Does Continuous ST‐Segment Monitoring Add Prognostic Information to the TIMI,PURSUIT, and GRACE Risk Scores?

Background: Recurrent ischemia is frequent in patients with non‐ST‐elevation acute coronary syndromes (NST‐ACS), and portends a worse prognosis. Continuous ST‐segment monitoring (CSTM) reflects the dynamic nature of ischemia and allows the detection of silent episodes. The aim of this study is to investigate whether CSTM adds prognostic information to the risk scores (RS) currently used. Methods: We studied 234 patients with NST‐ACS in whom CSTM was performed in the first 24 hours after admission. An ST episode was defined as a transient ST‐segment deviation in ≥1 lead of ≥ 0.1 mV, and persisting ≥1 minute. Three RS were calculated: Thrombolysis in Myocardial Infarction (TIMI; for NST‐ACS), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Supression Using Integrilin (PURSUIT; death/MI model), and Global Registry of Acute Coronary Events (GRACE). The end point was defined as death or nonfatal myocardial infarction (MI), during 1‐year follow‐up. Results: ST episodes were detected in 54 patients (23.1%) and associated with worse 1‐year outcome: 25.9% end point rate versus 12.2% (Odds Ratio [OR]= 2.51; 95% Confidence Interval [CI], 1.18–5, 35; P = 0.026). All three RS predicted 1‐year outcome, but the GRACE (c‐statistic = 0.755; 95% CI, 0.695–0.809) was superior to both TIMI (c‐statistic = 0.632; 95% CI, 0.567–0.694) and PURSUIT (c‐statistic = 0.644; 95% CI: 0.579–0.706). A GRACE RS > 124 showed the highest accuracy for predicting end point. The presence of ST episodes added independent prognostic information the TIMI RS (hazard ratio [HR]= 2.23; 95% CI, 1.13–4.38) and to PURSUIT RS (HR = 2.03; 95% CI, 1.03–3.98), but not to the GRACE RS. Conclusions: CSTM provides incremental prognostic information beyond the TIMI and PURSUIT RS, but not the GRACE risk score. Hence, the GRACE risk score should be the preferred stratification model in daily practice. Ann Noninvasive Electrocardiol 2011;16(3):239–249     

STaVR抬高对急性冠状动脉综合征预后评估的价值

目的探讨心电图STaVR抬高对急性冠状动脉综合征预后评估的价值。方法回顾性分析68例急性冠状动脉综合征患者的心电图和冠状动脉造影资料、临床资料。根据STaVR抬高是否≥0.05mV分为抬高组（n=23）和非抬高组（n=45）。结果病变血管涉及左主干和左前降支近段的分别为抬高组13例（56.5％）和非抬高组1例（2.2％）,病变范围为多支病变的分别为9例（39.1％）和8例（17．8％）,发生心脏事件分别为7例（30.4％）和4例（8.9％）,两组差异均有非常显著性意义（P〈0．01）。结论急性冠状动脉综合征患者STaVR抬高提示左主干和左前降支近段病变、多支病变的可能,对判断预后有参考价值。     

ST‐Segment Resolution Prior to Primary Percutaneous Coronary Intervention Is a Poor Indicator of Coronary Artery Patency in Patients with Acute Myocardial Infarction

Background: The prognostic value of ST‐segment resolution (STR) after initiation of reperfusion therapy has been established by various studies conducted in both the thrombolytic and mechanic reperfusion era. However, data regarding the value of STR immediately prior to primary percutaneous coronary intervention (PCI) to predict infarct‐related artery (IRA) patency remain limited. We investigated whether STR prior to primary PCI is a reliable, noninvasive indicator of IRA patency in patients with ST‐segment elevation myocardial infarction (STEMI). Methods: The study population consisted of STEMI patients who underwent primary PCI at our institution between 2000 and 2007. STR was analyzed in 12‐lead electrocardiograms recorded at first medical contact and immediately prior to primary PCI and defined as complete (≥70%), partial (70%? 30%), or absent (<30%). Results: In 1253 patients with a complete data set, STR was inversely related to the probability of impaired preprocedural flow (P_{for trend} < 0.001). Although the sensitivity of incomplete (<70%) STR to predict a Thrombolysis in Myocardial Infarction (TIMI) flow of <3 was 96%, the specificity was 23%, and the negative predictive value of incomplete STR to predict normal coronary flow was only 44%. Conclusions: This study establishes the correlation between STR prior to primary PCI and preprocedural TIMI flow in STEMI patients treated with primary PCI. However, the negative predictive value of incomplete STR for detection of TIMI‐3 flow is only 44% and therefore should not be a criterion to refrain from immediate coronary angiography in STEMI patients. Ann Noninvasive Electrocardiol 2010;15(2):107–115     

Evaluation of Non-ST Segment Elevation Acute Chest Pain Syndromes with a Novel Low-Profile Continuous Imaging Ultrasound Transducer

