ST segment elevation and chest pain during cryoablation of atrial flutter.

A 61-year-old male was treated with cryoablation for typical atrial flutter. Cryoablation was performed percutaneously with an 8-mm tip catheter to achieve a bidirectional conduction block of the cavo-tricuspid isthmus. When freezing at the point where bidirectional isthmus block occurred, the patient experienced chest pain and ECG showed ST segment elevations corresponding to the right coronary artery. Cryoablation may be painless per se, but patients should be told to report chest discomfort and surface ECG must be followed carefully during ablation.     

心肌梗死溶栓疗法危险评分在无ST段抬高急性冠状动脉综合征患者危险分层中的作用

目的　探讨心肌梗死溶栓疗法 (TIMI)危险评分在无ST段抬高的急性冠状动脉综合征 (ACS)患者危险分层及预后预测中的作用。方法　连续收入住院且随访资料齐全的无ST段抬高的ACS患者 2 4 8例 ,仔细询问病史、体检、心电图检查及检测心肌损伤标志物变化。按TIMI危险评分的 7个变量进行计分 ,将患者分成不同的危险层次。分析患者危险评分值对住院期与随访期复合心血管事件的影响。结果　复合心血管事件 (共 4 1例 )的发生随评分增加而呈进行性增高。对比分析TIMI危险评分与肌钙蛋白I(cTnI)水平对复合心血管事件的预测性 ,显示 4 1例复合心血管事件中cTnI阳性组占 38例 ,cTnI阳性患者的复合心血管事件发生率也随TIMI危险评分值增加而逐渐增高。结论　TIMI危险评分用于无ST段抬高ACS患者的危险分层与预后预测操作方便、实用、有效 ,且较单用cTnI检测或许更能显示出对危险分层与预后预测的量化特性     

Transient ST segment elevation occurring without anginal pain. Correlations with Prinzmetal's angina.

Two cases presenting with episodes of marked ST segment elevation occurring with, but most often without, anginal pain are reported. The changes were recorded through continuous ECG monitoring during Prinzmetal's angina and in the course of myocardial infarction. Such transient asymptomatic ECG abnormalities reveal silent acute myocardial ischemia and are often unrecognized. However, they may lead to severe arrhythmias or myocardial infarction, and sudden deaths occurring in the course of ischemic heart disease are likely to be explained on this basis. Transient episodes of silent ST segment elevation similar to those occurring in Prinztal's angina have been reported in various circumstances. They bring into discussion the delimitations of variant angina pectoris.     

An octogenarian with chest pain, ST segment elevation and hypotension (The fifth case)

1 病历摘要 患者,男性,81岁,因“持续性胸痛2.5h”于2003年1月21日入院。入院前2.5h于生气后出现心前区压榨样疼痛,疼痛无放射,持续不缓解,伴胸闷、心悸、大汗、恶心,呕吐胃内容物一次,含服“速效救心丸”等药物无缓解。起病后未小便。既往史:     

A case of recurrent chest pain with reversible left ventricular dysfunction and ST segment elevation on electrocardiogram

There is a syndrome consisting of acute infarction-like symptoms and ECG findings, and transient left ventricular apical ballooning without epicardial coronary artery obstruction. A 67-year-old female admitted to our hospital because of severe anterior chest pain was diagnosed as having this syndrome. Since stenotic, spastic, or occlusive sites were not found in epicardial coronary arteries by emergency cardiac catheterization, we speculated coronary microvasculature involvement in the pathophysiology of the event. Four weeks later in a drug-free condition, there was no significant epicardial coronary vasospasm by intracoronary acetylcholine administration (IC-ACh). The average peak flow velocity (APFV) of the left coronary artery (LCA) was measured using the Doppler flow wire method. Under maximal dilatation of the epicardial LCA by intracoronary nitroglycerin administration, IC-ACh was again performed taking into consideration that the change in APFV in response to IC-ACh reflects a coronary microvascular response to it. In the nonischemic control subjects, basal APFV increased to 296+/-29% (n = 24) of the basal value after IC-ACh. In this patient, although IC-ACh did not cause vasospasm in epicardial LCA, APFV was decreased to 54% of its basal value. After administration of a Ca antagonist and KATP opener, she had no chest symptoms and was discharged from the hospital. In 2003, she forgot to take her medication for 3 days and then experienced a sudden recurrence of the same type of attack. She started her medication again and her symptoms disappeared. Three weeks later, she underwent an assessment of the coronary microvascular response to ACh with medicine. Her APFV after ACh increased to 177% of the basal value.     

