Comparative Prognostic Significance of Simultaneous Versus Independent Resolution of ST Segment Depression Relative to ST Segment Elevation During Acute Myocardial Infarction

Objectives. We sought to determine the prognostic significance of simultaneous versus independent resolution of ST segment depression that occurs concomitant with ST segment elevation during acute myocardial infarction (AMI).Background. ST segment depression in leads other than those showing ST segment elevation during AMI is a common phenomenon. Whether this indicates adverse outcomes remains controversial. We hypothesized that the timing of ST segment depression resolution relative to ST segment elevation resolution might differentiate between a high risk group and a low risk group of patients.Methods. Continuous 12-lead ST segment monitoring was performed after thrombolytic therapy for AMI in 413 patients, 261 of whom met technical criteria for analysis. Blinded analysis of ST segment depression resolution patterns was used to group patients as follows: 1) no ST segment depression at any time (control group); 2) ST segment depression resolving simultaneously with ST segment elevation (simultaneous group); and 3) ST segment depression persisting after ST segment elevation resolution (independent group). These patterns were correlated with the outcomes—recurrent angina, reinfarction, heart failure and death—using chi-square analysis and the Fisher exact test for categoric variables and the Wilcoxon rank-sum test for continuous variables.Results. The incidence of recurrent angina, reinfarction and heart failure was similar among the three groups. In-hospital mortality, however, was significantly higher in the independent group (13%) than either the simultaneous group (1%, p < 0.001) or the control group (0%, p = 0.002).Conclusions. Continuous analysis of ST segment resolution identifies, among patients with AMI with concomitantly occurring ST segment elevation and depression, a subgroup with increased in-hospital mortality. The pathogenic mechanism of increased mortality is not currently known.     

Frühzeitiger kombinierter Einsatz von Revaskularisation und intraaortaler Ballon-Gegenpulsation bei kardiogenem Schock im Rahmen eines akuten Myokardinfarkts

Objectives

Cardiogenic shock (CS) remains the leading cause of death in patients hospitalized for acute myocardial infarction (AMI). Historically, conventional therapy has been associated with a 90% mortality rate. Several studies have demonstrated the importance of early revascularization strategies for lowering mortality. The additional use of intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. Therefore, this study reviews our experience of infarct-related CS treatment with early aggressive combined use of revascularization and IABP.

Methods

Retrospectively, 50 consecutive patients (36 male) with CS complicating AMI, admitted to our department during 2005 and 2006, were analyzed. Mean age was 68.9 years. All patients underwent early coronary angiography with an option of percutaneous coronary intervention (PCI), and IABP was implanted immediately after the procedure.

Results

In-hospital mortality, as the primary outcome measure of the study, was 42%. CS presented with ST elevation MI (STEMI) in 50%, as non-STEMI (NSTEMI) in 50%. Upon admission, 30% of CS had required cardiopulmonary resuscitation (CPR), 72% were on mechanical ventilation, and 10% acquired prehospital thrombolysis. Single coronary vessel disease (CVD) presented in 18%, dual CVD in 18%, and triple CVD in 64% of CS. Average left ventricular ejection fraction (EF) was 27.9%. There were no significant differences concerning the EF in the CS subgroups STEMI vs. NSTEMI and non-survivors vs. survivors. PCI was successfully performed in 88% of CS, one patient underwent IABP and then was submitted to emergency CABG. Clinically significant signs of sepsis were present in 32%, the more in the non-survivor group (48% vs. 21%, p < 0.05).

Conclusion

Our data suggest that a treatment strategy with early aggressive combined use of revascularization and IABP can also improve survival in high-risk patients with CS complicating AMI.     

Effect of intraaortic balloon pumping on left ventricular function in patients with persistent ST segment elevation after revascularization for acute myocardial infarction.

