisions.

Prognostic significance of the distortion of terminal portion of QRS complex on admission electrocardiogram in ST segment elevation myocardial infarction

BACKGROUND

ECG on admission has been used in predicting prognosis and risk stratification in ST segment elevation acute myocardial infarction (STEMI).

OBJECTIVE

To analyze the admission ECG in STEMI based on abnormality observed in terminal portion of QRS and its correlation to hospital mortality.

METHOD

160 consecutive patients of STEMI were classified into subjects without (Group I) and with distortion of terminal QRS (Group II), Pattern A--Emergence of J point at ≥50% of the R wave amplitude in leads with qR configuration or Pattern B--Absence of the S waves, in leads with Rs configuration in two consecutive leads.

RESULTS

Out of 160 patients of STEMI, 69 (43.1%) had distortion of QRS. There were 13 deaths (8.1%). Hospital mortality was found to be significantly more in subjects with distortion than those without (15.9% V/S 2.1%, p < 0.001). Patients with QRS distortion tended to have larger infarction as assessed by Killip class on admission (p < 0.05), anterior location of MI (p < 0.01) and presence of significant Q waves in leads with ST segment elevation (p < 0.0001). With multiple logistic regression analysis using hospital mortality as a dependent variable and all studied risk factors as independent variables, QRS distortion on admission ECG was the only variable found to be statistically significant (Adjusted OR = 7.161, p < 0.05).

CONCLUSION

ECG on admission is a simple, cheap, universally available investigation that can predict the short term prognosis in STEMI and would help in deciding which patients should go for other myocardial revascularization procedures.

ST-segment deviation in lead aVR on admission is not associated with left ventricular function at predischarge in first anterior wall ST-segment elevation acute myocardial infarction

Previous studies have shown that the analysis of ST-segment deviation in lead aVR on admission provides useful information on angiographic coronary anatomy and risk stratification in acute coronary syndromes. However, the association between ST-segment deviation in lead aVR on admission and left ventricular (LV) function has not been fully investigated in anterior wall acute ST-segment elevation myocardial infarction. In this study, 237 patients with first anterior wall acute ST-segment elevation myocardial infarction were examined. The patients were divided into the following 3 groups according to ST-segment deviation in lead aVR on admission: 85 with ST-segment elevation ≥0.5 mm (group A), 106 without ST-segment deviation (group B), and 46 with ST-segment depression ≥0.5 mm (group C). LV ejection fractions at predischarge were compared among the 3 groups. Among the 3 groups, there were significant differences in the prevalences of proximal left anterior descending coronary artery (LAD) occlusion (group A 75.3%, group B 56.6%, group C 45.7%, p = 0.002), long LAD (group A 27.1%, group B 31.1%, group C 56.5%, p = 0.002), and good collaterals to the LAD (group A 40.0%, group B 25.4%, group C 17.4%, p = 0.01). LV ejection fractions at predischarge did not differ among the 3 groups (group A 56.4 ± 12.5%, group B 56.9 ± 12.7%, group C 53.3 ± 12.2%, p = 0.26). On a multiple regression analysis, establishment of Thrombolysis In Myocardial Infarction grade 3 flow, proximal LAD occlusion, and long LAD were associated with the LV ejection fraction at predischarge. In conclusion, ST-segment deviation in lead aVR on admission is not associated with LV function at predischarge in first anterior wall acute ST-segment elevation myocardial infarction.

Evaluation of trimetazidine in angina pectoris by echocardiography and radionuclide angiography: a meta-analysis of randomized, controlled trials

BACKGROUND

The objective of this meta-analysis was to evaluate the efficacy of the metabolic agent trimetazidine (TMZ) as monotherapy in the treatment of stable angina pectoris, from echocardiography and radionuclide angiography data.

HYPOTHESIS

Treatment with TMZ proved to be as effective as other first-line antianginal agents for coronary patients, and it provided additional efficacy in combination with hemodynamic agents.

METHODS

A search of the literature published between 1965 and 2008 was performed on the MEDLINE and EMBASE databases. Only randomized, controlled trials were included in this meta-analysis. Patients had to be treated for at least 2 weeks with data on the following 4 parameters at baseline and at the end of the treatment period: left ventricular ejection fraction (LVEF), LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and wall motion score index (WMSI). The quality of the trials was assessed by the Jadad score.

