Limitations of a QRS scoring system to assess left ventricular function and prognosis at hospital discharge after myocardial infarction

The value of a QRS scoring system derived from 12 lead electrocardiograms to estimate left ventricular ejection fraction was assessed in a prospective study of 285 hospital survivors of myocardial infarction. In these patients both the QRS score and ejection fraction were measured by radionuclide ventriculography at discharge. The correlation between ejection fraction and QRS score was weak. In 22 patients who died during six to 12 months follow up the ability of the ejection fraction and QRS score to predict mortality was assessed in terms of sensitivity, specificity, predictive value of a positive and negative test, and efficiency. For ejection fraction less than 40% and a QRS score greater than or equal to 6 sensitivity was respectively 73% and 64%, specificity 73% and 56%, predictive value of a positive test 18% and 11%, predictive value of a negative test 97% and 95%, and efficiency 73% and 56%. Both ejection fraction and QRS score may be used to identify patients at low and high risk during one year follow up, but, contrary to initial expectations, the QRS score appears to be of little value in estimating ejection fraction and is less accurate than ejection fraction in predicting late survival in hospital survivors of myocardial infarction.     

心电图和超声心动图及左心室造影检查在心肌梗死合并室壁瘤患者中的诊断价值

目的探讨心电图和超声心动图及左心室造影对左心室室壁瘤的诊断价值。方法以手术发现为金标准,回顾性分析心肌梗死患者108例与室壁瘤患者17例,比较心电图和超声心动图及左心室造影检查对诊断左心室室壁瘤的敏感性、特异性、诊断准确率。结果心电图和超声心动图及左心室造影诊断室壁瘤的敏感性、特异性、诊断准确率分别为:58.8%,83.5%,40.0%;41.2%,95.6%,63.6%;86.7%,91.9%,65.0%。结论心电图对室壁瘤诊断具有简便,价廉,快速的特点,临床可作为首选方法。但确诊左心室室壁瘤,需要行超声心动图、左心室造影等检查。     

Limitations of a QRS scoring system to assess left ventricular function and prognosis at hospital discharge after myocardial infarction.

The value of a QRS scoring system derived from 12 lead electrocardiograms to estimate left ventricular ejection fraction was assessed in a prospective study of 285 hospital survivors of myocardial infarction. In these patients both the QRS score and ejection fraction were measured by radionuclide ventriculography at discharge. The correlation between ejection fraction and QRS score was weak. In 22 patients who died during six to 12 months follow up the ability of the ejection fraction and QRS score to predict mortality was assessed in terms of sensitivity, specificity, predictive value of a positive and negative test, and efficiency. For ejection fraction less than 40% and a QRS score greater than or equal to 6 sensitivity was respectively 73% and 64%, specificity 73% and 56%, predictive value of a positive test 18% and 11%, predictive value of a negative test 97% and 95%, and efficiency 73% and 56%. Both ejection fraction and QRS score may be used to identify patients at low and high risk during one year follow up, but, contrary to initial expectations, the QRS score appears to be of little value in estimating ejection fraction and is less accurate than ejection fraction in predicting late survival in hospital survivors of myocardial infarction.     

单独用aVR导联鉴别诊断宽QRS波心动过速——附200份心电图分析

目的:应用Verecki新提出的单独运用aVR导联新法则对宽QRS 波心动过速进行鉴别诊断,评价其敏感性、特异性、阳性预测值、阴性预测值及诊断符合率.方法:选择200份经电生理检查诊断明确的宽QRS 波心动过速的心电图,采用单盲法由2位研究人员运用aVR导联新法则进行回顾性分析,并进行一致性检验后,统计aVR导联新法则每一步的诊断情况,计算敏感性、特异性、阳性预测值,阴性预测值及诊断符合率.结果:运用aVR导联新法则诊断的敏感性为97.6%,特异性为 67.7%,阳性预测值94.3%,阴性预测值为84.0%,诊断符合率为93.0%,对左室特发性室速的误诊例数为0.结论:单独运用aVR导联进行诊断具有高效准确,特别适合左室室速的鉴别诊断,适合临床应用.     

