Location Of Acute Myocardial Infarction Research Articles

Assessing the Short-term Survival of Patients with Acute Myocardial Infarction and Some of its Predicting Factors in Dezful during 2018-2019

Background and Objectives Cardiovascular diseases are the leading cause of death and the most important cause of disability in most countries. This study aimed to investigate short-term survival (28 days) in patients with acute myocardial infarction (AMI) and to determine some predictive factors of short-term survival in these patients. Subjects and Methods This study was a retrospective cohort study conducted on 260 patients with AMI in Ganjavian Hospital, a referral hospital in Dezful, Iran, during 2018-2019. Life table and Kaplan Meier analyses were used for the assessment of short-term survival rate. Log rank, Wilcoxon tests, and Cox multivariate regression were used to compare survival functions and determine the predictive factors of short-term survival. Results The mean age of the patients was 57.91 ± 10.76 years, and 193 (74.23%) were male. The survival rate was 90% on the 28th day. In Cox regression, the risk of death in women was higher than that in men (HR=1.82, 95% CI: 1.08-3.47). Also, the risk of death had a statistically significant association with diabetes status (HR=2.87,95% CI: 1.21-6.78), history of ACS (HR=3.03, CI95%: 1.32-6.92), EF<30 (HR=5.24, CI95%: 1.68-9.30), thrombolytic drugs (HR=1.84, CI95%: 1.10-3.57), arrhythmia (HR=6.98,95% CI: 2.31-21.08) and anterior MI (HR=1.67, CI95%: 1.27-2.79). Conclusion In the AMI patients, the 28-day survival rate was about 90%, which was the highest risk of death in the first 8 days after an AMI. The factors of sex, diabetes status, history of ACS, EF, thrombolytic drugs, arrhythmia, and location of AMI were associated with the survival of patients. Therefore, timely and appropriate follow-up of treatment, especially in high-risk groups, plays an important role in increasing survival in patient with AMI

MTHFR C677T polymorphism, homocysteine, burden, and location of AMI and ACI.

We aimed to investigate the relationship between homocysteine levels and MTHFR C677T polymorphisms and acute ischemic vascular events and focused on the differential effects of the MTHFR C677T polymorphisms on the burden and location of AMI and ACI. 102 acute cerebral infarction (ACI) and acute myocardial infarction (AMI) patients who were admitted to the First Hospital of Jilin University in northeast China as the patient group, 83 healthy people who were hospitalized during the same period served as a control group. MTHFR C677T genotypes were identified via Polymerase Chain Reaction (PCR)-Fluorescent Probe Method. Patient group had higher serum homocysteine levels (p=0.013), lower serum folic acid (p<0.001), and Vit B12 levels (p=0.004) compared to the control group. Homocysteine levels in the patient group with the TT genotypes of the MTHFR C677T polymorphisms were higher than those with the CC and CT genotypes (p<0.05). Folic acid levels in the patients with TT genotypes were lower than those with the CC genotypes (p<0.05), but not in the control group (p>0.05). There were negative and significant associations between serum homocysteine levels and serum vitamin B12 levels in the control group (r=-0.234, p=0.033), but not between serum homocysteine levels and serum folic acid levels (r=-0.103, p=0.355). Conversely, there was a negative and significant association between serum homocysteine levels and serum folic acid levels in the patients' group (r=-0.257, p=0.01), but not between serum homocysteine levels and serum vitamin B12 levels (r=-0.185, p=0.64). No statistically significant differences in MTHFR C677T genotype and C/T alleles distribution were investigated between the patient and control group (p>0.05). The MTHFR C677T polymorphism did not differentially affect the burden and location of AMI and ACI. Homocysteine played a common role in atherosclerosis-related acute ischemic vascular events. These correlations were modified by MTHFR C677T polymorphisms and influenced by folic acid levels. The MTHFR C677T polymorphisms were not directly related to acute ischemic vascular events, nor did they differentially affect the burden and location of AMI and ACI.

Acute Myocardial Infarction Detection Using Deep Learning-Enabled Electrocardiograms.

