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Ottander P, Nilsson JB, Jensen SM, Näslund U. Ischemic ST-segment episodes during the initial 24 hours of ST elevation myocardial infarction predict prognosis at 1 and 5 years. J Electrocardiol 2010; 43:224-9. [DOI: 10.1016/j.jelectrocard.2009.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Indexed: 11/24/2022]
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Nilsson JB, Jensen S, Ottander P, Näslund U. The electrocardiographic reperfusion peak in patients with ST-elevation myocardial infarction. SCAND CARDIOVASC J 2009; 41:25-31. [PMID: 17365974 DOI: 10.1080/14017430601120380] [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] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To analyse the incidence and the prognostic value of the reperfusion peak in a population of patients with AMI treated with thrombolysis. DESIGN Two hundred and sixty-nine patients with ST-elevation myocardial infarction treated with thrombolysis were monitored with continuous on-line vectorcardiography. RESULTS A reperfusion peak defined as a transiently increased ST-VM of >50 microV followed by an immediate decrease to a level lower than the starting point was seen in 112 of all 269 (42%) patients and in 111 of 149 (75%) of the patients with successful ST-resolution. A reperfusion peak was an independent predictor of better prognosis both in the short- and the long term but had no implications on the prognosis in the subgroup with successful ST-resolution. CONCLUSION A reperfusion peak was equally common in patients treated with thrombolysis having a successful ST-resolution as observed in studies of patients with successful primary coronary angioplasty. The reperfusion peak was associated with better prognosis and should be recognised as a possible marker of successful reperfusion but can mimic aggravated ischemia.
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Affiliation(s)
- Johan B Nilsson
- Department of Cardiology, Heart Centre, University Hospital, Umeå, Sweden.
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Schultz T, Mannheimer C, Dellborg M, Pilhall M, Börjesson M. High prevalence of gastroesophageal reflux in patients with clinical unstable angina and known coronary artery disease. ACTA ACUST UNITED AC 2008; 10:37-42. [PMID: 17851977 DOI: 10.1080/17482940701364877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Esophageal disease may mimic acute anginal pain. However, the prevalence of gastroesophageal reflux in the acute setting of patients with clinically unstable angina (UA) pectoris is not known. The aim of this study was to determine the co-existence of coronary artery disease (CAD) and gastroesophageal reflux in UA, and to study the feasibility of esophageal investigation in the chest pain unit. DESIGN 22 patients with clinical UA and confirmed CAD were monitored by continuous vector cardiography and pH-measurement during 24 h of observation. Symptoms of chest pain and episodes of ischemia and reflux were recorded. RESULTS 11 patients (50%) showed abnormal gastroesophageal reflux and another three (14%) had an increased number of reflux episodes. pH-measurements and esophageal manometry were well tolerated. Few chest pain episodes were recorded during the study period, and no association between chest pain, reflux, and ischemia could be shown. CONCLUSION Esophageal reflux is common in patients with UA and established CAD. As reflux-related chest pain may imitate angina pectoris, it is clinically important that gastroesophageal examination in patients with UA seems to be feasible and well tolerated in the 'acute setting'.
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Affiliation(s)
- Tomas Schultz
- Department of Medicine, Multidisciplinary Pain Center, Sahlgrens University Hospital/Ostra, Goteborg, Sweden.
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4
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Nilsson JB, Boman K, Jansson JH, Nilsson T, Näslund U. The influence of acute-phase levels of haemostatic factors on reperfusion and mortality in patients with acute myocardial infarction treated with streptokinase. J Thromb Thrombolysis 2007; 26:188-95. [PMID: 17721741 DOI: 10.1007/s11239-007-0086-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 08/01/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND The fibrinolytic system and von Willebrand factor (vWF) have been shown to play a role as risk factors for myocardial infarction. We performed this prospective cohort study to determine if components in the fibrinolytic system or vWF before or during treatment of AMI with streptokinase (SK) could predict reperfusion, recurrent ischaemia, reinfarction or mortality at one year, or mortality at five years. Reperfusion and recurrent ischaemia were assessed by continuous vectorcardiography. The setting was Umeå university hospital and Skellefteå county hospital, Sweden. RESULTS 139 patients were included; successful reperfusion was obtained in 53%. tPA activity, PAI-activity, PAI-mass concentration and vWF were analysed immediately on arrival and after 4 and 10 h. High fibrinolytic activity, measured as tPA activity > 25 U/L after the start of treatment, was associated with reperfusion. No significant associations between pre-treatment levels of the fibrinolytic variables or vWF and reperfusion or recurrent ischaemia were found. Elevated levels of PAI-1 mass concentration and PAI-1 activity after the start of SK treatment were associated with a higher risk for death at one year, but not at five years. High levels of vWF were associated with worse prognosis but not when corrected for age. CONCLUSION Pre-treatment levels of PAI-1, vWF and tPA activity showed no association with reperfusion or recurrent ischaemia. Elevated levels of PAI-1 activity after the start of treatment were associated with worse prognosis.
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Affiliation(s)
- Johan B Nilsson
- Department of Cardiology, Heart Centre, University Hospital, Umea 901 85, Sweden.
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5
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Eriksson M, Hofman-Bang C, Persson H, Tornvall P. Limited prognostic value of noninvasive assessment of reperfusion by continuous vectorcardiography in an unselected cohort of patients with acute ST-elevation myocardial infarction treated with thrombolysis. J Electrocardiol 2007; 40:305-10. [PMID: 17292384 DOI: 10.1016/j.jelectrocard.2006.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 12/14/2006] [Indexed: 11/29/2022]
Abstract
AIMS We studied the prognostic value of different reperfusion criteria of short-term continuous vectorcardiography (VCG) in an unselected cohort of 400 patients with ST-elevation myocardial infarction, treated at 4 coronary care units in Stockholm, Sweden, between 1999 and 2002. The main outcome measure was 1-year mortality. RESULTS Of 400 study patients, 41 (10.2%) died within 1 year. One-year mortality in patients without reperfusion at 90 minutes, defined as ST resolution below 50% on VCG, was 11.6% compared with 9.0% in patients with reperfusion, (P = 0.4). Ninety-eight (24.5%) patients underwent intervention before discharge and percutaneous coronary intervention or coronary artery bypass grafting or both during the index admission. Percutaneous coronary intervention or coronary artery bypass grafting was related to improved 1-year survival (97 +/- 2% vs 87 +/- 2%, P = .0076). ST-vector magnitude resolution at 90 minutes was lower in patients who underwent intervention (P = .045). None of the reperfusion criteria of VCG was significantly associated with 1-year mortality. CONCLUSION Our results show that noninvasive assessment of reperfusion by continuous VCG has limited prognostic value in unselected patients treated with thrombolysis because of ST-elevation myocardial infarction when subsequent revascularizations are performed. However, VCG might be useful in selecting patients for coronary angiography with subsequent revascularization.
