Restricted myocardial infarction. Coronary angiographic and ventriculographic findings. Comparison with acute coronary insufficiency and transmural infarction]

The findings at coronary arteriography and ventricular angiography in 52 patients with a restricted myocardial infarct were compared with those of 106 patients with acute coronary insufficiency and 100 with transmural infarcts. Certain features place restricted myocardial infarction in an intermediate category when compared with the two other syndromes. The percentage of coronary occlusions was significantly higher in transmural infarction (23.5%) and in restricted infarction (16.6%) than in acute coronary insufficiency 6.8%). Study of the vessel beyond a tight stenosis (greater than or equal to 75% was particularly effective in clearly separating the three groups. As a result, 63% of patients with coronary insufficiency, 40% of these with restricted infarcts, and only 23% of patients with a transmural infarct could be referred for surgery. Ventricular angiography showed a close relationship between restricted infarction and acute coronary insufficiency because ventricular function appeared normal or subnormal (localised hypokinesia) in 69% and 81% of cases respectively, compared with 4% of cases of transmural infarction. Restricted myocardial infarction appears to resemble coronary insufficiency, but shows elevation of enzymes and often more marked disease of distal vessels.     

急性心肌梗死合并心源性休克患者冠脉病变特点及再灌注疗法的效果

目的　探讨急性心肌梗死 (AMI)合并心源性休克患者的冠脉病变特点及再灌注疗法的效果。方法　以74例AMI患者为对象 ,按是否合并心源性休克分为休克组 16例 ,非休克组 5 8例 ,对比两组患者的临床资料 ,冠脉造影及再灌注疗法对预后的影响。结果　休克组院内病死率显著高于非休克组 (P <0 0 5 ) ;休克组各种并发症比例均显著高于非休克组 ,其中梗死延展休克组发生率为 38% ,非休克组为 5 % (P <0 0 1) ;冠脉造影显示 ,休克组 3支病变显著高于非休克组 (P <0 0 1) ,前者 99%以上的严重狭窄病变多、钙化严重及侧支循环发育不良。再灌注治疗后 ,梗死相关冠脉再通率休克组显著低于非休克组 (P <0 0 5 ) ,休克组院内病死率受梗死相关冠脉再通与否的影响 ,再通的 6例仅 1例死亡 ,而未再通的 5例 3例死亡。结论　AMI合并心源性休克患者 ,冠脉病变严重、复杂 ,病死率高 ,改善预后的关键是恢复再灌注及预防梗死延展。     

Coronary arteriographic findings in cocaine abuse-induced myocardial infarction

A 31-year-old black man was admitted with an acute anterior myocardial infarction 20 minutes after IV cocaine abuse. Cardiac catheterization showed a totally occluded left anterior descending artery. Intracoronary and intravenous streptokinase resulted in thrombolysis: repeat angiography showed a normal anterior descending.     

Pathogenesis of impending myocardial infarction and acute myocardial infarction: clinical and angiographic evaluation of coronary thrombosis as a precipitating factor

In order to investigate the role of coronary thrombosis as a precipitating factor of acute myocardial infarction (AMI), we examined coronary angiographic findings in 89 patients with AMI taken within 24 hours of the onset and in 42 patients with prolonged angina attack of impending myocardial infarction (impending MI) taken within 50 hours of the last angina attack. Furthermore, in the patients with impending MI, the effects of intracoronary and intravenous thrombolytic therapy and anticoagulant therapy used to prevent impending MI from developing into AMI, were also studied. (1) In 72 of 89 patients (81%) with AMI, coronary thrombi were detected angiographically. The thrombi were detected most frequently (88%) in angiographs taken within 3 hours of onset. (2) In 23 of 42 patients with impending MI, coronary thrombi were detected angiographically. In 6 patients with coronary thrombi who underwent intracoronary thrombolysis during angina attack, occlusive coronary thrombi in ischemia-related vessels were the observed, and recanalization by thrombolysis with intracoronary urokinase infusion relieved chest pain and improved ECG changes. (3) The incidence of AMI in 42 patients with impending MI who were treated with intracoronary and intravenous thrombolytic therapy and anticoagulant therapy was significantly less than in the conventional therapy group (80 patients) (11.9% vs. 27.5%; p less than 0.05). In 4 of 5 patients with developing AMI, coronary thrombi were detected angiographically in the acute phase of impending MI. These results indicate that coronary thrombosis plays an important role not only in the precipitation of impending MI but also in the development of impending MI to AMI.     