Background: Acute myocardial infarction (AMI) is associated with a poor prognosis. Therefore, accurate diagnosis and early intervention of the culprit lesion are of extreme importance. Therefore, we developed a neural network algorithm in this study to automatically diagnose AMI from 12-lead electrocardiograms (ECGs).Methods: We used the open-source PTB-XL database as the training and validation sets, with a 7:3 sample size ratio. Twenty-One thousand, eight hundred thirty-seven clinical 12-lead ECGs from the PTB-XL dataset were available for training and validation (15,285 were used in the training set and 6,552 in the validation set). Additionally, we randomly selected 205 ECGs from a dataset built by Chapman University, CA, USA and Shaoxing People's Hospital, China, as the testing set. We used a residual network for training and validation. The model performance was experimentally verified in terms of area under the curve (AUC), precision, sensitivity, specificity, and F1 score.Results: The AUC of the training, validation, and testing sets were 0.964 [95% confidence interval (CI): 0.961–0.966], 0.944 (95% CI: 0.939–0.949), and 0.977 (95% CI: 0.961–0.991), respectively. The precision, sensitivity, specificity, and F1 score of the deep learning model for AMI diagnosis from ECGs were 0.827, 0.824, 0.950, and 0.825, respectively, in the training set, 0.789, 0.818, 0.913, and 0.803, respectively, in the validation set, and 0.830, 0.951, 0.951, and 0.886, respectively, in the testing set. The AUC for automatic AMI location diagnosis of LMI, IMI, ASMI, AMI, ALMI were 0.969 (95% CI: 0.959–0.979), 0.973 (95% CI: 0.962–0.978), 0.987 (95% CI: 0.963–0.989), 0.961 (95% CI: 0.956–0.989), and 0.996 (95% CI: 0.957–0.997), respectively.Conclusions: The residual network-based algorithm can effectively automatically diagnose AMI and MI location from 12-lead ECGs.

Impact of RV involvement on LV remodeling after acute Myocardial Infarction assessed by Cardiac Magnetic Resonance Imaging

The purpose of this study was to investigate the impact of the right ventricular involvement as assessed on cardiac MRI (CMR) in patients with reperfused acute myocardial infarction (AMI). Materials and methods 250 patients with reperfused AMI were included in a prospective multicenter study (clinical trials: NCT 01113268 )–PREGICA Trial. All patients underwent CMR imaging within 4 days following primary percutaneous coronary intervention (PCI) and at 6 months follow-up. Right and left-ventricular volumes and function were retrospectively calculated using dedicated software. Data study consisted on topography and size of myocardial infarction and of the quantification of microvascular obstruction. Right and left-ventricular remodeling were defined as end-diastolic volume (EDV) increase > 20 between immediate CMR and 6-month follow-up. The presence of RV infarction was compared with the prevalence of LV and RV remodeling. All patients were successfully reperfused within first 6 hours after chest pain onset. Location of AMI was as follow: 140 (56%) had anterior MI, 75 (30%) had inferior MI and 35 (14%) had lateral MI. RV infarction was observed in 85 patients (34%) of the cohort. RV remodeling did not occur alone. It was observed in 86 patients (34.7%) and was associated with LV remodeling. A strong association between right and left-ventricular remodeling was noted ( P = 0.027). RV involvement in AMI is not rare and is a good predictor of LVEF impairment at 6 months. LV and RV remodeling are strongly associated. LV infarct size and microvascular obstruction do not influence RV remodeling but have an important role in LV remodeling.

Clinical and electrocardiographic characteristics of infarctional ventricular ectopic beats: An observational study.

The purpose of this study was to explore the clinical and electrocardiographic characteristics of infarctional ventricular ectopic beats (IVEBs).Thirty-eight acute myocardial infarction (AMI) patients with IVEB and 109 AMI patients without IVEB were analyzed. The morphological changes of QRS complex, ST segment, and T wave were compared to IVEB with sinus rhythm from the same period and fully evolved phase.An IVEB QRS complex often revealed the right bundle branch block morphology, in addition to Q wave AMI; no-Q wave AMI also had IVEB. Single-factor analysis found that IVEB often appeared in early AMI (<6 hours), and they were more frequent in inferoposterior with/without right ventricular involvement, large area AMI and thrombolytic reperfusion than in anterior or anteroseptal myocardial infarction, small area AMI, and unthrombolytic nonreperfusion. Multifactors no conditional logistic regression analysis revealed a positive correlation between IVEB and early AMI, AMI size, Killip heart function degree, inferoposterior with/without right ventricular involvement, and thrombolytic reperfusion. The Q wave of IVEB was wider, and the ST segment elevation was higher than those of the same period in sinus rhythms. The infarctional morphological changes of IVEB could be found before the same period in sinus rhythm and elevated myocardial enzymes.IVEBs were not rare. They were useful for early diagnosis and location of AMI.