Increasing precordial QRS voltage correlates with improvement in left ventricular function following anterior myocardial infarction

To evaluate whether changes in QRS voltage reflect changes in left ventricular function after myocardial infarction, 28 patients were studied following anterior myocardial infarction. Two-dimensional echocardiograms and 12-lead electrocardiograms were obtained during the acute phase of the infarction and again after at least 30 days of recovery (mean, 8 +/- 8 months). At follow-up, 11 patients (group A) showed improvement in left ventricular systolic function; 9 had increased net QRS voltage in V1-6 and 8 in V1-4. No improvement in ventricular function was found in 17 patients (group B); 7 had increased QRS voltage in V1-6 (p less than 0.05 vs group A) and only 5 in V1-4 (p less than 0.05 vs group A). For detection of improved left ventricular function, the sensitivity, specificity, and predictive value of the change in net QRS voltage for leads V1-6 was 82%, 59%, and 56% respectively, and for leads V1-4 was 73%, 71%, and 62% respectively. Neither R wave voltage, Q wave voltage, nor the total number of Q waves was reliable for identifying patients with improving left ventricular function. Thus, increasing net QRS voltage in the precordial electrocardiographic leads during long-term follow-up after anterior myocardial infarction correlates with and has a reasonable sensitivity for detection of improvement in left ventricular systolic performance.     

Fragmented narrow QRS complex: Predictor of left ventricular dyssynchrony in non-ischemic dilated cardiomyopathy

BackgroundCardiac resynchronization therapy is an important therapeutic modality in drug refractory symptomatic patients of heart failure with wide QRS (≥120 ms) on electrocardiogram. However, wide QRS (considered as a marker of electrical dyssynchrony) occurs in only 30% of heart failure patients, making majority of drug refractory heart failure patients ineligible for resynchronization therapy. Significant numbers of patients with narrow QRS have echocardiographic evidence of left ventricular dyssynchrony. However, there is sparse data about additional features on the surface ECG which can predict intraventricular dyssynchrony. This study was undertaken to assess the utility of fragmented narrow QRS complex to predict significant intraventricular dyssynchrony in symptomatic patients of non-ischemic dilated cardiomyopathy.Method100 symptomatic patients of non-ischemic dilated cardiomyopathy with narrow QRS complexes (50 each with fragmented and normal QRS) were recruited. Tissue Doppler imaging was used to assess intraventricular dyssynchrony as per ‘Yu index’.Results78% patients (n = 39) in fQRS complex group and 14% (n = 7) in normal QRS complex group had significant intraventricular dyssynchrony (χ² = 20.61; p < 0.000005). fQRS complexes had 84.78% sensitivity, 79.62% specificity, a positive predictive value of 78% and negative predictive value of 86% to detect intraventricular dyssynchrony. fQRS also had sensitivity and specificity of 93% and 90% respectively to localize the dyssynchronous segment.ConclusionfQRS is a marker of electrical dyssynchrony, which results in significant intraventricular dyssynchrony in patients of non-ischemic dilated cardiomyopathy and a narrow QRS interval. fQRS localizes the dyssynchronous segment and might be useful in identifying patients who can benefit from cardiac resynchronization therapy.     

Sympathetic overactivity in patients with left ventricular aneurysm in early period after anterior myocardial infarction: does sympathetic activity predict aneurysm formation?

Left ventricular aneurysm (LVA) is an important complication of acute transmural myocardial infarction (MI) that bears great clinical significance because of high mortality. Heart rate variability (HRV) analysis is extensively used to evaluate autonomic modulation of sinus node and to identify patients at risk for an increased cardiac mortality. In this study, the authors evaluated HRV in patients with LVA in the early period after acute anterior wall MI. They compared 18 patients (7 men, 11 women, with an average age of 56.1 +/-8.2 years) with LVA and 46 patients (34 men, 12 women, with an average age of 56.4 +/-5.9 years) without LVA. Mean heart rate, low frequency (LF) and low-frequency/high-frequency (LF/HF) ratio were significantly higher and standard deviation of normal-to-normal RR intervals (SDNN), root mean square of successive differences (RMSSD), number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50), and HF were lower in the patients with LVA. A SDNN <78 ms separated the patients with aneurysm from those without aneurysm with a sensitivity of 78%, specificity of 83%, positive predictive accuracy of 79%; a LF/HF ratio >2.4 with a sensitivity of 92%, specificity of 88%, and positive predictive accuracy of 92%. Single-vessel disease increased the left ventricular aneurysm formation by 5.1 fold, total left anterior descending artery (LAD) occlusion by 3.1 fold, mean heart rate >75 beats/minute by 2.3 fold, SDNN <78 ms by 7.9 fold, and LF/HF ratio >2.4 by 12.9 fold, but well-developed collaterals decreased the aneurysm formation by 4.4 fold. As a result, HRV analysis supplies parameters with high predictive value for LVA formation in the early period after acute anterior MI. The higher sympathetic activity and reduced heart rate variability may be associated with a higher incidence of complications such as ventricular arrhythmias and increased mortality in patients with LVA.     

