Clinical usefulness and prognostic value of elevated cardiac troponin I levels in acute pulmonary embolism

Background

Right ventricular myocardial ischemia and injury contribute to right ventricular dysfunction and failure during acute pulmonary embolism. The objective of this study was to evaluate the clinical usefulness of cardiac troponin I (cTnI) in the assessment of right ventricular involvement and short-term prognosis in acute pulmonary embolism

Methods

Thirty-eight patients with acute pulmonary embolism were included in the study. Clinical characteristics, right ventricular involvement, and clinical outcome were compared in patients with elevated levels of serum cTnI versus patients with normal levels of serum cTnI.

Results

Among the study population (n = 38 patients), 18 patients (47%) had elevated cTnI levels (mean ± SD 1.6 ± 0.7 ng/mL, range 0.7-3.7 ng/mL, median, 1.4 ng/mL), and comprised the cTnI-positive group. In the other 20 patients, the serum cTnI levels were normal (≤0.4 ng/mL), and they comprised the cTnI-negative group. In the cTnI-positive group (n = 18 patients), 12 patients (67%) had right ventricular dilatation/hypokinesia, compared with 3 patients (15%) in the cTnI-negative group (n = 20 patients, P = .004). Right ventricular systolic pressure was significantly higher in the cTnI-positive group (51 ± 8 mm Hg vs 40 ± 9 mm Hg, P = .002). Cardiogenic shock developed in a significantly higher number of patients with elevated serum cTnI levels (33% vs 5%, P = .01). In patients with elevated cTnI levels, the odds ratio for development of cardiogenic shock was 8.8 (95% CI 2.5-21).

Conclusions

Patients with acute pulmonary embolism with elevated serum cTnI levels are at a higher risk for the development of right ventricular dysfunction and cardiogenic shock. Serum cTnI has a role in risk stratification and short-term prognostication in patients with acute pulmonary embolism.     

Comparison of the correlation of the Selvester QRS scoring system with cardiac contrast-enhanced magnetic resonance imaging-measured acute myocardial infarct size in patients with and without thrombolytic therapy

Background

After an acute myocardial infarction (MI), it is important to define the infarct size because it is related to mortality and morbidity. The Selvester QRS Score is an electrocardiographic (ECG) method that has been developed for estimating MI size. It has been shown to correlate well with postmortem anatomically measured sizes of single MI in patients who did not receive thrombolytic therapy. The aim of this study was to test the hypothesis that correlation between Selvester QRS Score-estimated MI size and contrast-enhanced magnetic resonance imaging (ceMRI)-measured MI size is equivalent in patients who did vs those who did not receive thrombolytic therapy.

Methods

Thirty-six patients with MI (24 with thrombolytic therapy and 12 without) received ceMRI and ECG at admission and at 1 or 6 months after admission. Indeed, in 23 of the patients, the therapy was intravenous only. The Selvester QRS Score was calculated using the 1-month ECG or, if not available, the 6-month ECG. The correlation between the 2 measures of MI size was determined for all patients and for the 2 groups separately.

Results

The mean MI size in the group that did not receive thrombolytic therapy was 8.5% ± 6.4% estimated by the Selvester QRS Score and 11.7% ± 10.2% measured by ceMRI. For the group that received thrombolytic therapy, Selvester QRS Score was 13.9% ± 11.1% and ceMRI was 20.2% ± 11.3%. The mean MI size in both groups combined was 12.1% ± 10.0% estimated by the Selvester QRS Score and 17.3% ± 11.5% measured by ceMRI. The Spearman rank correlation coefficient between Selvester QRS Score and ceMRI was 0.74 (P < .0001) for all patients, 0.74 (P < .0001) for the group that received thrombolytic therapy, and 0.64 (P = .024) for the group that did not receive thrombolytic therapy.

Conclusions

The associations between Selvester QRS Score and ceMRI-based MI were statistically significant and similar in both groups.     

