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

BackgroundECG on admission has been used in predicting prognosis and risk stratification in ST segment elevation acute myocardial infarction (STEMI).ObjectiveTo analyze the admission ECG in STEMI based on abnormality observed in terminal portion of QRS and its correlation to hospital mortality.Method160 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.ResultsOut 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).ConclusionECG 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.     

Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction

ObjectivesThe aim of this study was to examine the temporal trends and outcomes of mechanical complications after myocardial infarction in the contemporary era.BackgroundData regarding temporal trends and outcomes of mechanical complications after ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation myocardial infarction (NSTEMI) are limited in the contemporary era.MethodsThe National Inpatient Sample database (2003 to September 2015) was queried to identify all STEMI and NSTEMI hospitalizations. Temporal trends and outcomes of mechanical complications after STEMI and NSTEMI, including papillary muscle rupture, ventricular septal defect, and free wall rupture, were described.ResultsThe analysis included 3,951,861 STEMI and 5,114,270 NSTEMI hospitalizations. Mechanical complications occurred in 10,726 of STEMI hospitalizations (0.27%) and 3,041 of NSTEMI hospitalizations (0.06%), with no changes in trends (p = 0.13 and p = 0.83, respectively). The rates of in-hospital mortality in patients with mechanical complications were 42.4% after STEMI and 18.0% after NSTEMI, with no significant trend changes (p = 0.62 and p = 0.12, respectively). After multivariate adjustment, patients who had mechanical complications after myocardial infarction had higher in-hospital mortality, cardiogenic shock, acute kidney injury, hemodialysis, and respiratory complications compared with those without mechanical complications. Predictors of lower mortality in patients with mechanical complications who developed cardiogenic shock included surgical repair in the STEMI and NSTEMI cohorts and percutaneous coronary intervention in the STEMI cohort.ConclusionsContemporary data from a large national database show that the rates of mechanical complications are low in patients presenting with STEMI and NSTEMI. Post–myocardial infarction mechanical complications continue to be associated with high mortality rates, which did not improve during the study period.     

Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease

BackgroundThe electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary artery anatomy.MethodsWe describe the ECG findings in 2 cases of proximal left anterior descending (LAD) artery occlusion in ST-elevation myocardial infarction (STEMI) associated with 3-vessel coronary artery disease.ResultsBoth patients had atypical ECG patterns of ST-segment elevation in leads V₂, I, and aVL and ST-segment depression with positive T waves suggestive of extensive subendocardial ischemia in leads II, III, aVF, and V₃ through V₆; acute proximal LAD occlusion and concomitant 3-vessel coronary artery disease were observed angiographically.ConclusionElectrocardiographic changes in proximal LAD STEMI may be modified by the presence of significant atherosclerotic disease elsewhere in the coronary vasculature. Recognition of this ECG pattern may aid the clinician in the rapid identification of high-risk STEMI.     

Prognostic significance of the initial electrocardiographic pattern in patients with inferior wall acute myocardial infarction

The purpose of the study was to determine whether the initial electrocardiographic pattern is predictive of in-hospital mortality in inferior wall acute myocardial infarction. It is commonly perceived that patients with acute myocardial infarction presenting with greater ST elevation have a worse prognosis. The initial electrocardiogram of patients (n = 213) with inferior wall myocardial infarction was categorized based on the pattern of ST-segment elevation in inferior leads: (A) ST< 1 mm with tall T waves, (B) ST ≥ 1 mm with normal terminal QRS, and (C) ST≥ 1 mm with distortion of terminal QRS. ST deviation from baseline was calculated for all leads. Patients with maximal precordial ST depression in V₄-V₆ and pattern A had an in-hospital mortality rate of 68.8% compared with 16.9% for the entire study group. By univariate analysis, only pattern A was significantly predictive of in-hospital mortality [odds ratio = 2.91,95% confidence interval (CI) 1.22–6.93], but by multivariate analysis adjusted for (1) age, (2) diabetes mellitus, (3) previous myocardial infarction, (4) thrombolytic therapy, (5) precordial ST-depression pattern, and (6) patterns of ST elevation, maximal ST depression in V₄-V₆ was significantly predictive (odds ratio = 4.93, 95% CI 1.79–13.56), whereas pattern A was not (odds ratio = 1.12, 95% CI 0.36–3.52). Contrary to popular perception, patients with inferior wall myocardial infarction presenting with minimal ST-segment elevation are at highest risk for in-hospital mortality, especially if accompanied by maximal precordial ST depression in V₄-V₆.     

Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI

Background

Despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area.

Methods

We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers.

Results

The incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI.

Conclusions

The results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction.     

Identificación y cuantificación del efecto fin de semana y festivos en la atención del síndrome coronario agudo en el Sistema Nacional de Salud

Introduction and objectivesTo analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays.MethodsRetrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non–ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018.ResultsA total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS.ConclusionsWHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays.     

Ventricular arrhythmias are associated with increased QT interval and QRS dispersion in patients with ST-elevation myocardial infarction

Introduction and ObjectivesThe electrocardiogram continues to be essential in the diagnosis of acute myocardial infarction, and a useful tool in arrhythmic risk stratification. We aimed to determine which electrocardiographic variables can successfully predict the occurrence of ventricular arrhythmias (VA) in patients following ST-segment elevation myocardial infarction (STEMI).MethodsWe performed an observational study including 667 patients with STEMI admitted to the University Hospital in Sancti Spíritus, Cuba. Demographic variables, cardiovascular risk factors, and clinical variables were recorded. Electrocardiographic variables included QT interval duration (measured and corrected) and QT dispersion, QRS duration and dispersion, JT interval duration and ST-segment elevation magnitude. We also determined left ventricular ejection fraction and glomerular filtration rate. A binary statistical regression model and a regression tree were used to determine the variables that successfully predicted VA.ResultsVA occurred in 92 (13.8%) patients, within the first 48 hours in 68 (73.9%) and after this period in 24 (26.1%) patients. The variables associated with VA were QT interval duration >529 ms and QT dispersion >66 ms, QRS dispersion >50 ms, and the presence of ST-segment elevation in six or more leads.ConclusionsThe main predictor of VA occurring during the initial 48 hours was QT interval duration, while, after this period, it was QRS dispersion.     

A simple electrocardiographic predictor of the outcome of patients with acute myocardial infarction treated with a thrombolytic agent: A Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-derived analysis

Objectives. This analysis aimed to evaluate in a large patient cohort the relation between ST segment alterations after fibrinolytic therapy for acute myocardial infarction and 1) the combined end point of in-hospital mortality plus clinical congestive heart failure or extensive left ventricular damage, and 2) mortality 30 and 180 days after randomization.Background. Angina relief, enzyme release acceleration and ST segment normalization are related to coronary artery reperfusion and prognosis. Electrocardiographic (ECG) evaluation before and after fibrinolytic drug administration has been used to predict short-and long-term clinical outcome in acute myocardial infarction.Methods. Patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial underwent a standard ECG on admission and after 4 h of alteplase or streptokinase therapy; 7,426 recordings were suitable for ST segment analysis. A decrease ≥ 50% in the sum of ST segment elevation in all ECG leads was adopted as the cutoff for predicting coronary artery patency. Recanalization was deemed to have occurred in 4,951 patients (group A) versus 2,475 patients without reperfusion (group B).Results. Group A patients experienced a lower incidence of the combined end point than did group B patients (16.2% vs. 22.9%, respectively), as well as of all its components (death, clinical heart failure, ejection fraction < 35%, injured myocardial segment > 45%, QRS score > 10). Thirty- and 180-day mortality rates were lower in group A than group B (3.5% and 5.7% vs. 7.4% and 9.9%, respectively); relative risk (Cox) was 0.46 (95% confidence interval [CI] 0.37 to 0.57) for 30-day and 0.58 (95% CI 0.48 to 0.70) for 180-day mortality. Patients in group A had significantly less ventricular fibrillation and sustained ventricular tachycardia but more ischemic episodes (early recurrent angina plus myocardial infarction recurrence).Conclusions. A simple, inexpensive instrumental evaluation, unaffected by different epidemiologic and clinical characteristics of the population analyzed, can allow early assessment of the effectiveness of fibrinolytic treatment with respect to the main clinical outcomes.     