Atrial fibrillation during myocardial infarction with and without ST segment elevation

INTRODUCTION: The occurrence of atrial fibrillation (AF) in the acute phase of myocardial infarction with ST segment elevation is common and responsible for an excess hospital mortality. The aim of this work was to define the incidence, predictive factors, and the prognostic impact of AF during MI with and without raised ST segment in the RICO study. PATIENTS AND METHODS: Between January 2001 and July 2003, 1701 patients were included in this study: 130 (7.6%) had AF in the first 24 hours of management (AF+ group); 1571 (92.4%) remained in sinus rhythm (AF- group). RESULTS: Among the 1701 patients included in this study, 1197 (70.4%) had MI with raised ST and 504 (29.6%) had MI without raised ST. The incidence of AF was identical whatever the type of MI (7.6% with raised ST versus 7.7% without, p=0.334). The presence of Killip class >2 on admission and chronic obstructive pulmonary disease were independent predictive factors for the occurrence of AF (OR=3.84, p=0.007, and OR=2.47, p=0.014 respectively). The presence of AF was significantly associated with the occurrence of ventricular arrhythmia and/or cardiovascular mortality during admission in the non-selected MI population whatever the type of MI (raised ST ; AF+; 34% and AF-; 18%, p<0.01 versus without raised ST; AF+; 36% and AF-; 16%, p = 0.01). CONCLUSION: This study provides evidence that the incidence of AF during the first 24 hours of MI, as well as its poor prognosis, are identical whether or not there is ST segment elevation.     

N-terminal pro brain natriuretic peptide on admission for early risk stratification of patients with chest pain and no ST-segment elevation

OBJECTIVES: The study evaluated the prognostic value of single measurement of N-terminal pro brain natriuretic peptide (NT-proBNP) obtained on admission in patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation. BACKGROUND: Patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation constitute a large and heterogeneous population. Early risk stratification has been based on clinical background factors, electrocardiography (ECG) and biochemical markers of myocardial damage. The neurohormonal activation has, so far, received less attention. METHODS: The NT-proBNP was analyzed on admission in 755 patients admitted because of chest pain and no ST-segment elevation. Patients were followed concerning death for 40 months (median). RESULTS: The median NT-proBNP level was 400 (111 to 1646) ng/l. Compared to the lowest quartile, patients in the second, third and fourth quartiles had a relative risk of subsequent death of 4.2 (1.6 to 11.1), 10.7 (4.2 to 26.8) and 26.6 (10.8 to 65.5), respectively. When NT-proBNP was added to a Cox regression model including clinical background factors, ECG and troponin T, the NT-proBNP levels were independently associated with prognosis. CONCLUSIONS: A single measurement of NT-proBNP on admission will substantially improve the early risk stratification of patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation. A combination of clinical background factors, ECG, troponin T and NT-proBNP obtained on admission will provide a highly discerning tool for risk stratification and further clinical decisions.     

氯吡格雷对非ST段抬高急性冠脉综合征患者炎症的影响

目的探讨氯吡格雷对非ST段抬高急性冠脉综合征（ACS）患者炎症因子的近期及长期影响。方法采用病例对照研究，接受介入治疗的非ST段抬高的ACS患者被分成两组，两组均接受标准治疗，其中A组（72例）服用氯吡格雷（波立维）75mg／d共1年，B组（93例）服用氯吡格雷75mg／d共6个月，分别检测两组在服药前及服药后第1、3、6、12个月的高敏C反应蛋白（hSCRP）、白介素-6（IL-6）等炎症标记物水平。结果与治疗前比，两组患者在治疗后第1、3、6个月时的CRP、IL-6均明显降低，但两组间CRP等同期比较无明显差异；第12个月时A组CRP、IL-6仍继续下降，B组CRP等轻度升高，且显著高于A组患者。结论氯吡格雷具有独立的抗炎作用，长期与阿司匹林等合用可进一步降低炎症水平。     

Prognostic significance of troponin T elevation in patients without chest pain

Increased cardiac troponin with chest pain is important for the diagnosis, triage, and treatment of patients in the emergency department. However, the use of troponin for the diagnosis and triage of patients without chest pain is poorly established. The aim of this study was to determine 30-day and 1-year mortality and morbidity of troponin T increases in patients without chest pain. This retrospective study compared 92 hospitalized patients without (study group) and 91 patients with chest pain (control group), followed up for 1 year. Study group patients had troponin T >0.04 mug/L, normal creatine kinase or creatine kinase-MB fraction <5%, and no electrocardiographic ischemia. Excluded were high-risk patients with end-stage kidney disease, those with left ventricular ejection fraction <40%, and the critically ill. Outcome variables included 30-day and 1-year death, myocardial infarction, unstable angina, and coronary revascularization rates. Thirty-day (13.0% vs 4.4%; p = 0.032) and 1-year (33% vs 4.6%; p <0.001) mortality rates were significantly higher in the study group, whereas myocardial infarction, unstable angina, and revascularization were infrequent. In conclusion, patients with increased troponin T and no chest pain had a high mortality rate and required careful follow-up.     

