Marker Of Successful Reperfusion Research Articles

The Role of T Peak – T End Interval Reduction on Electrocardiogram as a Marker of Successful Reperfusion in Patients with ST Elevation Myocardial Infarction undergoing Fibrinolytic Therapy

Background: Immediate reperfusion is the key of ST Elevation Myocardial Infarction (STEMI) Management. Despite the superiority of primary percutaneous coronary intervention (PCI), fibrinolytic therapy is still the preferred choice in many settings because of their availability and easy resources. Assessment of successful fibrinolytic determines the next strategy, ST-segment resolution (STR) correlates well with TIMI flow, reflects myocardial perfusion, and has a better prognostic value. T Peak – T End (Tpe) interval is proposed to be a valuable tool for reperfusion marker as it measures the transmural dispersion of repolarization (TDR) which can be an additional myocardial perfusion assessment. This study aims to see whether the Tpe interval reduction can be a marker of the successful reperfusion in patients with STEMI treated with fibrinolytic. 
 Methods : This cross-sectional study involved STEMI patients underwent fibrinolytic therapy. Tpe interval was measured at admission and 90 minutes after fibrinolytic, then the changes in the form of difference (ms) and resolution (%) were assessed and compared between successful and failed reperfusion groups according to STR.
 Results: Among total of 86 patients, there were 53 patients (61.2%) with successful reperfusion. Tpe interval reduction was greater in the successful reperfusion group. The value of Tpe difference in predicting STR ³ 50% had a sensitivity of 66% and specificity of 75.8% with an area under curve (AUC) of 0.726 and a cut-off point of 20 ms. While the AUC of Tpe resolution 0.726 with a cut-off point of 16.2%, had a sensitivity of 66% and a specificity of 72.7%.
 Conclusion: The Tpe interval reduction can be a valuable additional marker of successful reperfusion in patients with STEMI treated with fibrinolytic.
 
 

Spontaneous systolic blood pressure drop early after mechanical thrombectomy predicts dramatic neurological recovery in ischaemic stroke patients.

Spontaneous blood pressure drop within the first 24 h has been reported following arterial recanalisation in ischaemic stroke patients. We aimed to assess if spontaneous blood pressure drop within the first hour after mechanical thrombectomy is a marker of early neurological recovery. Retrospective observational single-centre study including ischaemic stroke patients treated with mechanical thrombectomy. Blood pressure parameters from admission, mechanical thrombectomy start, mechanical thrombectomy end and hourly within 24 h after mechanical thrombectomy were reviewed. Primary outcome was early dramatic neurological recovery (8-point-reduction in NIHSS or NIHSS ≤ 2 at 24 h). Secondary outcome was functional independence at 90 days (mRankin 0-2). We included 458 patients in our analysis. Two-hundred (43.7%) patients achieved dramatic neurological recovery following mechanical thrombectomy. One hour after mechanical thrombectomy end, median systolic blood pressure was significantly different between outcome groups (129 vs. 138 mmHg, p = 0.005) and a higher drop in median systolic blood pressure was seen in the dramatic neurological recovery group (15 vs. 9 mmHg). Optimal cut-off for predicting dramatic neurological recovery was a systolic blood pressure drop of 10.5 mmHg (sensitivity 0.54, specificity 0.55, AUC 0.55). On multivariate analysis, spontaneous systolic blood pressure drop was associated with higher odds of achieving dramatic neurological recovery (OR for 10 mmHg blood pressure drop 1.14, 95% CI 1.01-1.29, p = 0.04). No significative association between any blood pressure parameter drop and functional independence at 90 days was found. We hypothesised that spontaneous systolic blood pressure drop is a marker of successful reperfusion and, therefore, a marker of improvement of cerebral autoregulation due to the reduced final ischaemic core. Spontaneous systolic blood pressure drop after mechanical thrombectomy is an early predictor of dramatic neurological recovery.

T wave inversions in leads with ST elevations in patients with acute anterior ST elevation myocardial infarction is associated with patency of the infarct related artery

ObjectivesFollowing reperfusion therapy, early T wave inversions (TWI) have been shown to be a marker of successful reperfusion. We aimed to evaluate the relationship of TWI on the presenting ECG with spontaneous reperfusion as assessed by coronary angiography in patients with ST elevation (STE) myocardial infarction (STEMI). MethodsData of 146 consecutive patients presenting to the St. Luke's Episcopal Hospital Emergency Department with acute STEMI undergoing primary percutaneous coronary intervention (p-PCI) between January, 2007 and October, 2010 were retrospectively analyzed. Clinical data, ECG and angiographic data were reviewed. Patients were dichotomized based on T wave morphology on the presenting ECG into 2 groups – those with TWI and those with positive T waves (PTW). ResultsThirty-one patients (21.2%) had TWI, while 115 (78.8%) had PTW. Sixty-four (43.8%) patients had anterior STE and 75 (51.3%) had inferior STE. Anterior STE was more likely to have TWI than non-anterior (29.7% vs. 14.6; p=0.014). By angiography, infarct related artery (IRA) patency (TIMI 2–3 flow) was seen in 45 (30.8%). TWI was more likely to be associated with IRA patency compared to PTW (51.6% vs. 25.2%; p=0.008). In patients with anterior STEMI and TWI, patent IRA was seen more frequently compared to those with PTW (68.4% vs. 20%; p<0.001). There was no association of T wave morphology and TIMI flow in patients with non-anterior STEMI. Patients presenting with stuttering symptoms were more likely to have TWI (70.4% vs. 10.2%; p <0.001) suggesting recurrent episodes of reperfusion and ischemia. ConclusionsIn anterior STEMI patients, TWI on the presenting ECG is associated with spontaneous reperfusion. This relationship was not found among patients with non-anterior STEMI.