Influence of thrombolytic therapy, with or without intra-aortic balloon counterpulsation, on 12-month survival in the SHOCK trial

Background

The enhancement of diastolic coronary blood flow by the combination of thrombolytic therapy (TT) and intra-aortic balloon counterpulsation (IABP) in experimental studies provides a rationale for their combined use in acute myocardial infarction (MI) complicated by cardiogenic shock. We examined the relation between TT (with and without IABP) and 12-month survival in the SHould We Emergently Revascularize Occluded Coronaries for Cardiogenic ShocK (SHOCK) Trial.

Methods and results

Among 302 patients with myocardial infarction and cardiogenic shock who were randomized in the SHOCK Trial, 16 had absolute contraindications to TT. Among 150 patients randomly assigned to initial medical stabilization (IMS), 63% received TT, as recommended per protocol, compared with 49% of 152 patients randomly assigned to emergency revascularization, in whom TT was not recommended if immediate angiography was available. IABP deployment, which was protocol-recommended, was used in 86% of patients. The rate of severe bleeding was similar in patients receiving TT and in those not receiving TT (31% vs 26%, P = .37). Among patients randomly assigned to IMS, TT was associated with improved 12-month survival (unadjusted mortality hazard ratio, 0.59; P = .01; mortality hazard ratio adjusted for age and prior MI, 0.62; P = .02). TT was not associated with improved 12-month survival among patients randomly assigned to emergency revascularization (unadjusted mortality hazard ratio, 0.93; P = .76; mortality hazard ratio adjusted for age and prior MI, 1.06, P = .81). The test for interaction of TT and randomization group P value was .16, and there was insufficient statistical power to demonstrate a differential effect of TT on 12-month survival by treatment group assignment.

Conclusions

Among patients randomly assigned to IMS in the SHOCK Trial, TT was associated with improved 12-month survival and did not significantly increase the risk of severe bleeding.     

Comparison of serial measurements of infarct size and left ventricular ejection fraction by contrast-enhanced cardiac magnetic resonance imaging and electrocardiographic QRS scoring in reperfused anterior ST-elevation myocardial infarction

Background

Left ventricular ejection fraction (LVEF) is a powerful prognostic marker after acute myocardial infarction and is dependent on infarct magnitude. Contrast-enhanced cardiac magnetic resonance (ceCMR) represents the current criterion standard means of LVEF and infarct size measurement. Infarct size and LVEF can be estimated from the 12-lead electrocardiogram (ECG) using the Selvester QRS score. We examined for the first time the relationship between serial measures of LVEF and infarct size by ceCMR and ECG in patients with reperfused anterior ST-elevation myocardial infarction (STEMI) and depressed LVEF.

Methods

Thirty-four patients (mean ± SD age, 59 ± 11.8 years; 70.6% male) underwent ceCMR and simultaneous ECG at mean 93 hours after admission and at 12 and 24 weeks. The QRS score was calculated on each ECG, from which infarct size and LVEF were estimated and compared with the equivalent ceCMR measurements.

Results

Infarct size on ceCMR was higher than that by QRS score at each time-point (P < .001) with modest correlation (r = 0.56-0.78, P < .001). Left ventricular ejection fraction was consistently significantly higher on CMR than on ECG, with weak correlation (r = 0.37-0.51, P < .05). We derived a novel equation relating QRS score to CMR-measured LVEF in the subacute phase of infarction: LVEF = 61 − (1.7 × QRS score) (%).

Conclusions

In patients with reperfused anterior ST-elevation myocardial infarction and depressed LVEF, ceCMR is moderately correlated with the QRS in the serial measurement of infarct size and LVEF. Infarct size (measured by ceCMR) and LVEF are consistently higher than those calculated on the QRS score in the acute and subacute phases of infarction.     

Too little aspirin for secondary prevention after acute myocardial infarction in patients at high risk for cardiovascular events: Results from the MITRA study

Background

A meta-analysis of randomized trials has shown a significant reduction of mortality rate in patients receiving aspirin for secondary prevention after acute myocardial infarction (AMI). However, a significant number of patients do not receive aspirin after AMI. Little is known about why aspirin is withheld or the long-term outcome of these patients today.