The purpose of the present study was to assess the impact of intraaortic balloon pumping (IABP) in patients with persistent ST elevation who underwent revascularization within 6 h of their first acute anterior myocardial infarction (AMI). Persistent ST elevation after revascularization was defined as being > or =50% of the initial value on return to the coronary care unit. Twenty-four patients were treated without IABP (control group) and 27 patients were treated with IABP (IABP group). There was no significant difference between the 2 groups in pretreatment left ventricular ejection fraction (LVEF), end-diastolic volume index or end-systolic volume index. After 137+/-46 days, the change in the LVEF was significantly higher in the IABP group than in the control group (5+/-13% vs 13+/-15%, p=0.04). However, the left ventricular end-diastolic volume index was similar between the 2 groups during follow-up (pretreatment: 77+/-19 ml/m(2) vs 74+/-13 ml/m(2), p=0.54; follow-up: 86+/-22 ml/m(2) vs 83+/-18 ml/m(2), p=0.60). These data suggest that IABP enhances the improvement in LVEF independent of remodeling in AMI patients with persistent ST elevation after revascularization.     

High-risk subgroups of patients with non-Q wave myocardial infarction based on direction and severity of ST segment deviation

To determine the significance of the direction of ST segment deviation on admission of patients who evolved non-Q wave myocardial infarction (MI), 97 patients with initial ST segment depression were compared to 207 patients with initial ST segment elevation. Patients with ST segment depression developed smaller infarcts than those with ST segment elevation (creatine kinase MB isoenzyme 8.2 vs 13.3 gmEq/m2, p less than 0.002), but had a lower left ventricular ejection fraction on admission (44% vs 51%, p less than 0.001), more in-hospital complications, and a higher cumulative 1-year mortality (29% vs 11%, p less than 0.001) that could be accounted for by an excess of adverse baseline characteristics. Although a severity index (combining magnitude and extent of the initial ST segment deviation) was not useful for discriminating prognosis of patients with non-Q wave MI who presented with ST segment depression, it was useful in identifying a subgroup of patients with ST segment elevation with an adverse prognosis. The poor outcome of patients with non-Q wave MI presenting with either ST segment depression or severe ST segment elevation on admission suggests that patients in these subgroups should receive close surveillance and should possibly be considered for aggressive therapy.     

Early angiography versus conservative treatment in patients with non-ST elevation acute myocardial infarction: MITI Investigators. Myocardial Infarction Triage and Intervention

OBJECTIVES: To compare short- and long-term outcome after early invasive or conservative strategies in the treatment of non-ST segment elevation acute myocardial infarction (AMI). BACKGROUND: It is uncertain whether or not there is benefit from emergent invasive diagnosis and treatment of AMI in patients without ST segment elevation on the admission electrocardiogram (ECG). METHODS: In a cohort of 1,635 consecutive patients with AMI who presented to hospitals without ST segment elevation on their admission ECG, we compared treatments, hospital course and outcome in 308 patients who presented to hospitals whose initial strategy favored early angiography and appropriate intervention when indicated versus 1,327 similar patients who presented to hospitals that favor a more conservative initial approach. RESULTS: At baseline, patients admitted to hospitals favoring an early invasive strategy were younger, more predominately Caucasian and had less comorbidity. Early coronary angiography occurred in 58.8% versus 8% (p < 0.001), and early angioplasty was performed in 44.8% versus 6.1% (p < 0.001) in the two different cohorts. Patients treated in hospitals favoring the early invasive strategy had a lower 30-day (5.5% vs. 9.5%, p = 0.026) and four-year mortality (20% vs. 37%, p < 0.001). Multivariate analysis showed a trend towards lower hospital mortality (OR = 0.56, 95% CI: 0.29 to 1.09) and a significant lower long-term mortality (hazard ratio = 0.61, 95% CI: 0.47 to 0.80) in patients admitted to hospitals favoring an early invasive strategy. CONCLUSIONS: These data suggested that an early invasive strategy in patients with AMI and nondiagnostic ECG changes is associated with lower long-term mortality.     