A Simple Non-invasive ECG Technique to Localize Culprit Vessel Occlusion Site in ST-Elevation Myocardial Infarction (STEMI) Patients

Background: Electrocardiograms (ECGs) are essential in identifying the type and location of acute myocardial infarction. In the setting of inferior wall myocardial infarction (IWMI), identification of the right coronary artery (RCA) as the culprit artery is important because of the potential complications associated with its involvement. Objectives: The study was conducted to identify the culprit artery responsible for STEMI from ECG tracings. To validate Fiol’s algorithm in Eastern Indian population and to compare the ECG findings with coronary angiogram. Methods: The cross-sectional study was conducted in 100 patients with acute STEMI. Patients presenting with acute ST-elevation myocardial infarction within 12 h of symptom onset were included in the study. In this study, we focused on Fiol’s algorithm and some other pre-specified criteria for prediction of occluded vessels. Cohen’s kappa statistical method was used to correlate ECG localisation of culprit artery with that of coronary angiogram. Results: Out of 100 STEMI patients, 73 patients had left anterior descending as the culprit artery, 24 patients had right coronary artery as the culprit artery and 3 patients had left circumflex artery as the culprit artery (73%, 24% and 3% respectively). Following Fiol’s algorithm, we have found that ECG has: high specificity (86%) but low sensitivity of 29% for an occlusion proximal to D1. Moderate sensitivity and moderate specificity (62% and 69% respectively) was noted for an occlusion distal to D1. Similarly, high sensitivity (90%) but low specificity (33%) was noted for lesion proximal to S1. Cohen’s kappa κ=1 suggests excellent agreement between ECG and coronary angiogram for inferior wall MI (both RCA and LCx occlusion). Conclusion: It can be concluded that ECG can reliably predict the culprit artery in STEMI patients. The Fiol’s algorithm is validated and considered as a simple tool to localize the infarct related artery in anterior wall myocardial infarction (AWMI) and inferior wall myocardial infarction (IWMI).

Better in-hospital outcome among hypertensive subjects developing acute myocardial infarction-study in a tertiary cardiac care center in Bangladesh

Background:In-hospital complications and mortality in hypertensives developing acute myocardial infarction(AMI) may be different from those of normotensive counterpart.The aim of the current study was to analyze in-hospital complication and outcome of AMI in hypertensive patients and compare it with age and sex matched normotensive AMI patients.Methods: In-hospital complications of 112 hypertensive patients with AMI admitted over a period of 1 year (April 2014 to March 2015) were compared with the control group. Location and types of AMI were determined by ECG. Patients were considered to be hypertensive if they were taking antihypertensive treatment or were found to have a systolic blood pressure (SBP) e”140 mmHg and/or a diastolic blood pressure (DBP) e”90 mmHg on repeated measurements. Both groups were studied prospectively. The results were analyzed by SPSS software.Results:Out of total 112 patients 69 were male and 43 were female in each group. Male: female ratio was 1.6:1. Mean age of the study population was 67.3±10.2 yrs (range 41 to 83 yrs). Mean blood pressure values were 145.7±11.5/88.3±8.9 mmHg in the hypertensive and 127.3±9.7/75.8±5.6 mmHg in normotensive group respectively. A significantly higher prevalence of diabetes, dyslipidemia, chronic kidney disease, stroke and peripheral vascular disease were found in the hypertensive compared with the normotensive subjects. Hypertensive AMI patients had higher left ventricular ejection fraction compared with the normotensives(0.51±0.13 vs 0.47±0.15). A higher frequency of paroxysmal atrial fibrillation(AF) (10.7% vs 7.1%, P&lt;0.05) and a lower frequency of atrioventricular block (5.4 % vs 8.0%), ventricular fibrillation (2.7% vs 4.5%), cardiogenic shock (4.5% vs 9.8%, P&lt;0.01) and a lower inhospital mortality(6.2% vs 10.7%, P&lt;0.01) were found among the hypertensives compared with the normotensives.Conclusion: Hypertensive AMI patients had a significantly higher incidence of AF, lower incidence of cardiogenic shock and an overall better inhospital outcome compared with the normotensives, probably owing to a better preserved left ventricular function, prior use of cardioprotective drugs and yet undefined mechanism.Bangladesh Heart Journal 2016; 31(1) : 10-17