The utility of fragmented QRS complexes to predict significant intraventricular dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval

BACKGROUND:

Fragmented QRS complexes in the electrocardiograms (ECGs) of patients with coronary artery disease are associated with adverse cardiac events. However, there are limited data on its predictive usefulness in patients with nonischemic dilated cardiomyopathy. Left ventricular dyssynchrony is common in heart failure patients who have wide QRS intervals, but its frequency in patients with narrow QRS intervals is uncertain.

OBJECTIVES:

To investigate the relationship between fragmented QRS complexes and intraventricular dyssynchrony in patients with nonischemic dilated cardiomyopathy in sinus rhythm.

METHODS:

Sixty nonischemic dilated cardiomyopathy patients with sinus rhythm and narrow QRS intervals were recruited. Forty patients had a fragmented QRS in their basal ECG, and 20 patients did not have a fragmented QRS. Patients were analyzed for correlation between fragmented QRS complexes and intraventricular dyssynchrony.

RESULTS:

The maximal difference in time to the peak myocardial systolic velocity between any two left ventricular segments (Max-ASE Sys), and maximal difference between Max-ASE Sys and the mean value of all segments (Max-ASE to Mean Sys) were significantly higher in patients with fragmented QRS complexes (P=0.001 and P=0.003, respectively). Seventy-two per cent of the patients with fragmented QRS complexes had significant left ventricular dyssynchrony; 15% of patients without fragmented QRS complexes had significant left ventricular dyssynchrony (P<0.0001). The presence of fragmented QRS complexes in leads corresponding to the specific ventricular segment in basal ECG was found to detect intraventricular dyssynchrony with 90.6% sensitivity (negative predictive value of 85%).

CONCLUSION:

Fragmentation in the resting ECG is associated with significant intraventricular dyssynchrony in patients with nonischemic cardiomyopathy, narrow QRS and sinus rhythm. Fragmentation in ECG might be useful in identifying patients who could benefit from cardiac resynchronization therapy.     

Electrocardiographic diagnosis of left ventricular hypertrophy in the presence of left bundle branch block

The electrocardiographic diagnosis of LVH in the presence of LBBB has previously been difficult. Thirty-seven patients with complete LBBB were identified and had echocardiography performed. Using an accepted echocardiographic formula, left ventricular mass was calculated. Twenty of the 37 patients (54%) were classified as having severe LVH. Multiple conventional ECG criteria for LVH were then evaluated. No QRS voltage criteria showed any difference between patients with and without LVH (P = NS). There was also no correlation between either QRS axis or left atrial enlargement and left ventricular mass (P = NS). However, the QRS duration was significantly longer in the patients with LVH (160 +/- 12 msec) than in the normal patients (148 +/- 11 msec) (P less than 0.001). The sensitivity, specificity, positive predictive value, and accuracy of several voltage criteria and QRS duration were examined. The best voltage criteria had a sensitivity of only 50% and a predictive value of 63%. However, a QRS duration greater than 155 msec had a sensitivity of 60% and a predictive value of 82%. This study demonstrates that the conventional QRS voltage criteria for LVH are not accurate in LBBB. A relationship exists between increasing QRS duration in LBBB and LVH; therefore, the relative probability adjectives: "consider," "possible," and "probable" should be used. QRS duration greater than 155 msec is predictive of LVH despite the presence of LBBB.     

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.     

Electrocardiographic detection of left ventricular hypertrophy in the presence of left anterior fascicular block

The hitherto available electrocardiographic indexes for the detection of left ventricular hypertrophy in the presence of left anterior fascicular block do not provide a reliable diagnosis. Consequently, a new index based on the behavior of the QRS complex in left anterior fascicular block in the frontal and horizontal plane was constructed and its value assessed by echocardiographic measurements. The new index SIII + (R + S) maximal precordial greater than or equal to 30 mm was applied to the electrocardiograms of 50 patients without myocardial infarction and without right bundle branch block, showing a specificity of 87%, a sensitivity of 96%, a positive predictive value of 89% and a negative predictive value of 95%. Echocardiographic measurements were used as reference. Compared with the electrocardiographic indexes used so far (which were also applied to the 50 electrocardiograms), the new index showed a comparable high specificity and a distinctly superior sensitivity. The apparent paradox--why the electrocardiographic diagnosis of left ventricular hypertrophy is easier in the presence rather than in the absence of left anterior fascicular block--is discussed.     