RESULTS

Eleven clinical studies meeting our criteria were analyzed. Results showed that TMZ significantly improved LVEF, with a mean increase of 6.88% (95% confidence interval [CI]: 5.50-8.25), and significantly reduced LVESV by 11.58 mL (95% CI: 5.79-17.37) and WMSI by 0.23 (95% CI: 0.07-0.38). Changes in LVEDV were variable. In both the long term and the short term, TMZ can improve LV function. The efficacy was unchanged in patients with diabetes mellitus.

CONCLUSIONS

This meta-analysis confirmed the efficacy of TMZ monotherapy in improving LV function compared with placebo.

Tombstoning ST-Elevation Myocardial Infarction

Tombstoning ST elevation myocardial infarction can be described as a STEMI characterized by tombstoning ST-segment elevation. This myocardial infarction is associated with extensive myocardial damage, reduced left ventricle function, serious hospital complications and poor prognosis. Tombstoning ECG pattern is a notion beyond morphological difference and is associated with more serious clinical results.Despite the presence of a few reports on tombstoning ST elevation, there is no report which reviews STEMI demonstrating this electrocardiographic pattern.

Utilization of ST-segment deviation sum and change scores to identify acute myocardial infarction

OBJECTIVE

No information is currently available regarding the optimal cutoff values of the baseline ST-segment deviation sum (STDsum(baseline)) and 60-minute ST-segment deviation change (STDchange(60 min)) for predicting acute myocardial infarction (AMI).

METHODS

A retrospective study was performed in 783 admitted patients with chest pain who had suspected acute coronary syndrome and absence of left ventricular hypertrophy or bundle branch block on the initial electrocardiogram (ECG). The STDsum(baseline) was defined as the sum in millimeters (1 mm = 0.1 mV) of the absolute value of ST-segment deviations in all 12 leads at the initiation of continuous 12-lead ECG monitoring session. The STDchange(60 min) was defined as the absolute value of the difference between the baseline and 60-minute STDsum. Three cutoff values are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI was greater than or equal to 5, 10, and 20, respectively.

RESULTS

Acute myocardial infarction occurred in 162 (20.7%) patients. The smallest cutoff value of the STDsum(baseline) for AMI with a +LR equal to or greater than 5, 10, and 20 was 9.6, 12.4, and 14.1 mm, respectively. In the subset of 699 patients without ST-segment elevation AMI on initial ECG, the smallest cutoff value of the STDchange(60 min) for AMI with a +LR equal to or greater than 5, 10, and 20 was 2.4, 3.5, and 7.9 mm, respectively.

CONCLUSIONS

Clinical studies need to be performed to determine if STDsum and STDchange, in conjunction with physician pretest probability of AMI, can be used to select patients who may benefit from emergent reperfusion therapy and other aggressive medical management strategies.

Predicting late myocardial recovery and outcomes in the early hours of ST-segment elevation myocardial infarction traditional measures compared with microvascular obstruction, salvaged myocardium, and necrosis characteristics by cardiovascular magnetic resonance

OBJECTIVES

The aim of this study was to determine whether a very early imaging strategy improves the prediction of late systolic dysfunction and poor outcomes in ST-segment elevation myocardial infarction (STEMI) compared with traditional predictors.

BACKGROUND

Earlier prediction of poor outcomes after STEMI is desirable, because it will allow tailored therapy at the earliest possible time, when benefits might be greatest.

METHODS

One hundred and three patients with acute STEMI were studied by contrast-enhanced cardiovascular magnetic resonance within 12 h of primary angioplasty and at 6 months and followed >2 years. The primary end point was left ventricular (LV) dysfunction, whereas poor outcomes were a key secondary end point.

RESULTS

Traditional risk factors were only modest predictors of late LV dysfunction. Late gadolinium enhancement (LGE) volume maintained a stronger association to LV ejection fraction change than infarct transmurality, microvascular obstruction, or myocardial salvage during STEMI (p = 0.02). Multivariable logistic regression identified LGE volume during STEMI as the best predictor of late LV dysfunction (odds ratio: 1.36, p = 0.03). An LGE >or=23% of LV during STEMI accurately predicted late LV dysfunction (sensitivity 89%, specificity 74%). The LGE volume provided important incremental benefit for predicting late dysfunction (area under the curve = 0.92, p <or= 0.03 vs. traditional risk factors). Twenty-three patients developed poor outcomes (1 death, 2 myocardial infarctions, 5 malignant arrhythmias, 4 severe LV dysfunction <35%, 11 hospital stays for heart failure) over 2.6 +/- 0.9 years; LGE volume remained a strong independent predictor of poor outcomes, whereas LGE >or=23% carried a hazard ratio of 6.1 for adverse events (p < 0.0001).

