Early Resolution Of ST-segment Elevation Research Articles

Preprocedural Ticagrelor Treatment was Associated with Improved Early Reperfusion and Reduced Short-term Heart Failure in East-Asian ST-segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

PurposeThe purpose of this monocentric retrospective observational study is to investigate whether a loading dose of ticagrelor treatment before percutaneous coronary intervention (PCI) procedure improves the early reperfusion and short-term heart function in East-Asian ST segment elevation myocardial infarction (STEMI) patients.Patients and MethodsThe study included 326 STEMI patients undergoing primary PCI in Jiading Central Hospital. One hundred and forty patients received a loading dose of ticagrelor before entering the catheter laboratory. One hundred and eighty-six patients received a loading dose of ticagrelor in the catheter laboratory before the initiation of PCI. Reperfusion endpoints included the presence of self-patency in the culprit artery, the ST-segment elevation resolution over 50% within 24 h after PCI, and the presence of no-reflow in the culprit artery. Clinical endpoints included all-cause mortality, new-onset heart failure, reinfarction and stent thrombosis within 28 days after PCI. Secondary clinical endpoints included mechanical complications and bleeding events.ResultsIn comparison with the in-lab treatment group, the preprocedural treatment group had a significant higher proportion of self-patency in the culprit artery (25.71% vs 16.67%, P=0.045) and early ST-segment elevation resolution (48.57% vs 27.96%, P<0.001). Preprocedural ticagrelor treatment was associated with a significant reduction of new-onset heart failure (9.29% vs 18.82%, p=0.016). Stent thrombosis risks were numerically reduced in the preprocedural treatment group (0.71% vs 1.61%, P=0.466). The rates of major cardiovascular adverse events, reinfarctions and mortality did not differ between the two groups. Bleeding events in the preprocedural treatment group was notn significantly higher than the in-lab treatment group (4.39% vs 1.39%, P=0.142).ConclusionPreprocedural administration of a loading dose of ticagrelor was associated with improved early reperfusion and reduced short-term heart failure in East-Asian STEMI patients undergoing primary PCI, but care should be taken for excess bleeding events.

Morphine use and myocardial reperfusion in patients with acute myocardial infarction treated with primary PCI

BackgroundMorphine is frequently used in ST-segment elevation myocardial infarction (STEMI) patients, even if recently it has been associated with a delayed onset of action of the oral antiplatelet agents. There are no data regarding the impact of morphine on myocardial reperfusion after primary percutaneous coronary intervention (PPCI). ObjectiveThis study sought to assess myocardial reperfusion by early ST-segment resolution (≥50% at 30minutes) according to morphine use in STEMI patients undergoing PPCI. Methods182 STEMI patients undergoing PPCI and receiving either prasugrel (n=51) or ticagrelor (n=131), who were antiplatelet and anticoagulant therapies naïve, were included in the study. All patients had serial ST-segment elevation evaluations by ECG and residual platelet reactivity assessments by VerifyNow P2Y12 Reactivity Units (PRU). ResultsOverall, 74 (41%) patients received morphine according to the attending physician's preference and showed lower ST-segment resolution rate as compared with patients without morphine (76% vs 87%, p=0.047). Higher baseline TIMI flow<2 rate (79% vs 64%, p=0.036) and peak CPK values (1821 [924–3283] U/L vs 1483 [718–2327] U/L, p=0.034) were observed in morphine patients. Moreover, a delayed response to oral antiplatelet (PRU area under the curve [AOU0–8]: 1448±448 vs 686±292, p=0.001) was documented in patients with morphine as compared with those without. The independent predictors of early ST-segment elevation resolution failure were PRU≥208 after antiplatelet loading (OR 2.78, 95% CI 1.08–7.14; p=0.034) and TIMI flow grade<3 after PPCI (OR 5.89, 95% CI 1.64–21.12; p=0.009), but not morphine use. ConclusionsIn STEMI patients undergoing PPCI, morphine use is associated with a higher residual platelet reactivity and a poorer myocardial reperfusion. Independent predictors of impaired myocardial reperfusion were high residual platelet reactivity and TIMI flow grade after PPCI but not morphine use, questioning the direct relationship between morphine and worse myocardial reperfusion.