Background: This investigation was designed to test the hypothesis that continuous cardiac imaging using an ultrasound transducer developed in our laboratory (ContiScan) is superior to electrocardiogram (ECG) monitoring in the diagnosis of coronary artery disease (CAD) in patients with acute non-ST segment elevation chest pain syndromes. Methods: Seventy patients with intermediate to high probability of CAD who presented with typical anginal chest pain and no evidence of ST segment elevation on the ECG were studied. The 2.5-MHz transducer is spherical in its distal part mounted in an external housing to permit steering in 360 degrees. The transducer was placed at the left sternal border to image the left ventricular short-axis view and recorded on video tape at baseline, during and after episodes of chest pain. Two ECG leads were continuously monitored. The presence of CAD was confirmed by coronary arteriography or nuclear or echocardiographic stress testing. Results: Twenty-four patients had regional wall motion abnormalities (RWMA) on their initial echo which were unchanged during the period of monitoring. All had evidence of CAD. Twenty-eight patients had transient RWMA. All had evidence of CAD. Eighteen patients had normal wall motion throughout the monitoring period, 14 of these had no evidence of CAD, and four had evidence of CAD. These four patients did not have chest pain during monitoring. The sensitivity, specificity, and accuracy of echocardiographic monitoring for diagnosing non-ST elevation myocardial infarction was 88%, 100%, and 91% respectively. The sensitivity, specificity, and accuracy of the ECG for diagnosis of CAD were 31%, 100%, and 52%, respectively. Echocardiography was superior to ECG (P < 0.001). Conclusions: The data indicate that continuous cardiac imaging is superior to ECG monitoring for the diagnosis of CAD in patients presenting with acute non-ST segment elevation chest pain syndromes. This technique could be a useful adjunct to ECG monitoring for myocardial ischemia in the acute care setting.     

Elevated Serum Cardiac Troponin in Non‐acute Coronary Syndrome

Cardiac troponins (CTn) are the most sensitive and specific biochemical markers of myocardial injury and risk stratification. The assay for troponin T (cTnI) is standardized, and results obtained from different institutions are comparable. This is not the case with troponin I (cTnT), and clinicians should be aware that each institution must analyze and standardize its own results. Elevated cTn levels indicate cardiac injury, but do not define the mechanical injury. The differentiation of cTn elevation caused by coronary events from those not related to an acute coronary syndrome (ACS) is tiresome, at times vexing, and often costly. Elevation of cTn in non‐ACS is a marker of increased cardiac and all‐cause morbidity and mortality. The cause of these elevations may involve serious medical conditions that require meticulous diagnostic evaluation and aggressive therapy. At present, there are no guidelines to treat patients with elevated troponin levels and no coronary disease. The current strategy of treatment of patients with elevated troponin and non‐ACS involves treating the underlying causes. Copyright © 2009 Wiley Periodicals, Inc.     

ST‐segment elevation on intracoronary electrocardiogram after percutaneous coronary intervention is associated with worse outcome in patients with non‐ST‐segment elevation myocardial infarction

The AMPLATZER^TM Vascular Plug 4 (AVP4) is a self‐expandable, replaceable occluder made of Nitinol wire mesh, which allows the safe and effective interventional occlusion of medium size vessels. This report describes an infant diagnosed with pulmonary atresia, ventricular septal defect, and multifocal collateral lung perfusion through four major aortopulmonary collateral arteries (MAPCAs). A central aorto‐pulmonary shunt was performed at 4 months of age. Because of postoperative pulmonary hyperperfusion, one of the MAPCAs was closed interventionally using a 5 mm AVP4. This MAPCA originated from the descending aorta (DAO) near the fifth thoracic vertebra and ran behind the esophagus to the lower lobe of the right lung. The MAPCA was closed near its origin from the DAO. Four weeks later, the patient presented with severe gastrointestinal bleeding, caused by perforation of the AVP4 into the esophagus. The occluder was extracted surgically, the MAPCA was clipped and the esophageal injury was sutured. To date, there have been no reports describing esophageal perforation due to an AVP4. The perforation in this patient may have been due to implantation of the AVP4 near the aorta in a MAPCA segment located directly in front of the spine and behind the esophagus. Another possible factor may have been the requirement for a gastrointestinal feeding tube. Although the occluder is soft and flexible, the spindle‐shaped ends may cause trauma if they are located close to other structures. © 2016 Wiley Periodicals, Inc.     