CONCLUSIONS

During the hyperacute phase of STEMI, LGE volume provides the strongest association and incremental predictive value for late systolic dysfunction and discerns poor late outcomes.

Grade 3 ischemia on the admission electrocardiogram predicts failure of ST resolution and of adequate flow restoration after primary percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Failure of ST-segment resolution (STR) after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction is associated with adverse outcome but currently cannot be predicted on admission. Our aim was to determine whether failure of STR can be predicted from clinical and electrocardiographic data available on admission and whether the adverse outcome associated with grade 3 ischemia (distortion of the terminal portion of the QRS complex) is mediated through impaired tissue reperfusion.

METHODS

We prospectively studied 100 consecutive patients who underwent PPCI for a first ST-elevation myocardial infarction. Multiple variables available on admission were analyzed as predictors of STR. Electrocardiograms and angiograms were analyzed by blinded investigators.

RESULTS

Grade 2 ischemia was found in 71 patients (71%) and 29 (29%) had grade 3 ischemia. Complete STR was observed in 42 (59%) of 71 patients with grade 2 ischemia as compared to 8 (28%) of 29 patients with grade 3 ischemia (P = .004). In a multivariate model, grade 3 ischemia was the sole predictor of failure of STR (odds ratio [OR] 0.26, 95% CI 0.1-0.72) and the strongest predictor of failure to achieve TIMI grade 3 flow (OR 0.07, CI 0.02-0.3) and TIMI myocardial perfusion grade 3 (OR 0.09, CI 0.02-0.4) after the procedure.

CONCLUSIONS

Grade 3 ischemia is a strong independent predictor available on admission of failure to achieve myocardial reperfusion after PPCI, as assessed both electrocardiographically and angiographically. This association may underlie the larger infarcts associated with grade 3 ischemia and may allow the identification upon admission of patients who require more aggressive management to improve reperfusion.

Grade 3 ischemia on admission electrocardiogram and chest pain duration predict failure of ST-segment resolution after primary percutaneous coronary intervention for acute myocardial infarction

OBJECTIVES

ST resolution (STR) is a surrogate marker of myocardial tissue reperfusion and a predictor of outcome after primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI). Terminal QRS distortion (grade 3 ischemia) has been shown to predict failure of STR after thrombolysis for STEMI, but the ability of grade 3 ischemia to predict STR with pPCI is unclear.

METHODS

We retrospectively analyzed 155 patients who underwent pPCI and compared grade 2 ischemia (ST elevation without terminal QRS distortion; n = 89) to grade 3 ischemia (n = 66) on admission for baseline characteristics, in-hospital course, and STR immediately after pPCI and at 18 to 24 hours.

RESULTS

Patients with grade 3 ischemia were older (60 +/- 12 vs 56 +/- 11 years; P = .018), had more anterior STEMI (42% vs 17%; P = .0004), and were less often smokers (41% vs 90%; P = .004). The grade 3 ischemic group had significantly less complete STR (35% vs 75% [P < .00001] immediately after pPCI and 33% vs 79% [P < .00001] 18-24 hours after pPCI), a longer hospital stay (6.4 +/- 4.1 vs 4.9 +/- 1.9 days; P = .008), and higher peak CKMB (292 +/- 231 vs 195 +/- 176 ng/mL; P = .0005). Duration of symptoms before pPCI (odds ratio [OR], 0.838; 95% confidence interval [CI], 0.724-0.969; P = .017) and grade 3 ischemia (OR, 0.181; 95% CI, 0.068-0.480; P < .001) were negative predictors of complete STR, whereas nonanterior STEMI (OR, 5.95; 95% CI, 2.154-16.436; P < .001) and initial sum of ST elevation (OR, 3.132; 95% CI, 1.140-8.605; P = .027) were positive predictors.

CONCLUSION

Grade 3 ischemia on presentation of STEMI and duration of chest pain are strong independent predictors of failure to achieve complete STR after pPCI.

Electrocardiographic Diagnosis of ST-elevation Myocardial Infarction

The ECG is an essential part of the initial evaluation of patients who have chest pain, especially in the immediate decision-making process in patients who have ST-elevation myocardial infarction. This article reviews and summarizes the current information that can be obtained from the admission ECG in patients who have ST-elevation acute myocardial infarction, with an emphasis on: (1) prediction of final infarct size, (2) estimation of prognosis, and (3) the correlations between various ECG patterns and the localization of the infarct and the underlying coronary anatomy.