Tc-99m tetrofosmin myocardial SPECT perfusion imaging: comparison of rest-stress and stress-rest protocols

Aim. The purpose of this study was to evaluate the diagnostic value of Tc-99m tetrofosmin SPECT myocardial perfusion scintigraphy rest/stress and stress/rest protocols for the assessment of coronary artery disease (CAD). Methods. 65 patients underwent both rest and stress SPECT imaging in a one-day protocol and coronary angiography within 2 months before or after scintigraphy. Scintigraphic data was obtained according to two different protocols; 1) rest-stress (n=18) and 2) stress-rest (n=47). Results. Scintigraphic evidence for myocardial ischaemia was found in 36 patients (55%). The overall sensitivity to detect CAD (>50% luminal stenosis) was 94% (34/36), specificity 66% (19/24), positive predictive value 77%, negative predictive value 90%. The sensitivity to detect CAD for protocols 1 and 2 were 100% and 93%, specificity 56% and 70%, positive predictive value 69% and 81% and negative predictive value 100% and 88%, respectively. The left anterior descending coronary artery showed a sensitivity (overall, protocol 1 & 2) of 78%, 75% (3/4) and 79% (15/19) and a specificity of 71%, 64% (9/14) and 75% (21/28). The right coronary artery showed a sensitivity (overall, protocol 1 & 2) of 91%, 100% (6/6) and 88% (14/16) and a specificity of 70%, 92% (11/12) and 61% (19/31). The left circumflex coronary artery showed a sensitivity (overall, protocol 1 & 2) of 50%, 67% (2/3) and 46% (6/13) and a specificity of 94%, 100% (15/15) and 91% (31/34). Conclusion. Tc-99m tetrofosmin appears to be a valuable tool in predicting significant CAD. The sensitivity and the positive predictive value are high, making this test highly appropriate for the diagnosis of CAD. The diagnostic value of the individual coronary arteries is high to moderate. No significant differences were found between both protocols.     

The signal-averaged electrocardiogram in predicting coronary artery disease

The ability to noninvasively detect coronary artery disease (CAD) in patients undergoing diagnostic cardiac catheterization was studied using a signal-averaged electrocardiogram. An initial study of 13 patients revealed that a QRS duration greater than or equal to 100 msec, a root mean square voltage in the terminal 40 msec of the QRS less than 50 microV, and a low amplitude signal (LAS) duration greater than 28 msec were suggestive of CAD. These parameters were then used prospectively to examine 40 consecutive patients with chest pain of undetermined etiology referred for cardiac catheterization. Patients with CAD had significantly longer filtered QRS and LAS durations and lower root mean square voltages compared with patients without CAD. The sensitivity, specificity, and positive predictive value of a single parameter ranged from 62% to 76%, 74% to 89%, and 75% to 87%, respectively. Thus the signal-averaged electrocardiogram may be a useful tool in evaluating patients for the presence of CAD.     

Portable-type signal-averaged electrocardiography with dipyridamole to detect patients with coronary artery disease.

BACKGROUND: In a retrospective study portable-type signal-averaged electrocardiography (SAECG) with dipyridamole stress was found to identify patients with coronary artery disease (CAD) at their bedside with high sensitivity and specificity, so the utility of this method was prospectively investigated in the present study. METHODS AND RESULTS: Standard 12-lead QRS wave SAECG was performed before and after dipyridamole stress at the bedside in 71 patients with chest pain (43 males, mean age 63 +/-9 years). The filtered QRS duration (fQRSd) before and after dipyridamole stress was determined by multiphasic oscillation method for each of the standard 12 leads, and the maximal value of changes in fQRSd (MAX DeltafQRSd) among the 12 leads was determined. The positive test was defined as MAX DeltafQRSd >or=5 ms, and negative as MAX DeltafQRSd <5 ms based on the previous study. Selective coronary arteriography was performed next. In the positive group (n=31), 25 patients had significant stenosis of the coronary artery and 6 did not. In the negative group (n=40), 5 patients had significant stenosis and 35 did not. The sensitivity, specificity, positive predictive accuracy and negative predictive accuracy for CAD detection by SAECG was 83%, 85%, 81% and 88%, respectively. CONCLUSIONS: Dipyridamole-stress portable SAECG is useful for detecting CAD at the patient's bedside with high sensitivity and specificity.     

