Heart insufficiency in acute myocardial infarct. Long-term prognostic implications. Study of 213 cases of myocardial infarct

OBJECTIVE: To evaluate intra-hospital and first year prognosis of the acute myocardial infarction. DESIGN: Univariate analysis of hospital and late mortalities in 21 characteristics on the evolution of the acute phase of myocardial infarction of patients sequentially admitted in a coronary care unit. SETTING: Coronary care unit and out patient clinic of a school hospital. PATIENTS: A group of 213 patients with acute myocardial infarction admitted sequentially in a coronary care unit was studied. MATERIAL AND METHODS: Making use of a computerized information system the following characteristics f the patients were prospectively studied: age, sex, previous history of myocardial infarction, angor, diabetes, hypertension and tabacism, presence of left ventricular dysfunction electrocardiographic localization of the infarction, presence of angor in the acute phase of the infarction, epistenocardic pericarditis, hypertensive reaction, hypotension, sinus tachycardia, sinus bradycardia, supraventricular disrhythmias, ventricular disrhythmias, A-V block, complete right bundle branch block, complete left bundle block and peak of CPK values. Univariate analysis was made between each one of these characteristics and hospitalar and one year mortalities. RESULTS: Statistically significant differences were obtained in the hospitalar mortality in the following characteristics: age (p less than 0.001), sex (p less than 0.03), previous history of diabetes (p less than 0.05) and tabagism (p less than 0.005), left ventricular disfunction (p less than 0.0005), hypotension (p less than 0.005), sinus tachycardia (p less than 0.0005), sinus bradycardia (p less than 0.024), A. V. block (p less than 0.004), and peak of CPK (p less than 0.05). Statistically significant differences were found in one year mortality in the following characteristics: age (p less than 0.001), left ventricular disfunction (p less than 0.02), sinus tachycardia (p = 0.0116) and peak of CPK (p less than 0.05). Conclusion: Influence in the hospitalar mortality was demonstrated by the following characteristics of the patients with myocardial infarction: age, sex, previous history of diabetes and tabagism, left ventricular disfunction, infarct size expressed by the peak values of CPK, sinus tachycardia, sinus bradycardia, hypotensive reaction in the acute phase of the myocardial infarction and A-V block. Mortality in the late phase infarction was influenced by age, left ventricular dysfunction, sinus tachycardia and peak values of CPK.     

Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. TAMI Study Group

Previous studies report larger myocardial infarcts and increased in-hospital mortality rates in patients with inferior wall acute myocardial infarction (AMI) and complete atrioventricular block (AV), but the clinical implications of these complications in patients treated with reperfusion therapy have not been addressed. The clinical course of 373 patients--50 (13%) of whom developed complete AV block--admitted with inferior wall AMI and given thrombolytic therapy within 6 hours of symptom onset was studied. Acute patency rates of the infarct artery after thrombolytic therapy were similar in patients with or without AV block. Ventricular function measured at baseline and before discharge in patients with complete AV block showed a decrement in median ejection fraction (-3.5 vs -0.4%, p = 0.03) and in median regional wall motion (-0.14 vs +0.24 standard deviations/chord, p = 0.05). The reocclusion rate was higher in patients with complete AV block (29 vs 16%, p = 0.03). Patients with complete AV block had more episodes of ventricular fibrillation or tachycardia (36 vs 14%, p less than 0.001), sustained hypotension (36 vs 10%, p less than 0.001), pulmonary edema (12 vs 4%, p = 0.02) and a higher in-hospital mortality rate (20 vs 4%, p less than 0.001), although the mortality rate after hospital discharge was identical (2%) in the 2 groups. Multivariable logistic regression analysis revealed that complete AV block was a strong independent predictor of in-hospital mortality (p = 0.0006). Thus, despite initial successful reperfusion, patients with inferior wall AMI and complete AV block have higher rates of in-hospital complications and mortality.     