Methods

The Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) registry is a multicenter registry of patients with AMI in Germany.

Results

Of 4902 patients, 509 (10%) did not receive aspirin at the time of discharge from the hospital. The mean follow-up period for these patients was 17 months. Relative contraindications to aspirin were significantly associated with the withholding of aspirin (in-hospital bleeding: odds ratio [OR], 3.56; 95% CI, 1.86-6.80; history of peptic ulcer: OR, 2.49; 95% CI, 1.62-3.83). Absolute contraindications to aspirin were rare (2.2%). Other medications of proven benefit were also given less often in these patients (β-blockers: 49.0% vs 61.9%, P <.001; angiotensin-converting enzyme inhibitors: 65.6% vs 70.2%, P = .06; statins: 12.2% vs 15.1%, P = .10). Patients who were not given aspirin were at high risk for vascular events. They were more likely to have a history of prior AMI (OR, 1.34; 95% CI, 1.02-1.79), were in critical clinical condition at admission more often (cardiogenic shock: OR, 1.98; 95% CI, 1.09-3.56; overt heart failure: OR, 1.6; 95% CI, 1.05-2.3), and received acute revascularization less often (OR, 1.32; 95% CI, 1.05-1.67). The 1-year mortality was 2-times higher in patients who did not receive aspirin than in patients who did receive aspirin (16.5% vs 8.3%, P <.001). A significant association of withheld aspirin at discharge with a higher long-term mortality rate was confirmed with multivariate analysis (OR, 1.62; 95% CI, 1.15-2.29).

Conclusions

Ten percent of patients who sustained an AMI did not receive aspirin at the time of hospital discharge. Most of these patients were at high risk for cardiovascular events. Withheld aspirin was significantly associated with higher mortality rate during follow up.     

Consideration of QRS complex in addition to ST-segment abnormalities in the estimated "risk region" during acute anterior myocardial infarction

Background

The myocardial area at risk (MaR) has been estimated in patients with acute myocardial infarction (AMI) by using ST segment-based electrocardiographic (ECG) methods. As the process from ischemia to infarction progresses, the ST-segment deviation is typically replaced by QRS abnormalities causing a falsely low estimated total MaR if determined by using ST segment-based methods. The purpose of this study was to investigate if consideration of the abnormalities in the QRS complex, in addition to those in the ST segment, provides a more accurate estimated total MaR during anterior AMI than by considering the ST segment alone.

Methods

Twenty-five patients with acute anterior ST elevation myocardial infarction (STEMI) received technetium Tc 99m-sestamibi before percutaneous coronary intervention. Single photon emission computed tomography (SPECT) was performed within 2 hours after treatment and was used as a criterion standard for the estimated total MaR. The ECG recorded at admission in the hospital was used for the ECG estimated total MaR. This included an ST-segment estimated ischemic component of the total MaR (Aldrich score) and an estimated infarcted component of the total MaR in the acute phase of AMI by QRS abnormalities (Selvester score). These scores were added for the combined ECG score.

Results

The ischemic component of the total MaR estimated by the Aldrich score alone had no statistically significant correlation with SPECT (r = 0.21, P = .32). The infarcted component of the total MaR estimated by the Selvester score showed a significant correlation with SPECT (r = 0.49, P = .01). Each score gave a significant underestimated total MaR measured by SPECT (P < .01). When the Aldrich and Selvester scores were combined, the correlation with SPECT was r = 0.47, P = .02. The combined score still underestimated the total MaR by SPECT (P < .01), though the difference was smaller in comparison to either method alone (P < .01).

Conclusion

The ECG estimated total MaR was more accurate by taking both ST deviation and QRS abnormalities into account than by using either method alone. A new ECG method to determine the total MaR during acute coronary occlusion should consider both its ischemic and infarcted components.     