Acute myocardial infarction with cardiogenic shock on admission: Incidence, prognostic implications, and current treatment strategies

Little data exist about current treatment strategies the efficacy of thrombolytic therapy and outcome of patients with acute myocardial infarction (AMI) presenting in cardiogenic shock (CS). Data from the German multicenter "60 Minutes Myocardial Infarction Project" were used to analyze a large number of patients with AMI and CS on admission and to compare those to patients without CS. Between July 1993 and September 1994 a total of 7,085 patients with AMI were registered. Out of these, 179 patients (2.5%) presented in CS (systolic blood pressure < 100 and heart rate > 100/min, resuscitated patients were excluded). Patients in CS were significantly older than patients without CS. Their in-hospital mortality was 47.1% compared with 12.4% in patients without CS (p = 0.001). The prevalence of the following clinical parameters was significantly higher in patients with CS than in those without CS: bundle branch block, prior MI, and a non-diagnostic ECG (all p < 0.05). Thrombolytic therapy was used in 36.3% of patients in CS and in 50.8% of those without CS (p = 0.001). The in-hospital mortality in patients with CS receiving thrombolytic therapy was significantly lower than in patients with CS who did not receive thrombolytic agents (33.3% versus 55.1%; p = 0.006). In daily clinical practice in Germany thrombolytic treatment is used in only 36.3% of patients with AMI presenting in CS on admission. The use of thrombolysis in CS on admission is associated with a lower in-hospital mortality.     

"Tombstoning" of ST segment in acute myocardial infarction -- effect on clinical course

INTRODUCTION: There are many reports evaluating the effects of the amplitude of ST segment elevation in acute myocardial infarction with ST segment elevation (STEMI) on infarction zone and course. There are, however, few publications dealing with the effects of ST segment elevation shape in STEMI patients on their clinical course and prognosis. AIM: Assessment of the rate of "tombstoning" of ST segment (TOMB-ST) in STEMI patients and the effects on their clinical outcome. METHODS: The study involved 207 consecutive patients with STEMI hospitalised in the period 2000-2002 analysed with respect to the in-hospital complication rate. RESULTS: On admission, TOMB-ST was observed in 55 (26.1%) subjects. TOMB-ST was more common in anterior MI (39.8%) than in inferior MI (10.6%). Patients with TOMB-ST compared to non-TOMB-ST ones had a significantly higher mortality rate (38.2% vs 9.9%, p <0.001), heart failure (45.6% vs 28.3%, p <0.026), ventricular fibrillation (18.1% vs 6.4%, p <0.016), and lower left ventricular ejection fraction (40.9% vs 48.6%, p <0.001). The sum of amplitudes of ST segment deviations (SigmaST) >20 mm was indicative for the subgroup of patients with TOMB-ST and trend towards higher mortality (40% vs 30%, NS). However, in patients without TOMB-ST, SigmaST >20 mm identified two subgroups with significantly different mortality rates (20% vs 4%, p=0.001). CONCLUSIONS: TOMB-ST was observed in one fourth of patients with STEMI. This abnormality was associated with an increased mortality rate, higher incidence of heart failure and ventricular fibrillation as well as decreased left ventricular ejection fraction. In the population with TOMB-ST, increased mortality was independent of the total amplitude of ST segment displacement; this relation was, however, observed in patients with STEMI without TOMB-ST.     

Recurrent ischemia after acute myocardial infarction: clinical profile and significance of electrocardiographic ST changes during the attacks]

This study investigated the clinical characteristics of acute myocardial infarction (AMI) complicated by recurrent ischemia, especially relating to the electrocardiographic ST changes during the attacks. Fifty-six patients with AMI were complicated by recurrent ischemia (ischemia group), and 238 were not (non-ischemia group). The ischemia group was preceded by prior episodes of angina or myocardial infarction in 88%, as compared with 65% in the non-ischemia group (p less than 0.05). There were non Q wave infarction in 45% of the ischemia group, and 24% of the non-ischemia group (p less than 0.05). The overall in-hospital mortality rate was similar in the ischemia group (13%) and in the non-ischemia group (17%), although the causes were predominantly pump failure in the former and cardiac rupture in the latter. ST segment elevation occurred in 29 patients and ST depression occurred in 26 patients of the ischemia group during the attacks. Multivessel coronary arterial lesions were more frequently present in the latter subgroup than the former (38% vs 79%, p less than 0.05). The in-hospital cardiac deaths were also more frequently noted in the latter subgroup. Recurrent ischemia after AMI with concomitant electrocardiographic ST depression is a high risk subgroup, and, therefore, aggressive revascularization procedures may be indicated in such cases if suitable.     