Early resolution of ST-segment elevation after reperfusion therapy for acute myocardial infarction: Its relation to echocardiography-determined left ventricular global and regional function and deformation

AimsTo evaluate the relationships between ST-segment resolution (STR) and echocardiography-determined left ventricular (LV) global and regional function and deformation in the sub-acute phase of STEMI. Methods and ResultsSTR, defined as either complete (≥70%) or incomplete (<70%), was evaluated 60minutes after primary percutaneous coronary intervention (PCI) of 84 STEMI patients. Conventional two-dimensional (2D) echocardiography and 2D speckle-tracking echocardiography (STE) were performed at 3–7days after reperfusion. LV deformation [including the infarction-related regional longitudinal (RLS), circumferential (RCS), and radial (RRS) strains, and global longitudinal (GLS), circumferential (GCS), and radial (GRS) strains] was measured by 2D STE. LV segmental function was assessed by wall motion score index (WMSI). Patients in incomplete vs. complete STR groups had higher WMSI (p<0.001); decreased peak amplitude of RLS (p<0.001), RCS (p=0.008), RRS (p=0.002); and decreased peak amplitude of GLS (p<0.001), GCS (p<0.001), GRS (p=0.003). RLS (r=0.27, p=0.015) and GLS (r=0.33, p=0.003) were best correlates of STR at the regional and global level, respectively. ConclusionsSTR correlated with global and regional LV function and deformation in patients with sub-acute phase of STEMI after PCI. RLS and GLS were the strongest correlates of STR at the regional and global levels, respectively.

Thrombus aspiration in primary angioplasty for ST-segment elevation myocardial infarction.

Mechanical reperfusion with primary percutaneous coronary intervention in acute ST-segment-elevation myocardial infarction is superior to fibrinolysis in terms of short-term and long-term outcome, provided that it can be delivered on time and by an experienced team. Balloon angioplasty and stent implantation of an occluded epicardial vessel during ST-segment-elevation myocardial infarction can cause disruption of the frail thrombus containing lesions associated with suboptimal myocardial reperfusion and microcirculatory obstruction. Distal embolization of atherothrombotic material can be prevented by thrombus aspiration during primary angioplasty. Mechanical aspiration via end-hole large-lumen thrombectomy catheters has been shown to improve Thrombolysis in Myocardial Infarction (TIMI) flow and result in a more consistent early resolution of ST-segment elevation in multiple registries. More recently, a more sophisticated quantification of the myocardial damage has been applied using myocardial scintigraphy and magnetic resonance, with no difference between patients treated with thrombectomy and patients treated with conventional therapy. The expectations in terms of lasting mortality benefit raised by the first Dutch single-center randomized trial of thrombectomy versus predilation with plain old balloon angioplasty (Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction, TAPAS) were not confirmed by a much larger Swedish trial (Thrombus Aspiration ST-Segment Elevation Myocardial Infarction, TASTE) showing no outcome changes. Although we are waiting for new trials to clarify these controversial results, thrombectomy is still used in selected patients with high thrombus load or with persistent occlusion of the infarct-related artery after wire passage. Here we review the various systems available and discuss their relative merits and the reported results.

063 Predictive factors of ST-Segment resolution after primary angioplasty for acute myocardial infarction

In the setting of acute myocardial infarction (AMI), early resolution of ST-segment elevation was a useful predictor of final infarct size, left ventricular function and clinical outcome. to determine the predictive factors of ST-segment resolution immediately following primary coronary angioplasty for AMI. primary angioplasty was performed in 270 consecutive patients with first AMI, they were divided into 2 groups according to whether ST-segment resolution occurred 1 hour after the procedure. ST-segment resolution ≥70% was considered as ‘complete’ ST-segment resolution, whereas ST-segment resolution < 70% was considered as ‘incomplete’ ST-segment resolution. of the 270 patients, 156 (57.8%) had complete ST-segment resolution. Patients with pre-infarction angina had a greater degree of ST-segment resolution than those without angina (71 ± 21% vs. 49 ± 43%, p<0.02). On multivariate analysis, the absence of pre-infarction angina (OR = 2.7; CI 1.7–3.4, p = 0.03) as well as the admission after H4 (OR = 3.5; CI 1.58–8.06, p = 0.002), patient age ≥70 year (OR = 5.6; CI 2.23–14.4, p<0.001) and initial TIMI flow grade 0/1 (OR = 13.6; CI 4.5–21.2, p<0.001) were major independent predictors of poor ST-segment resolution; whereas sex, coronary risk factors, killip class on admission, multivessel disease and extent of collaterals were not significant. There was a significant difference in survival free of major adverse cardiovascular events, at multivariate analysis, incomplete ST-segment resolution was an independent factor of 1-year mortality (p = 0.016). Rapid ST-segment resolution was associated with a better clinical outcome and prognosis after successful primary PTCA. Pre-infarction angina, age < 70 years, TIMI flow 2/3 and ischemia time < 4 hours were associated with a greater degree of ST-segment resolution after primary angioplasty.