Prognostic significance of microalbuminuria in non-diabetic patients with acute myocardial infarction

BACKGROUND: The aim of this study was to examine whether the presence of microalbuminuria (20-200 microg/min) can predict in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction. METHODS: Two hundred twenty-three (172 men and 51 women) non-diabetic patients with acute myocardial infarction were studied prospectively. The main outcome measures of the study were based on a comparison of in-hospital mortality and major non-fatal in-hospital events (pulmonary edema, post-infarction angina, infarct extension, mechanical complications, conduction disturbances and ventricular arrhythmias) between microalbuminuric and normoalbuminuric patients. RESULTS: A significant proportion of patients (33.6%) had microalbuminuria. Seventy-six patients (34%) developed an in-hospital event (fatal or non-fatal). Six patients (2.7%) with acute myocardial infarction died in the hospital. Patients with microalbuminuria had a higher mortality rate in comparison with normoalbuminuric patients (6.6% vs. 0.68%, p = 0.01). For non-fatal events, the incidence of pulmonary edema and ventricular arrhythmias was significantly higher in patients with microalbuminuria (14.6% vs. 3.4%, p < 0.001 and 12% vs. 3.4%, p = 0.01, respectively). The combined end-point of the total number of fatal and non-fatal events was significantly higher in patients with microalbuminuria (57.3% vs. 22.3%, p < 0.001). In multiple logistic regression analysis, microalbuminuria (p < 0.001) and ejection fraction (p = 0.01) were independently related to the occurrence of major in-hospital events. CONCLUSIONS: Microalbuminuria is a significant predictor of in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction.     

右室心肌梗死对急性下壁心肌梗死临床特征和预后的影响

目的：分析右室心肌梗死(心梗)对急性下壁心梗临床特征和预后的影响。方法：比较急性单纯性下壁心梗(第一组)和急性下壁心梗合并右室心梗(第二组)两组患的临床特征和院内病死率。结果：共176例患符合入选条件，第一组115例，第二组61例。第一组低血压、快速心律失常(包括阵发性室上性心动过速，阵发性心房颤动，领发室性早搏，室性心动过速，心室纤颤等)、缓慢心律失常(包括窦性心动过缓，房室传导阻滞)、心功能不全的发生率和院内病死率显低于第二组(P＜0．05)。静脉溶栓、急诊PTCA和未行再灌注治疗的院内病死率在第一组的分别为3．23％，3．33％和29．17％，在第二组分别为9．25％，13．04％和82．35％。结论：当急性下壁心梗合并右室心梗时，患的临床表现更为严重，院内病死率增高。积极行溶栓或急诊PTCA治疗，可显降低其院内病死率.     

Clinical course and long-term prognosis in patients with recurrent myocardial infarction

Retrospective study was based on analysis of 881 patients treated in our ward in 1992-1996. Their fate was estimated through 2-6 years after the past myocardial infarction (MI). There were among of them 147 (16.7%) with second and 20 (2.3%) with third or next MI. Then we compared in-hospital course and long-term prognosis in patients with recurrent MI (group I, n = 167) to patients with the first MI (group II, n = 714). We have also evaluated influence of the time-period between the both episodes of myocardial infarctions on the prognosis. The chi-square test was applied to identify the significance of the difference between both groups. Using the Kaplan-Meier method, figures of survival curves were created. Patients in group I were about 4.9 year-older than in group II/(median age was 64.8 +/- 10.7 vs 59.9 +/- +/- 11.3 years p < 0.05). More popular were also diabetes (30.5% vs 18.5%, p < 0.001), advanced hypertension (31.7% vs 20.5% p < 0.01) and higher ratio of current smokers (51.5%) among risk factors in patients from group I. Second myocardial infarction had more serious in-hospital course than the first one. It could be the result of anterior location and more often cardiac complications like ventricular arrhythmias including VF, disturbances of intraventricular conductions, cardiogenic shock and pulmonary oedema with especially of first hours of acute myocardial infarction. Mortality rate in the group I was 2.2 times higher to compare with group II (24.0% vs 10.9%, p < 0.001). Significance higher mortality was in the first year of follow-up and among patients with recurrent myocardial infarction within 12 months after the first one. CONCLUSION: Previous myocardial infarction is significant risk factor that elevate in-hospital course and long-term mortality rate. We observed the higher mortality rate when the recurrent myocardial infarction occurred within 12 months after the first one. The longer time-period since the first myocardial infarction the better prognosis was observed in our analysis.     