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.     

Absence of gender differences in clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction. A report from the SHOCK Trial Registry.

OBJECTIVES: The aim of this study was to assess the impact of gender on clinical course and in-hospital mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND: Previous studies have demonstrated higher mortality for women compared with men with ST elevation myocardial infarctions and higher rates of CS after AMI. The influence of gender and its interaction with various treatment strategies on clinical outcomes once CS develops is unclear. METHODS: Using the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) Registry database of 1,190 patients with suspected CS in the setting of AMI, we examined shock etiologies by gender. Among the 884 patients with predominant left ventricular (LV) failure, we compared the patient demographics, angiographic and hemodynamic findings, treatment approaches as well as the clinical outcomes of women versus men. This study had a 97% power to detect a 10% absolute difference in mortality by gender. RESULTS: Left ventricular failure was the most frequent cause of CS for both gender groups. Women in the SHOCK Registry had a significantly higher incidence of mechanical complications including ventricular septal rupture and acute severe mitral regurgitation. Among patients with predominant LV failure, women were, on average, 4.6 years older, had a higher incidence of hypertension, diabetes and a lower cardiac index. The overall mortality rate for the entire cohort was high (61%). After adjustment for differences in patient demographics and treatment approaches, there was no significant difference in in-hospital mortality between the two gender groups (odds ratio = 1.03, 95% confidence interval of 0.73 to 1.43, p = 0.88). Mortality was also similar for women and men who were selected for revascularization (44% vs. 38%, p = 0.244). CONCLUSIONS: Women with CS complicating AMI had more frequent adverse clinical characteristics and mechanical complications. Women derived the same benefit as men from revascularization, and gender was not independently associated with in-hospital mortality in the SHOCK Registry.     

New diagnostic criteria for acute myocardial infarction and in-hospital mortality.

BACKGROUND: The recent introduction of new diagnostic criteria for acute myocardial infarction (AMI), with troponin measurement, has increased the number of patients admitted with this diagnosis. OBJECTIVE: To evaluate the epidemiologic and prognostic implications of the new diagnostic criteria for AMI. METHODS: This was a retrospective study of 586 patients admitted for acute coronary syndrome (ACS) to the coronary care unit of our hospital, between 2002 and 2003. Data were collected from RECIMA, the Madeira Ischemic Heart Disease Registry. The population was analyzed following two different definitions of ACS: 1 - old criteria (Group I): AMI with ST elevation (typical symptoms or ECG with ST-segment elevation and raised CK-MB >2x), AMI without ST elevation (typical symptoms or ECG without ST elevation and raised CK-MB >2x) and unstable angina (UA) (symptoms or ECG indicative of ischemia, with normal CK-MB, regardless of troponin status); 2 - new criteria (Group II): AMI with ST elevation (typical symptoms or ECG with segment ST elevation and raised CK-MB >2x or troponin), AMI without ST elevation (typical symptoms or ECG without ST-segment elevation and raised CK-MB >2x or troponin) and UA (symptoms or ECG indicative of ischemia, with normal enzymes). We evaluated whether this change in criteria had any influence on in-hospital mortality. RESULTS: The new criteria significantly (by 11.9 %) increased the total number of patients admitted with AMI. This was due to an increase in AMI without ST elevation (p < 0.001) and a decrease in patients with UA (p < 0.001), with no changes in AMI with ST elevation. In-hospital mortality was lower in patients with AMI diagnosed by the new criteria and in those with UA. CONCLUSION: The overall increase in AMI resulting from the new diagnostic classification was accompanied by a decrease, although not statistically significant, of in-hospital mortality, probably due to the lower risk of the population analyzed.     