Impact of acute hyperglycemia on left ventricular function after reperfusion therapy in patients with a first anterior wall acute myocardial infarction

Objective

This study was undertaken to assess the relationship between acute hyperglycemia and left ventricular function after reperfusion therapy for acute myocardial infarction (AMI).

Methods

This study consisted of 529 patients with a first anterior wall AMI who underwent coronary angiography followed by coronary angioplasty or thrombolysis within 12 hours after the onset of chest pain. Plasma glucose was measured at the time of hospital admission. Acute hyperglycemia was defined as plasma glucose >10 mmol/L.

Results

Although acute hyperglycemia was associated with both lower acute left ventricular ejection fraction (LVEF) (46% ± 12% vs 48% ± 10%, P = .026) and lower predischarge LVEF (51% ± 15% vs 56% ± 15%, P = .001), the difference was more pronounced in the latter and the change in LVEF was significantly smaller in patients with acute hyperglycemia (4.8% ± 11.2% vs 8.0% ± 13.8%, P = .022). Multivariable analysis showed that there was a significant correlation between plasma glucose and impaired predischarge LVEF, even after adjustment of acute LVEF (r = −0.13, P = .005). Thirty-day mortality tended to be higher in patients with acute hyperglycemia than in patients without (7.1% vs 3.5%, P = .06). Multivariable analysis showed that plasma glucose (per 1 mmol/L increase) was an independent predictor of 30-day mortality after AMI (odds ratio 1.12, 95% CI 1.03-1.22, P = .009).

Conclusion

Acute hyperglycemia was independently associated with impaired left ventricular function and higher 30-day mortality after AMI. These results may provide a potential explanation for poor outcomes of patients with AMI and acute hyperglycemia.     

The stability of the ST segment estimation of myocardial area at risk between the prehospital and hospital electrocardiograms in patients with ST elevation myocardial infarction

Purpose

Several ST segment deviation scores have been developed to estimate the myocardial area at risk (AAR) during acute myocardial infarction (AMI), which can be used to measure the effectiveness of reperfusion therapy. The purpose of this study was to assess whether one of these ST segment deviation scores (the Aldrich score) is sufficiently stable between the electrocardiogram (ECG) recorded in the ambulance (ECG 1) and the ECG recorded at the time of admission to the hospital (ECG 2) to be used as a baseline estimation of the AAR.

Methods

The Aldrich scores were compared between ECG 1 and ECG 2 in 77 patients who met the criteria for ST elevation myocardial infarction. The ECGs had a time interval of at least 5 minutes and were recorded before reperfusion therapy. Sufficiently stable was defined as 95% of the patients did not show a temporal change of the Aldrich score of more than 4.5%.

Results

The mean time interval between ECG 1 and ECG 2 was 20 ± 9 minutes. Forty-three percent of the total study population showed an “unstable Aldrich score” between ECG 1 and ECG 2. Fifty-seven percent showed a “stable Aldrich score”, which means that the 95% standard for sufficiently stable was not fulfilled. By dividing the population based on infarct location, the group with inferior AMI (n = 43) showed more stability (67%) than the group with anterior AMI (n = 34) (44%) (P < .05). However, this remains less than the 95% stability standard.

Conclusion

For both inferior and anterior AMI locations, the Aldrich score was not sufficiently stable to be used as a reliable baseline estimation of the AAR in AMI.     

Changes in the amplitude of electrocardiogram QRS complexes during follow-up of heart failure patients

Introduction

Changes in the electrocardiogram QRS amplitudes (ECGΔ) during follow-up of heart failure (HF) patients have not been clinically exploited heretofore.

Methods

We examined ECGΔ during follow-up of HF patients by employing 42 triplets of ECGs, other laboratory and HF-related clinical data corresponding to clinical stability, worsening, and recovery from 37 HF patients.