急性右心室心肌梗死的临床特点及预后分析

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

Comparison of acute myocardial infarct size to two-year mortality in patients <65 to those > or =65 years of age

Older patients have higher in-hospital and longer term mortality after myocardial infarction. To determine if larger infarct size correlates with this observation, myocardium at risk was measured on arrival to the hospital in 347 patients with acute myocardial infarction, and final infarct size was measured at hospital discharge in a subset of 274 of these patients. Myocardium at risk and final infarct size were quantified by tomographic technetium-99m sestamibi imaging. Statistical analyses examined the associations between age, myocardium at risk, final infarct size, and both in-hospital and postdischarge mortality. Median value for age was 64 years, and myocardium at risk was 24% and final infarct size was 12% of the left ventricle. There was no correlation between age and myocardium at risk (r = 0.04, p = NS) or final infarct size (r = 0.06, p = NS). In-hospital mortality was 4% overall and was 2% for patients <65 years old versus 6% for those > or =65 years old (chi-square 11.3, p<0.001). In-hospital mortality was not associated with myocardium at risk (chi square <1, p = NS). For the subset of 274 patients in whom final infarct size was measured, the subsequent 2-year mortality rate was 3% and was independently associated with both age (chi-square 15.6, p<0.001) and final infarct size (chi-square 9.7, p = 0.002). Survival was excellent for patients who were either <65 years old (2-year mortality 1%) or had an infarct size <12% (2-year mortality 0%). For patients > or =65 years old with infarct size > or =12%, 2-year mortality was 13%. These results demonstrate that older patients do not have larger infarcts. Advanced age is associated with higher in-hospital and postdischarge mortality, independent of infarct size.     

Predisposing Factors and Prognostic Value of Sustained Monomorphic Ventricular Tachycardia in the Early Phase of Acute Myocardial Infarction

Objectives. The purpose of the study was to analyze the factors that favor the occurrence of sustained monomorphic ventricular tachycardia in the early phase (<48 h) of acute myocardial infarction and to establish its prognostic implications.

Background. Sustained monomorphic ventricular tachycardia early in the course of an acute myocardial infarction is an uncommon arrhythmia, and its significance has not been specifically studied.

Methods. The clinical characteristics and prognosis of sustained monomorphic ventricular tachycardia were studied in 21 (1.9%) of 1,120 consecutive patients admitted to the coronary care unit with a diagnosis of myocardial infarction.

Results. Patients with sustained monomorphic ventricular tachycardia had a larger infarct on the basis of peak creatine kinase, MB fraction (CK-MB) isoenzyme activity (435 ± 253 IU/liter vs. 168 ± 145 IU/liter, p < 0.001) and higher mortality rate (43% vs. 11%, p < 0.001). By logistic regression analysis, independent predictors of sustained monomorphic ventricular tachycardia were CK-MB (odds ratio [OR] 11.8), Killip class (OR 4.0) and bifascicular bundle branch block (OR 3.1). Moreover, sustained monomorphic ventricular tachycardia was itself an independent predictor of mortality (OR 5.0). Compared with patients with ventricular fibrillation, those with sustained monomorphic ventricular tachycardia had a worse Killip class (Killip class >I: 63% vs. 30%, p < 0.05), higher CK-MB activity (430 ± 260 IU/liter vs. 242 ± 176 IU/liter, p < 0.01) and higher arrhythmia recurrence rate (31% vs. 4%, p < 0.01). During the follow-up period, 5 (42%) of 12 survivors in the sustained monomorphic ventricular tachycardia group died of cardiac-related causes. Recurrence of ventricular tachycardia was seen in two patients (17%).

