Non-anterior Acute Myocardial Infarction Research Articles

Risk factors for early death in acute myocardial infarction patients complicating with ventricular septal rupture

Objective: To assess the clinical characteristics and identify the risk factors in the acute myocardial infarction (AMI) patients complicating with ventricular septal rupture (VSR). Methods: A retrospective study was performed on 96 AMI patients complicating with VSR, who were hospitalized in the Second Xiangya Hospital of Central South University, Hunan Provincial Peoples' Hospital, the First Affiliated Hospital of University of South China, the Second Affiliated hospital of University of south China, Xiangtan Central Hospital from December 2007 to May 2017. There were 46 females and the age was (66.2±10.7) years (from 43 to 90 years). Patients were divided into in-hospital survival group (n=64) and in-hospital death group (n=32). The 96 patients were also divided into the early death group (survived ≤2 weeks after admission, n=50) and non-early death group (survived>2 weeks after admission, n=46). Multivariate logistic regression was used to analyze the independent risk factors of the early death. Results: Location of VSR was available in 71 patients, VSR was located at the apical or anterior septum near the apical region in 64.0% (32/50) patients with the anterior AMI, VSR was located at the posterior wall and basal inferior segment in 57.1% (12/21) patients with non-anterior AMI. Compared to the in-hospital survival group, patients in the in-hospital death group were older ((69.6±11.3) years vs. (64.6±10.1) years, P=0.031), incidence of non-ventricular aneurysm (71.9% (23/32) vs. 37.5% (24/64), P=0.001) and anterior AMI (84.4%(27/32) vs. 62.5%(40/64), P=0.028) was significantly higher in the in-hospital death group than in the in-hospital survival group. The comparison between the early death group and non-early death group showed that older age, female, no history of angina or myocardial infarction, Killip grade>Ⅲ, and non-ventricular aneurysm were related to increased risk of the early mortality in this patient cohort. Logistic regression analysis revealed that female (OR=5.109,95%CI 1.19-22.00, P=0.012), no history of angina or myocardial infarction (OR=23.34, 95%CI 3.44-158.37, P=0.001), Killip grade>Ⅲ(OR=5.35, 95%CI 1.26-22.66, P=0.019) and non-ventricular aneurysm (OR=6.30,95%CI 1.67-23.73, P=0.005) were independent risk factors for early death in this patient cohort. Conclusion: The risk factors of in-hospital death include older age, non-ventricular aneurysm and anterior AMI. Female, no history of angina or myocardial infarction, Killip grade>Ⅲ and non-ventricular aneurysm are independent risk factors for the early death of AMI patients complicating VSR.

China PEACE risk estimation tool for in-hospital death from acute myocardial infarction: an early risk classification tree for decisions about fibrinolytic therapy

ObjectivesAs the predominant approach to acute reperfusion for ST segment elevation myocardial infarction (STEMI) in many countries, fibrinolytic therapy provides a relative risk reduction for death of ∼16% across the...

Abstract 12197: China PEACE Risk Tool for Acute Myocardial Infarction: An Early Risk Classification Tree for Decisions About Fibrinolytic Therapy

Introduction: Timely fibrinolytic therapy is recommended to reduce short-term mortality for patients with ST-elevation myocardial infarction (STEMI). However, the absolute treatment benefit is related to baseline mortality risk, and may be offset by the risks of major bleeding for low-risk patients. We constructed a baseline risk-assessment tool in eligible but untreated patients, to estimate the absolute benefits from fibrinolytic treatment. Methods: The China PEACE study includes a nationally representative sample of patients admitted with acute myocardial infarction (AMI) in 162 Chinese hospitals. Comprehensive clinical information was centrally abstracted from medical records using standardized data definitions. We identified 3741 patients with STEMI who were fibrinolytic-eligible, but did not receive reperfusion therapy, and separated the cohort randomly into derivation and validation cohorts. We employed classification and regression tree methods to produce a simple algorithm to estimate the risk of in-hospital mortality. Results: The overall in-hospital mortality rate was 14.7%. In both derivation and validation cohorts, the combination of systolic blood pressure (≥ 100 mm Hg), age (< 60 years old), and male gender identified one fifth of the patients with an average mortality risk less than 3.0%; half of this group with a non-anterior AMI had an average in-hospital mortality risk of 1.5%. The classification tree performed consistently across study years, and in hospitals with or without PCI capability. Conclusions: Nearly one in five fibrinolytic-eligible patients with STEMI have an low estimated risk of death, with an absolute benefit of fibrinolytic therapy could be insufficient to justify the risks of major bleeding. The tool with three simple factors, easily available at hospital presentation, can identify these individuals and support decision-making about the use of fibrinolytic therapy.