045 Predictive factors of ST-segment resolution after primary angioplasty and clinical outcome

In the setting of acute myocardial infarction (AMI), early resolution of ST-segment elevation was a useful predictor of final infarct size, left ventricular function and clinical outcome. to determine the predictive factors of ST-segment resolution immediately following primary coronary angioplasty for AMI. primary angioplasty was performed in 270 consecutive patients with first AMI, they were divided into 2 groups according to whether ST-segment resolution occurred 1 hour after the procedure. ST-segment resolution ≥ 70% was considered as ‘complete’ ST-segment resolution, whereas ST-segment resolution < 70% was considered as ‘incomplete’ ST-segment resolution. of the 270 patients, 156 (57.8%) had complete ST-segment resolution. Patients with pre-infarction angina had a greater degree of ST-segment resolution than those without angina (71 ±21% vs. 49± 43%, p<0.02). On multivariate analysis, the absence of pre-infarction angina (OR=2.7; CI 1.7-3.4, p=0.03) as well as the admission after H4 (OR=3.5; CI 1.58-8.06, p=0.002), patient age ≥ 70 year(OR= 5.6; CI 2.23-14.4, p<0.001) and initial TIMI flow grade 0/1 (OR=13.6; CI 4.5-21.2, p<0.001) were major independent predictors of poor ST-segment resolution; whereas sex, coronary risk factors, killip class on admission, multivessel disease and extent of collaterals were not significant. There was a significant difference in survival free of major adverse cardiovascular events, at multivariate analysis =, incomplete ST-segment resolution was an independent factor of 1-year mortality (p=0.016). Rapid ST-segment resolution was associated with a better clinical outcome and prognosis after successful primary PTCA. Pre-infarction angina, age < 70 years, TIMI flow 2/3 and ischemia time < 4 hours were associated with a greater degree of ST-segment resolution after primary angioplasty.

Abstract 6181: ST Segment Resolution and Pathological Findings of Aspirated Materials in Patients with ST Elevation Acute Myocardial Infarction

Early resolution of ST-segment elevation (STR) is a potent predictor of better clinical outcome after PCI in ST elevation acute myocardial infarction (STEMI). The aim of this study was to determine the association of aspirated materials and serial change of ST elevation. We studied 150 consecutive STEMI patients with assessable ECG recording, in whom standard PCI was performed with the adjunctive use of aspiration thrombectomy. STR(+) was defined as more than 50% resolution of ST-segment elevation at 60min after PCI. Aspirated materials were pathologically classified into thrombus only group (fresh, lytic, or organized) or thrombus and atheroma complex group, and compared between STR(+) and STR(−). TIMI flow grade, IVUS findings after aspiration(ruptured plaque, calcification, thrombus and echo signal attenuation), area under the curve (AUC) of CK-MB release, and pathological findings were also compared between the two groups. Seventy-six patients (50.6%) showed STR and 74 patients didn’t. RCA culprit lesion was significantly more frequent in STR(+)(P&lt;0.05). There was no significant difference in other patient characteristics or IVUS findings in the present cohort. AUC of CK-MB was lower in STR(+)(p=0.02). TIMI 3 flow was more frequently achieved in STR(+)(p&lt;0.05). Fresh thrombus was more frequent in STR(+)(p&lt;0.05), whereas atheromatous component and lytic or organized thrombus were frequently observed in STR(−)(p&lt;0.05). Culprit lesions in STEMI, when atheroma and thrombus complex with lytic or organized thrombus was aspirated, caused more myocardial damage and less frequent STR.