0437: Impact of RV involvement on LV remodeling after acute MI

The purpose of this study was to investigate the impact of the right ventricular involvement as assessed on cardiac MRI (CMR) in patients with reperfused acute myocardial infarction (AMI). 147 patients with reperfused AMI were included in a prospective multicenter study (clinical trials: NCT 01113268). All patients underwent CMR imaging within 4 days following primary percutaneous coronary intervention (PPCI) and at 6 months follow-up. Right and left ventricular volumes and function were retrospectively calculated using dedicated software. Data study consisted of topography and size of myocardial infarction and of the microvascular obstruction measurements. Right and left ventricular remodeling were defined as end-diastolic volume (EDV) increase >20 between immediate CMR and 6-month follow-up. The presence of RV infarction was compared with the prevalence of LV and RV remodeling. All patients were successfully reperfused within first 6 hours after chest pain onset. Location of AMI was as follow: 82 (56%) had anterior MI, 44 (30%) had inferior MI and 21 (14%) had lateral MI. RV infarction was observed in 50 patients (34%) of the cohort. RV remodeling did not occur alone. It was observed in 51 patients (34.7%) and was associated with LV remodeling. A strong association between right and left ventricular remodeling was noted (p=0.027). RV involvement in AMI is not rare and is a good predictor of LV EF impairment at 6 months. LV and RV remodeling are strongly associated. LV infarct size and microvascular obstruction do not influence RV remodeling but have an important role in LV remodeling.

The evaluation of relationship between abo blood groups and cardiovascular risk factors in patients with acute myocardial infarction in durres population

Introduction: Cardiovascular (CV) diseases are the most important causes of morbidity and mortality in many developing and developed countries. An association between ABO blood groups (BGs) and the risk of coronary artery disease (CAD) has been known for many years, although there have not been enough surveys to prove it. However, it is not yet known how significant the association between the ABO BGs and CAD is in the clinical practice. Aim: The aim was to investigate a possible association of ABO (BGs) and CV risk factors among the patients with acute myocardial infarction (AMI) in Durres population. Materials and Methods: This transversal prospective study included 239 patients with AMI admitted to in the Cardiology Department, Regional Hospital of Durres, Albania between January 2012 and August 2013. In patients with AMI were collected data on risk factors such as smoking, age, gender, hypertension (HTN) and blood lipids, diabetes, obesity, family history and previous myocardial infarction(MI). Participants provided blood samples for cholesterol, glucose (fasting blood sugar) and BGs. Standard 12-lead electrocardiograms were obtained immediately after admission. The location and complication of AMI were assessed. Data was analyzed on SPSS version 16 and a P Results: In the present study of 239 patients, 32.6% (78) had BG O, 38,1% (91) had BG A, 17.2%(41) had BG B and 12.1%(29) had BG AB. Of the total of 239, 52,3% (125) were smoker, 66,9% (160) were hypertensive, 51.4% (123) were obese, 30.5% (73) had diabetes mellitus (DM), 71,1% (170) had high serum cholesterol level, 37.6% (90) had positive family history and mean age was 66.1 ΁ 21 years. In individuals the incidence of AMI was higher in those with BG A than in those with other BG P 0.001. AMI was less frequent in BG AB. The frequency of CV risk factors was similar in patients with different BGs. However, the patients with BG A had a higher incidence of high serum cholesterol level, diabetes and HTN than those with the other BGs but not a statistically significant difference P > 0.05. There were no significant differences between BGs in location of AMI. No significant differences were found between BGs and complications in acute myocardial infarction. Conclusions: Blood group A is related to the higher incidence of AMI, high serum cholesterol level, HTN and DM, while the results did not provide convincing evidence that any BGs were strongly associated with HTN, diabetes and location of MI. Association of ABO BGs distribution with CV risk factors, CAD and MI needs to be clarified with multicenter, prospective and large-scale studies.