Conclusions. Sustained monomorphic ventricular tachycardia during the first 48 h of myocardial infarction is a sign of extensive myocardial damage and an independent predictor of in-hospital mortality.

(J Am Coll Cardiol 1996;28:1670–6)>     

Incidence and short-term prognosis of late sustained ventricular tachycardia after myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-3) Data Base.

BACKGROUND: There is little epidemiologic information from large multicenter databases on sustained monomorphic ventricular tachycardia occurring after the initial 48 hours of myocardial infarction. METHODS: We reassessed its incidence and short-term prognosis in 16,842 patients with a definite myocardial infarction enrolled in the Gruppo Italiano per lo Studio della Soprovvivenza nell'Infarto Miocardico (GISSI-3) trial. RESULTS: The incidence rate of late sustained ventricular tachycardia by 6 weeks was around 1%. Older age, a history of hypertension, diabetes, and myocardial infarction, nonadministration of lytic therapy, Killip class > I, > or = 6 leads with ST-segment elevation, higher heart rate, and bundle branch block on admission were significantly more frequent among patients with than without late sustained ventricular tachycardia. Patients with ventricular tachycardia had a more complicated course in-hospital and posthospital to 6 weeks than the reference group did. The arrhythmia was associated with a significant excess of pump failure, atrial flutter-fibrillation, asystole, atrioventricular block, ventricular fibrillation within the first 48 hours of myocardial infarction, and recurrent ischemic events. Larger left ventricular end-systolic volumes and lower ejection fractions were more frequent among ventricular tachycardia patients than in the reference group by 6 weeks. Death rates by 6 weeks were 35% for patients with ventricular tachycardia and 5% for those without the arrhythmia. Irrespective of the stratification of patients by site and type of infarct and presence/absence of bundle branch block, the occurrence of the arrhythmia was associated with reduced 6-week survival. CONCLUSION: In a proportional hazard regression model late sustained ventricular tachycardia was retained as a strong, independent predictor of 6-week mortality after myocardial infarction (hazard ratio 6.13, 95% confidence interval 4.56-8.25).     

Prognostic significance of electrocardiographic site of infarction after correction for enzymatic size of infarction

To assess whether the site of myocardial infarction is an independent prognostic indicator, the outcome of patients with anterior myocardial infarction was compared with that of patients with inferior infarction. A consecutive series of patients who had suffered their first myocardial infarction was analyzed (398 with anterior and 391 with inferior infarction). Patients with anterior myocardial infarction had a higher 1 year mortality than those with inferior infarction (18.3% vs 10.5%, p = .002). When patients were matched for infarct size determined by peak creatine kinase (CK) level expressed as a multiple of the upper limit of normal, those with anterior myocardial infarction tended to have a higher 1 year mortality than those with inferior infarction for all subgroups of peak CK. Early mortality (day 1 to 28 after myocardial infarction) was greater in the anterior than in the inferior myocardial infarction group (10% vs 6.4%, p = .03); this was most significant when peak CK was greater than four times normal (12.4% vs 7.0%, p = .04). Late mortality was also higher in the anterior (8.4% vs 4.1%, p = .04) than the inferior infarction group and this was most significant when peak CK was less than two times normal (15.2% vs 0%, p = .02) or greater than eight times normal (10.6% vs 4.1%, p = .04). Multivariate analysis with proportional-hazards regression confirmed the prognostic significance of location of infarction independent of peak CK level. Thus, infarct location was found to be a predictor of prognosis that is independent of infarct size based on peak CK levels.     

Nonparoxysmal junctional tachycardia in acute myocardial infarction: Computer-assisted detection

Thirty consecutive patients with acute myocardial infarction had continuous magnetic tape recording of their electrocardiograms (lead II) for the period of their stay in the coronary care unit. Analysis of the 24 hour tape recordings was implemented on a Honeywell model 316 digital computer.