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Affiliation(s)
- Michael Eriksson
- Department of Cardiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
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6
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Johanson P, Swedberg K, Dellborg M. ST variability during the first 4 hours of acute myocardial infarction predicts 1-year mortality. Ann Noninvasive Electrocardiol 2006; 6:198-202. [PMID: 11466137 PMCID: PMC7027724 DOI: 10.1111/j.1542-474x.2001.tb00108.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Early and complete myocardial reperfusion is the goal when treating a patient with acute myocardial infarction. To achieve this in each individual, an on-line, accurate, easily handled and preferably noninvasive technique to monitor flow alterations is needed. Recurrent ST-segment elevation has been shown to reflect cyclic disturbances in perfusion. METHODS We have retrospectively analyzed ST variability in 102 patients with acute myocardial infarction randomized to 100 mg of rt-Pa or placebo. Patients were monitored for 24 hours using vectorcardiography. RESULTS Patients alive at one year (86%) had significantly less ST variability during the first four hours: 4.3 versus 7.1 episodes, P = 0.007. Patients having six or more ST episodes showed a 31.3% one-year mortality as compared to no mortality in patients having no ST variability. Furthermore ST variability was reduced by fibrinolysis. CONCLUSION Early ST variability detectable in real time is associated with worse outcome.
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Affiliation(s)
- P Johanson
- Clinical Experimental Research Laboratory, Sahlgrenska University, Hospital/Ostra, SE-416 85 Göteborg, Sweden.
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7
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Weston P, Johanson P, Schwartz LM, Maynard C, Jennings RB, Wagner GS. The value of both ST-segment and QRS complex changes during acute coronary occlusion for prediction of reperfusion-induced myocardial salvage in a canine model. J Electrocardiol 2006; 40:18-25. [PMID: 17069840 DOI: 10.1016/j.jelectrocard.2006.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Analysis of ST-segment elevation for assessment of patients with suspected acute coronary occlusion is in widespread use for diagnostic and prognostic purposes. In this study, changes in the QRS complex also were analyzed to determine if these changes that are seldom used clinically can provide additional prognostic information. An acute coronary occlusion canine model, in which direct measurements of myocardial salvage were made, was used to assess whether ST-segment and QRS complex changes during coronary occlusion yielded independent estimates of the amount of salvage provided by reperfusion with arterial blood. METHODS AND RESULTS Continuous electrocardiographic recordings were obtained from 14 study dogs undergoing a 90-minute period of coronary artery occlusion in which the severity of the ischemia during the occlusion was estimated at 10 and 45 minutes by microsphere injections. After 3 hours of reperfusion, the myocardium at risk and postmortem infarct size was measured. Myocardial salvage correlated inversely with both ST-segment elevation (r = -0.85; P < .0001), and QRS complex prolongation (r = -0.72; P = .003). When dogs were paired so that they had equal amounts of ST elevation but differed with respect to the presence of QRS prolongation, less myocardial salvage was found in those with QRS prolongation. The independent value of QRS prolongation was supported further by the observation that presence of QRS prolongation resulted in a loss of the highly significant correlation between ST elevation and salvage (r = -0.60; P = .2). CONCLUSIONS High magnitudes of ST elevation are correlated significantly with less myocardial salvage. Moreover, for a given magnitude of ST elevation, the presence of concurrent QRS prolongation is associated with even less myocardial salvage.
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Johanson P. Electrocardiogram dynamics for risk stratification in ST-segment elevation myocardial infarction—immediate and serially updated information on outcome. J Electrocardiol 2006; 39:S75-8. [PMID: 16962128 DOI: 10.1016/j.jelectrocard.2006.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Revised: 06/02/2006] [Accepted: 06/02/2006] [Indexed: 11/27/2022]
Abstract
Early and serially updated predictions of final infarct-size and clinical outcome--before, during and after reperfusion treatment of ST-elevation myocardial infarction might allow a more individualized treatment: High-risk patients with a predicted major loss of viable myocardium can be identified immediately or during therapy, at a stage when treatment may still be modified; and low-risk patients with predictions of small infarcts and good outcome already after standard primary reperfusion therapy can be identified and thereby avoid a possibly harmful intensified treatment. The necessary information for such predictions seem to be available from the standard 12-lead ECG and from ST-segment monitoring. Today this information, however, is not readily available in clinical practice. Automated algorithms need to be engineered for a broader use and for possibilities of a refined triage and thus for a more individualized strategy of reperfusion therapy.
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Affiliation(s)
- Per Johanson
- Department of Medicine/Cardiology, Coronary Intensive Care Unit, Sahlgrenska University Hospital, Ostra, 416 85 Göteborg, Sweden.
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9
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Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic Markers of Reperfusion in ST-elevation Myocardial Infarction. Cardiol Clin 2006; 24:367-76, viii. [PMID: 16939829 DOI: 10.1016/j.ccl.2006.04.007] [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] [Indexed: 11/26/2022]
Abstract
The outcome of patients who fail to reperfuse with thrombolytic therapy or percutaneous coronary intervention (PCI) for ST-elevation acute myocardial infarction (STEMI) may be improved with additional pharmacologic and mechanical interventions such as rescue PCI or intravenous glycoprotein IIb/IIIa infusion. The standard 12-lead ECG is the most commonly available and suitable tool for routine bedside evaluation of the success of reperfusion therapy for STEMI. This article reviews and discusses the current data on the four ECG markers for prediction of the perfusion status of the ischemic myocardium: ST-segment deviation, T-wave configuration, QRS changes, and reperfusion arrhythmias.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555, USA
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Abstract
The number of leads needed in clinical electrocardiography depends on the clinical problem to be solved. The standard 12-lead ECG is so well established that alternative lead systems must prove their advantage through well-conducted clinical studies to achieve clinical acceptance. Certain additional leads seem to add valuable information in specific patient groups. The use of a large number of leads (eg, in body surface potential mapping) may add clinically relevant information, but it is cumbersome and its clinical advantage is yet to be proven. Reduced lead sets emulate the 12-lead ECG reasonably well and are especially advantageous in emergency situations.
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Affiliation(s)
- Elin Trägårdh
- Department of Clinical Physiology, Lund University Hospital, SE-221 85 Lund, Sweden.
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Johanson P, Armstrong PW, Barbagelata NA, Chaitman BR, Clemmensen P, Dellborg M, French J, Goodman SG, Green CL, Krucoff MW, Langer A, Pahlm O, Reilly P, Wagner GS. An Academic ECG Core Lab Perspective of the FDA Initiative for Digital ECG Capture and Data Management in Large-Scale Clinical Trials. ACTA ACUST UNITED AC 2005. [DOI: 10.1177/009286150503900402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM, Macfarlane PW, Sommargren C, Swiryn S, Van Hare GF. AHA scientific statement: practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized electrocardiology and the American Association of Critical-Care Nurses. J Cardiovasc Nurs 2005; 20:76-106. [PMID: 15855856 DOI: 10.1097/00005082-200503000-00003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas Computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide "best practices" for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, time frames, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.