0203: One-year survival according to use of thrombus aspiration for primary percutaneous coronary intervention. FAST-MI 2010 registry

Data from randomized trials evaluating thrombus aspiration (TA) in patients with ST-Elevation Myocardial Infarction (STEMI) are conflicting. Therefore, we assessed one-year survival in STEMI patients participating in the FAST-MI (French Registry of ST-elevation and non-ST-elevation Myocardial Infarction) 2010 according to TA during primary percutaneous coronary intervention (PCI), such as used in the real world. FAST-MI 2010 is a nationwide French registry that included 4,169 patients with acute myocardial infarction (AMI) at the end of 2010 in 213 centres. Of those, 2,087 patients had STEMI or left bundle branch block (LBBB), of whom 1,538 had primary PCI, with TA used in 671 (44%). Patients with TA were younger (61±13.5 vs. 63±14 years), with a similar GRACE (Global Registry of Acute Coronary Events) risk score (140±31 vs. 143±34), and a shorter median time from symptom onset (245 vs. 285 min); location of AMI, history of MI, PCI or coronary artery bypass surgery did not differ significantly. Thirty-day mortality was 2.1% vs. 2.1% (adjusted p=0.18) and one-year survival was 95.5% vs. 94.8%. Using fully adjusted Cox multivariate analysis, hazard ratio for one-year death was 1.14 (95% confidence interval [CI], 0.63 to 2.07). After propensity score matching (480 patients per group), one-year survival was also similar with both strategies. In a real-world setting of patients admitted with STEMI, the use of TA during primary PCI was not associated with improved one-year survival. Clinicaltrials.gov identifier: NCT01237418

Influence of Second- and Third-Degree Heart Block on 30-Day Outcome Following Acute Myocardial Infarction in the Drug-Eluting Stent Era

This study was conducted to investigate the prognostic value of heart block among patients with acute myocardial infarction (AMI) treated with drug-eluting stents. A total of 13,862 patients with AMI, registered in the nation-wide AMI database from January 2005 to June 2013, were analyzed. Second- (Mobitz type I or II) and third-degree atrioventricular block were considered as heart block in this study. Thirty-day major adverse cardiac events (MACE) including all causes of death, recurrent myocardial infarction, and revascularization were evaluated. Percutaneous coronary intervention with implantation of drug-eluting stent was performed in 89.8% of the patients. Heart block occurred in 378 patients (2.7%). Thirty-day MACE occurred in 1,144 patients (8.2%). Patients with heart block showed worse clinical parameters at initial admission, and the presence of heart block was associated with 30-day MACE in univariate analyses. However, the prognostic impact of heart block was not significant after adjustment of potential confounders (p = 0.489). Among patients with heart block, patients with a culprit in the left anterior descending (LAD) coronary artery had worse clinical outcomes than those of patients with a culprit in the left circumflex or right coronary artery. LAD culprit was a significant risk factor for 30-day MACE even after controlling for confounders (odds ratio 5.28, 95% confidence interval 1.22 to 22.81, p = 0.026). In conclusion, despite differences in clinical parameters at the initial admission, heart block was not an independent risk factor for 30-day MACE in adjusted analyses. However, a LAD culprit was an independent risk factor for 30-day MACE among patients with heart block.

Effect of Coronary Thrombus Aspiration During Primary Percutaneous Coronary Intervention on One-Year Survival (from the FAST-MI 2010 Registry)