In the first 24 hours after admission to the coronary care unit, 12 of the 30 patients (40 percent) exhibited nonparoxysmal junctional tachycardia; in 5 the arrhythmia was not recognized by conventional monitoring techniques. For the subsequent 3 days, the incidence rate of the arrhythmia was 13 percent for the first 48 hours and 3 percent for 72 hours. Although the mortality rate in patients with nonparoxysmal junctional tachycardia was greater than in patients not demonstrating the arrhythmia (33 versus 6 percent), there was a greater percentage of patients with anterior infarction in the former group; therefore, mortality may have been related to site of infarction rather than being reflective of the arrhythmia or its associated pathophysiologic state. Of possible significance is the association of a greater degree of sinus arrhythmia with nonparoxysmal junctional tachycardia.

The incidence of nonparoxysmal junctional tachycardia in this group of patients was greater than previously reported. It is possible that computer tape analysis may have provided more accurate recognition of the arrhythmia and, thus, more realistic incidence data. The association of nonparoxysmal junctional tachycardia with sinus arrhythmia could only have been recognized by computer technique. The computer system is not a diagnostic system but rather a tape review method.     

Electrogram characteristics in postinfarction ventricular tachycardia: effect of infarct age

OBJECTIVES: The purpose of this study was to correlate infarct age with characteristics of the endocardial electrograms (EGM) obtained in patients undergoing mapping procedures for postinfarction ventricular tachycardia (VT). BACKGROUND: Experimental studies have demonstrated that infarct age influences EGM duration in the subepicardial left ventricle (LV). The relationship between infarct age and endocardial EGM characteristics has not been investigated in patients with postinfarction VT. METHODS: In a consecutive series of 23 patients with a history of remote infarction (range 1 to 31 years) and VT, endocardial LV mapping was performed with an electroanatomical mapping system (CARTO, Biosense Webster Inc., Diamond Bar, California) during sinus rhythm. Electrogram morphology and width were analyzed and correlated with infarct age. Isthmus sites of the VT re-entry circuits were identified by entrainment mapping and related to the results of substrate mapping. RESULTS: There was a significant correlation between infarct age and width of the bipolar endocardial EGM during baseline rhythm in the peri-infarct zone (r = 0.84; p < 0.0001). Increasing infarct age was associated with progressive activation delays in the scar and with isolated potentials separated by an isoelectric interval, the duration of which also correlated with infarct age (r = 0.77; p < 0.001). Among all endocardial sites, the VT isthmus sites displayed the most delay and broadest EGMs during sinus rhythm. CONCLUSIONS: The presence of broad, fractionated EGMs and isolated potentials indicates a healed myocardial infarction; the older the infarction, the broader the EGM width. Remodeling over time alters the electrophysiologic properties of the peri-infarct tissue.     

Prognostic significance of the implantation of a temporary pacemaker in patients with acute myocardial infarction

OBJECTIVE: Indication of temporary pacemakers in patients during acute myocardial infarction was widely studied in the pre-thrombolytic era without having determined whether the generalization of fibrinolysis might have changed the overall incidence and significance of temporary pacemakers. Our aim was to determine the incidence and the prognostic significance of insertion of temporary pacemakers in patients with acute myocardial infarction. PATIENTS AND METHODS: In a study involving 1,239 patients consecutively admitted to hospital with acute myocardial infarction we studied clinical characteristics and prognosis depending on temporary pacemaker insertion or not. We performed an univariate analysis on in-hospital mortality and those selected variables were introduced in to a logistic regression analysis. RESULTS: A temporary pacemaker was indicated in 55 patients (4.4%), prophylactically in 22% and therapeutically in 78%. Temporary pacemakers were inserted in 55% of the patients with advanced AV block and in the 10% of the patients with bundle-branch block. Pacemaker insertion was associated with higher number of affected leads in the ECG, and higher CK peak, regardless of the association with thrombolysis. The following complications were more often observed in patients with temporary pacemakers: atrial fibrillation, heart failure, right bundle-branch block, advanced atrioventricular block and in-hospital mortality (45.4 vs 10.2%; p < 0.001). Need for a temporary pacemaker was less frequent in patients treated with thrombolytics compared with those not treated (3.0 vs 6.1%; p < 0.02). Pacemaker insertion had an independent value for predicting in-hospital mortality (OR = 5.51; 95% CI, 2.71-11.19). CONCLUSION: The insertion of a temporary pacemaker in acute myocardial infarction is less frequent nowadays than on the pre-thrombolytic era. Pacemaker insertion is associated with higher indices of infarct extension and in-hospital mortality, having independent prognostic value on the in-hospital mortality.     