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Steg PG, Francois L, Iung B, Himbert D, Aubry P, Charlier P, Benamer H, Feldman LJ, Juliard JM. Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction. Eur Heart J 2005; 26:1831-7. [PMID: 15930039 DOI: 10.1093/eurheartj/ehi331] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS The long-term value of rescue percutaneous transluminal coronary angioplasty (PTCA) in patients with ST-segment elevation myocardial infarction who received thrombolytic therapy but failed to achieve early recanalization of the artery is still debated. This study aimed to compare long-term outcomes after successful thrombolysis vs. systematic attempted rescue PTCA. METHODS AND RESULTS A total of 362 consecutive patients with STEMI hospitalized within 6 h of symptom onset and treated with intravenous thrombolytic therapy were studied. Of these, 345 underwent coronary angiography within 90 min. Sixty per cent of patients achieved TIMI 3 flow and were treated medically; the in-hospital death rate in this group was 4%. Nine per cent of patients had TIMI 2 flow and 31% TIMI 0-1 flow. In this latter group, rescue PTCA was attempted in 85.8% with a hospital death rate of 5.5% (20% with failed vs. 4% with successful rescue PTCA, P=0.03). Eight year actuarial survival without recurrent myocardial infarction was no different in patients who had successful thrombolytic therapy and in patients with attempted rescue PTCA [78 and 95% CI (71-85) vs. 78 and 95% CI (68-87), respectively, hazard ratio: 0.93 (0.52-1.65), P=0.80]. Total mortality, cardiac mortality, and other composite endpoints also did not differ between groups. CONCLUSION Routine attempted rescue PTCA 90 min after thrombolytic therapy in patients with persistent occlusion of the infarct-related vessels achieves long-term clinical outcomes which do not differ from those obtained by successful thrombolysis.
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Affiliation(s)
- Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75877 Paris Cedex 18, France.
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Johanson P, Fu Y, Goodman SG, Dellborg M, Armstrong PW, Krucoff MW, Wallentin L, Wagner GS. A dynamic model forecasting myocardial infarct size before, during, and after reperfusion therapy: an ASSENT-2 ECG/VCG substudy. Eur Heart J 2005; 26:1726-33. [PMID: 15824078 DOI: 10.1093/eurheartj/ehi221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Serial forecasts of final myocardial infarct (MI) size during fibrinolytic treatment (Rx) of ST-elevation MI would allow the identification of high-risk patients with a predicted major loss of viable myocardium, at a point when treatment may still be modified. We investigated a model for such forecasting, using time and the ECG. METHODS AND RESULTS We collected 234 patients with ST-elevation MI, without signs of previous MI, bundle branch block, or hypertrophy. MI size was determined by the Selvester score and was "forecasted" at: admission with patients stratified by delay time and an ECG acuteness score into three groups (EARLY, DISCORDANT, and LATE); 90 min after Rx by > or =70% ST-recovery or not and occurrence of "reperfusion peaks"; 4 h after Rx by ST re-elevations. EARLY patients had smaller final infarct sizes than LATE (9.4 vs. 20%, P=0.01). EARLY patients with > or =70% ST-recovery without a reperfusion peak had smaller infarct sizes than those with (3.1 vs. 12.5%, P=0.001). EARLY patients without ST re-elevations had smaller infarct sizes (1.5%) than those with some (9%) or many re-elevations (12%), P<0.001. CONCLUSION Final infarct size can be forecasted using delay time and serial ECGs. Serially updated forecasts seem especially important when both clock-time and initial ECG- signs indicate earliness.
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Affiliation(s)
- Per Johanson
- Division of Cardiology, Sahlgrenska University Hospital/Ostra, SE-41685 Göteborg, Sweden.
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Crisafulli A, Altavilla D, Marini H, Bitto A, Cucinotta D, Frisina N, Corrado F, D'Anna R, Squadrito G, Adamo EB, Marini R, Romeo A, Cancellieri F, Buemi M, Squadrito F. Effects of the phytoestrogen genistein on cardiovascular risk factors in postmenopausal women. Menopause 2005; 12:186-92. [PMID: 15772566 DOI: 10.1097/00042192-200512020-00013] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The phytoestrogen genistein has been shown to be the most efficacious in clinical and experimental studies. We studied whether genistein treatment affects some cardiovascular risk markers in postmenopausal women. DESIGN Sixty healthy postmenopausal women, who were 52 to 60 years of age, were enrolled in a 6-month double-blind, placebo-controlled, randomized study. After a 4-week stabilization on a standard fat-reduced diet, participants were randomly assigned to receive either genistein (n = 30; 54 mg/d) or placebo (n = 30). At baseline and after a 6-month treatment, we measured fasting glucose, insulin, insulin resistance (HOMA-IR), osteoprotegerin (OPG), fibrinogen, and sex hormone-binding globulin (SHBG). RESULTS By comparison with placebo, genistein treatment decreased significantly fasting glucose (genistein = -8.7 +/- 2.3%; placebo = 3.2 +/- 2.3%; P < 0.001), fasting insulin (genistein = -12 +/- 3.33%; placebo = 36 +/- 3.29%; P < 0.001), and HOMA-IR (genistein = -14 +/- 5.8%; placebo = 42 +/- 0.6%; P < 0.001). After genistein-treatment, fibrinogen decreased (genistein = 3.18 +/- 0.12 g/L; placebo = 3.83 +/- 0.04 g/L; P < 0.001) with respect to placebo. In the genistein group, serum OPG was lower (-2 +/- 0.3%) than in placebo (9 +/- 1.5%; P < 0.001), and serum SHBG was higher (63 +/- 3.8 nmol/L) compared with placebo (53 +/- 2.9 nmol/L; P < 0.05). CONCLUSION Our study suggests that genistein may have a favorable effect on some cardiovascular markers.
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Johanson P, Wallentin L, Nilsson T, Bergstrand L, Lindahl B, Dellborg M. ST-segment analyses and residual thrombi in the infarct-related artery: a report from the ASSENT PLUS ST-monitoring substudy. Am Heart J 2004; 147:853-8. [PMID: 15131542 DOI: 10.1016/j.ahj.2003.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evolution of the ST segment during ST-elevation myocardial infarction (STEMI) has been shown to yield more information on prognosis than widely used invasive measurements. With continuous ST monitoring, even very occasional dynamic changes can be analyzed. We have recently suggested that ST variability during the reperfusion-phase is of prognostic importance. We wanted to further investigate this and relate it to angiographic findings. METHODS A total of 177 patients with STEMI were examined in the ST-monitoring substudy of the ASessment of the Safety and Efficacy of a New Thrombolytic (ASSENT) PLUS trial, comparing dalteparin with heparin as adjunctive therapy to t-PA. Patients underwent 24 hours of ST monitoring. These recordings were blindly analyzed by 2 independent observers. A coronary angiogram was performed on days 4 to 7, also blindly evaluated by 2 persons. RESULTS Occurrence of ST re-elevations during and after the reperfusion-phase was significantly associated with residual thrombi and TIMI-flow in the infarct-related artery. Patients without any ST re-elevations showed a thrombus in only 5% of cases, as compared with 86% of patients with prolonged (lasting >30 minutes) ST re-elevations. In a multivariate comparison including baseline-data and treatment, most information on persistence of thrombi was contributed by the presence of any ST re-elevations (odds ratio, 5.8; 95% CI, 1.3-26). CONCLUSION ST re-elevations during the first day of an acute myocardial infarction are associated with residual thrombi in the infarct-related artery even 4 to 7 days after the STEMI.