Differentiation between right and circumflex coronary artery disease on thallium myocardial perfusion scanning

Thallium defects in the inferior and lateral walls of the heart were correlated with right and circumflex coronary artery disease (CAD) in 405 patients who underwent coronary arteriography. In the 102 patients with either single right or left circumflex (LC) CAD, inferior segment defects (anterior view) were associated with right CAD, and both lateral segment defects (40 ° left anterior oblique view) and posteroinferior defects (60 ° left anterior oblique view) were associated with LC CAD. In all 405 patients, inferior segment defects had a sensitivity of 65%, a specificity of 92%, and a predictive accuracy of 89% for right CAD, and lateral segment defects had a sensitivity of 52%, a specificity of 96%, and a predictive accuracy of 90% for LC CAD. Posteroinferior defects had a low predictive accuracy for narrowing in either artery. The presence or absence of concomitant anterior defects did not alter these results. Narrowing in both right and LC coronary arteries was best identified by a combination of inferior and lateral segment defects (sensitivity 30%, specificity 96%, predictive accuracy 72% ). Narrowing in only 1 of these 2 arteries was best identified by a combination of inferior segment without lateral segment defects for right CAD (sensitivity 63%, specificity 86%, predictive accuracy 55%) and lateral segment without inferior segment defects for LC CAD (sensitivity 45%, specificity 92%, predictive accuracy 57%). Thallium scanning identifies significant narrowing in the right and LC coronary arteries, and these may be separated by the pattern of defects.     

Improving the predictive ability of the signal-averaged electrocardiogram with a linear logistic model incorporating clinical variables

To improve the predictive accuracy of the signal-averaged electrocardiogram, we created a linear logistic model for predicting ventricular tachycardia during electrophysiologic testing. This signal-averaged electrocardiographic model was created from data obtained from 214 patients undergoing electrophysiologic testing (70 had ventricular tachycardia during electrophysiologic testing) by using stepwise logistic regression to rank eight clinical and nine signal-averaged electrocardiographic variables. The best predictors were ejection fraction, history of infarction, ventricular ectopic pairs or nonsustained ventricular tachycardia on Holter monitoring, QRS duration after 25-Hz filtering, and root mean square voltage of the terminal 40 msec of the QRS complex after 40- and 80-Hz filtering. Cross validation (a statistical technique that can be used to accurately evaluate how a predictive model will perform on a prospective patient population) was used to validate the model. After cross validation, the model's sensitivity was 91% and specificity was 59% for predicting ventricular tachycardia during electrophysiologic testing. This model compared favorably with established 25-Hz late-potential criteria (QRS duration of more than 110 msec and root mean square voltage of less than 25 microV of the terminal 40 msec of the QRS complex; sensitivity, 64%; specificity, 85%) and with established 40-Hz late-potential criteria (QRS duration of more than 114 msec or root mean square voltage of less than 20 microV of the terminal 40 msec of the QRS complex or duration of the low-amplitude signal less than 40 microV at the terminal QRS complex that is greater than 38 msec; sensitivity, 84%; specificity, 54%).(ABSTRACT TRUNCATED AT 250 WORDS)     

改良Brugada四步法诊断室性心动过速价值初探

为评价改良的Brugada四步法诊断室性心动过速（VT）的价值，对心电图表现为宽QRS波（QRS时限＞110ms），心动过速行射频消融术的连续病例24例（其中经心脏电生理检查证实VT19例，室上性心动过速5例）进行回顾性分析，结果显示改良的Brugada四步法对VT的敏感性为94．7％，特异性为80％，阳性预告值为94．7％。     

A new ECG algorithm for the localization of accessory pathways using only the polarity of the QRS complex