Surgical revascularization in acute myocardial infarct]

To determine the potential role of emergency surgical revascularization as treatment of acute myocardial infarction (AMI), results in 79 patients undergoing operation for myocardial revascularization during AMI from January 1986 to January 1991 were reviewed. Clinical characteristics for inclusion in the study were: 1) emergency operation; 2) persistent angina not controlled by medical therapy; 3) fixed ST segment elevation until surgical procedure, independently from magnitude of enzymatic levels. The 79 patients were divided in 2 groups: 27 with AMI or evolving AMI (Group 1); 52 with AMI due to complications during PTCA (Group 2). Twenty-eight patients had extremely severe clinical conditions. Mean interval between the beginning of AMI and operation was 4.2 +/- 6.7 hours, with a statistically significant difference between Group 1 (8.7 +/- 10.0) and Group 2 (1.9 +/- 1.0). One hundred ninety-two grafts were performed (2.4 +/- 1.1 grafts/patient). Overall hospital mortality was 10.1% (CL 6.7-13.3) (8 deaths) with a difference between Group 1 [18.5% (CL 10.7-25.3)] and Group 2 [5.8% (CL 4.7-6.6)] (p = 0.074). The incidence of perioperative myocardial infarction was 30.4% (CL 24.9-35.1) for that one in the area of ischemic muscle and 2.6% (CL 0.8-4.1) for infarction in remote muscle. Multivariate analysis for the entire series (79 patients) identified as independent predictors of increased in-hospital mortality: preoperative cardiogenic shock (p = 1.000E-4) and hyperlipidemia (p = 0.008). In Group 1 multivariate analysis identified as independent predictors of increased in-hospital mortality: the attempt of revascularization by PTCA and hyperlipidemia; in Group 2: preoperative need of mechanical ventilatory support.(ABSTRACT TRUNCATED AT 250 WORDS)     

Predictive factors of major adverse cardiac events in acute myocardial infarction patients complicated by cardiogenic shock undergoing primary percutaneous coronary intervention.

BACKGROUND: The aim of this study was to assess in-hospital mortality and major adverse cardiac events (MACE) during long-term clinical follow-up of patients who developed cardiogenic shock (CS) after acute myocardial infarction (AMI) and who underwent primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: The data from 147 patients with CS after AMI (61.7 +/-10.4 years, M:F =156:99) who underwent primary PCI at Chonnam National University Hospital between January 1999 and December 2002 were analyzed: clinical characteristics, coronary angiographic findings and mortality during admission, and MACE during a 1-year clinical follow-up. Of the enrolled patients, 121 patients survived (group I, M:F =94:27) and 26 died (group II, M:F =14:12) during admission. By binary logistic regression analysis, in-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization (p=0.02, odds ratio (OR) =1.3). Eighty-nine patients (60.5%) survived without MACE during the 1-year clinical follow-up and MACE was associated with a C-reactive protein (CRP) of more than 1 mg/dl (p=0.002, OR =6.3) and low TIMI flow after coronary revascularization (p<0.001, OR =7.8). CONCLUSIONS: Primary PCI achieving TIMI 3 flow reduces in-hospital death in AMI with CS. High concentration of CRP and low TIMI flow are associated with MACE during long-term clinical follow-up.     

Impact of pre-hospital emergency in the management and prognosis of acute myocardial infarction.