Results from randomized trials evaluating thrombus aspiration (TA) in patients with ST-elevation myocardial infarction (STEMI) are conflicting. We assessed 1-year survival in STEMI patients participating in the French Registry of Acute ST-Elevation and non-ST-Elevation Myocardial Infarction (FAST-MI) 2010 according to the use of TA during primary percutaneous coronary intervention (PCI). FAST-MI 2010 is a nationwide French registry that included 4,169 patients with acute myocardial infarction at the end of 2010 in 213 centers. Of those, 2,087 patients had STEMI, of whom 1,538 had primary PCI, with TA used in 671 (44%). Patients with TA were younger (61 ± 13.5 vs 63 ± 14 years), with a similar risk score of the Global Registry of Acute Coronary Events (140 ± 31 vs 143 ± 34) and a shorter median time from symptom onset (245 vs 285 minutes); location of acute myocardial infarction, history of myocardial infarction, PCI, or coronary artery bypass surgery did not differ significantly. Thirty-day mortality was 2.1% versus 2.1% (adjusted p = 0.18), and the rate of 1-year survival was 95.5% versus 94.8%. Using fully adjusted Cox multivariate analysis, hazard ratio for 1-year death was 1.13 (95% confidence interval 0.66 to 1.94). After propensity score matching (480 patients per group), 1-year survival was also similar with both strategies. In a real-world setting of patients admitted with STEMI, the use of TA during primary PCI was not associated with improved 1-year survival.

Assessment of myocardial infarction by cardiac magnetic resonance imaging and long-term mortality.

BackgroundCardiac magnetic resonance imaging provides detailed anatomical information on infarction. However, few studies have investigated the association of these data with mortality after acute myocardial infarction.ObjectiveTo study the association between data regarding infarct size and anatomy, as obtained from cardiac magnetic resonance imaging after acute myocardial infarction, and long-term mortality.MethodsA total of 1959 reports of “infarct size” were identified in 7119 cardiac magnetic resonance imaging studies, of which 420 had clinical and laboratory confirmation of previous myocardial infarction. The variables studied were the classic risk factors – left ventricular ejection fraction, categorized ventricular function, and location of acute myocardial infarction. Infarct size and acute myocardial infarction extent and transmurality were analyzed alone and together, using the variable named “MET-AMI”. The statistical analysis was carried out using the elastic net regularization, with the Cox model and survival trees.ResultsThe mean age was 62.3 ± 12 years, and 77.3% were males. During the mean follow-up of 6.4 ± 2.9 years, there were 76 deaths (18.1%). Serum creatinine, diabetes mellitus and previous myocardial infarction were independently associated with mortality. Age was the main explanatory factor. The cardiac magnetic resonance imaging variables independently associated with mortality were transmurality of acute myocardial infarction (p = 0.047), ventricular dysfunction (p = 0.0005) and infarcted size (p = 0.0005); the latter was the main explanatory variable for ischemic heart disease death. The MET-AMI variable was the most strongly associated with risk of ischemic heart disease death (HR: 16.04; 95%CI: 2.64-97.5; p = 0.003).ConclusionThe anatomical data of infarction, obtained from cardiac magnetic resonance imaging after acute myocardial infarction, were independently associated with long-term mortality, especially for ischemic heart disease death.

Electrocardiographic identification of the culprit coronary artery in inferior wall ST elevation myocardial infarction

Electrocardiograms (ECGs) are essential in identifying the type and location of acute myocardial infarction. In the setting of inferior wall myocardial infarction (IWMI), identification of the right coronary artery (RCA) as the culprit artery is important because of the potential complications associated with its involvement. To evaluate previous ECG criteria used for the identification of RCA involvement and validate them in the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT 4 PCI) cohort; and to develop an improved simplified score to identify RCA involvement. ASSENT 4 PCI patients with IWMI (n=710) were included in the present study. A literature review was conducted to identify previously published criteria to detect RCA involvement. Logistic regression was used to develop a new simplified algorithm for identifying RCA involvement. The sensitivities and specificities of six previous ECG criteria were substantially lower when applied to the ASSENT 4 PCI population. A new algorithm found that ST segment depression in leads I, aVL and V6, and ST segment elevation of greater than 1 mm in lead aVF was associated with a higher likelihood of RCA involvement, and any ST segment depression in V1 and V3 was associated with a lower likelihood of RCA involvement. A simplified risk score found a prevalence of RCA involvement of over 90% among patients with scores of greater than two. The ECG is useful in identifying RCA involvement in IWMI before angiography. Previously published criteria appear to be inadequate, and the simple algorithm presented in the current study may be a useful tool in identifying RCA involvement at the bedside.

AVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction

This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI). The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation > or =1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of > or =1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of > or =1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with > or = 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation > or =1 mm was associated with higher mortality. aVR ST elevation is an important adverse prognostic sign in AMI.

Results of Intracoronary Stem Cell Therapy After Acute Myocardial Infarction

To assess the effect of autologous bone-marrow cell (BMC) therapy in patients with acute myocardial infarction in a rigorous double-blind, randomized, placebo-controlled trial. Patients with reperfusion >6 hours after symptom onset were randomly assigned in a 2:1 ratio to receive intracoronary BMC or placebo therapy 5 to 7 days after symptom onset. The patients were stratified according to age, acute myocardial infarction localization, and left ventricular (LV) function. Rigorous double-blinding was ensured using autologous erythrocytes for the placebo preparation that was visually indistinguishable from the active treatment. Serial cardiac magnetic resonance imaging studies were performed before study therapy and after 1, 3, and 6 months. The primary end point was the difference in the LV ejection fraction from baseline to 6 months. The secondary end points included changes in the LV end-diastolic and end-systolic volume indexes and infarct size. A total of 42 patients were enrolled (29 in the BMC group and 13 in the placebo group) in the integrated pilot phase. A mean of 381 x 10(6) mononuclear BMCs were administered. The baseline clinical and cardiac magnetic resonance imaging parameters did not differ. Compared to baseline, the difference in LV ejection fraction for the placebo group versus BMC group was 1.7 +/- 6.4% versus -0.9 +/- 5.5% at 1 month, 3.1 +/- 6.0% versus 1.9 +/- 4.3% at 3 months, and 5.7 +/- 8.4% versus 1.8 +/- 5.3% at 6 months (primary end point; not significant). No difference was found in the secondary end points between the 2 groups, including changes in infarct size or LV end-diastolic and end-systolic volume indexes. In conclusion, in this rigorous double-blind, randomized, placebo-controlled trial, we did not observe an evidence for a positive effect for intracoronary BMC versus placebo therapy with respect to LV ejection fraction, LV volume indexes, or infarct size.

Location of Acute Myocardial Infarction and Associated Arrhythmias and Outcome

Cardiac arrhythmias and conduction abnormalities complicating acute myocardial infarction (AMI) have been associated with adverse prognosis in numerous reports. Small studies have frequently associated different arrhythmias with various distributions of myocardial infarctions. We analyzed a nationally representative hospital discharge database to evaluate the relationship between the location of AMI and the associated arrhythmias and conduction abnormalities and their impact on in-hospital mortality. We searched the National Hospital Discharge Survey database for patients with a diagnosis of AMI and collected data on the associated arrhythmias and conduction abnormalities. In-hospital death was used as end point for analysis. A total of 21,807 patients, representing 2,632,217 hospital discharges in the United States, with a primary diagnosis of AMI from 1996 to 2003 were included in this analysis. Patients with inferior or posterior AMI were more likely to develop complete heart block compared to those with anterior or lateral AMI (3.7% vs 1.0%, hazard ratio [HR] = 3.9, p <or= 0.001), but less likely to die prior to hospital discharge (7.7% vs 11.3%, HR = 0.65, p <or= 0.001). Patients with an inferior or posterior AMI are more likely to develop conduction system abnormalities when compared to patients with an anterior or lateral AMI. On the other hand, anterior or lateral MI is a significant predictor of in-hospital death.

The Dipolar ElectroCARdioTOpographic (DECARTO)–like method for graphic presentation of location and extent of area at risk estimated from ST-segment deviations in patients with acute myocardial infarction