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

BackgroundPrimary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.MethodsA sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.ResultsMale patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%.ConclusionIn-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.     

Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting With ST-Segment Elevation Myocardial Infarction

BackgroundCardiovascular disease remains a major cause of morbidity and mortality among homeless adults. Despite major advances in the management of ST elevation myocardial infarction (STEMI), limited information is available for the clinical presentation and management and outcome of STEMI among patients experiencing homelessness (PEH).MethodsAll patients presenting with STEMI between January 1, 2008 and December 31, 2017 at a PCI capable STEMI network inner city hospital comprised the study population. Baseline characteristics, homeless status and clinical outcomes were determined from hospital records. The primary outcome of in-hospital mortality was compared between PEH and nonhomeless patients using a log-binomial regression model with propensity score adjusted standardised mortality ratio weighting (SMRW).ResultsAmong 2854 STEMI admissions during the study period, 75 patients (2.6%) were identified as PEH. The PEH group was younger (58 vs 63 years; P = 0.0002), predominantly male (96% vs 76%), and more likely to present with cardiogenic shock or cardiac arrest (17% vs 6%) compared with the nonhomeless group. The in-hospital mortality remained significantly higher among PEH (risk ratio 3.83, 95% confidence interval 1.27-11.60) after propensity score adjustment.ConclusionsDespite universal health care and contemporary STEMI management, PEH presenting with STEMI experienced a 4-fold higher in-hospital mortality compared with the nonhomeless cohort. Targeted interventions are needed to improve STEMI outcomes in this high-risk group.     

Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST

BackgroundAccording to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance.ObjectivesWe aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo.MethodsWe used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05.ResultsNearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001).ConclusionEven simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.     

Use of Intravascular Imaging in Patients With ST-Segment Elevation Acute Myocardial Infarction

BackgroundThe use and impact of intravascular imaging in ST-elevation myocardial infarction (STEMI) patients has received limited study.MethodsWe queried the National Inpatient Sample database (NIS) between January 2016 and December 2017 to identify hospitalizations of STEMI patients who underwent percutaneous coronary intervention (PCI). We used a 1:2 propensity-score (PS) matched analysis to compare in-hospital outcomes in patients with vs. without use of intravascular imaging. We conducted a multivariable regression analysis to identify variables independently associated with in-hospital mortality.ResultsWe identified 252,970 weighted discharges of PCI in STEMI patients, 5.5% of which included intravascular imaging. Patients in whom intravascular imaging was used were more likely to have acute stent thrombosis (4.7% vs. 1.4%, p < 0.001) and present with anterior STEMI (48.1% vs. 39.1%, p < 0.001). After PS matching (intravascular imaging n = 14,015, no intravascular imaging n = 28,025), the use of intravascular imaging was associated with lower in-hospital mortality (3.6% vs. 4.8%, p = 0.010). The risk of in-hospital complications and discharge to a facility (nursing facility or short-term acute hospital) was similar between both groups before and after PS matching. The use of intravascular imaging was associated with a higher index hospitalization cost [$25,218 vs. $20,515, p < 0.001]. On multivariable analysis, intravascular imaging was independently associated with lower in-hospital mortality [OR 0.735 (95% CI 0.662–0.816), p < 0.001].ConclusionIntravascular imaging was used in 5.5% of PCIs in STEMI patients and was independently associated with lower in-hospital mortality and higher index hospitalization cost.     