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Affiliation(s)
- Per Johanson
- Department of Medicine/Cardiology, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.
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17
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Fesmire FM, Eriksson SV. Vectorcardiography risk stratifies emergency department chest pain patients with left ventricular hypertrophy on the initial 12-lead ECG. Ann Noninvasive Electrocardiol 2004; 9:149-55. [PMID: 15084212 PMCID: PMC6932677 DOI: 10.1111/j.1542-474x.2004.92536.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vectorcardiographic (VCG) measurements of ST-vector magnitude (VM) and QRS-vector difference (VD) have been demonstrated to be independent predictors of adverse outcome (AO) and acute myocardial infarction (AMI) in emergency department (ED) chest pain patients with absence of bundle branch block or left ventricular hypertrophy (LVH) on the initial 12-lead electrocardiogram (ECG). The prognostic value of ST-VM and QRS-VD in ED chest pain patients with LVH on the initial 12-lead ECG has not been previously investigated. METHODS A prospective observational study was performed in 196 consecutive ED chest pain patients with suspected AMI and presence of voltage criteria for LVH on initial ECG who underwent continuous VCG monitoring during the initial evaluation. The optimal baseline ST-VM value and 2-hour QRS-VD value were defined as the most accurate value on the receiver operator characteristic curve (value with lowest false-negative and false-positive rate). Thirty-day AO was defined as AMI, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or cardiac death occurring within 30 days of initial ED visit. RESULTS Fourteen patients (7.1%) were diagnosed as 24-hour AMI and 28 patients (14.3%) experienced 30-day AO. The optimal cut-off value for predicting 30-day AO was > 124 microV for ST-VM and > 21.7 microV for QRS-VD. Patients with either a positive ST-VM or a positive QRS-VD had 8.8 times increased odds of AMI (95% confidence interval, CI, 1.9-40.3; P = 0.003); 4.3 times increased odds of 30-day PTCA/CABG (95% CI 1.3-13.8; P = 0.019); and 3.8 times increased odds of 30-day AO (95% CI 1.6-9.3; P = 0.003). CONCLUSIONS Baseline ST-VM and 2-hour QRS-VD risk stratifies ED chest pain patients with LVH voltage criteria on the initial 12-lead ECG.
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Affiliation(s)
- Francis M Fesmire
- Heart-Stroke Center, Erlanger Medical Center, University of Tennessee College of Medicine, Chattanooga, TN 37405, USA.
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Maas ACP, Wyatt CM, Green CL, Wagner GS, Trollinger KM, Pope JE, Langer A, Armstrong PW, Califf RM, Simoons ML, Krucoff MW. Combining baseline clinical descriptors and real-time response to therapy: the incremental prognostic value of continuous ST-segment monitoring in acute myocardial infarction. Am Heart J 2004; 147:698-704. [PMID: 15077087 DOI: 10.1016/j.ahj.2003.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical descriptors and ST-segment recovery variables hold prognostic information for clinical outcome after thrombolysis for acute myocardial infarction (MI). We sought to define the incremental prognostic value of continuous 12-lead ST-segment monitoring variables to clinical risk descriptors identified by the Global Utilization of Streptokinase and TPA (alteplase) for Occluded Coronary Arteries (GUSTO-I) trial 30-day mortality analysis. METHODS Of 1,777 patients enrolled in continuous ST-segment substudies from the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI-9), GUSTO-I, Duke University Clinical Cardiology Study (DUCCS-II), Integrilin to manage Platelet Aggregation to Combat Thrombus in Acute Myocardial Infarction (IMPACT-AMI), Promotion of Reperfusion by Inhibition of Thrombin During Myocardial Infarction Evolution (PRIME), and Platelet Aggregation Receptor Antagonist Dose Investigation and Reperfusion Gain in Myocardial Infarction (PARADIGM) trials, 825 patients qualified for assessment of time to recovery. ST recovery variables analyzed were time to stable ST-recovery and late ST elevation. Patients who were at low clinical risk (n = 261) had no high-risk descriptors, and patients at high clinical risk (n = 564) had at least 1 of these high-risk descriptors: age >or=70 years, systolic blood pressure <or=110 mm Hg, heart rate >or=90 beats/min, anterior MI, or previous MI. High (n = 90), moderate (n = 318), and low (n =417) ST-risk groups were defined by the presence of both slow ST recovery and late ST elevation, one or the other, or neither, respectively. End points analyzed were inhospital death and combined death, reinfarction, or congestive heart failure. RESULTS There was a trend toward increased mortality rate in the high-clinical/high-ST-risk group. For the composite end point, ST subgrouping resulted in significant event stratification in both patients at low and high clinical risk. In multivariable analysis, age and heart rate were independent predictors of both mortality and the composite end point. Late ST elevation added incremental prognostic information. CONCLUSION Age, heart rate, and late ST elevation are powerful, independent predictors of adverse clinical outcome. Continuous monitoring allows noninvasive assessment of the response to therapy. Consequently, this technique will enhance the potential to risk-stratify individual patients in a real-time setting.
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Johanson P, Wagner GS, Dellborg M, Krucoff MW. ST-segment monitoring in patients with acute coronary syndromes. Curr Cardiol Rep 2003; 5:278-83. [PMID: 12801445 DOI: 10.1007/s11886-003-0063-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ST-segment analyses from electrocardiograms during acute coronary syndromes (ACS) have repeatedly shown strong mechanistic links to coronary artery patency and myocardial reperfusion. In these patients, such analyses have also consistently been reported to have close correlations with outcome--correlations superior even to those reported for invasive coronary flow measurements and outcome. Continuous multilead ST-monitoring of patients with ACS provides accurate and noninvasive information on the dynamics of the myocardial reperfusion process over time. This information can be used for improved early diagnostic accuracy, evaluation of treatment efficacy, early risk-stratification, and can be supportive in clinical decision making regarding these patients. Continuous multilead ST-monitoring during ACS is no longer a cumbersome source of more nuisance than benefit, but can be an accurate and useful tool in multicenter clinical trials, as well as in clinical medicine.
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Affiliation(s)
- Per Johanson
- Duke University Medical Center, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27705, USA.