Influences of electrocardiographic ischaemia grades and symptom duration on outcomes in patients with acute myocardial infarction treated with thrombolysis versus primary percutaneous coronary intervention: results from the DANAMI-2 trial

OBJECTIVE

To determine whether ischaemia grade (GI) on the presenting ECG and duration of symptoms can identify subgroups of patients who would derive more benefit than the general population of patients with ST segment elevation acute myocardium infarction (STEMI) from primary percutaneous coronary intervention (pPCI) over thrombolytic treatment (TT) in reducing mortality or reinfarction.

METHODS

1319 DANAMI-2 (Danish trial in Acute Myocardial Infarction-2) patients were classified as having grade 2 ischaemia (GI2; ST segment elevation without terminal QRS distortion) or grade 3 ischaemia (GI3; ST segment elevation with terminal QRS distortion in > or = 2 adjacent leads), and were divided into early and late groups split by the median time (3 h) from symptom onset to treatment. Outcomes were 30-day mortality and reinfarction.

RESULTS

Mortality was significantly higher for GI3 than for GI2 (9.7% v 4.8%, p < 0.001) and doubled for patients presenting late (GI2: 6.0% v 3.3%, p = 0.01; GI3: 12.5% v 4.7%, p = 0.05). Overall mortality did not differ significantly between pPCI and TT; however, a 5.5% absolute mortality reduction was seen in GI3 treated early with pPCI (1.4% v 6.9%, p = 0.10). Reinfarction rate was particularly high among GI3 patients presenting late and treated with TT (12.2%). pPCI in such patients significantly reduced the rate of reinfarction (0%, p < 0.001). Logistic regression analysis showed that age (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.06 to 1.12, p < 0.001), prior angina (OR 2.56, 95% CI 1.44 to 4.54, p = 0.001), heart rate (OR 1.03, 95% CI 1.01 to 1.04, p = 0.001) and GI3 (OR 1.91, 95% CI 1.06 to 3.44, p = 0.031) were independently associated with mortality, whereas the sum of ST segment elevation was not.

CONCLUSIONS

GI3 is an independent predictor of mortality among patients with STEMI. Mortality increased significantly with symptom duration in both GI2 and GI3. pPCI may be especially beneficial for patients with GI3 presenting early, whereas patients with GI3 presenting late and treated with TT are at particular risk of reinfarction.

Effects of trimetazidine on myocardial perfusion and the contractile response of chronically dysfunctional myocardium in ischemic cardiomyopathy: a 24-month study

OBJECTIVE

The aim was to assess the long-term effect of trimetazidine on myocardial perfusion, using gated single photon emission computerized tomography (SPECT).

METHODS

200 patients (aged 54.7 +/- 12 years) with ischemic left ventricular dysfunction (LVD) and multivessel coronary artery disease were randomized to receive trimetazidine 20mg three times daily or a placebo for 24 months. At baseline and after 24 months of treatment, all patients underwent a symptom-limited cardiopulmonary exercise test concluded by the injection of (99m)Tc-MIBI (technetium-99m methoxy-isobutyl-isonitrile). Imaging of post-stress gated SPECT and resting gated SPECT were performed. Standard antianginal therapy was interrupted for 48 hours (nitrates for 6 hours) before the exercise tests and resumed immediately after testing.

RESULTS

On initial evaluation, summed stress and rest scores (SSS and SRS, respectively), systolic wall thickness (SWT), and wall motion score index (WMI), heart rate, SBP, and rate pressure product were similar at rest and peak exercise in both groups. After 24 months, 91% of patients in the trimetazidine group versus 22% in the placebo group showed a significant decrease of the frequency of anginal episodes per week (3.9 vs 5.7, p < 0.01). Weekly nitroglycerin (glyceryl trinitrate) tablet consumption was significantly lower with trimetazidine than with placebo at endpoint (2.3 +/- 0.8 vs 6.1 +/- 1.6, p < 0.01). This was supported by perfusion SPECT data. Compared with baseline values, SSS and SRS were significantly reduced with trimetazidine (from 19.8 +/- 7.7 to 11.2 +/- 6.1, p < 0.00001 and from 12.4 +/- 8.7 to 5.8 +/- 3.3, p < 0.00001, respectively). There was a nonsignificant decrease from baseline values in both SRS and SSS with placebo group (from 11.9 +/- 8.3 to 11.2 +/- 7.4 and 18.1 +/- 6.3 to 17.9 +/- 9.2, respectively). Duration of peak exercise increased significantly from baseline values with trimetazidine (from 4.6 to 5.8 minutes, p < 0.01) but not with placebo (from 5.4 to 5.8 minutes). Accordingly, mean maximum work at peak exercise improved by 1.2 metabolic equivalents with trimetazidine. This was proved by gated SPECT with an increase in SWT score of 89.5% (p < 0.00001) and in ejection fraction of 23% with trimetazidine (p < 0.001) without significant changes in hemodynamic parameters.