Results

The % changes (Δ%) in the summed QRS amplitude of all 12 leads (ΣQRS_12L), 6 precordial leads (ΣQRS_V1-V6), 6 limb leads (ΣQRS_6L), leads I+II (ΣQRS_{I + II}), and lead aVR were evaluated. Also relationships between the ECG variables and body weight (BW), percent body-fat, and B-type natriuretic peptide (BNP) were examined. The QRS amplitude(s) in all ECG variables decreased from clinical stability to worsening HF, and returned to baseline at recovery. During HF worsening, Δ% was highest in lead aVR (−15.3 ± 12.3%), followed by Δ% in ΣQRS_6L (−12.9 ± 10.1%) and ΣQRS_{I + II} (−12.1 ± 10.8%). At worsening HF and its recovery, Δ% in ΣQRS_6L correlated with Δ% in percent body-fat (r = 0.333, P = .031; r = 0.308, P = .047). At recovery, Δ% in each ECG variable correlated with Δ% in BW. Receiver operating characteristic (ROC) analysis showed that ≥16% reduction of ΣQRS_6L and ΣQRS_{I + II} discriminated between stable and worsening HF, with a sensitivity of 43% and 40%, and specificity of 98% for both. ECG variables from limb lead(s) had as good area under the curve (AUC) (0.78-0.84) as BNP (AUC: 0.88) for identifying worsening HF.

Conclusions

Changes of the QRS amplitudes in ECGs are as useful for monitoring HF patients as BNP.     

Type 1 electrocardiographic burden is increased in symptomatic patients with Brugada syndrome

Background

Spontaneous type 1 electrocardiographic (ECG) is a risk factor for arrhythmic events in Brugada patients but the importance of the proportion of time with a type 1 ECG is unknown.

Patients and Methods

Thirty-four Brugada patients (15 symptomatic) underwent a 24-hour 12-lead ECG recording. One-minute averaged waveforms displaying ST-segment elevation above 200 μV, with descending ST-segment and negative T-wave polarity on leads V₁-V₃ were considered as type 1 Brugada ECG. The burden was defined as the percentage of type 1 Brugada waveforms.

Results

Type 1 ECG on lead V2 was more frequent in symptomatic patients (median 80.6% [15.7-96.7] vs 12.4% [0.0-69.7], P = .05). Patients with a permanent type 1 pattern on lead V₂ were more likely to be symptomatic (5/6) than patients without type 1 ECG during a 24-hour period (2/9) (P < .05).

Conclusion

Type 1 pattern is more prevalent across a 24-hour period in symptomatic Brugada patients.     

Effects of losartan and captopril on left ventricular systolic and diastolic function after acute myocardial infarction: results of the Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan (OPTIMAAL) echocardiographic substudy

Background

Angiotensin-converting enzyme inhibitors have been shown to attenuate adverse remodeling after acute myocardial infarction (AMI), and the same has been suggested for angiotensin II type 1 receptor antagonists in animal models. Therefore the aim of the study was to compare the effects of losartan and captopril on regional systolic, diastolic, and overall left ventricular (LV) function after AMI.

Methods

Two hundred twenty-five patients aged ≥50 years with documented AMI and heart failure and/or LV dysfunction were randomly assigned treatment with either losartan (50 mg/d) or captopril (50 mg 3 times/d). Echocardiography was performed at randomization and after 3 months; echocardiograms were analyzed blinded at the core laboratory. Main outcome measures were changes in wall motion score index (WMSI), E-wave deceleration time (E-DT), and Tei index of overall LV function.

Results

WMSI decreased in both groups (losartan 1.58 ± 0.23 to 1.52 ± 0.26, P = .009, captopril 1.60 ± 0.24 to 1.48 ± 0.22, P < .001), although the decrease was greater in patients allocated to captopril (captopril −0.12 ± 0.17 vs losartan −0.05 ± 0.19, P = .007). In both groups E-DT increased, although the increase was significant only in patients treated with captoril (193 ± 61 ms to 208 ± 70 ms, P = .05). The change in E-DT was not different between treatment groups (captopril 14 ± 74 ms vs losartan 7 ± 80 ms, P = .52). Tei index decreased in both groups (losartan 0.59 ± 0.13 to 0.55 ± 0.15, P = .04, captopril 0.62 ± 0.15 to 0.55 ± 0.13, P < .001). However, the reduction was significantly greater in patients treated with captopril (captopril −0.08 ± 0.14 vs losartan −0.03 ± 0.14, P = .01).