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20
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Kawahito S, Kitahata H, Tanaka K, Nozaki J, Oshita S. Dynamic QRS-complex and ST-segment monitoring by continuous vectorcardiography during carotid endarterectomy. Br J Anaesth 2003; 90:142-7. [PMID: 12538368 DOI: 10.1093/bja/aeg031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many authors report a high incidence of cardiac events during carotid endarterectomy. The aim of the present study was to evaluate the usefulness of dynamic continuous on-line vectorcardiography for monitoring the occurrence of myocardial ischaemia during carotid endarterectomy. METHODS We studied 21 patients undergoing carotid endarterectomy. Patients underwent general anaesthesia with isoflurane or sevoflurane. The vectorcardiogram was monitored continuously during carotid endarterectomy. Electrodes were placed according to the previously described lead system and connected to a computerized system for on-line vectorcardiography. Two trend variables were recorded: the QRS vector difference, which reflects changes in the shape of the QRS complex; and the ST vector magnitude, which represents deflection of the ST segment from the isoelectric level. The ST segment deflection was measured 60 ms after termination of the QRS complex. RESULTS Vectorcardiography was successfully recorded in all 21 patients. Three patients showed intraoperative vectorcardiogram abnormalities. In one of these three patients, both ST vector magnitude and QRS vector difference increased after induction of anaesthesia and ST vector magnitude returned to baseline after administration of nitroglycerin. In the other two patients, both ST vector magnitude and QRS vector difference gradually increased after cross-clamping of the internal carotid artery and ST vector magnitude returned to baseline after unclamping. QRS vector difference remained elevated for several hours in all three patients. CONCLUSIONS Monitoring ST vector magnitude and QRS vector difference by vectorcardiography may be useful for identifying myocardial ischaemia during carotid endarterectomy.
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Affiliation(s)
- S Kawahito
- Department of Anesthesiology, Tokushima University School of Medicine, 3-18-15 Kuramoto, Tokushima 770-8503, Japan.
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Nilsson JB, Nilsson TK, Jansson JH, Boman K, Söderberg S, Näslund U. The effect of streptokinase neutralizing antibodies on fibrinolytic activity and reperfusion following streptokinase treatment in acute myocardial infarction. J Intern Med 2002; 252:405-11. [PMID: 12528758 DOI: 10.1046/j.1365-2796.2002.01049.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate tissue plasminogen activator (tPA) activity as a measure of fibrinolytic response to treatment with streptokinase (SK) and to relate this to the effect of pretreatment SK antibodies and to successful reperfusion assessed by continuous computerized vectorcardiography (VCG). SETTING Umeå University Hospital. SUBJECTS A total of 104 patients with acute myocardial infarction (AMI) treated with SK and no history of previous SK treatment were studied. The tPA activity was measured 4 h after the start of treatment. The effect of pre-existing neutralizing antibodies to SK was analysed with a functional assay in pretreatment samples. Reperfusion was evaluated with VCG. MAIN OUTCOME MEASURES Successful reperfusion. RESULTS Fifty-five patients (53%) were classified as successfully reperfused. The risk for failed reperfusion was calculated in logistic regression models. In a univariate model, a borderline significant increase in the risk of failed reperfusion was observed in intermediate levels of SK neutralizing antibodies, but not in the highest levels. In a multivariate model, only high tPA activity, >25 U mL(-1), at 4 h (OR 0.17: 95% CI: 0.06-0.51) was associated with a higher rate of reperfusion whilst longer time to treatment (OR 1.17; 95% CI: 1.02-1.35) was associated with a higher risk of failed reperfusion. There was no significant correlation between neutralizing antibodies to SK and tPA activity at 4 h. CONCLUSION The SK treatment of AMI induced high levels of tPA activity which were associated with successful reperfusion. The effect of pre-existing SK antibodies had no significant influence on reperfusion and were not correlated to the fibrinolytic activity obtained.
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Affiliation(s)
- J B Nilsson
- Department of Cardiology, Heart Centre, University Hospital, Umeå, Sweden.
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22
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Fesmire FM, Eriksson SV, Stout PK, Wojcik JF, Wharton DR. Use of baseline ST-vector magnitude to identify electrocardiographic injury in patients with suspected acute myocardial infarction. Am J Emerg Med 2002; 20:535-40. [PMID: 12369028 DOI: 10.1053/ajem.2002.34801] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
No information is currently available regarding optimal cut-off values of the ST-vector magnitude (ST-VM) for predicting acute myocardial infarction (AMI) in emergency department (ED) chest pain patients undergoing vectorcardiographic (VCG) monitoring. A prospective observational study was performed in 1,722 chest pain patients with suspected acute coronary syndrome and absence of bundle branch block (BBB) and left ventricular hypertrophy (LVH) on initial ECG who underwent continuous VCG ST-segment monitoring during the initial ED evaluation. Three cut-off values for baseline ST-VM are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI is greater than 5, 10, and 20, respectively. AMI occurred in 158 of 1,722 patients (9.2%) without BBB or LVH on initial ECG. Optimal cut-off values at the predetermined +LR values of 5, 10, and 20, were 121 microV (sensitivity, 41.8%; specificity, 92.0%), 151 microV (sensitivity, 29.1%; specificity, 97.1%), and 175 microV (sensitivity, 25.9%; specificity, 98.7%), respectively. Combining the earlier-mentioned cut-off values with physician judgment of initial pretest probability (high, intermediate, or low, respectively) resulted in a relative increase in identification of injury of 37.5% as compared with the ED physician's interpretation of initial ECG (41.8% v 30.4%; P <.0001), and 65.2% as compared with the official ECG interpretation (41.8% v 25.3%; P <.0001). Increasing ST-VM results in increasing likelihood of AMI. Clinical studies need to be performed to determine if ST-VM cut-off values of 121, 151, and 175 microV in conjunction with physician pretest probability of AMI can be used as criterion for emergent reperfusion therapy in patients without LVH or BBB on the initial ECG.
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Affiliation(s)
- Francis M Fesmire
- Department of Emergency Medicine, Erlanger Medical Center, University of Tennessee College of Medicine, Chattanooga, TN 37405, USA.
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Johanson P, Svensson AM, Dellborg M. Clinical implications of early ST-segment variability. A report from the ASSENT 2 ST-monitoring sub-study. Coron Artery Dis 2001; 12:277-83. [PMID: 11428536 DOI: 10.1097/00019501-200106000-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Evolution of the ST-segment during acute myocardial infarction has been shown to yield more information on prognosis than invasive measurements. By continuous ST-monitoring even very occasional dynamic changes can be analysed. We have recently suggested these variations to be of prognostic importance and possibly reflect individual abilities to deal with a vascular event. We wanted to confirm these findings. METHODS Four hundred and forty-eight patients were included in the vectorcardiographic sub-study of the second Assessment of Safety and Efficacy of a New Thrombolytic (ASSENT 2) trial. Patients underwent 24 h of ST-monitoring. ST-trend curves were blindly analysed by two independent observers. RESULTS ST-variability, defined as an increase of the ST-segment shift of > or = 25 microV for 2 min or more, was found to predict death, reinfarction at 30 days or urgent revascularization. By combining variability with resolution of the ST-segment elevation we could identify a high-risk group with 9.9%, and a low-risk group with only 0.8% 30-day mortality. Hypertensive patients, suggested to have an impaired secretion of endogenous t-PA, expressed significantly more ST-variability, possibly a non-invasive marker of impaired capability of dissolving and preventing thrombi. CONCLUSION Small variations in ST-segment shift during the first 4 h of acute myocardial infarction predict worse outcome.