ST Resolution 1 Hour After Fibrinolysis for Prediction of Myocardial Infarct Size: Insights from ASSENT 3

Acute ST-segment elevation myocardial infarction requires prompt restoration of myocardial perfusion to salvage myocardium at risk of ischemic necrosis and improve clinical outcome. Early resolution of ST-segment elevation during the time after reperfusion has been associated with both these end points. From the ASsessment of the Safety and Efficacy of a New Thrombolytic regimen (ASSENT) 3 trial, 3,425 patients were analyzed to investigate whether the amount of ST-segment resolution, divided into 3 groups (complete, >70%; partial, 30% to 70%; and no resolution, <30%), in the first hour after initiation of therapy was a predictor of final infarct size, estimated by peak creatine kinase and Selvester QRS score on the discharge electrocardiogram. Complete compared with partial and no ST resolution resulted in significantly (p<0.001) smaller infarct sizes of 10.5%, 13.2%, and 15.0% of the left ventricle and significantly (p=0.001) fewer patients with peak creatine >5 times the upper reference level at 50.3%, 71.8%, and 76.3%, respectively. In conclusion, our findings supported previous smaller studies suggesting that early resolution of ST elevation, as a sign of early myocardial reperfusion, resulted in less myocardial damage and preservation of left ventricular function.

Correlation of Serial Cardiac Magnetic Resonance Imaging Parameters With Early Resolution of ST-Segment Elevation After Primary Percutaneous Coronary Intervention

The aim of the present study was to determine whether the parameters of cardiac magnetic resonance imaging (CMRI) might correlate with early ST-segment resolution (STR) after primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). CMRI was performed in 45 STEMI patients (age: 56.6+/-13.0 years) at 8.2+/-8.0 days (early phase) and 3.3+/-1.1 months (late phase) after successful PCI. CMRI parameters were compared between 2 groups: > or = 70% STR (group 1, n = 21) and < 70% STR (group 2, n = 24). Both groups had similar baseline characteristics, except for a higher frequency of > or = 2 myocardial blush grade and shorter pain-to-balloon time in group 1. Early-phase CMRI showed that persistent microvascular obstruction (PMO) (38.1% vs 91.7%, p < 0.001) occurred less frequently and the percent infarct mass against total left ventricular (LV) mass (17.7+/-8.7% vs 29.1+/-13.4%, p = 0.001) was smaller in group 1. Late-phase CMRI revealed a significant increase in LV end-diastolic volume (-1.5+/-8.7 vs 14.5+/-25.5 ml, p = 0.026) and reduced ejection fraction (55.0+/-9.9% vs 47.8+/-11.1%, p = 0.027) in group 2. CMRI demonstrated that early STR might be related to PMO and infarct size, and predicts LV dysfunction and adverse LV remodeling. Also, early-phase CMRI findings are comparable to late-phase CMRI in association with early STR.

Safety and Efficacy of the FilterWire EZ in Acute ST-Segment Elevation Myocardial Infarction

Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) achieves a high epicardial reperfusion rate; however, it is often suboptimal in achieving myocardial reperfusion due to distal embolization of atherothrombotic particles. The present study assessed whether the capture of embolic particles during PCI would improve myocardial reperfusion outcome. In a multicenter, prospective, randomized, controlled study, 100 patients with STEMI and coronary angiographic evidence of thrombotic occlusion were randomly assigned to PCI using the FilterWire EZ (n=51) or a control group (n=49) using regular guidewires. The FilterWire EZ was successfully delivered across the lesion in 84% of patients in the FilterWire EZ group. Primary efficacy end points, including markers of epicardial (Thrombolysis In Myocardial Infarction grade flow) and myocardial reperfusion (myocardial blush score and percent early resolution of ST-segment elevation), did not differ between the 2 study groups. Further, 60- and 90-minute percent ST-segment resolutions were identical in the 2 groups. In a subgroup analysis, a blush score of 3 was achieved in 94% of patients in whom the filter's landing zone was in a vessel diameter>2.5 mm compared with only 55% in those with smaller vessel diameter (p=0.04). This corresponds to a better debris capture in filters located in large versus small vessels (p=0.08). In conclusion, in patients with STEMI, use of the FilterWire EZ as an adjunct to primary PCI did not improve angiographic or electrocardiographic measurements of reperfusion compared with conventional PCI only.