Prognostic value of brain natriuretic peptide in ST-elevation myocardial infarction patients: A Portuguese registry

IntroductionBrain natriuretic peptide (BNP) is a highly sensitive and specific biomarker for the extent of myocardial infarction that is strongly related to short- and long-term prognosis in patients with acute coronary syndromes.ObjectiveTo assess the prognostic value of BNP levels in a Portuguese cohort of ST-elevation myocardial infarction (STEMI) patients.MethodsWe performed a retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010 and 2019. Patients were divided into three groups according to BNP level (<100 pg/ml, 100-399 pg/ml and ≥400 pg/ml) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. For sample homogenization, propensity score matching and pairwise matching with a tolerance level of 0.005 were performed.ResultsA total of 1650 patients were included, of whom 21.5% presented high BNP levels (≥400 pg/ml). These were older and had more comorbidities, lower admission systolic blood pressure and hemoglobin, higher heart rate, Killip class and creatinine, worse left ventricular systolic function and severe coronary anatomy. Higher BNP was associated with more in-hospital complications, in-hospital mortality and adverse outcomes at one year.ConclusionBNP levels during the index hospitalization were a powerful prognostic biomarker for all-cause mortality and major adverse cardiac events in patients admitted with STEMI to Portuguese hospitals.     

Heterogeneity of the No-Reflow Group After Primary Percutaneous Coronary Intervention Due to ST-Segment Elevation Myocardial Infarction - Are There Sex Differences?

AimsAssessment of the diversity in the no-reflow population after primary percutaneous coronary intervention (pPCI) due to ST-segment elevation myocardial infarction (STEMI). Are there any gender-related differences?Material and methodsAnalysis of 1063 STEMI patients with Thrombolysis in Myocardial Infarction (TIMI) grade 0 or 1 following pPCI. The study group consisted of 685 patients with TIMI grade 0 and of 378 patients with TIMI grade 1. We analyzed clinical characteristics, in-hospital mortality and 2-year follow-up in both groups.ResultsAmong women with the TIMI grade 1 an atrial fibrillation, tachycardia and impaired ejection fraction were more common than in men. The vessel responsible for myocardial infarction was most commonly the left anterior descending (LAD) in women, whereas the right coronary artery (RCA) in men. These differences were not observed in group with TIMI grade 0. We observed a higher incidence of in-hospital death in the population with TIMI grade 0 compared with TIMI grade 1 (21.9% vs 17.2%; p 0.0189). In the TIMI grade 1 group there was significantly higher incidence of in-hospital mortality in women compared to men (13.2% vs 22.7%; p 0,0159). Among women with postprocedural TIMI grade 0 in all periods of long-term follow-up the mortality was significantly higher compared to men (9.5% vs 17%; p 0,0111; 11.8% vs 19.7%; p 0.0139 and 16.7% vs 23.9%; p 0.043 for 6-,12-months and 2-years of follow up respectively).ConclusionsPatients with no-reflow phenomenon in infarct related artery after pPCI constitute a more diverse group than previously thought. Some differences are most likely gender-specific. The female sex might have an adverse effect on in-hospital mortality in case of TIMI grade 1 and on the long-term prognosis among patients with TIMI grade 0.     

The prognostic value of the combined use of QRS distortion and fragmented QRS in patients with acute STEMI undergoing primary percutaneous coronary intervention

Background

No study has investigated the prognostic importance of the combined use of QRS distortion and fragmented QRS (fQRS) for risk stratification in acute ST segment elevation myocardial infarction (STEMI).