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Affiliation(s)
- P Johanson
- Clinical Experimental Research Laboratory, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.
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24
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How to monitor myocardial ischemia. Curr Opin Crit Care 2000. [DOI: 10.1097/00075198-200010000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vaturi M, Birnbaum Y. The use of the electrocardiogram to identify epicardial coronary and tissue reperfusion in acute myocardial infarction. J Thromb Thrombolysis 2000; 10:137-47. [PMID: 11005936 DOI: 10.1023/a:1018762509887] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: (1) ST-segment measurements, (2) T-wave configuration, (3) QRS changes, and (4) reperfusion arrhythmias. Complete and stable (> or = 70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30 to 70%) or no (<30%) ST-segment resolution. Early inversion of the T waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude, and width; R-wave amplitude; and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes has not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm, are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST segments and T waves occur during reperfusion therapy and the days after. Whereas changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes is less clear, and especially whether changes in the QRS complex and T wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and reischemia should be used for therapeutic decision making in the clinical setting.
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Affiliation(s)
- M Vaturi
- The Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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26
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Vaturi MD M, Birnbaum MD Y. The use of the electrocardiogram to identify epicardial coronary and tissue reperfusion in acute myocardial infarction. J Thromb Thrombolysis 2000; 10:5-14. [PMID: 10947909 DOI: 10.1023/a:1018794918584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The standard 12-lead ECG gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST-elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: 1) ST-segment measurements; 2) T-wave configuration; 3) QRS changes; and 4) reperfusion arrhythmias. Complete and stable (> or = 70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30% to 70%) or no (< 30%) ST-segment resolution. Early inversion of the T-waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude and width, R-wave amplitude and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes have not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST-segments and T-waves occur during reperfusion therapy and the days after. While changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes are less clear, and especially whether changes in the QRS-complex and T-wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and re-ischemia should be used for therapeutic decision-making in the clinical setting.
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Affiliation(s)
- M Vaturi MD
- The Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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Strandberg LE, Ericsson CG, O'Konor ML, Bergstrand L, Lundin P, Rehnqvist N, Tornvall P. Diabetes mellitus is a strong negative prognostic factor in patients with myocardial infarction treated with thrombolytic therapy. J Intern Med 2000; 248:119-25. [PMID: 10947890 DOI: 10.1046/j.1365-2796.2000.00007.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To assess the long-term prognostic values of baseline demographic data, occurrence of vectorcardiographic signs of reperfusion, left ventricular function and coronary angiographic features. DESIGN Longitudinal study of morbidity and mortality. SETTING Coronary care unit at Danderyd Hospital, Stockholm, Sweden. SUBJECTS A total of 222 patients (mean age 61 years) with a suspected acute myocardial infarction treated with thrombolysis were investigated and followed for 2-5 years (mean 1216 days). MAIN OUTCOME MEASURES Death or a new myocardial infarction. RESULTS Age above 55 years (P < 0.05), a previous diagnosis of diabetes mellitus (P < 0.005), hypertension (P < 0.05), heart failure (P < 0.001) and myocardial infarction (P < 0.05), a previous use of beta-blockers (P < 0.05) and an ejection fraction below 60% (P < 0.01) were predictors for death or a new myocardial infarction in univariate analysis. Sex, a previous history of smoking or angina pectoris, vectorcardiographic signs of reperfusion or degree of coronary artery disease had no prognostic values. In multivariate analysis including age above 55 years, a previous diagnosis of diabetes mellitus, hypertension and myocardial infarction, and an ejection fraction below 60%, only age (P < 0.05), diabetes mellitus (P < 0. 01) and ejection fraction (P < 0.05) were predictors for death or a new myocardial infarction. CONCLUSIONS The results of the present study emphasize the importance of diabetes mellitus as a long-term prognostic risk factor in patients with myocardial infarction treated with thrombolysis. Further studies are needed to determine the mechanisms behind this increased risk.
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Affiliation(s)
- L E Strandberg
- Department of Internal Medicine, Norrtälje Hospital, Stockholm, Sweden
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28
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Akkerhuis KM, Maas AC, Klootwijk PA, Krucoff MW, Meij S, Califf RM, Simoons ML. Recurrent ischemia during continuous 12-lead ECG-ischemia monitoring in patients with acute coronary syndromes treated with eptifibatide: relation with death and myocardial infarction. PURSUIT ECG-Ischemia Monitoring Substudy Investigators. Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy. J Electrocardiol 2000; 33:127-36. [PMID: 10819406 DOI: 10.1016/s0022-0736(00)80069-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Computer-assisted continuous monitoring of the ST-segment allows detection and quantification of recurrent ischemia in patients with acute coronary syndromes. In a substudy of the PURSUIT (Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy) trial, this technique was used to evaluate the effects of the glycoprotein IIb/IIIa inhibitor eptifibatide on the incidence and severity of recurrent ischemia, and to investigate the relationship between recurrent ischemia and the occurrence of subsequent death or myocardial (re)infarction. A total of 258 patients with unstable angina or evolving myocardial infarction without ST elevation were monitored for 24 hours during infusion with either eptifibatide or placebo with a computer-assisted 12-lead ECG-ischemia monitoring device. Recurrent ischemic episodes were identified by an automated computer algorithm. Two hundred and sixteen patients (84%) had ECG recordings suitable for analysis. Ischemic episodes were detected in 35 (33%) of the 105 eptifibatide patients and in 32 (29%) of the 111 placebo patients (not significant). No difference in ischemic burden was apparent between both treatment groups. Patients who exhibited 2 or more episodes of recurrent ischemia more frequently died or suffered a myocardial infarction, both at 7 and 30 days, as well as through the 6-month follow-up. A greater ischemic burden was significantly related to adverse outcome during the 6-month follow-up period. Real-time computer-assisted continuous multilead ECG-ischemia monitoring may help to identify patients with unstable coronary syndromes at increased risk of adverse outcome and, thus, allow for better prognostic triage and more appropriate selection of therapeutic strategies. Integration of these systems in coronary care units and emergency wards should, therefore, be recommended.
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Affiliation(s)
- K M Akkerhuis
- Thoraxcenter, Erasmus University and University Hospital Rotterdam, Rotterdam, The Netherlands.