Coronary atherosclerosis in Type II diabetes: angiographic findings and clinical outcome

Aims/hypothesis. Prevalence and incidence of coronary heart disease (CHD) are increased in patients with Type II (non-insulin-dependent) diabetes mellitus; whether this is entirely due to more extensive coronary atherosclerosis is, however, controversial. Methods. We analysed the clinical, angiographic and follow-up data of 2253 consecutive patients undergoing coronary angiography over the decade 1983–1992. Results. Abnormal coronary arteries (≥ 50 % stenosis) were found more frequently in diabetic than in non-diabetic subjects (85 vs 67 %, p < 0.0001), the excess being explained by a higher prevalence of three-vessel disease (36 vs 17 %, p < 0.0001). The sum of all angiographically detectable lumen stenoses (atherosclerosis score, ATS) was higher in diabetic than in non-diabetic subjects (352 ± 232 vs 211 ± 201 units, p < 0.0001). After adjusting for measured cardiovascular risk factors, diabetes was still associated with an excess ATS (114 units in men and 187 units in women, p < 0.0001 for both, p < 0.03 for the interaction ATS x sex). Within the diabetic group, the only variable that was independently (of sex and age) associated with ATS was serum cholesterol, whereas plasma glucose concentration, disease duration and type of treatment were not correlated with the severity of coronary atherosclerosis. In contrast, clinical grade proteinuria was not associated with a more diffuse coronary atherosclerosis either in diabetic (366 ± 243 vs 354 ± 233 units) or non-diabetic subjects (231 ± 201 vs 207 ± 197 units). Over a mean follow-up period of 88 months, 19 % of diabetic patients compared with 10 % of non-diabetic patients died of a cardiac cause (age and sex-adjusted odds ratio OR = 1.34 [1.14–1.57]). In a Cox model adjusting for age, sex and all major risk factors, diabetes was still associated with a significant excess risk of dying of a cardiac cause (OR = 1.37 [1.14–1.60]); this excess was similar to, and independent of, that carried by the presence of prior myocardial infarction in the whole population (OR = 1.42 [1.25–1.62]). Proteinuria was associated with a higher risk of cardiac death, particularly in diabetic patients, independently of coronary atherosclerosis (adjusted OR = 1.46 [1.03–1.99]). Conclusion/interpretation. In patients undergoing angiography, diabetes, especially in women, is associated with more severe and diffuse coronary atherosclerosis which is not explained by either the traditional risk factors or the presence of proteinuria. On follow-up, these patients experience an excess of cardiac deaths, to which coronary atherosclerosis and proteinuria make independent, quantitative contributions. [Diabetologia (2000) 43: 632–641] Received: 13 December 1999 and in revised form: 7 March 2000     

Relationship between electrocardiographic pattern and angiographic findings in inferior myocardial infarction

The relationship between electrocardiographic pattern and angiographic features was assessed in 86 patients with inferior myocardial infarction. Although the occurrence of inferior Q wave was similar in patients with isolated left circumflex (LCX) or right coronary artery (RCA) occlusion, lateral Q wave and abnormal R wave in lead V1 were more frequent in the former. In patients with LCX-related infarction, abnormal R wave in lead V1 associated with inferior and/or lateral Q waves may indicate left ventricular dysfunction, total occlusion of the LCX without collateral circulation, and high cardiac event rate during longterm follow-up.     

女性ST段抬高心肌梗死患者临床特点和近期预后分析

目的评价女性ST段抬高心肌梗死患者的临床特点、住院期间心脏不良事件发生和病死率。方法入选我院1994年1月～2006年12月初发急性ST段抬高心肌梗死患者1233例,男性901例,女性332例,对两者临床特点、危险因素、住院并发症和病死率进行比较。结果与男性比较,女性患者年龄偏高,发病至就诊时间长,非典型症状多见;女性患者高血压、糖尿病、高脂血症、具有多重危险因素患者的比例高于男性(P0.05,P0.01);女性患者入院后接受再灌注治疗的比例低于男性;女性患者住院期间发生心力衰竭和病死率明显高于男性。结论女性心肌梗死患者临床特点、接受有效治疗的比例、住院期间预后均较男性差。     

Coronary angiographic morphology in myocardial infarction: a link between the pathogenesis of unstable angina and myocardial infarction