Effects of preinfarction angina pectoris on infarct size and in-hospital mortality after coronary intervention for acute myocardial infarction

We studied the effect of preinfarction angina on in-hospital outcomes after percutaneous coronary intervention for anterior and nonanterior acute myocardial infarction. Beneficial effects of preinfarction angina on infarct size and in-hospital outcome are evident in patients with anterior infarction, but not in those with nonanterior infarction.

Intravenous nicorandil in conjunction with coronary reperfusion therapy is associated with better clinical and functional outcomes in patients with acute myocardial infarction.

The aim of this retrospective study was to assess whether intravenous nicorandil, a hybrid of NO and a KATP channel opener, in conjunction with percutaneous coronary intervention (PCI) improves the long-term prognosis in patients with acute myocardial infarction (AMI). Intravenous nicorandil has already been shown to improve the in-hospital prognosis of patients with anterior AMI. The study population consisted of 272 patients with a reperfused AMI who were admitted during a similar time interval, before (control; n=114) and after nicorandil treatment (n=158). In the nicorandil group, a 4 mg bolus injection was given, followed by 6 mg/h infusion for 24 h and then oral nicorandil at 15 mg/day for at least 1 month. In the patients with an anterior AMI, left ventricular (LV) function was better and the frequency of LV remodeling was lower after 3 months in the nicorandil group; however, in those with a non-anterior AMI, there were no differences in functional outcome and the frequency of LV remodeling between the 2 groups. The frequency of cardiac events was significantly lower in the nicorandil group, and the use of nicorandil was derived as a potential factor related to freedom from cardiac events (p<0.01, odds ratio = 0.27). Nicorandil treatment was associated with better myocardial perfusion and a better functional and clinical outcome than PCI alone, and this beneficial effect was maintained for a long time, particularly in patients with anterior AMI.

Prognostic significance of admission cardiac troponin T in patients treated successfully with direct percutaneous interventions for acute ST-segment elevation myocardial infarction.

Cardiac troponin T (cTnT) elevations at admission indicate a high-risk subgroup of patients with acute ST-segment elevation myocardial infarction, possibly due to a higher failure rate of reperfusion therapies. We sought to determine the predictive role of admission cTnT in patients with ST-segment elevation myocardial infarction undergoing successful direct percutaneous coronary intervention. A total of 218 consecutive patients with ST-segment elevation myocardial infarction were enrolled. Patients were stratified according to admission cTnT and infarct location. They were followed prospectively for short-term and long-term outcomes. RESULTS A positive cTnT (47.7%) was associated with higher mortality rates at 30 days (14.4% vs. 3.5%, p = .003) and 12 months (17.3% vs. 4.4%, p =.007). cTnT allowed discrimination of patients at high and low risk for cardiac death at 30 days and 12 months among anterior (19.2% vs. 7.9%, p = .19, and 25% vs. 13.2%, p = .22, respectively) and, more impressively, among nonanterior acute myocardial infarction (9.6% vs. 1.3%, p = .04, and 11.5% vs. 1.3%, p = .017, respectively). In multivariate analysis, older age, anterior infarct location, and depressed left ventricular function were the most potent independent predictors of future risk. Among clinical variables available at admission, cTnT indicated independently a higher risk of cardiac death (odds ratio, 3.1 [1.07-9.01], p =.038). This increased risk associated with a positive cTnT was almost independent of time delays from onset of symptoms to admission (3.8 vs. 2.3 hrs in cTnT-positive vs. cTnT-negative patients, p <.001). Admission cTnT is a strong predictor of future cardiac risk in patients with ST-segment elevation myocardial infarction, despite successful restoration of Thrombolysis in Myocardial Infarction grade 3 coronary flow by direct percutaneous coronary intervention.