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29
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Nørgaard BL, Rasmussen BM, Dellborg M, Thygesen K. Positional changes of spatial QRS- and ST-segment variables in normal subjects: implications for continuous vectorcardiography monitoring during myocardial ischemia. J Electrocardiol 2000; 33:23-30. [PMID: 10691171 DOI: 10.1016/s0022-0736(00)80097-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Electrocardiographic QRS- and ST-segment changes are to be expected during changes in body posture. We prospectively analyzed the influence of changes in body position on continuous vectorcardiography monitoring of QRS-vector difference (QRS-VD) and ST change-vector magnitude (STC-VM) according to the currently used criteria of myocardial ischemia in 21 normal subjects. Fifteen (71%) and 6 (29%) subjects had significant positional QRS-VD and STC-VM changes, respectively. Vectorcardiography changes were most frequent and pronounced in the left lateral position. An alternative to the existing criterion of ischemia is proposed to improve the specificity of STC-VM. Subjects with positional QRS-VD changes had higher mean STC-VM values as compared with those without such changes. Otherwise no characteristics among those with positional vectorcardiography changes could be identified. There was no statistically significant association between positional QRS-VD and STC-VM changes (R = .13, P = .57). We conclude that the clinical use of QRS-VD in its present form for continuous vectorcardiography monitoring of myocardial ischemia seems to be of limited practical value, because of the presence of frequent "pseudo-ischemic" changes. STC-VM seems to have a significant potential of continuous vectorcardiography monitoring. However, an indicator of body position change or even an algorithm enabling on-line correction for positional vectorcardiography changes seems to be essential to improve the accuracy of this technique in identifying myocardial ischemia.
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Affiliation(s)
- B L Nørgaard
- Department of Medicine and Cardiology, Aarhus University Hospital, Denmark
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30
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Moons KG, Klootwijk P, Meij SH, van Es GA, Baardman T, Lenderink T, van den Brand M, Habbema JD, Grobbee DE, Simoons ML. Continuous ST-segment monitoring associated with infarct size and left ventricular function in the GUSTO-I trial. Am Heart J 1999; 138:525-32. [PMID: 10467204 DOI: 10.1016/s0002-8703(99)70156-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether in patients with myocardial infarction, the intensity and duration of myocardial ischemia as measured by continuous ST monitoring are associated with infarct size and residual left ventricular function. METHODS AND RESULTS The analyses included patients with myocardial infarction, receiving thrombolytic therapy, who were enrolled in the electrocardiographic substudy of GUSTO-I, monitored by a vector-derived 12-lead electrocardiographic recording system, and in whom either infarct size (defined as cumulative release of alpha-hydroxybutyrate dehydrogenase activity per liter of plasma over a 72-hour period [Q(72)]) or left ventricular ejection fraction (LVEF) was determined. With the use of linear regression analysis, we investigated the association of various ST-trend characteristics with Q(72) (206 patients) and with LVEF (180 patients). A higher area under the ST trend since thrombolysis until 50% ST recovery and a higher area under recurrent ischemic episodes (ST reelevations) were significantly associated with a higher Q(72), whereas only a higher area under recurrent ischemic episodes was significantly associated with a lower LVEF. These associations remained after adjusting for other patient characteristics such as age, sex, infarct location, and time to treatment. CONCLUSIONS These findings support the physiologic hypothesis that both the intensity and duration of myocardial ischemia (both reflected by the estimated areas under the ST-trend curve) determine myocardial damage and thus are associated with infarct size and ejection fraction in patients with acute myocardial infarction who receive thrombolytic therapy.
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Affiliation(s)
- K G Moons
- Julius Center for Patient Oriented Research, Utrecht University, The Netherlands
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Nørgaard BL, Rasmussen BM, Dellborg M, Thygesen K. Temporal and positional variability of the ST segment during continuous vectorcardiography monitoring in healthy subjects. J Electrocardiol 1999; 32:149-58. [PMID: 10338033 DOI: 10.1016/s0022-0736(99)90093-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Continuous vectorcardiography ST-segment monitoring (cVST) is a well-established method in the diagnosis and risk evaluation of patients with acute myocardial ischemia. Previous investigations have demonstrated that electrocardiographic ST-segment changes are to be expected, during both repeated measurements and changes in body position. We prospectively analyzed the influence of spontaneous temporal variation (technical and biological noise) and changes in body position on the ST segment (ST-vector magnitude [ST-VM]) during cVST of 21 healthy human subjects. The 95% expectancy range of the spontaneous intraindividual ST-VM variation was found to be +/-8 microV for the error of measurement, and +/-14 and +/-24 microV during 24-hour and day-to-day cVST measurements, respectively. Positional ST-segment changes in the orthogonal leads were frequent, especially in leads X and Z, and in the left lateral position. Positional orthogonal ST-segment changes resulted in significant ST-VM changes in two of seven subjects. It is concluded that the low spontaneous temporal ST-VM variation must be considered as good reproducibility. Moreover, the present findings support currently used ST-VM ischemia criteria. However, the impact of positional changes on ST-VM seems to be of importance (with the possibility of false-positive results) and should be taken into account during cVST.
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Affiliation(s)
- B L Nørgaard
- Department of Medicine and Cardiology, Aarhus University Hospital, Denmark
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Ohlin H, Pavlidis N, Ohlin AK. Effect of intravenous nitroglycerin on lipid peroxidation after thrombolytic therapy for acute myocardial infarction. Am J Cardiol 1998; 82:1463-7. [PMID: 9874048 DOI: 10.1016/s0002-9149(98)00688-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Free oxygen radicals are produced after coronary artery occlusion and reperfusion. Polyunsaturated fatty acids are oxidized by free radicals to lipid peroxides. Measurements of plasma malondialdehyde (MDA) formed by the breakdown of lipid peroxides are often used as markers of lipid peroxidation. The effect of intravenous nitroglycerin on plasma MDA levels was studied in 43 patients who received thrombolytic therapy for acute myocardial infarction. Plasma MDA levels in patients were elevated on admission to the hospital compared with healthy controls, and normalized within 48 hours. A greater increase in plasma MDA concentrations after thrombolysis was found in patients with noninvasive signs of reperfusion than in patients judged to have a persistent occlusion. In the 23 patients receiving immediate intravenous nitroglycerin infusion, plasma MDA levels did not change from baseline to 90 minutes (0.92+/-0.22 and 0.92+/-0.23 micromol/L, p=0.99), whereas a significant increase was found in the 20 control patients who did not receive nitroglycerin (from 0.83+/-0.22 to 1.01+/-0.30 micromol/L, p=0.0004) (p=0.036 for the difference between groups). Successful reperfusion after thrombolytic therapy entails increased lipid peroxidation. Intravenous nitroglycerin reduces lipid peroxidation during myocardial ischemia and reperfusion.