Prevalence and Significance of Accelerated Idioventricular Rhythm in Patients With ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Accelerated idioventricular rhythm (AIVR) has been considered a marker of successful reperfusion in fibrinolytic-treated patients. Evidence is limited regarding its significance in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PPCI). The purpose of the present study was to determine the prevalence and associated outcomes of arrhythmias and conduction disturbances occurring during PPCI. In 503 patients with ST-elevation myocardial infarction, the arrhythmias and conduction disturbances occurring from arrival at the catheterization laboratory to 90 minutes after PPCI were registered. Continuous ST-monitoring was performed to determine the interval from the first wire to complete ST resolution. The area at risk was evaluated in the acute phase and the final infarct size (FIS) after 1 month using myocardial perfusion imaging. Mortality was registered at a median follow-up of 2.9 years. The most common arrhythmias observed during PPCI were AIVR (42%), sinus bradycardia (28%), and nonsustained ventricular tachycardia (26%). The arrhythmias associated with the FIS included AIVR (unstandardized regression coefficient [B] = 5.27, p <0.001), sustained ventricular tachycardia (B = 15.7, p <0.001), and sinus bradycardia (B = -4.12, p = 0.001). Right bundle branch block was the only conduction disturbance associated with FIS (B = 7.17, p = 0.001). Patients with AIVR less often achieved spontaneous ST resolution before PPCI (13% vs 36%, p <0.001), less often had Thrombolysis In Myocardial Infarction flow 3 on admission (3% vs 33%, p <0.001), had a larger area at risk (35% vs 23% of the left ventricle, p <0.001), had a longer time to complete ST resolution (39 vs 21 minutes, p <0.001), had a larger FIS (13% vs 5% of the left ventricle, p <0.001) but had similar mortality (8.6% and 6.5%, p = 0.39) compared to patients without AIVR. In conclusion, AIVR is the most frequent arrhythmia occurring during PPCI in patients with ST-elevation myocardial infarction. However, it is not a marker of successful reperfusion but is associated with extensive myocardial damage and delayed microvascular reperfusion.

A simple MR algorithm for estimation of myocardial salvage following acute ST segment elevation myocardial infarction

To assess myocardial salvage in acute ST segment elevation myocardial infarction (STEMI) by using contrast-enhanced CMR. Forty-four consecutive patients (38 male; mean age 59 +/- 10 years) with a first acute STEMI underwent acute percutaneous coronary intervention with successful restoration of TIMI grade 3 flow. CMR was performed 2 +/- 1 days after reperfusion on a standard 1.5 T MR Scanner that included a steady-state free precession cine imaging for LV function and an inversion-recovery fast low angle shot (TR 8 ms, TE 4 ms, FA 25 degrees ) sequences for late gadolinium enhancement (LGE) following the injection of 0.2 mmol/kg BW gadodiamide. The myocardium at risk (MR) was approximated by the volume of myocardium exhibiting LGE and/or impaired wall motion. The myocardial salvage index (MSI) was calculated as the volume of the MR minus the volume of LGE divided by the volume of the MR. Reperfusion therapy was rated successful with an ST elevation resolution (STR) > or =70% and was considered inadequate below 70%. Infarct size (LGE) was 17 +/- 13% of LV mass, the mean STR was 53.4 +/- 28.3%, and the MSI was 10.9 +/- 6.2%. There was a good correlation between the MSI and the STR (r = 0.695, P < 0.0001). Thirty patients had an STR below 70%, and 14 patients had an STR greater than 70%. The MSI was greater in patients with a STE resolution of more than 70% (12 +/- 11 vs. 6 +/- 3%, P < 0.0001). A simple MR algorithm based upon the relationship of functional impairment, which includes myocardial stunning, to the extent of LGE (infarct necrosis) is in accordance with STR as a clinical marker of successful reperfusion in acute myocardial infarction.