Balloon-Based Distal Protection Device Improves the Recovery of Left Ventricular Function after Primary Coronary Angioplasty

Background and Objectives：Despite the high success rate of primary angioplasty in cases of acute myocardial infarction (AMI), myocardial reperfusion can frequently be compromised, mainly due to distal embolization, which can be effectively prevented with the use of distal protection devices. The goal of this study was to see whether PercuSurge ® , a balloon-based distal protection device, could improve myocardial reperfusion and late clinical outcomes after primary coronary angioplasty. Subjects and Methods：Between April 2002 and July 2003, 29 patients with AMI, within 12 hours of the onset of symptoms, were scheduled to undergo primary angioplasty using PercuSurge ® (PS group). Thirty patients were selected as a control group by matching the 5 clinical and angiographic variables; the clinical status and coronary angiograms were also prospectively reviewed and analyzed. Results： There were no significant differences in the baseline clinical and angiographic characteristics, including the left ventricular ejection fraction (LVEF) between two groups. The procedures were successful, without complications, in all patients from both groups. However, the PS group was associated with a significantly higher incidence of myocardial blush score of 3 (PS 58%, control 30%, p=0.001) and early ST-segment elevation resolution (PS 76%, control 47%, p=0.02) compared to the control group. The PS group also showed a greater LVEF at 60 days after the procedure (PS 51±5%, control 46±8%, p=0.007). There was no significant difference in the incidences of death or myocardial infarction between the two groups during the follow-up period. Conclusion：The use of the PercuSurge ® was found to be safe and feasible during primary angioplasty, and this system also improved the recovery of the left ventricular function as well as myocardial reperfusion following primary coronary angioplasty. (Korean Circulation J 2006;36:84-90)

ST resolution after mechanical reperfusion closely correlates with myocardial salvage and associtated with patients prognosis after acute anteroseptal MI

Background: Early resolution of ST-segment elevation is an indicator of final infarct size and clinical outcomes. However, the relationship between the degree of ST resolution and the indexes derived from perfusion scintigraphy such as area at risk(AAR), infarct size(IR), and salvaged myocardium(SI) is unclear. Methods: Consecutive 65 patients with anteroseptal myocardial infarction with successful mechanical reperfusion, whose AAR, IS, and SI could be assessed by myocardial perfusion imaging, were studied. Serial 12 leads electrocardiograms were performed at baseline, 90 minutes after reperfusion. ST resolution was defined as complete (>70%, n = 16), partial (<70% to 30%, n = 36), or no resolution (<30%, n = 13). Results: Patients with no resolution group tended to be longer time to reperfusion (complete: 4.0 ± 7.5 partial: 6.5 ± 8.2 No: 7.4 ± 6.6). Peak CPK inversely correlated with level of ST resolution(complete:1689 ± 1395 partial:3078 ± 2577 No:5252 ± 2537 p < 0.01). As for the scintigraphical indexes such as AAR, IR, and SI, all these indexes had significant association with the level of ST resolution(AAR: complete 114 ± 54 partial 145 ± 58 no 178 ± 51 p < 0.05, IS:complete 21 ± 26 partial 66 ± 60 no 131 ± 31 p < 0.001, SI: complete 81.9 ± 16.2 partial 57.6 ± 29.4 no 27.7 ± 23.9 p < 0.001). Furthermore, patients with no resolutions experienced high prevalence of the occurrence of congestive heart failure than partial and complete resolution groups. Conclusion: Early resolution of ST-segment elevation closely correlated with AAR, IS, and SI as assessed by scintigraphy and closely associated with patients prognosis.

Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction

This randomized trial compared rheolytic thrombectomy before direct infarct artery stenting with direct infarct artery stenting alone in 100 patients with a first acute myocardial infarction (AMI). The primary end point of the study was early ST-segment elevation resolution, and the secondary end points were corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, infarct size, and 1-month clinical outcome. The primary end point rates were 90% in the thrombectomy group and 72% in the placebo group (p = 0.022). Randomization to thrombectomy was independently related to the primary end point (odds ratio 3.56, p = 0.032). The corrected Thrombolysis In Myocaridal Infarctions (TIMI) frame count was lower in the thrombectomy group (18.2 ± 7.7 vs 22.5 ± 11.0, p = 0.032), and infarct size was smaller in the thrombectomy group (13.0 ± 11.6% vs 21.2 ± 18.0%, p = 0.010). At 1 month, there were no major adverse cardiac events. Rheolytic thrombectomy before routine direct infarct-related artery (IRA) stenting is highly feasible and provides more effective myocardial reperfusion in patients undergoing percutaneous coronary intervention for AMI.