CONCLUSION

Trimetazidine improves ischemic attacks in patients with ischemic cardiomyopathy, clinically and objectively as seen in gated SPECT myocardial perfusion. The improvement in myocardial function with trimetazidine was not accompanied by hemodynamic changes.

Grade 3 ischemia on the admission electrocardiogram predicts rapid progression of necrosis over time and less myocardial salvage by primary angioplasty

BACKGROUND

Among patients with ST-elevation acute myocardial infarction, those with terminal QRS distortion (grade 3 ischemia) have higher mortality and larger infarct size (IS) than patients without QRS distortion (grade 2 ischemia).

METHODS

We assessed the relation of baseline electrocardiographic ischemia grades to area at risk (AR) and myocardial salvage [100 (AR-IS)/AR] in 79 patients who underwent primary angioplasty for first ST-elevation acute myocardial infarction and had technetium Tc 99m sestamibi single-photon emission computed tomography before angioplasty (AR) and at predischarge (IS). Patients were classified as having grade 2 ischemia (ST elevation without terminal QRS distortion in any of the leads, n = 48), grade 2.5 ischemia (ST elevation with terminal QRS distortion in 1 lead, n = 16), or grade 3 ischemia (ST elevation with terminal QRS distortion in >2 adjacent leads, n = 15).

RESULTS

Time to treatment was comparable among groups. AR was comparable among groups (38% +/- 20%, 33% +/- 23%, and 34% +/- 23%, respectively; P = .70). There were no differences among groups in residual myocardial perfusion (severity index 0.28 +/- 0.12, 0.29 +/- 0.16, and 0.30 +/- 0.15 in grades 2, 2.5, and 3 ischemia, respectively; P = .97). In contrast, there was a trend toward lower myocardial salvage (45% +/- 32%) in the grade 3 group than in the grade 2 (65% +/- 33%) and grade 2.5 (65% +/- 40%) groups ( P = .16). Salvage was dependent on time only in the grade 3 group. Spearman rank correlation coefficients between time to treatment and percentage salvage were 0.003 ( P = .99), -0.24 ( P = .38), and -0.63 ( P = .022) for grades 2, 2.5, and 3, respectively.

CONCLUSIONS

Patients with grade 3 ischemia have rapid progression of necrosis over time and less myocardial salvage. This admission pattern is a predictor of myocardial salvage by primary angioplasty.

Refinement and interobserver agreement for the electrocardiographic Sclarovsky-Birnbaum Ischemia Grading System

BACKGROUND

Electrocardiogram-derived grades of ischemia at the time of patient presentation with acute myocardial infarction have proved useful in predicting the salvageability by reperfusion therapy, final infarct size, severity of left ventricular dysfunction, and short- and long-term prognosis.

SUBJECTS AND METHODS

The Sclarovsky-Birnbaum Ischemia Grading System based on the relation between the acute appearances of the T wave, the ST segment, and the QRS complex was considered as a means of enhanced ECG analysis in this group of patients. The evaluation of a training population (n = 46) resulted in refinement of the published description of the Sclarovsky-Birnbaum Ischemia Grading System, and a test population (n = 50) was utilized for investigating the interobserver agreement among 5 observers in determining the grade of ischemia.

RESULTS

The agreement among the observers applying the "refined" Sclarovsky-Birnbaum Ischemia Grading System was 0.89. Complete agreement was found for the ECGs of 80% of the patients, and the most common reason for disagreement was the application of the terminal T-negativity criterion.

CONCLUSIONS

The refined Sclarovsky-Birnbaum Ischemia Grading System can be performed manually with low interobserver variability. It has potential for support of the acute myocardial infarction triage decision as an electrocardiographic method for evaluating the level of ischemic protection at the time of either pre-hospital or emergency-department presentation.