A new electrocardiographic marker of successful reperfusion after thrombolytic treatment in acute ST-elevation myocardial infarction patients: change in QRS duration at postthrombolytic 90th-minute electrocardiogram

A new electrocardiographic marker of successful reperfusion after thrombolytic treatment in acute ST-elevation myocardial infarction patients: change in QRS duration at postthrombolytic 90th-minute electrocardiogram

The electrocardiographic reperfusion peak in patients with ST-elevation myocardial infarction

Objectives. To analyse the incidence and the prognostic value of the reperfusion peak in a population of patients with AMI treated with thrombolysis. Design. Two hundred and sixty-nine patients with ST-elevation myocardial infarction treated with thrombolysis were monitored with continuous on-line vectorcardiography. Results. A reperfusion peak defined as a transiently increased ST-VM of >50 µV followed by an immediate decrease to a level lower than the starting point was seen in 112 of all 269 (42%) patients and in 111of 149 (75%) of the patients with successful ST-resolution. A reperfusion peak was an independent predictor of better prognosis both in the short- and the long term but had no implications on the prognosis in the subgroup with successful ST-resolution. Conclusion. A reperfusion peak was equally common in patients treated with thrombolysis having a successful ST-resolution as observed in studies of patients with successful primary coronary angioplasty. The reperfusion peak was associated with better prognosis and should be recognised as a possible marker of successful reperfusion but can mimic aggravated ischemia.

Early peak creatine kinase activity is not always a marker of successful reperfusion with myocardial salvage in patients with reperfused anterior acute myocardial infarction

Background Although early peak creatine kinase activity (peak CK) is considered a reliable marker of coronary reperfusion in patients with acute myocardial infarction (AMI), whether early peak CK indicates good myocardial salvage is unclear. Moreover, some patients have late peak CK despite successful reperfusion, and its clinical implication remains to be elucidated. Methods and Results We examined the association of the time to peak CK with predischarge left ventricular function in 124 patients with a first AMI who had successful reperfusion within 6 hours from symptom onset. Patients were classified according to the time from reperfusion to peak CK: group A, 61 patients with peak CK <6 hours; group B, 42 with peak CK from 6 to 12 hours; and group C, 21 with peak CK >12 hours. There were no differences among the 3 groups in age, sex, method of reperfusion, time from symptom onset to reperfusion, collateral circulation, or the extent of risk area estimated by number of leads with ST-segment elevation. Left ventricular ejection fraction measured by predischarge left ventriculography was lowest in group A, followed by group B, and highest in group C (median values, 43%, 52%, and 60%, P <.01). Left ventricular dysfunction (left ventricular ejection fraction ≤40%) occurred in 26 (43%) patients in group A, 8 (19%) in group B, and none in group C (P <.01). Conclusions We conclude that compared with early peak CK, late peak CK consistently reflects good myocardial salvage in patients with anterior AMI who had successful reperfusion within 6 hours from symptom onset. (Am Heart J 2001;141:759-64.)

Signal‐Averaged ECG in Noninvasive Assessment of Reperfusion in the Acute Phase of Myocardial Infarction

Background:Coronary artery patency after thrombolytic therapy has important prognostic implications for survival after acute myocardial infarction (Ml). Several noninvasive methods have been tested to assess the effectiveness of thrombolytic therapy. However, the value late potential (LP) analysis from the signal‐averaged ECG for assessment of reperfusion has not been established. Methods:In 50 patients (34 males, 16 females, mean age 59 ± 12 years, range, 35 years to 84 years) with acute Ml, signal‐averaged ECG recordings were performed using the FD‐3 solid‐state Holter recorder and analyzed prior to and 1, 2, and 3 hours from the initiation of thrombolytic treatment. Reduction in ST elevation of &gt; 50% compared with baseline values was taken as a marker of successful reperfusion. Results:At 2 hours, 28 (56 %) patients were considered to have successful reperfusion: LPS were not present in any patient with successful reperfusion compared with 8 (36%) patients without reperfusion (P = 0.002). At 3 hours 31 (62 %) patients were considered to have successful reperfusion: 1 (3%) had abnormal signal‐averaged ECG versus 6 (35%) patients without reperfusion (P = 0.01). An abnormal signal‐averaged ECG identified patients with failed reperfusion with very high specificity and positive predictive value (100% and 100% at 2 hours; 97% and 86% at 3 hours, respectively). Conclusions:Patients with failed reperfusion have abnormal signal‐averaged ECGs more frequently than patients with successful reperfusion. Thus, signal‐averaged ECG may be helpful for identification of patients without reperfusion who may urgently need invasive treatment or rethrombolysis to restore blood flow in the infarct‐related artery. A.N.E. 1999;4(3):301–308

Accelerated idioventricular rhythm

The term accelerated idioventricular rhythm describes an ectopic ventricular rhythm with 3 or more consecutive ventricular premature beats with a rate faster than the normal ventricular intrinsic escape rate of 30 to 40 beats per minute, but slower than ventricular tachycardia. Accelerated idioventricular rhythm differs from ventricular tachycardia by additional features such as the onset with a long coupling interval, the end by a gradual decrease of the ventricular rate or increase of the sinus rate and, last but not least, by a good prognosis. Clinically, accelerated idioventricular rhythm can occur in any form of structural heart disease and occasionally in adults or children without structural heart disease. Accelerated idioventricular rhythm most often can be seen in patients with coronary artery disease. Its occurrence after thrombolysis during acute myocardial infarction is a marker of successful reperfusion. Since accelerated idioventricular rhythm is usually hemodynamically well tolerated and not associated with malignant ventricular tachycardias; as a rule, no specific treatment other than care of the underlying heart disease is necessary. The present overview discusses electrocardiographic criteria, possible mechanisms, and the clinical significance of accelerated idioventricular rhythms.