Intracoronary ST segment evolution during primary coronary stenting predicts infarct zone recovery

In patients with acute myocardial infarction (AMI), early ST segment elevation resolution on ECG predicts myocardial reperfusion and LV recovery. Intracoronary ECG is more sensitive than surface ECG to detect regional ischemia. In patients undergoing primary percutaneous coronary intervention (PCI), we investigated if failed myocardial reperfusion, despite successful infarct vessel recanalization, could be rapidly and easily identified by intracoronary ST segment monitoring from guidewire recording. We recorded intracoronary and standard ECG during primary coronary stenting (PCI) in 50 patients with AMI (59 +/- 11 years; anterior AMI in 66%). All patients had a successful PCI and underwent 2D echocardiography soon after PCI and 6 months later. Following PCI, intracoronary ST resolution >/= 50% from baseline was documented in 39 patients (78%; group A; from 11 +/- 8 to 1 +/- 2 mm) but not in 11 (22%; group B; from 11 +/- 8 to 8 +/- 5 mm). Group A had slightly shorter ischemic time (202 +/- 94 vs. 238 +/- 112 min in B; P = 0.2) and smaller peak CK values (2,752 +/- 2,038 vs. 4,802 +/- 3,671 U/L in B; P = 0.02). After PCI, ST resolution was found on standard ECG in 34 (87%) group A and in 3 (27%) group B patients. At 6-month follow-up, left ventricular ejection fraction was greater in group A (47% +/- 8% vs. 39% +/- 8% in B; P < 0.001) with improved wall motion score index (from 2.2 +/- 0.3 to 1.7 +/- 0.3 in A; from 2.3 +/- 0.4 to 2.1 +/- 0.4 in B; P < 0.001). There were no significant differences between intracoronary and standard ECG for sensitivity (92% vs. 86%) and specificity (62% vs. 57%) to predict improved infarct zone recovery after 6 months. ST elevation resolution on intracoronary recording during PCI predicts infarct zone recovery. Monitoring ST segment evolution by intracoronary ECG allows prompt and inexpensive identification in the catheterization laboratory of those patients without myocardial reperfusion, who may require adjunctive therapeutic interventions after successful infarct vessel recanalization.

“Mirror-lake” serial relationship of electrocardiographic and biochemical indices for the detection of reperfusion and the prediction of salvage in patients with acute myocardial infarction

Background Serial observations of biochemical markers in the blood and bioelectric markers on the electrocardiogram (ECG) have been used to evaluate the effectiveness of reperfusion therapy in acute myocardial infarction (AMI). This study presents a combined method for clinical use, based on the “mirror-lake” tendency of the serial changes in these markers. Methods Consecutive thrombolytic-treated patients with AMI (n = 43) had ST-segment monitoring (Mortara Eli 100) and frequent serum sampling of myoglobin (MG) concentration. Their acutely predicted and finally estimated AMI sizes and myocardial salvage extents were calculated from the 12-lead standard ECG. Patients having 2 positive reperfusion indices (ST resolution at least 50%, and an increase in MG at least 2.4 fold) at 2 hours after initiation of thrombolytic therapy were considered the “complete reperfusion” group, and patients with discordant or 2 negative reperfusion indices after 2 hours of thrombolytic therapy were considered the “limited reperfusion” group. Results Patients with complete reperfusion (n = 22) versus patients with limited reperfusion (n = 21) had +12% versus −1% myocardial salvage ( P < .0001). The serial changes in the ST segment mirrored the serial changes in the MG concentration, and the rates of increase in MG correlated with the rates of resolution of the ST-segment elevation. Conclusion Myocardial salvage (measured by ECG indices) is greatest when an early increase in serum MG is “mirrored” by early resolution of ST-segment elevation.