Wall thickening assessment with tissue harmonic echocardiography results in improved risk stratification for patients with non-ST-segment elevation acute chest pain.

OBJECTIVES: To demonstrate whether the improved imaging quality gained by using tissue harmonic echocardiography in place of fundamental echocardiography results in the improved risk stratification of patients presenting with non-ST-elevation acute chest pain. METHODS AND RESULTS: Eighty patients with over 30 min of non-ST-elevation chest pain that had lasted less than 6 h were recruited. All patients underwent resting tissue harmonic and fundamental echocardiographic scans. Diagnosis for acute myocardial infarction was made on a 24 h creatine kinase-MB sample. Echocardiographic images were reported by two experienced blinded observers. Patients were followed up at least 4 months after admission. Endpoints included all-cause mortality, non-fatal myocardial infarction and revascularisation procedures. Tissue harmonic echocardiography allowed assessment of all myocardial segments in all patients compared to 43/78 patients ( p<0.001 ) with fundamental echocardiography. A wall thickening abnormality demonstrated on tissue harmonic echocardiography and not fundamental echocardiography was a significant predictor of index myocardial infarction on admission ( p<0.007 ) and for an adverse cardiac event during follow up ( p=0.002 ). CONCLUSIONS: Tissue harmonic echocardiography is superior to fundamental echocardiography for accurate assessment of systolic wall thickening and hence risk stratification for patients presenting with acute chest pain and non-diagnostic electrocardiogram changes.     

Exercise induced ST segment depression preceding ST segment elevation

A case of exercise induced ST segment depression preceding ST segment elevation in precordial leads and persistent ST segment depression in inferior leads is reported. Such an exercise response should suggest significant fixed coronary stenosis in addition to coronary spasm.     

Infective endocarditis presenting with ST segment elevation

Despite diagnostic and therapeutic advances, mortality and morbidity associated with infective endocarditis (IE) remains high. Congestive heart failure and complications such as septic embolization and aortic root abscess are the main causes. Although aortic root abscess is a common complication of IE involving the aortic valve, acute myocardial infarction (AMI) is a rare complication in patients with endocarditis, whether in the acute or later phase of infection. In most cases, the infarction is either anterior or anterolateral. To the best of the present authors' knowledge, only one case of infarction at a purely inferior site has been reported previously. In the present case, IE with an aortic root abscess presented clinically as an acute inferior wall myocardial infarction.     

Quantitative assessment of ST segment elevation in Brugada patients

BACKGROUND: ST segment elevation in the right precordial leads constitutes the electrocardiogram (ECG) hallmark of Brugada syndrome (BS). This pattern is variable and can be concealed, but the magnitude and the cause of ST segment fluctuations have been poorly investigated. OBJECTIVE: Our goal was to quantify ST changes and to assess rate and autonomic influences on ST level. METHODS: A 12-lead ECG was continuously recorded during 24 hours in 20 patients with BS (ages 49 +/- 12) and 10 healthy subjects (ages 32 +/- 7). Using two-dimensional binning we obtained average QRS-T complexes every 30 minutes (time bins) and at different RR intervals (rate bins) for each subject. ST level was measured at five different points located 90, 100, 110, 120, and 140 ms after Q onset (Qo). In BS patients, the highest ST elevation was measured 110 ms after Qo (Qo+110). RESULTS: ST level changes between time points were significantly greater in patients with BS compared with control subjects: on lead V2, the range of ST level at Qo+110 was 264 +/- 85 microV in BS and 91 +/- 22 microV in control subjects (P <.01). In BS, ST level decreased with heart rate acceleration: the difference in ST level at Qo+110 for RR = 900 and 600 ms was 55 +/- 53 microV (P <.01). HFnu was positively, although weakly, correlated with ST level (R(2) = 0.02, P <.01). CONCLUSIONS: ECG changes observed in patients with BS are related in part to heart rate influences on ST segment level. These spontaneous fluctuations over a 24-hour time period suggest that Holter recordings may improve the ECG diagnosis sensitivity in BS.