Comparison of radionuclide and enzymatic estimate of infarct size in patients with acute myocardial infarction

A comparison was made of the estimated size of the myocardial infarction occurring in 26 patients with a first infarction using creatine kinase (CK) enzyme release between radionuclide gated blood pool measurement of total and regional ventricular function and thallium-201 scintigraphic measurement of myocardial perfusion defects. Creatine kinase estimates of infarct size (enzymatic infarct size) correlated closely with the percent of abnormal contracting regions, left ventricular ejection fraction and thallium-201 estimates of percent of abnormal perfusion area (r = 0.78, 0.69 and 0.74, respectively, p less than 0.01). A close correlation also existed between percent abnormal perfusion area and percent of abnormal contracting regions (r = 0.81, p less than 0.01) and left ventricular ejection fraction (r = 0.69, p less than 0.01). Enzymatic infarct size was larger in anterior (116 +/- 37 CK-g-Eq) than inferior (52 +/- 29 CK-g-Eq) myocardial infarction (p less than 0.01) and was associated with significantly more left ventricular functional impairment as determined by left ventricular ejection fraction (33 +/- 7 versus 60 +/- 10%) (p less than 0.01) and percent abnormal perfusion area (58 +/- 14 versus 13 +/- 12) (p less than 0.01). No significant correlation was observed between enzymatic infarct size and right ventricular ejection fraction. These different methods of estimating infarct size correlated closely with each other in these patients with a first uncomplicated myocardial infarction.     

Long-term prognosis after myocardial infarction in patients with previous coronary artery bypass surgery

A group of 205 patients hospitalized with myocardial infarction 2 to 162 months (mean 66) after bypass surgery and 205 control patients with myocardial infarction were compared and followed up for 34 +/- 25 months after hospital discharge. At baseline the postbypass group contained more men (p less than 0.03) and more patients with previous myocardial infarction (p less than 0.06), but the groups were otherwise comparable. Indexes of infarct size were lower in postbypass patients: sum of ST elevation, QRS score, peak serum creatine kinase (CK) (1,115 +/- 994 versus 1,780 +/- 1,647 IU/liter) and peak MB CK (all p less than or equal to 0.001). Postmyocardial infarction ejection fraction was 45 +/- 15% in the postbypass group and 43 +/- 15% in the control group (p = NS); in-hospital mortality rate was 4 and 5%, respectively (p = NS). When patent grafts were taken into account, the two groups were comparable in extent of coronary artery disease. At 5 years after discharge, cumulative mortality was similar in the postbypass and control groups (30 versus 25%, respectively, p = NS). However, postbypass patients had more reinfarctions (40 versus 23%, p = 0.007), more admissions for unstable angina (23 versus 18%, p = 0.04) and more revascularization procedures (34 versus 20%, p = 0.04) than did control patients. The total for these events at 5 years was 70% in the postbypass group and 49% in the control group (p = 0.001). Thus, although patients with previous bypass surgery who develop acute myocardial infarction have a smaller infarct, their subsequent survival is no better than that of other patients with acute myocardial infarction. They experience more reinfarctions and unstable angina. Previous bypass surgery is an important clinical marker for recurrent cardiac events after myocardial infarction.     

In-hospital sudden death after coronary care unit discharge.

In a retrospective analysis of in-hospital sudden death among patients with acute myocardial infarction, nine of 48 (18.7%) in-hospital deaths after discharge from the coronary care unit were judged "sudden." This group had a significantly prolonged coronary care unit course, a higher incidence of supraventricular and ventricular arrhythmias, and a noticeable incidence of anterior wall myocardial infarction as compared with those of a matched infarct control group. Seventy-seven percent of the sudden-death group had three or more concomitant high-risk factors as compared with only 3% of a matched control group.     

Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarction: comparison of single-vessel versus multivessel coronary artery disease.

Despite recent clinical trials of percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction, specific groups of patients that may benefit from adjunctive or alternative therapy have yet to be adequately characterized. The in-hospital outcome of 151 consecutive patients treated for acute myocardial infarction with urgent PTCA of the infarct-related artery was studied to identify a subgroup of patients at high risk. Patients were divided into two groups based on the angiographic presence of either single-vessel (n = 86) or multivessel (n = 65) coronary artery disease. Despite PTCA of only the infarct-related artery and similar baseline clinical characteristics such as age, peak serum creatine kinase concentration, left ventricular ejection fraction, and time from the onset of chest pain to arrival at the hospital, the group with multivessel disease had a lower rate of successful angioplasty (75% vs 92%, p < 0.005), with higher incidences of persistent total occlusion of the infarct-related artery (14% vs 3%, p < 0.02) and procedural complications during PTCA (28% vs 13%, p < or = 0.02), and were more likely to have multiple complications (12% vs 1%, p < 0.004). In addition, the group with multivessel disease had a higher rate of urgent (< or = 24 hours) coronary artery bypass graft surgery (13% vs 2%, p < 0.05) and a trend toward a higher in-hospital mortality rate (6% vs 1%, p < or = 0.17). By stepwise logistic regression, only the presence of single-vessel versus multivessel disease was predictive of PTCA success (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)     

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

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

The spectrum of unstable angina: Prognostic role of serum creatine kinase determination

A prospective study of 199 patients with unstable angina pectoris was undertaken to assess whether frequent serial sampling of serum creatine kinase (CK) was useful in predicting prognosis. Nineteen percent of the patients had transient CK elevations suggestive of a small myocardial infarct that was outside the detective ability of conventional electrocardiographic and enzymatic determinations. These patients had a 1 year mortality rate of 16 percent, which was significantly higher than that in the remaining patients (Fisher's exact test p = 0.05). Furthermore, the recurrence rate of myocardial infarction (14 percent) in the patients who had transient CK elevation was significantly greater than that (2 percent) in those who did not have CK elevation (Fisher's exact test p = 0.01). These data suggest that frequent serum CK sampling in the first 48 hours after admission for unstable angina has prognostic value and that persons with CK elevation may warrant a more aggressive approach to investigation and management.     

Measurement of myocardial infarct size by technetium pyrophosphate single-photon tomography

The primary determinant of prognosis after acute myocardial infarction (AMI) is the size of the acute infarct. The present study evaluates 46 patients with different infarct distributions and sizes to test the hypothesis that single photon emission computed tomography with technetium-99m pyrophosphate (Tc-99m-PPi) and blood pool overlay allows measurements of AMI size that provide insight into prognosis irrespective of infarct location. Identical Tc-99m-PPi and ungated blood pool projections were acquired over 180 degrees with a rotating gamma camera. Reconstructed sections were color-coded and superimposed for purposes of infarct localization. Areas of increased pyrophosphate uptake within myocardial infarcts were thresholded at 65% of peak activity. The blood pool was thresholded at 50% and subtracted so as to determine an endocardial border for the left ventricle. Using this method, myocardial infarcts weighed 2.5 to 81.2 g. The correlation of infarct mass with prognosis showed that patients without previous AMI and with acute infarcts that weighed more than 40 g had an increased frequency of death and congestive heart failure (p less than 0.001). The correlation of measured infarct mass with peak serum creatine kinase level was significant (r = 0.83, p less than 0.001; y = 0.015x + 13.20). The correlation coefficients for anterior, inferior and nontransmural AMI were not significantly different from those for the entire group. In conclusion, tomographically determined infarct mass data correlate with subsequent clinical prognosis, and Tc-99m-PPi tomography with blood pool overlay is a safe and effective means of sizing infarcts in patients with AMI.