Microvascular Integrity and Ventricular Function according to Early ST-Segment Resolution in Acute Myocardial Infarction

Background and Objectives:Early resolution of ST-segment elevation improves the short and long-term mortalities in acute myocardial infarction (AMI). However, the correlations between the ST segment resolution and microvascular integrity, or functional recovery of the left ventricle, were not explored. Subjects and Methods: The study population consisted of 42 AMI patients who received thrombolytic therapy (35 male, 54±11 years) and consecutive successful percutaneous coronary intervention (PCI) (<30% of residual stenosis, recovered TIMI 3 flow) within 7 days. The coronary flow reserve (CFR) was measured at the segment just distal to the angioplasty site using intracoronary Doppler wire following a successful PCI. Electrocardiograms (ECG) were evaluated before, and within 90-150 minutes after, of the thrombolytic therapy. The percentage change in the ST segment resolution, from the baseline to follow-up, was categorized into complete resolution (70%, n=24), partial resolution (30% to <70%, n=10) and no resolution (0% to <30%, n=8). The ejection fraction (EF) and regional wall motion score indices (RWMSI) were assessed by 2D-echocardiography before, and following the PCI (9±5 months). Results: Complete ST segment resolution was observed in 57%, partial resolution in 24%, and no resolution in 19% of patients. The CFR was significantly higher in the complete resolution group than in the no resolution group, and the minimal coronary vascular resistance index was significantly lower in the complete resolution group than in the no resolution group (2.1±0.5 vs. 1.4±0.4, p=0.006;2.31±0.99 mmHg·sec·cm vs. 3.84±2.19 mmHg·sec·cm, p=0.035, respectively). The changes in the EF and RWMSI were significantly better in complete resolution group than in the no resolution group (10±9% vs. 0±5%, p=0.028;-1.03±0.50 vs. 0.24±0.66, p=0.004, respectively), and the left ventricular end diastolic and systolic volume indices were significantly increased in the no resolution group at follow-up (42.0±14.8 mL/m vs. 55.8±18.1 mL/m, p=0.006;23.2±10.9 mL/m vs. 30.5±15.9 mL/m, p=0.039, respectively). Conclusion:In the AMI patients, with a recovered TIMI 3 flow, following thrombolysis and successful elective PCI, there were differences in the coronary flow reserve according to the degree of early resolution of the ST segment. The patients with an early complete resolution of the ST segment showed the most favorable preservation of the microvascular integrities and improvement of the left ventricular function. The degree of early resolution of the ST segment might be a useful indicator for the prediction of left ventricular functional changes at follow-up. (Korean Circulation J 2003;33 (3):183-195)

Effects of abciximab pretreatment in patients with acute myocardial infarction undergoing primary angioplasty

In summary, our study indicates that abciximab pretreatment in patients with ST-elevation myocardial infarction may be beneficial because it partially restores epicardial patency before a primary angioplasty attempt and facilitates early ST-segment elevation resolution.

Early Resolution of ST-Segment Elevation Correlates With Myocardial Salvage Assessed by Tc-99m Sestamibi Scintigraphy in Patients With Acute Myocardial Infarction After Mechanical or Thrombolytic Reperfusion Therapy

Early resolution of ST-segment elevation is an indicator of final infarct size and clinical outcomes. Whether this correlation is an expression of initial infarct characteristics or degree of myocardial salvage achieved with reperfusion therapy is unclear. We prospectively included 243 patients with acute myocardial infarction (AMI) treated with either coronary stenting (122 patients) or thrombolysis (121 patients). Serial 12-lead electrocardiograms (ECG) were performed at baseline and 90 minutes after initiation of therapy. ST-segment resolution was defined as complete (> or =70%), partial (<70% to 30%), or no resolution (<30%). Paired technetium-99m sestamibi scintigraphic studies were performed to calculate the initial perfusion defect, final infarct size, and the proportion of initial defect salvaged with reperfusion (salvage index). ST-segment resolution correlated significantly with salvage index (P=0.008), final infarct size (P<0.001), and 6-month mortality (P=0.03). In the groups with complete, partial, and no resolution, salvage index was 0.54+/-0.32, 0.39+/-0.36, and 0.33+/-0.60; final infarct size was 12.5+/-12.0%, 20.0+/-13.9%, and 22.7+/-19.4% of the left ventricle; 6-month mortality was 2.4%, 6.2%, and 12.8%, respectively. After adjustment for baseline characteristics, ST-segment resolution was the second strongest predictor of salvage index (P=0.007) after the type of reperfusion, stenting, or thrombolysis (P=0.001); it was greater after stenting than after thrombolysis (P<0.001). Early resolution of ST-segment elevation in surface ECG correlates with myocardial salvage as assessed by scintigraphy in patients with AMI after reperfusion therapy. These data provide an explanation for the favorable prognostic value of the ST-segment resolution and support the use of this parameter to compare the efficacy of different reperfusion strategies.