Conclusion

Losartan and captopril improve systolic and overall LV function after AMI, but the benefit is greater for patients treated with captopril.     

Relation of admission QRS duration with development of angiographic no-reflow in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous interventions

Background

Although QRS-complex changes during ischemia have been described previously, their relation with no-reflow is not clear.

Purpose

To evaluate relation of admission QRS duration with angiographic no-reflow, we studied 162 patients who underwent primary angioplasty.

Methods

Twelve-lead electrocardiogram with a paper speed of 50 mm/s was recorded on admission and repeated after angioplasty. Patients were divided into reflow and no-reflow groups based on postangioplasty coronary thrombolysis in myocardial infarction flow grade.

Results

Patients in the no-reflow group (26 patients) were older (P = .001) and had significantly longer pain-to-balloon interval (P = .007). The patients in the no-reflow group had significantly longer QRS duration on admission electrocardiogram compared with patients in the reflow group (interquartile range, 80-93 [median, 84] milliseconds vs 60-80 [median, 76] milliseconds, respectively; P < .001). After adjusting all variables, QRS duration on admission was found to be independently related to angiographic no-reflow (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P = .003).

Conclusion

QRS duration on admission may be valuable in predicting no-reflow.     

Diagnostic accuracy of a new detection algorithm for atrial fibrillation in cardiac telemonitoring with portable electrocardiogram devices

Background

Telemedical approaches targeting cardiac outpatients try to include electrocardiogram (ECG) analysis. Increasing numbers of monitored patients require automated preanalysis of the ECG to prioritize the evaluation for the clinical professional to enable an efficient intervention.

Methods

ECGs were recorded from 60 patients, both with a standard 12-lead ECG and with a new handheld ECG device having dry electrodes for direct skin contact. Recordings of the handheld device were automatically analyzed by a new algorithm. The 12-lead recordings were evaluated by a blinded cardiologist and then compared to the automated analysis of the handheld ECG. Sensitivity and specificity of the algorithm for the detection of atrial fibrillation (AF) were calculated.

Results

A total of 60 ECG strips having 122 ± 36 beats were registered. One hundred percent of the ECG strips were sufficient for automated heart rate count; 96.6%, for automated AF analysis; and 80%, for PQ, QRS, and QTc time measurements. AF detection had a sensitivity of 92.9% and a specificity of 90.9%. There was no difference in heart rate count between automated and manual analysis (median, 71 vs 70 beats per minute; P = .51). Automated measurements of a summary complex showed no difference for PQ time (165 vs 161 milliseconds, P = .50) but overestimated QRS (119 vs 90 milliseconds, P = .001) and QTc (489 vs 417 milliseconds, P < .001) times as compared to the 12-lead recordings analyzed manually.

Conclusion

The new algorithm is suitable for automated preanalysis of the ECG data with regard to AF. It could be used for rapid selection of ECGs with relevant rhythm abnormalities from a large pool. Electrocardiographic data remain to be evaluated by health care professionals for exact diagnosis.     

Sex Differences in the Management and Outcomes of Ontario Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction

Background

Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied.

Methods

We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization.

Results

The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes.

Conclusion

Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.     

Oxidized low-density lipoprotein levels circulating in plasma and deposited in the tissues: comparison between Helicobacter pylori-associated gastritis and acute myocardial infarction

Background

Oxidized low-density lipoprotein (ox-LDL) is a key factor in the progression of atherosclerosis. We developed a sensitive method for measuring plasma ox-LDL levels using a novel anti-ox-LDL antibody. Recently, several studies have shown positive associations between Helicobacter pylori (H pylori) infection and coronary heart disease. Thus the question arises whether an increase in the plasma levels of ox-LDL occurs in patients with H pylori gastritis.