INTRODUCTION: In recent decades pre-hospital emergency plans have been developed in Portugal, in order to improve the quality and efficiency of medical care in acute situations. However, the real impact of these measures in the treatment of acute coronary patients has not been thoroughly studied. OBJECTIVE: To evaluate the impact of pre-hospital emergency care (PHE) in the management and prognosis of patients admitted to hospital with acute myocardial infarction (AMI). POPULATION: Three hundred and eighty-one consecutive patients admitted to our hospital with AMI between 7/1/2001 and 12/31/2002. METHODS: The patients referred to the Emergency Department (ED) after PHE care were prospectively compared with other patients admitted with AMI (controls), in terms of clinical and demographic characteristics, initial ECG, time of symptoms-to-ED, symptoms-to-ECG, and door-to-needle/balloon, Killip class, in-hospital morbidity and mortality, ejection fraction (EF) at discharge, morbidity and mortality during the first year and EF after one year. RESULTS: Of the 51 patients (mean age 66, 57% male) of the PHE group, 55% (mean age 66, 64% male) presented ST elevation on admission ECG. Of the 330 patients (mean age 63 years, 70% male) of the control group, ST elevation was present in 41% (p = 0.05), mean age 59 years (p < 0.02), 77% male (NS). There were no significant differences between the groups when cardiovascular risk factors, cardiac event history and comorbidity were studied. Time of symptoms-to-ED (124 vs. 256 min) and symptoms-to-ECG (138 vs. 292 min) were shorter in the PHE group (p < 0.005 and < 0.003, respectively). Door-to-ECG time was 14 min vs. 36 min in the control group (p < 0.02). In patients with ST elevation, door-to-needle (77 vs. 105 min) and door-to-balloon (79 vs. 132 min) times were shorter after PHE (NS, p = 0.08). Overall, the time of symptoms-to-reperfusion was shorter in the PHE group. There were no differences in Killip class, in-hospital mortality or one-year mortality/morbidity. The prevalence of EF < 45% was lower in the PHE group, both at discharge (39 vs. 58%, p = 0.08) and on the first year echocardiogram (8.3 vs. 46%, p < 0.04). CONCLUSIONS: Compared to other patients with AMI, those admitted to the ED after PHE are older and more frequently present ST elevation. PHE has a significant impact in reducing the time between first symptoms and admission to the ED, first ECG and reperfusion therapy. In patients with ST elevation at admission, the prevalence of heart failure after one year was found to be significantly lower in the PHE group, revealing the positive impact of PHE care in AMI that persists after one-year follow-up.     

Q-wave evolution of a first acute myocardial infarction without significant ST segment elevation

BACKGROUND: Some patients with acute myocardial infarction presenting without significant ST segment elevation develop a Q-wave infarction. It is unclear whether these patients can be identified from the admission electrocardiogram (ECG) and whether they differ in their in-hospital prognosis from those who retain a non-Q-wave myocardial infarction. METHODS: In 432 consecutive patients admitted to our centre with a first acute myocardial infarction without Q waves and with ST segment amplitudes < or =0.1 mV on admission, we assessed the frequency, the electrocardiographic predictors and the short-term implications of a Q-wave evolution. RESULTS: In 94 patients (22%), a Q-wave myocardial infarction evolved before hospital discharge (14 anterior, 26 inferior, six lateral, and 48 posterior). Minor anterior ST segment elevation was 36% sensitive and 95% specific in predicting anterior Q waves; minor inferior ST segment elevation, 42% and 89%, respectively, for inferior Q waves; and a maximal ST segment depression > or =0.2 mV in leads V2-V3 with upright T waves and without remote ST segment depression, 38% and 97%, respectively, for posterior R waves. Although patients with a Q-wave evolution had a greater creatinkinase MB peak than those retaining a non-Q-wave pattern (191+/-113 vs. 105+/-77 IU/l, respectively, P<0.001), they experienced a benign in-hospital course, with similar risk of severe complications after adjustment for the baseline clinical predictors than non-Q-wave patients. CONCLUSIONS: About one fifth of patients with a first acute myocardial infarction without a significant ST segment elevation develop a Q-wave infarction and the admission ECG can help identify them. This evolution, however, is not associated with a worse in-hospital outcome.     

Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation

OBJECTIVES

We sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation.

BACKGROUND

ST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear.

METHODS

In 432 patients with a first acute MI without Q waves or ≥0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death.

RESULTS

The presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V₅, or V₆) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 ± 96 vs. 122 ± 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 ± 12% vs. 66 ± 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001).

CONCLUSIONS

In patients with a first non–ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.     

Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation

OBJECTIVESWe sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation.BACKGROUNDST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear.METHODSIn 432 patients with a first acute MI without Q waves or ≥0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death.RESULTSThe presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V₅, or V₆) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 ± 96 vs. 122 ± 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 ± 12% vs. 66 ± 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001).CONCLUSIONSIn patients with a first non–ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.     