A graphic method was developed for presentation of the location and extent of the myocardium at risk in patients with acute myocardial infarction (AMI). This method is based on a mathematical processing of ST-segment deviations of standard 12-lead electrocardiogram following the concept of Titomir and Ruttkay-Nedecky in their dipolar electrocardiotopographic method. The center of the location of the area at risk is given by the spatial orientation of the resultant spatial ST vector, and the extent of the area at risk is derived from the Aldrich score. The areas at risk are projected on a spherical image surface, on which a texture of the anatomical quadrants of the ventricular surface and its coronary artery supply are projected. The method was tested in 10 patients with AMI with single-vessel disease, including 6 patients with an occlusion in the proximal left anterior descending coronary artery (LAD), 3 patients with an occlusion in the right coronary artery, and one patient with occlusion in the left circumflex coronary artery. The estimated areas at risk were compared with myocardial perfusion single photon emission computed tomography. Eight (80%) patients of 10 were correctly localized according to the Aldrich decision rules for the location of AMI. The areas at risk in patients with LAD occlusion correctly localized by the Aldrich score were situated in the anteroseptal and anterosuperior quadrants. In the inferior AMI group, the area at risk was localized in the posterolateral and inferior quadrants. The visual comparison with myocardial perfusion single photon emission computed tomography (SPECT) showed best agreement in patients with LAD involvement. The initial testing showed that this method allows a graphic presentation of estimated area at risk using clinically defined diagnostic rules. The area at risk can be displayed in images that are familiar for clinicians and can be compared with or superimposed on results of other imaging methods used in cardiology.

Is Functional Improvement after Myocardial Infarction Predicted with Myocardial Enhancement Patterns at Multidetector CT?

To prospectively evaluate the sensitivity of myocardial early perfusion defects (EDs) and late enhancement (LE) at multidetector computed tomography (CT) following acute myocardial infarction (AMI) to predict segment myocardial dysfunction and myocardial functional recovery (MFR), by using echocardiography as the reference standard. Institutional review board approval and informed consent were obtained. Twenty-six patients (25 men, one woman; mean age, 53 years+/-9 [standard deviation]), underwent baseline multidetector CT, coronary angiography, and echocardiography within a week of AMI and a follow-up echocardiography at 3 months. ED, LE, and late hypoattenuation were compared with regional left ventricular function and MFR. A logistic regression model and generalized estimating equation analysis were applied to estimate the predictive effect of ED and LE. Differences between groups were evaluated by using nonpaired Student t tests. All EDs and LE corresponded with AMI location determined by using angiography and echocardiography. For occluded arteries (n=5), no relationship was found between the presence of ED or LE and MFR. For patent arteries (n=21), presence of LE had a respective sensitivity and specificity of 73% and 85% for predicting follow-up segment dysfunction, compared with 57% and 90% for ED. In abnormal baseline segments, nonrecovery was clearly related to the presence and size of segment defect area for both ED (odds ratio: 1.95 [95% confidence interval: 0.9, 4.1] per square centimeter) and LE (odds ratio: 1.85 [95% confidence interval: 1.2, 2.9] per square centimeter). Segments that recovered had significantly lower prevalence of ED and LE, and if present, were significantly smaller than in segments remaining abnormal (P<.05). The presence and size of ED and LE at multidetector CT is closely related to follow-up segment myocardial dysfunction and MFR.

New Insights into the Circadian Rhythm of Acute Myocardial Infarction in Subgroups

The aim of this study was to determine the existence of the circadian rhythm (CR) in the onset of acute myocardial infarction (AMI) in different patient subgroups. Information was collected about 41,244 infarctions from the database of the ARIAM (Analysis of Delay in AMI) Spanish multicenter study. CR in AMI were explored in subgroups of cases categorized by age, gender, previous ischemic heart disease (PIHD), outcome in coronary care unit, infarction electrocardiograph (ECG) characteristics (Q wave or non‐Q wave), and location of AMI. Cases were classified according to these variables in the different subgroups. To verify the presence of CR, a simple test of equality of time series based on the multiple‐sinusoid (24, 12, and 8 h periods) cosinor analysis was developed. For the groups as a whole, the time of pain onset as an indicator of the AMI occurrence showed a CR (p<0.0001), with a morning peak at 10:10 h. All the analyzed subgroups also showed CR. Comparison between subgroups showed significant differences in the PIHD (p<0.01) and infarction ECG characteristics (p<0.01) groups. The CR of the subgroup with Q‐wave infarction differed from that of non‐Q wave subgroup (p<0.01) when the patients had PIHD (23% in Q wave infarction vs. 39.2% in non‐Q wave). AMI onset followed a CR pattern, which is also observed in all analyzed subgroups. Differences in the CR according to the Q/non‐Q wave infarction characteristics could be determined by PIHD. The cosinor model fit with three components (24, 12, and 8 h periods) showed a higher sensitivity than the single 24 h period analysis.