Methods

We measured plasma ox-LDL levels in patients with H pylori gastritis (n = 27) and compared them with those in patients with acute myocardial infarction (AMI) (n = 62) and stable angina pectoris (SAP; n = 63) and those in control subjects (n = 64). In addition, ox-LDL localization and the presence of macrophages and neutrophils were studied immunohistochemically in gastritis specimens and in coronary culprit lesions obtained from patients with AMI.

Results

Plasma ox-LDL levels in patients with AMI were significantly higher than those in patients with SAP (P <.0001), patients with H pylori gastritis (P <.0001), or in control subjects (P <.0001; AMI, 1.34 ± 0.95; SAP, 0.61 ± 0.29; Gastritis, 0.53 ± 0.17; control, 0.57 ± 0.23 ng/5μg LDL protein). Immunohistochemically, H pylori gastritis specimens showed distinct infiltration of macrophages and myeloperoxidase-positive neutrophils; however, ox-LDL localization was not detected. In contrast, coronary culprit plaques revealed strong positivity for ox-LDL in ruptured lipid cores with abundant macrophage-derived foam cells, and these plaques also contained myeloperoxidase-positive neutrophils.

Conclusion

Our results suggest that plasma ox-LDL levels do not seem to be associated with H pylori infection, but do relate to coronary plaque instability in AMI.     

Impact of electrical neurostimulation on persistent ST elevation after successful reperfusion by primary percutaneous coronary intervention

Aims

To study the effect of electrical neurostimulation on the ST segment shift in patients with ST elevation myocardial infarction (STEMI) with residual ST elevation after primary percutaneous coronary intervention (PCI).

Methods

After primary PCI, 38 patients with STEMI were divided into 2 groups. Group 1 received 15 minutes of active neurostimulation after the baseline electrocardiogram (ECG); group 2 received 15 minutes of active neurostimulation after 15 minutes of nonactive neurostimulation.

Results

In group 1, ST elevation decreased with neurostimulation from 0.65 ± 0.56 to 0.55 ± 0.51 (P = .02) and to 0.50 ± 0.52 (P = .01) without electrical neurostimulation. In group 2, ST elevation changed without neurostimulation from 0.37 ± 0.32 to 0.33 ± 0.30 (P = NS) and to 0.28 ± 0.27 (P = .01) with electrical neurostimulation. In a posthoc analysis, 17 responders had higher ST elevation at the ECG before active electrical neurostimulation than 21 nonresponders (P = .001).

Conclusion

Electrical neurostimulation may result in significant additional reduction of ST elevation in STEMI after reperfusion treatment, in particular in patients with marked ST elevation on the first ECG after successful primary PCI.     

QRS integral: an electrocardiographic indicator of mechanical interventricular asynchrony

Aim

The aim of this study was to investigate whether interventricular asynchrony (IVA) can be measured by electrocardiography.

Methods

Sixty-two patients (New York Heart Association heart failure functional class III: age, mean ± SD: 64 ± 9 years; ejection fraction, mean ± SD: 24% ± 8%; dilative cardiomyopathy/ischemic cardiomyopathy, n = 39/23) with left bundle branch block (QRS duration, mean ± SD: 165 ± 21 milliseconds) underwent a 120-channel body surface mapping. QRS integral was analyzed and compared with IVA (echo).

Results

Interventricular asynchrony was associated with significantly decreased QRS integrals 15 cm cranial and 6 cm lateral from V1 in patients with normal axis (n = 36): At a cutoff value of −26 milliseconds ? mV, receiver operating characteristic analysis to predict IVA revealed a sensitivity of 89% and a specificity of 83% (area under curve, mean ± SEM: 0.9 ± 0.07; P < .001). In patients with left axis deviation (n = 26), IVA showed significantly decreased QRS integrals 10 cm caudal from V1: at a cutoff value of −89 milliseconds ? mV, receiver operating characteristic analysis to predict IVA revealed a sensitivity of 83% and a specificity of 100% (area under curve, mean ± SEM: 0.9 ± 0.07; P < .002).