It has previously been shown that analysis of coronary morphology can separate unstable from stable angina. An eccentric stenosis with a narrow neck or irregular borders, or both, is very common in patients who present with acute unstable angina, whereas it is rare in patients with stable angina. To extend these observations to myocardial infarction, the coronary morphology of 41 patients with acute or recent infarction and nontotally occluded infarct vessels was studied. For all patients, 27 (66%) of 41 infarct vessels contained this eccentric narrowing, whereas only 2 (11%) of 18 noninfarct vessels with narrowing of 50 to less than 100% had this lesion (p less than 0.001). In addition, a separate group of patients with acute myocardial infarction who underwent intracoronary streptokinase infusion were also analyzed in similar fashion. Fourteen (61%) of 23 infarct vessels contained this lesion after streptokinase infusion compared with 1 (9%) of 11 noninfarct vessels with narrowing of 50 to less than 100% (p less than 0.01). Therefore, an eccentric coronary stenosis with a narrow neck or irregular borders, or both, is the most common morphologic feature on angiography in both acute and recent infarction as well as unstable angina. This lesion probably represents either a disrupted atherosclerotic plaque or a partially occlusive or lysed thrombus, or both. The predominance of this morphology in both unstable angina and acute infarction suggests a possible link between these two conditions. Unstable angina and myocardial infarction may form a continuous spectrum with the clinical outcome dependent on the subsequent change in coronary supply relative to myocardial demand.     

Coronary angiographic findings in the myocardial infarction involving the dorsal wall of the heart (author's transl)]

The Authors report the results of a coronary angiographic study in 12 patients with acute myocardial infarction in which the necrosis was extended to the dorsal wall of the heart. The electrocardiographic and vectorcardiographic criteria applied in order to assess the involvement of the dorsal wall have been those suggested by Perloff and by Hoffman and coll. and Massie and Walsh, respectively. The diagnosis of dorsal involvement has been also confirmed by the esophageal electrocardiogram. Discussing their results, the Authors consider the variants of blood supply of the posterior wall of the heart. On the basis of their angiographic findings, they underline that significant lesions of the circumflex artery, either alone or associated with narrowing of other main coronary arteries, are the most frequent finding in cases of myocardial infarction involving the dorsal wall of the heart.     

Clinical and angiographic outcome of patients with acute inferior myocardial infarction

OBJECTIVES: This study sought to determine the procedural success and the in-hospital outcome after primary coronary angioplasty in patients with acute inferior myocardial infarction and right ventricular involvement (RVI). BACKGROUND: RVI represents an easily detectable, highly prevalent subset of acute inferior infarction associated with poor outcome even in the era of thrombolysis. Primary PTCA may offer advantages in patients with inferior infarction involving the right ventricle. METHODS: Primary coronary angioplasty with optimal stenting was performed in 87 of 88 consecutive patients presenting within 24 hours after onset of acute inferior myocardial infarction. On the basis of right precordial ST segment elevations at admission, patients were classified into those without (n=61) and those with RVI (n=27). The patients were followed prospectively for angiographic success at 10 days and for in-hospital clinical outcome. RESULTS: Baseline characteristics including age, severity of coronary artery disease, proportion of stent implantation, and occurrence of cardiogenic shock were comparable. Patients with RVI had larger infarct sizes (lactate dehydrogenase level: 962 vs 580 U/l, P=0.03), developed more often complete atrioventricular block (18.5 vs. 2%, p=0.0038), needed more often parasympatholytics (48.1 vs 18.8%, p<0.001), and had a substantially higher incidence of the Bezold-Jarisch reflex (29.6 vs 6.6%, p<0.01) following reperfusion.Success of recanalization therapy acutely and at 10 days, as well as in hospital mortality were similar in patients with and without RVI (88.5 vs. 85.2%, 79.3 vs. 84.7%, 7.4 vs 9.8%). However, patients with RVI revealed a greater lumen gain acutely after PTCA (2.49 vs. 2.13 mm, p=0.025) and experienced less frequently major cardiac events (14.8 vs. 36.1%, p=0.04) which included reinfarction, re-ischemia, coronary bypass grafting, stent thrombosis, and cardiac death. In addition, procedural success was established more rapidly (fluoroscopy time: 10 vs 15 min., p=0.032) and with less contrast material (242 vs 295 ml, p=0.015) in patients with RVI. This is probably due to the more proximal location (84.6 vs 6.6%, p<0.0001) and the larger reference diameter (3.17 vs. 2.79 mm, p=0.03) of the occluded right coronary artery. CONCLUSIONS: Primary PTCA is an appropriate reperfusion strategy in patients with RVI. Further comparative studies are required to compare the effectiveness of primary PTCA with early thrombolytic therapy in this high risk setting.     