Impact of Reperfusion Strategy on Aborted Myocardial Infarction: Insights From a Large Canadian ST-Elevation Myocardial Infarction Clinical Registry

BackgroundReperfusion in ST-elevation myocardial infarction (STEMI) improves survival. Moreover, early reperfusion can abort the infarct and avoid significant myocardial necrosis. Yet, limited real world data exist and comparison between reperfusion strategies has not been established.MethodsUsing a comprehensive Canadian registry of consecutive STEMI patients, we prospectively collected serial electrocardiograms (ECGs) and clinical data from August 2006 to March 2011. Aborted myocardial infarction (AbMI) was defined as a maximal creatine kinase ≤ 2 times the upper limit of normal with evolutionary ECG changes of STEMI. ECG confounders and subjects with incomplete data were excluded.ResultsOf the 2235 STEMI patients reperfused within 12 hours, 16.0% were considered to have an AbMI. Numerically, higher rates of AbMI with fibrinolysis vs primary percutaneous coronary intervention were reported (17.0% vs 14.7%; P = 0.15) with a temporal pattern seen up to 4 hours from symptom onset in favour of fibrinolysis (P trend < 0.001). Most notably, the highest frequency of AbMI was observed within the first hour with fibrinolysis (31.1%). Improved in-hospital outcomes (death/shock/congestive heart failure) were seen with AbMI (5.6% vs 13.6%; P < 0.001; adjusted odds ratio, 0.22; 95% confidence interval, 0.08-0.57).ConclusionsIn a large contemporary Canadian STEMI registry, AbMI appears to be common and associated with improved clinical outcome. Early reperfusion seems to enhance AbMI particularly when fibrinolysis is administered within 1 hour of symptom onset.     

急性右心室心肌梗死的临床特点及预后分析

目的 对急性下壁心肌梗死住院患者的临床资料进行分析,观察合并右心室梗死对病情和转归的影响,并探讨早期再灌注治疗对预后的作用.方法 急性下壁心肌梗死患者304例,其中单纯下壁心肌梗死232例,合并右心室梗死72例,记录一般资料、并发症、实验室检查和治疗情况.结果 右心室梗死组心源性休克、机械并发症、完全性房室传导阻滞、心室颤动、持续性室速和再梗死均明显增高.单纯下壁心肌梗死组病死率为8.6%,右心室梗死组病死率为34.7%.右心室梗死组进行再灌注治疗者病死率为27.8%,保守治疗者病死率为55.6%.结论 右心室梗死作为急性心肌梗死的高危亚组,其严重并发症和病死率显著增加.通过早期再灌注治疗能显著降低右心室梗死的住院期病死率,改善预后.     

Electrocardiographic factors playing a role in ischemic ventricular fibrillation in ST elevation myocardial infarction are related to the culprit artery.

BACKGROUND: Sudden cardiac death caused by ischemic ventricular fibrillation (VF) associated with ST elevation myocardial infarction (STEMI) is one of the most frequent causes of death. OBJECTIVE: We hypothesized that electrocardiographic (ECG) characteristics differ between STEMI patients with and without ischemic VF. METHODS: Fifty-five first STEMI patients with at least one 12-lead ECG recorded before ischemic VF were compared with 110 first STEMI patients without ischemic VF. Patients with bundle branch blocks or high-degree atrioventricular blocks with escape rhythms were not included. ECG measurements were performed manually after scanning the ECG with the most prominent ST deviation into a software environment and magnifying it 4 times. RESULTS: Mean age was 57 +/- 12 years, and 126 patients were male. No differences were present between the VF and control group regarding baseline, enzymatic, and angiographic data. In left circumflex artery and right coronary artery myocardial infarction, a longer QRS interval (109 +/- 23 ms vs. 91 +/- 16 ms, P = .02 and 107 +/- 24 ms vs. 93 +/- 19, P = .02) was present. In the latter the PR interval (211 +/- 64 ms vs. 160 +/- 36 ms, P <.001) and ST deviation score (3.6 +/- 1.0 mV vs. 1.7 +/- 1.5 mV, P <.001) were also increased. In the left anterior descending artery group no differences in conduction intervals and ST deviation score were present. CONCLUSION: Longer PR and QRS intervals in right coronary artery and left circumflex artery MI fit with the perfusion and activation pattern of the atrioventricular node and the ventricular myocardium. Myocardium perfused by the left anterior descending artery is activated earliest, hiding any intraventricular conduction delay within the QRS complex. Intramural slowed conduction could be a substrate for ischemic VF.     