Diagnostic value of routine clinical parameters in acute myocardial infarction: a comparison to delayed contrast enhanced magnetic resonance imaging. Delayed enhancement and routine clinical parameters after myocardial infarction

AIMS

Contrast enhanced magnetic resonance imaging (ceMRI) has been shown to reliably identify irreversible myocardial injury. The aim of this study was to compare the findings on ceMRI with routine clinical markers of myocardial injury in patients with acute myocardial infarction (MI).

METHODS AND RESULTS

Twenty-four patients with acute MI were investigated at 1.5 T. The global myocardial function was analysed with a standard cine MR protocol and a stack of short axis slices encompassing the entire left ventricle. Corresponding short axis slices were acquired for delayed ceMRI 15-20 min after the administration of 0.2 mmol gadolinium-DTPA/kg body weight. Mass of hyperenhancement and peak creatine kinase release (peak CK) was determined for each patient. The presenting 12-lead ECG was analysed for ST-elevation on admission and later development of Q-waves. Mass of hyperenhancement correlated moderately well to peak CK (r = 0.65, p < 0.01) and endsystolic volume index (r = 0.55, p < 0.01). Mass of hyperenhancement was inversely correlated to ejection fraction (r = -0.50, p = 0.02). Neither the presence of ST elevation on the admission ECG nor the later development of Q-waves did relate to the transmural extent of hyperenhancement and to the mass of hyperenhancement.

CONCLUSION

Mass of hyperenhancement significantly correlates to global myocardial function and to peak CK. However, there is no relationship between the findings in ceMRI and 12-lead ECG abnormalities on admission suggesting an advantage of ceMRI in defining transmural extent and depicting small areas of necrosis.

Correlation between clinical findings and the "tombstoning" electrocardiographic pattern in patients with anterior wall acute myocardial infarction

The tombstoning electrocardiographic pattern of a particular kind of ST-segment change, as observed in some patients during the early stages of acute myocardial infarction, is well known to be of prognostic value. However, little is understood of the causes and the relations of these changes. This study of 106 patients showed that in patients with tombstoning electrocardiographic patterns, infarction size is larger; left ventricular ejection fraction and preinfact angina are lower, and in-hospital complications are higher.

The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis

The electrocardiogram is considered an essential part of the diagnosis and initial evaluation of patients with chest pain. This review summarises the information that can be obtained from the admission electrocardiogram in patients with ST elevation acute myocardial infarction, with emphasis on: (1) prediction of infarct size, (2) estimation of prognosis, and (3) the correlations between various electrocardiographic patterns and the localisation of the infarct and the underlying coronary anatomy.

Comparison of primary coronary angioplasty versus thrombolysis in patients with ST-segment elevation acute myocardial infarction and grade II and grade III myocardial ischemia on the enrollment electrocardiogram

We investigated the impact of primary angioplasty compared with thrombolysis in 894 patients with ST elevation acute myocardial infarction and electrocardiographic grades II and III ischemia on enrollment. Patients were divided into 2 groups based on the enrollment electrocardiogram-grade III: (1) absence of an S wave below the isoelectric baseline in leads that usually have a terminal S configuration (leads V(1) to V(3)), or (2) ST J-point amplitude > or =50% of the R-wave amplitude in all other leads. To be included in the grade III group, grade III criteria in > or =2 adjacent leads were required. Patients with ST elevation but without grade III criteria were classified as having grade II. In-hospital mortality was 3.2% and 6.8% in the grade II (n = 616) and grade III (n = 278) groups, respectively (p = 0.016). In the grade II group, in-hospital mortality was similar in the thrombolysis and angioplasty subgroups (3.2% and 3.3%, p = 0.941). In patients with grade III, in-hospital mortality was 6.4% and 7.3%, respectively (p = 0.762). The odds ratio for the grade III group for death with thrombolysis was 2.06 (95% confidence intervals [CI] 0.82 to 5.19; p = 0.125); the odds ratio for primary angioplasty was 2.30 (95% CI 0.93 to 5.66; p = 0.07). In the thrombolysis group, reinfarction occurred in 3.3% and 6.5% of the grade II and grade III subgroups (p = 0.137). In the angioplasty group, reinfarction occurred in 1.3% and 4.4%, respectively (p = 0.239). Grade III ischemia on admission was associated with higher in-hospital and 30-day mortality and a higher rate of reinfarction. There was no difference in mortality between primary angioplasty and thrombolysis in the grade II and grade III ischemia patients.