Usefulness of QRS duration in the absence of bundle branch block as an early predictor of survival in non-ST elevation acute myocardial infarction

To determine whether an increased QRS duration in the absence of bundle branch block (BBB) on the presenting electrocardiogram of patients with acute myocardial infarction (AMI) is associated with decreased survival, we retrospectively reviewed 781 consecutive patients admitted to the coronary care unit of our institution with AMI without BBB between 1988 and 1998. In patients with ST elevation AMI (n = 412), the groups with QRS duration > or =100 ms and <100 ms had similar survival. Conversely, in patients with non-ST elevation AMI (n = 369), in-hospital, 1-, 3-, and 5-year survival was 84.4%, 75.6%, 66.7%, and 52.2%, respectively, in the group with QRS > or =100 ms compared with 95.4%, 89.2%, 83.8%, and 74.3%, respectively, in the group with QRS <100 ms (p <0.01, log-rank test). In patients with non-ST elevation AMI, those with QRS duration > or =100 ms were more likely to be men, to have had a prior AMI that healed, to be in Killip class II, III, or IV, and to have lower ejection fraction than patients with QRS duration <100 ms. After adjusting for age, sex, prior AMI or stroke, heart rate, and Killip class on admission, QRS duration > or =100 ms was independently associated with in-hospital and overall mortality in patients with non-ST elevation AMI. QRS duration > or =100 ms in the absence of BBB is an independent predictor of increased mortality in patients with non-ST elevation AMI.     

急性心肌梗死再灌注后心电图ST段抬高的意义

目的：探讨急性心肌梗死（AMI）患者接受经皮冠状动脉腔内成形术（PTCA）治疗心电图ST段持续高与临床预后的关系。方法：AMI患者共30例,比较PTCA前及术后1h12导联心电图抬高ST的总和,按ST段下降幅度分为两组,A组：AT段下降≥50％,B组：ST段下降＜50％。行小剂量多巴酚丁胺负荷超声心动图检查并随访复查超声心动图。结果：AMI发病早期基础状态和负荷状态及发病后第1、2、3个月左室射血分数（LVEF）A组均明显大于B组。多巴酚丁胺负荷状态下主动脉峰值血流加速度、每搏输出量及每搏指数A组明显大于B组。基于状态和负荷状态下总室壁运动积分指数（GWMSI）和梗死区室壁运动积分指数（IWMSI）A组均明显小于B组,AMI发病后1、2、3个月GWMSI A组均明显小于B组。发病第1、2个月IWMSI两组间差异无统计学意义。发病第3个月IWMSI A组明显小于B组。AMI直接PTCA后心电图ST段持续抬高的患者左室收缩功能及收缩储备功能以及梗死区室壁运动的恢复明显低于ST段迅速下降者。     

Angiographic correlates of anterior ST segment depression in acute inferior wall myocardial infarction.

This study was conducted prospectively to assess the correlation between the pattern of anterior ST segment depression on the admission electrocardiogram and the in-hospital morbidity and mortality in patients with acute inferior wall myocardial infarction. Coronary angiography was also done to assess its correlation, if any, with pattern of anterior ST segment depression. Our study cohort comprised of 165 consecutive patients with acute inferior wall myocardial infarction divided into four groups based on admission electrocardiogram. Group I (n = 33): patients with no anterior ST segment depression; group II (n = 16): patients with ST segment depression in leads V1-V3; group III (n = 71): patients with ST segment depression in leads V4-V6, I and aVF, and; group IV (n = 45): patients with ST segment depression in all anterior leads (V1-V6, I, aVL). The outcomes were analysed in terms of high grade atrioventricular block, Killip class II or higher failure, and in-hospital mortality. Coronary angiography was performed to analyse coronary anatomy. Group IV patients had increased incidence of complete heart block (37.8% vs 15.2% in the total group) (p < 0.001) and increased mortality (11.1% vs 4.2% in the total group) (p < 0.05). This group also had greater incidence of triple vessel disease (76.7%) (p < 0.001). Group II patients had greater incidence of double vessel disease (88.9%) (p < 0.05) and had no triple vessel disease. Group III patients had double vessel disease (76.5%) (p < 0.05) or triple vessel disease (23.5%) (p = NS) and no single vessel disease. Coronary angiography in group II showed greater incidence of involvement of left circumflex artery and right coronary artery while in group III there was left anterior descending artery and right coronary artery disease. We conclude that patients with anterior ST segment depression in group III and group IV categories are in high risk subset with acute inferior wall myocardial infarction.