Extent of ST-segment deviation in a single electrocardiogram lead 90 min after thrombolysis as a predictor of medium-term mortality in acute myocardial infarction

In evolving myocardial infarction, assessment of the sum of early resolution of ST-segment elevation (sumSTR) has become an established method to predict outcome. We have found previously that mortality is predicted more accurately by the existing ST-segment deviation in the single electrocardiograph (ECG) lead with maximum deviation (maxSTE) 90 min after start of thrombolysis. This report compares the power to predict medium-term mortality by these two approaches. An ST-segment resolution substudy was done in conjunction with the Intravenous nPA for Treatment of Infarcting Myocardium Early (InTIME) II Study, which compared mortality in patients with acute myocardial infarction randomly assigned lanoteplase or alteplase. In 2719 patients, a 12-lead ECG was assessed at baseline and 90 min after the start of thrombolytic therapy. MaxSTE achieved a better combination of sensitivities and specificities for mortality prediction than sumSTR. The area under the receiver-operating characteristic curves for 180-day mortality prediction was 0.680 for maxSTE and 0.622 for sumSTR (difference 0.058; 95% CI 0.027-0.088). Risk groups categorised at low, medium, or high risk by maxSTE comprised 43%, 32%, and 24% of patients and those by complete, partial, or no sumSTR comprised 40%, 36%, and 24% of all patients. The 180-day mortality rates for the three maxSTE risk groups were 3.1%, 7.1%, and 16.2%, and those for the sumSTR groups were 4.8%, 8.1%, and 11.7%. The 12-month Kaplan-Meier estimates were 4.1%, 8.8%, and 18.6%, and 5.9%, 9.9%, and 13.7%, respectively. MaxSTE predicts early and medium-term mortality more accurately than does sumSTR. The prognosis for an individual patient can be accurately estimated simply by the ST-segment deviation present in one ECG lead recorded 90 min after thrombolysis.

The significance of persistent ST elevation versus early resolution of ST segment elevation after primary PTCA

OBJECTIVESTo determine the prevalence and clinical significance of early ST segment elevation resolution after primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI).BACKGROUNDDespite angiographically successful restoration of coronary flow early during AMI, adequate myocardial reperfusion might not occur in a substantial portion of the jeopardized myocardium due to microvascular damage. This phenomenon comprises the potentially beneficial effect of early recanalization of the infarct related artery (IRA).METHODSIncluded in the study were 117 consecutive patients who underwent angiographically successful [Thrombolysis in Myocardial Infarction (TIMI III)] primary PTCA. The patients were classified based on the presence or absence of reduction ≥50% in ST segment elevation in an ECG performed immediately upon return to the intensive cardiac care unit after the PTCA in comparison with ECG before the intervention.RESULTSEighty-nine patients (76%) had early ST segment elevation resolution (Group A) and 28 patients (24%) did not (Group B). Group A and B had similar clinical and hemodynamic features before referring to primary PTCA, as well as similar angiographic results. Despite this, ST segment elevation resolution was associated with better predischarge left ventricular ejection fraction (LVEF) (44.7 ± 8.0 vs. 38.2 ± 8.5, p < 0.01). Group B patients, as compared with those of Group A, had a higher incidence of in-hospital mortality (11% vs. 2%, p = 0.088), congestive heart failure (CHF) [28% vs. 19%, odds ratio (OR) = 4, 95% confidence interval (CI) 1 to 15, p = 0.04], higher long-term mortality (OR = 7.3, 95% CI 1.9 to 28, p = 0.004 with Cox proportional hazard regression analysis) and long-term CHF rate (OR = 6.5, 95% CI 1.3 to 33, p = 0.016 with logistic regression).CONCLUSIONSAbsence of early ST segment elevation resolution after angiographically successful primary PTCA identifies patients who are less likely to benefit from the early restoration of flow in the IRA, probably because of microvascular damage and subsequently less myocardial salvage.