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Affiliation(s)
- H Ohlin
- Department of Cardiology, University Hospital, Lund, Sweden
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33
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Dellborg M, Andersen K. Key factors in the identification of the high-risk patient with unstable coronary artery disease: clinical findings, resting 12-lead electrocardiogram, and continuous electrocardiographic monitoring. Am J Cardiol 1997; 80:35E-39E. [PMID: 9296468 DOI: 10.1016/s0002-9149(97)00488-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article reviews a range of methods for identifying high-risk patients with unstable coronary artery disease, including clinical evaluation, the resting 12-lead electrocardiogram, continuous vectorcardiography, and a combined risk evaluation using continuous vectorcardiography and measurement of troponin-T. Clinical evaluation is not very accurate for identifying high-risk patients and modern techniques have not been fully validated in clinical trials. The combination of continuous vectorcardiography and biochemical monitoring is a very powerful method of identifying both very high- and very low-risk patients and may be increasingly used in the future.
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Affiliation(s)
- M Dellborg
- Ostra University Hospital, Gothenburg, Sweden
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Nilsson J, Nilsson T, Jansson JH, Boman K, Thögersen A, Näslund U. Relationship between fibrinolytic activity following streptokinase treatment in acute myocardial infarction and vectorcardiographic signs of reperfusion. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0268-9499(97)80050-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Juliard JM, Himbert D, Golmard JL, Aubry P, Karrillon GJ, Boccara A, Benamer H, Steg PG. Can we provide reperfusion therapy to all unselected patients admitted with acute myocardial infarction? J Am Coll Cardiol 1997; 30:157-64. [PMID: 9207637 DOI: 10.1016/s0735-1097(97)00119-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study sought to assess the maximal rate of acute Thrombolysis in Myocardial Infarction (TIMI) grade 3 patency that can be achieved in unselected patients. BACKGROUND Early and complete (TIMI grade 3 flow) reperfusion is an important therapeutic goal during acute myocardial infarction. However, thrombolysis, although widely used, is often contraindicated or ineffective. The selective use of primary and rescue percutaneous transluminal coronary angioplasty (PTCA) may increase the number of patients receiving reperfusion therapy. METHODS A cohort of 500 consecutive unselected patients with acute myocardial infarction were prospectively treated using a patency-oriented scheme: Thrombolysis-eligible patients received thrombolysis (n = 257) and underwent 90-min angiography to detect persistent occlusion for treatment with rescue PTCA. Emergency PTCA (n = 193) was attempted in patients with contraindications to thrombolysis, cardiogenic shock or uncertain diagnosis and in a subset of patients admitted under "ideal conditions." A small group of patients (n = 38) underwent acute angiography without PTCA. Conventional medical therapy was used in 12 patients with contraindications to both thrombolysis and PTCA. RESULTS Ninety-eight percent of patients received reperfusion therapy (thrombolysis, PTCA or acute angiography), and angiographically proven early TIMI grade 3 patency was achieved in 78%. Among patients with TIMI grade 3 patency, thrombolysis alone was the strategy used in 37%, emergency PTCA in 40% and rescue PTCA after failed thrombolysis in 15%; spontaneous patency occurred in 8%. CONCLUSIONS Reperfusion therapy can be provided to nearly every patient (98%) with acute myocardial infarction. Rescue and direct PTCA provided effective early reperfusion to patients in whom thrombolysis failed or was excluded.
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Affiliation(s)
- J M Juliard
- Cardiology Department, Hôpital Bichat, Paris, France
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Versaci F, Gaspardone A, Tomai F, Crea F, Chiariello L, Gioffrè PA. A comparison of coronary-artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery. N Engl J Med 1997; 336:817-22. [PMID: 9062089 DOI: 10.1056/nejm199703203361201] [Citation(s) in RCA: 200] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Randomized studies have shown that the use of coronary-artery stenting as the initial treatment for coronary stenosis is associated with a lower risk of restenosis than is standard coronary angioplasty. We prospectively investigated the efficacy of these two approaches in selected patients with isolated stenosis of the proximal left anterior descending coronary artery. METHODS A total of 120 patients with isolated stenosis of the proximal left anterior descending coronary artery were randomly assigned to stent implantation or standard coronary angioplasty. The primary clinical end points were the rate of procedural success (defined as residual stenosis of less than 50 percent and the absence of death, myocardial infarction, and the need for coronary-artery bypass surgery during the hospital stay) and the rate of event-free survival (defined as freedom from death, myocardial infarction, and the recurrence of angina) at 12 months. The angiographic end point was the rate of restenosis 12 months after the procedure. RESULTS The two treatment groups did not differ significantly with respect to demographic, clinical, or angiographic characteristics. The rates of procedural success were similar in the two groups of patients (95 percent in the stenting group vs. 93 percent in the angioplasty group, P = 0.98). The 12-month rates of event-free survival were 87 percent after stenting and 70 percent after angioplasty (P = 0.04). The rates of restenosis were 19 percent after stent implantation and 40 percent after angioplasty (P = 0.02). CONCLUSIONS In patients with symptomatic isolated stenosis of the proximal left anterior descending coronary artery, stenting had advantages over standard coronary angioplasty in that it was associated with both a lower rate of restenosis and a better clinical outcome.
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Affiliation(s)
- F Versaci
- Servizio Speciale di Diagnosi e Cura di Emodinamica, Università di Roma Tor Vergata, Italy
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Lindahl B. Biochemical markers of myocardial damage for early diagnosis and prognosis in patients with acute coronary syndromes. Minireview based on a doctorial thesis. Ups J Med Sci 1996; 101:193-232. [PMID: 9055387 DOI: 10.3109/03009739609178922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
In patients with suspected AMI. Monitoring of a combination of myoglobin and CK-MB or tn-T allowed ruling-in AMI within 2-3 hours and ruling-out AMI within 3-6 hours in almost all patients admitted with chest pain and a nondiagnostic ECG. This might have a large impact on the early handling and treatment of these patients. The neural network methodology, with monitoring of myoglobin, CK-MB and tn-T allowed, within the first three hours, reliable diagnosis/exclusion of AMI/MMD and prediction of infarct size in patients admitted with suspicion of AMI. The computer system was faster than clinicians. Thus, neural network methodology might be a useful support for the early assessment of patients with suspected myocardial infarction. In patients with unstable CAD. The risk of subsequent cardiac events is increased by increasing maximal levels of tn-T obtained during the initial 24 hours. Thereby a normal, a slightly elevated and a clearly elevated tn-T level identified a low, intermediate and high risk group, respectively, for MI or death. The tn-T level was an independent prognostic variable for MI or death in a multivariate analysis comparing other early available risk indicators. Furthermore, tn-T seemed to be superior to CK-MB (mass) for risk stratification. In patients able to perform a predischarge ET both the tn-T level and the ET response were independent prognostic indicators for MI or death. The combination of tn-T and the ET response allowed a further improved risk stratification. In patients with tn-T elevation at inclusion, prolonged dalteparin treatment was beneficial. However, in patients without tn-T elevation, long term dalteparin treatment had no protective effect. Thus, tn-T determination provides independent and important prognostic information in unstable CAD. In the selection of treatment strategy for the individual patient, this simple, inexpensive and early available biochemical test might be useful.
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Affiliation(s)
- B Lindahl
- Department of Cardiology, University Hospital, Uppsala, Sweden
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