A new algorithm is proposed for localization of accessory atrioventricular pathways by use of a 12-lead electrocardiogram (ECG). The polarity of the QRS complex in leads III, V₁, and V₂ from 102 patients with Wolff-Parkinson-White syndrome with manifested preexcitation who underwent successful radiofrequency catheter ablation was analyzed. Accessory pathways on the right side of the heart were localized to three regions around the tricuspid annulus, and left-sided pathways were localized to two regions around the mitral valve annulus. In 42 of 46 patients (91%) with left posterolateral accessory pathways, a common characteristic of the ECG was a positive QRS complex in leads III and V₁ (sensitivity 91%, specificity 95%). Of 19 patients with left inferior paraseptal or inferior accessory pathways, 16 (84%) had a negative QRS complex in lead III and a positive QRS complex in lead V₁ (sensitivity 84%, specificity 98%). All six patients with right anterosuperior paraseptal accessory pathways had a positive QRS complex in lead III but a negative QRS complex in lead V₁ (sensitivity 100%, specificity 97%). The 25 patients with right inferior paraseptal or inferior accessory pathways had a negative or isodiphasic QRS complex in leads III and V₁, but the QRS complex was positive in lead V₂ in 21 (84%) of these patients (sensitivity 84%, specificity 100%). Finally, five of the six patients (83%) with right anterior accessory pathways had a negative QRS complex in leads III, V₁, and V₂ (sensitivity 83%, specificity 96%). With the algorithm, the localization of accessory pathways was thus identified in 90 of the 102 patients (88%).     

Left ventricular aneurysm formation after anterior myocardial infarction: clinical and angiographic determinants in 809 patients.

BACKGROUND: Previous studies have reported controversial results regarding the clinical and angiographic factors involved in the left ventricular aneurysm (LVA) formation after myocardial infarction (MI). OBJECTIVE: This study was performed to determine the clinical and angiographic factors that are priori predictors of LVA following anterior myocardial infarction and so to provide a paradigm which may identify patients who were candidates for aneurysm formation. METHODS: Of the patients who underwent coronary angiography during the interval between 1995 and 2000 in our clinic, 809 were found to have anterior MI and LVA (aneurysm group) (677 men, 132 women, mean age 53.3+/-11.4 years). The clinical and the angiographic data of these patients were compared with those of 446 patients (399 men, 47 women, mean age 55.2+/-10.5 years) with previous anterior MI and without LVA (control group). RESULTS: LVA was found to occur more frequently in females (16.3% in women and 10.4%, in men, P=0.03) and in patients without previous angina (23.5 vs. 8.2%, P<0.0001). Major cardiovascular risk factors, previous anti-anginal medication and thrombolytic therapy did not show a significant difference between the two groups. Angiographic examination revealed that single-vessel disease, proximal left anterior descending artery (LAD) stenosis, total LAD occlusion, mean stenosis in LAD artery, end-diastolic pressure and left ventricular score were all higher in the aneurysm group compared to control group. After adjustment for other clinical and angiographic variables, single-vessel disease [odds ratio (OR) 5.89, 95% confidence interval (CI)=3.68-9.28, P<0.0001), absence of previous angina (OR=4.21, 95% CI=2.1-7.48, P=0.0003), total LAD occlusion (OR=2.63, 95% CI=1.97-3.53, P<0.0017) and female gender (OR=1.60, 95% CI=1.20-2.28, P=0.043) remained the independent determinants of LVA formation after anterior MI. CONCLUSION: In patients with LVA, logistic regression analysis revealed that (1) single-vessel disease, (2) absence of previous angina, (3) total LAD occlusion and (4) female gender were independent determinants in the formation of LVA after anterior MI. Coronary collateral status and risk factors, such as hypertension, diabetes mellitus, hypercholesterolemia, smoking and family history of CAD were not found to be important determinants in the aneurysm formation.     

The early recognition of right ventricular infarction: diagnostic accuracy of the electrocardiographic V4R lead

The sensitivity and specificity of ST-segment elevation in the right precordial lead V4R as an early indicator of right ventricular infarction were examined in a consecutive series of 110 patients admitted for acute inferior myocardial infarction. The sensitivity was 82.7%, the specificity 76.9% and the positive predictive value 70% in 58 patients with right ventricular infarction documented by autopsy or a combination of radionuclide ventriculography and one or more of the following tests: echocardiography, technetium-99m pyrophosphate scintigraphy and hemodynamic monitoring. The negative predictive value was 87.7%. Because of its simplicity and its high sensitivity and specificity, recording of V4R should be an intrinsic part of the early evaluation and electrocardiographic examination of acute inferior wall infarction.