Relationship Between Dobutamine Echocardiography and the Elevation of Cardiac Troponin I in Patients with Acute Coronary Syndromes

An elevated cardiac troponin I (cTnI) and a positive dobutamine echocardiography are powerful predictors for future cardiac events in patients with coronary artery disease. Investigating their correlation also should be helpful in understanding their clinical usefulness in evaluating patients with acute coronary syndromes (ACS). Dobutamine echocardiography and a blood sampling for cTnI were performed on 117 patients with ACS 70 +/- 2 hours after arriving at the hospital. CTnI was considered elevated when its value was greater than 2.0 ng/ml. Dobutamine echocardiography was positive in 86 (73.5%) patients, and cTnI was elevated in 37 (31.6%). The occurrence of positive dobutamine echocardiography in patients with elevated cTnI was significantly higher than in those with normal cTnI (86.5% vs. 67.5%, P = 0.042). More patients in the elevated cTnI group developed myocardial ischemia before or at the stage of dobutamine 20 microg/kg/min (43.2% vs. 15%, P = 0.002). When compared with patients with normal cTnI, patients with elevated cTnI had a lower ischemic threshold during dobutamine echocardiography, and more frequently had baseline echocardiographic wall-motion abnormalities, a history of myocardial infarction, and a positive dobutamine echocardiography. Using multivariate analysis, we found that only a lower dobutamine echocardiography ischemic threshold (P = 0.0008) and baseline wall-motion abnormalities (P = 0.0004) were associated independently with the elevation of cTnI. Our results suggest that in patients with ACS, dobutamine echocardiography can offer information regarding wall-motion abnormalities and ischemic threshold, which are suggested to have a clinical value similar to elevated cTnI.     

ECG Diagnosis and Classification of Acute Coronary Syndromes

In acute coronary syndromes, the electrocardiogram (ECG) provides important information about the presence, extent, and severity of myocardial ischemia. At times, the changes are typical and clear. In other instances, changes are subtle and might be recognized only when ECG recording is repeated after changes in the severity of symptoms. ECG interpretation is an essential part of the initial evaluation of patients with symptoms suspected to be related to myocardial ischemia, along with focused history and physical examination. Patients with ST‐segment elevation on their electrocardiogram and symptoms compatible with acute myocardial ischemia/infarction should be referred for emergent reperfusion therapy. However, it should be emphasized that a large number of patients may have ST‐elevation without having acute ST‐elevation acute coronary syndrome, while acute ongoing transmural ischemia due to an abrupt occlusion of an epicardial coronary artery may occur in patients with ST‐elevation less than the thresholds defined by the guidelines. Up‐sloping ST‐segment depression with positive T waves is increasingly recognized as a sign of regional subendocardial ischemia associated with severe obstruction of the left anterior descending coronary artery. Widespread ST‐segment depression, often associated with inverted T waves and ST‐segment elevation in lead aVR during episodes of chest pain, may represent diffuse subendocardial ischemia caused by severe coronary artery disease. In case of hemodynamic compromise, urgent coronary angiography has been increasingly recommended for these patients.     

Diagnostic Value of Exercise‐Induced ST‐Segment Elevation in Q‐Wave Leads. After Recent Myocardial Infarction

Background: Exercise‐induced ST‐segment elevation in an infarct territory with abnormal Q waves is a known marker for more severe left ventricular wall‐motion abnormalities. However, it is reported, that exercise‐induced ST‐segment elevation in infarct leads may indicate residual viability in the intarctregion. The aim of the study was to test whether exercise‐induced ST‐segment elevation is related to left ventricular (LV) dysfunction or to persistent viability in patients with previous myocardial infarction (MI). Methods: 145 consecutive patients (119 men, 26 women, age 58 ± 11 years) 2–3 weeks after Q‐wave Ml but without ST elevation at rest ECG were enrolled in the study. All patients underwent a target heart rate or symptom‐limited exercise testing (ET) with Bruce protocol. Exercise‐induced ST‐segment elevation < 1 mm above the baseline ST segment level (80 ms after J point) in more than 1 ECG lead with Q wave was considered to be significant. Patients were divided in two groups according to ET results: group I, 25 patients with significant exercise‐induced ST‐segment elevation and group II, 120 patients without exercise‐induced ST‐segment elevation. All patients underwent rest ECHO and low dose dobutamine stress echo (LOSE) within 7 days after ET. LV function was estimated using ejection fraction (EF). Results: More severe LV dysfunction was observed in patients from group 1 (EF 31 ± 8.16% vs EF 45 ± 10.3%). Myocardial viability (defined as an improvement of regional systolic wall thickening in the regions with resting regional wall‐motion abnormalities during LOSE 5 to 15 g/kg/min was recognized in 8 patients (32%) in group I and 31 patients (25.8%) in group II. There was no relation between exercise‐induced ST‐segment elevation and myocardial viability (chi‐square test: 2,809; NS). Conclusions: Exercise‐induced ST‐segment elevation in most cases is associated with left ventricular dysfunction. Patients with exercise‐induced ST‐segment elevation have a lower EF than those without and greater severity of resting wall‐motion abnormalities. Our results suggest that exercise‐induced ST‐segment elevation is not related to residual myocardial viability.