Comparison in Prevalence,Predictors, and Clinical Outcome of VSR Versus FWR after Acute Myocardial Infarction: The Prospective,Multicenter Registry MOODY Trial-Heart Rupture Analysis

BackgroundDifferences in the predictors between ventricular septal rupture (VSR) and free wall rupture (FWR) have not been fully studied. Data on the prevalence and clinical outcome of heart rupture are limited.HypothesisThis study aimed to investigate heart rupture incidence and clinical results in patients with acute myocardial infarction (AMI).MethodsOf 9265 AMI patients in the MOODY registry between March 1999 and October 2016, a total of 146 were studied. The primary clinical endpoint was rupture prevalence and in-hospital mortality. Independent factors of heart rupture were analyzed using Cox proportional model and were compared between patients with VSR and those with FWR.ResultsOf 9265 AMI patients, 146 (1.58%) patients had a heart rupture (FWR, 94 (1.02%)) and VSR (52 (0.56%)). All patients with FWR died during hospitalization, and in-hospital mortality was recorded in 37 (71.2%) patients with VSR, who had an extremely longer time delay from AMI onset to the first medical contact (FMC) (~20 h). FWR usually occurred in patients with ST-elevation myocardial infarction (STEMI) patients with a FMC ≥ 3 h, for whom primary reperfusion was not performed. Percutaneous repair at 1–2 weeks following AMI was associated with less mortality, and 9 of 38 patients who underwent non-primary reperfusion died post procedure.ConclusionThis study demonstrated the importance of shortening FMC to prevent VSR and of early primary reperfusion in STEMI patients to reduce FWR. Urgent closure of rupture is necessary to reduce in-hospital and 1-year mortality.Clinical trial registrationhttp://www.clinicaltrials.org, identifier: No. NCT03051048.     

Association between delayed transthoracic echocardiography and in-hospital mortality in type A acute aortic dissection-associated ST-segment elevated myocardial infarction

BackgroundThis study evaluates the association between transthoracic echocardiography (TTE) timing and in-hospital mortality among individuals presenting with ST-segment elevated myocardial infarction (STEMI) complicating type A acute aortic dissection (TAAAD).MethodsThis cohort study obtained the data of previously published case reports from searches of PubMed (1990–2020), and adults with STEMI secondary to TAAAD were finally included. Delayed TTE (dTTE) exposure was defined as when the TTE test was made available after antithrombotic management for STEMI due to an initially missed diagnosis of TAAAD. The primary outcome of interest was in-hospital mortality, comparing individuals with dTTE and those with emergency TTE (eTTE). The odds ratio (OR) with 95% confidence interval (CI) were calculated to provide an estimate of association.ResultsA total of 109 individuals with a mean age of 56.7 [standard deviation (SD) 12.9] years, and of whom 75 were men (68.8%) presenting with STEMI complicating TAAAD were included. Of all patients, 68 (62.4%) had a dTTE test, which tended to be associated with increased in-hospital mortality after adjustment (OR, 2.320; 95% CI, 0.743–7.248). The association between dTTE and in-hospital death was significant only among patients presenting with a high-risk examination (HRE) (OR, 11.196; 95% CI, 1.322–94.803) and with surgical therapy (OR, 5.375; 95% CI, 1.080–26.700), and not among those presenting with negative HRE (OR, 0.150; 95% CI, 0.016–1.397) and no surgical therapy (OR, 0.177; 95% CI, 0.008–4.018).ConclusionsThis study found an association between dTTE and increased in-hospital mortality in TAAAD-associated STEMI patients with surgical management. This association warrants further investigation.