青年心肌梗死患者临床特点和住院期转归

目的评价青年心肌梗死患者临床特点、住院期间不良事件和病死率。方法入选我院2002年1月至2007年12月初发ST段抬高型心肌梗死患者614例,按照患者年龄分为青年组(23～44岁,96例)和老年组(60～74岁,518例),将两组临床特点(包括性别、年龄、吸烟、化验指标、并存疾患)、危险因素分布、住院并发症和病死率进行比较。结果 (1)青年组与老年组比较,早发心血管病家族史(13.0%比5.6%,P=0.021)、吸烟(82.3%比42.1%,P<0.001)、高三酰甘油血症(56.7%比34.9%,P<0.001)者比例均增高,女性(4.2%比34.4%,P<0.001)、脑血管病(1.1%比15.3%,P<0.001)、血肌酐[(93.7±8.8)μmol/L比(104.3±61.9)μmol/L,P<0.001]均减低,具有多重危险因素的患者比例(40.1%比29.0%,P<0.05)高于老年组;(2)冠状动脉造影显示,青年组以单支病变为主,多支病变的比例明显低于老年组;(3)青年组住院期间无心源性休克及死亡病例。结论吸烟和高脂血症是青年心肌梗死患者最常见的危险因素,青年心肌梗死患者冠状动脉病变较轻,短期预后较好。     

Acute myocardial infarction due to the left main coronary artery occlusion: Electrocardiographic patterns,angiographic findings,revascularization and in-hospital outcomes

BackgroundPrimary angioplasty improves outcomes of acute myocardial infarction (AMI). However, in the highest risk subgroups, the mortality remains high despite modern catheter-based reperfusion therapy. This study analyzed patients with AMI caused by the left main coronary artery unstable lesion, a subgroup considered to be associated with very high early mortality.MethodsA multicenter registry enrolled 6742 consecutive patients with AMI. Ninety-seven patients (1,4% of the entire study population) had left main as the infarct related artery. Baseline clinical characteristics, ECG patterns, coronary angiographic and echocardiographic data were correlated with the revascularization therapies used and with in-hospital outcomes.ResultsTwenty-five patients (25,8%) died during the hospital stay. The deceased patients were older, had more freqently bundle branch block on the admission ECG, had higher Killip class on presentation, more frequently had TIMI flow <3 and PCI success rate was 72% (vs. 100% among survivors). Left main coronary artery (LMCA) lesion impaired distal flow (TIMI flow 0–2 on presentation) in 35 patients: the most frequent ECG presentation pattern for these LMCA occlusions was ST segment elevation (n=17), followed by RBBB (n=9; with LAH 6 and without LAH 3), LBBB (n=6) and ST segment depression (n=3). In other words: acute LMCA occlusion presents in 51% with ECG changes other than ST segment elevations. Patients with TIMI flow 0–2 had higher Killip class on admission, lower ejection fraction and higher in-hospital mortality (37% vs. 20%), when compared to those with TIMI flow 3 on the initial angiogram.ConclusionsDespite modern interventional therapy, acute myocardial infarction caused by the left main coronary artery obstruction bears high early mortality. The presence of bundle branch block, diminished TIMI flow on the initial angiogram, higher age and Killip class are related with increased mortality.     

Correlation of reciprocal ST-segment depression after acute myocardial infarction with coronary angiographic findings.

We studied 266 consecutive patients with acute myocardial infarction to assess the significance of electrocardiographic "mirror images". Ninety-four (group A) had anterior wall and 132 (group B) had inferior wall infarction. Thirty-one group A patients had stenosis of the right coronary artery greater than 85% in diameter (subgroup A1), and 63 either had a normal right coronary artery or less than 85% stenosis (subgroup A2). Of group B patients 62 had greater than 85% stenosis of the left anterior descending (subgroup B1) and 70 had a left anterior descending or less than 85% stenosis (subgroup B2). ST-segment depression was significantly greater in depth and duration in subgroup A1 than A2 (p = 0.02) and in subgroup B1 than B2 (p = 0.02, p = 0.01, respectively). Left ventricular ejection fraction was lower in subgroup A1 than A2 (p less than 0.001) and in B1 than B2 (p less than 0.001). There was a strongly positive correlation between depth and duration of ST-segment depression and the Gensini index (r = 0.78, 0.84) for anterior and inferior infarction, respectively. In conclusion, increased depth and duration of ST-segment depression opposite the infarct are indicative of ischemia, and are related to the extent of coronary artery disease, the degree of stenosis of the vessels supplying the opposite wall and of left ventricular dysfunction.     

Cine angiographic findings in young Iraqi men with first acute myocardial infarction

Among 100 consecutive Iraqi men aged 40 years or less with first acute myocardial infarction, coronary angiography performed 8-12 weeks later showed single-vessel coronary artery disease in 64, multivessel disease in 26, and normal coronary arteries in ten patients. Most patients (90%) had one or more coronary risk factors. The left anterior descending artery was involved in 66 patients, the right coronary artery in 38, and the circumflex artery in 29. Total occlusion was seen in 37 patients and severe (greater than or equal to 90%) stenosis in 14 patients. Severe wall motion abnormality (aneurysm formation) on left ventriculography was found in 33 patients. Thus, in developing countries as elsewhere, one-vessel coronary artery disease remains the most common angiographic finding in young men with first acute myocardial infarction.