Conclusions

Interventricular asynchrony strongly correlates with QRS integral. Key lead positions, however, are axis dependent and outside standard leads.     

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

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.     

Prognostic value of predischarge electrocardiographic measurement of infarct size after thrombolysis: insights from GUSTO I Economics and Quality of Life substudy

Background

Current methods for risk stratification after acute myocardial infarction (MI) include several noninvasive studies. In this cost-containment era, the development of low-cost means should be encouraged. We assessed the ability of an electrocardiogram (ECG) MI-sizing score to predict outcomes in patients enrolled in the Economics and Quality of Life (EQOL) sub study of the Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries -I (GUSTO-I) trial.

Methods

We classified patients by electrocardiographic Selvester QRS score at hospital discharge: those with a score 0-9 versus ≥10. Endpoints were 30-day and 1-year mortality, resource use, and quality-of-life measures.

Results

Patients with a QRS score <10 were well-matched with those with QRS score ≥10 with the exception of a trend to more anterior MI in the higher scored group. Patients with QRS score ≥10 had increased risk of death at 30-days (8.9% vs. 2.9% P < .001), and this difference persisted at 1 year (12.6% vs. 5.4%, P = .001). Recurrent chest pain, use of angiography, and angioplasty were similar during follow-up. However, there was a trend toward less coronary bypass surgery in patients with a QRS score ≥10. Readmission rates were higher at 30 days but similar at 1 year.

Conclusions

Stratification of patients after acute MI by a simple measure of MI size identifies populations with different long-term prognoses; patients with a QRS score ≥10 (approximately 30% of the left ventricle infarcted) at discharge have poorer outcomes in both the short- and long-term. The standard 12-lead ECG provides a simple, economical means of risk stratification at discharge.     

Prognostic importance of the oxidized product of catecholamines,adrenolutin, in patients with severe heart failure

Objectives

The purpose of this study was to assess whether adrenolutin, the inert product of the highly reactive molecules aminochromes, is increased in severe chronic heart failure and whether it is associated with a poor prognosis.

Background

Experimental evidence suggests that oxidative products of catecholamines, aminochromes, are more cardiotoxic than unoxidized catecholamines and may be increased in heart failure.

Methods

Adrenolutin was measured at baseline and at 1 and 3 months in 263 patients with chronic New York Heart Association class III or IV heart failure and a left ventricular ejection fraction of 22% ± 7%. Adrenolutin levels were compared with normal levels, and their relation to prognosis was evaluated.

Results

Baseline adrenolutin was increased (55 ± 90 pg/mL vs 8.4 ± 9.1 pg/mL for control, P < .02) and remained increased at 1 month (49 ± 65 pg/mL). During a mean follow-up of 309 ± 148 days (22-609 days), 57 patients died. Baseline adrenolutin levels correlated with mortality rates by univariate and multivariate analyses (relative risk 1.06, 95% CI 1.01-1.10 for each 17.9-pg/mL rise, P = .032). Left ventricular ejection fraction (P = .013) and New York Heart Association class (P = .009) were the only other variables associated with survival. Age, sex, plasma creatinine, plasma N-terminal atrial natriuretic peptide, and plasma norepinephrine levels were not retained in our model. Adrenolutin levels 1 month after random assignment were not significantly correlated with total mortality rate (P = .061) but were correlated with mortality rate from low output (relative risk 1.14, 95% CI 1.06-1.22, P = .002).

Conclusions

Plasma adrenolutin is increased in patients with heart failure and correlates with a poor prognosis independent of other important predictors of survival. This finding has potentially important pathophysiologic, prognostic, and therapeutic implications.