Predischarge Two-Dimensional Echocardiographic Evaluation of Left Ventricular Thrombosis After Acute Myocardial Infarction in the GISSI-3 Study

Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 ± 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction ≤40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class >I and early intravenous β-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral β-blocker therapy given or not given after early intravenous β-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction <40%. Killip class >I and the early intravenous β-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI.

Distortion of the Terminal Portion of the QRS on the Admission Electrocardiogram in Acute Myocardial Infarction and Correlation With Infarct Size and Long-Term Prognosis (Thrombolysis In Myocardial Infarction 4 Trial)

Previous studies have shown an association between distortion of the terminal portion of the QRS (QRS[+] pattern: emergence of the J point ≥50% of the R wave in leads with qR configuration, or disappearance of the S wave in leads with an Rs configuration) on admission and in-hospital mortality in acute myocardial infarction (AMI). However, the mechanism for this association is not known. We assessed the relation between QRS(+) pattern and coronary angiographic findings, infarct size, and long-term prognosis in the Thrombolysis In Myocardial Infarction 4 trial. Patients were allocated into 2 groups based on the presence (QRS[+], n = 85) or absence (QRS[−], n = 293) of QRS distortion. The QRS(+) patients were older (mean ± SD: 61.1 ± 10.6 vs 57.5 ± 10.6 years, p = 0.004), had more anterior AMI (49% vs 37%, p = 0.04), and less previous angina (42% vs 54%, p = 0.05). QRS(+) patients had larger infarct size as assessed by creatine kinase release over 24 hours (209 ± 147 vs 155 ± 129, p = 0.003), and predischarge sestamibi (MIBI) defect (17.9 ± 15.9% vs 11.2 ± 13.4%, p <0.001). When adjusting for difference in baseline characteristics, p values for the differences in 24-hour creatine kinase release were 0.03 and 0.64 for anterior and nonanterior AMI, respectively, and for MIBI defect size 0.03 and 0.02, respectively. One-year mortality (18% vs 6%, p = 0.03) was higher and the weighted end point of death, reinfarction, heart failure, or left ventricular ejection fraction <40% (0.33 ± 0.37 vs 0.24 ± 0.32, p = 0.13), tended to be higher in the anterior AMI patients with QRS(+). No difference in clinical outcome was found in patients with non-anterior AMI. These findings suggest that this simple electrocardiographic definition of presence of QRS(+) pattern on admission may provide an early estimation of infarct size and long-term prognosis, especially in anterior AMI. (Am J Cardiol 1996;78:396–403)

Effects of early enalapril treatment on global and regional wall motion in acute myocardial infarction

Angiotensin-converting—enzyme inhibitor therapy can preserve left ventricular (LV) function and geometric features and improve survival in subsets of patients with acute myocardial infarction (AMI). We investigated the effect of enalapril treatment initiated <24 hours after AMI on global and regional echocardiographic wall motion indexes obtained at 2 to 5 days and at 1 and 6 months in 428 consecutive patients enrolled in the randomized, placebo-controlled Cooperative New Scandinavian Enalapril Survival Study II. In anterior AM, the non—infarct-zone index deteriorated in the placebo group but remained unchanged in the enalapril-treated group (0.18 vs 0.02; p < 0.05), an effect related to attenuated LV volume expansion. No treatment effects were observed in nonanterior AMIs or in the entire unselected population. Thus in an unselected population with AMI, early enalapril treatment had no effect on LV function; yet in patients with anterior infarcts, LV function was maintained through preservation of function in the noninfarcted myocardium.