Use Of Reperfusion Therapy Research Articles

New Approaches to Neuroprotective Drug Development

All prior drug development programs of neuroprotective agents were unsuccessful for a variety of reasons related to both preclinical assessment and the design/implementation of clinical trials. The neuroprotection hypothesis of improving functional outcome related to salvaging ischemic brain tissue is strongly supported by robust preclinical data for many agents. In the future, monotherapy neuroprotection trials will be difficult but could be performed in underused centers with drugs that have very promising and complete preclinical results. Additional approaches for the testing and use of neuroprotective agents should be considered. Novel approaches would include extending penumbral survival for the later use of reperfusion therapy, reducing reperfusion injury after successful reperfusion, and using drugs with both neuroprotective and recovery enhancing effects, as exemplified by granulocyte colony-stimulating factor and citicoline. To maximize outcome after stroke, the combined use or reperfusion and neuroprotection is likely to be needed, so we must begin to perform carefully designed trials with this combination.

Reperfusion therapy in the acute management of ST‐segment‐elevation myocardial infarction in Australia: findings from the ACACIA registry

To describe the contemporary management and outcomes of patients presenting with ST-segment-elevation myocardial infarction (STEMI) in Australia. Observational analysis of data for patients who presented with suspected STEMI and enrolled in the Australian Acute Coronary Syndrome Prospective Audit from 1 November 2005 to 31 July 2007. Factors associated with use of reperfusion therapy and timely use of reperfusion therapy, and the effects of reperfusion on mortality. In total, 755 patients had suspected STEMI. Median time to presentation was 105 minutes (IQR, 60-235 minutes). Reperfusion therapy was used in 66.9% of patients (505/755), and timely reperfusion therapy in 23.1% (174/755). Thombolysis was administered in 39.2% of those who received reperfusion therapy (198/505), while 60.8% (307/505) received primary percutaneous intervention. Cardiac arrest (OR, 2.83; P = 0.001) and treatment under the auspices of a cardiology unit (OR, 2.14; P = 0.02) were associated with use of reperfusion therapy. A normal electrocardiogram on presentation (OR, 0.42; P = 0.01), left bundle branch block (OR, 0.18; P = 0.001), acute pulmonary oedema (OR, 0.34; P < 0.01), history of diabetes (OR, 0.54; P < 0.01), and previous lesion on angiogram of > 50% (OR, 0.51; P = 0.001) were associated with not using reperfusion. In hospital mortality was 4.0% (30/755), mortality at 30 days was 4.8% (36/755), and mortality at 1 year was 7.8% (59/755). Receiving reperfusion therapy of any kind was associated with decreased 12-month mortality (hazard ratio [HR], 0.44; 95% CI, 0.25-0.78; P < 0.01). Timely reperfusion was associated with a reduction in mortality of 78% (HR, 0.22; P = 0.04). There were no significant differences in early and late mortality in rural patients compared with metropolitan patients (P = 0.66). Timely reperfusion, not the modality of reperfusion, was associated with significant outcome benefits. Australian use of timely or any reperfusion remains poor and incomplete.

Implications and Reasons for the Lack of Use of Reperfusion Therapy in Patients with ST-segment Elevation Myocardial Infarction: Findings from the CRUSADE Initiative

Implications and Reasons for the Lack of Use of Reperfusion Therapy in Patients with ST-segment Elevation Myocardial Infarction: Findings from the CRUSADE Initiative

Implications and reasons for the lack of use of reperfusion therapy in patients with ST-segment elevation myocardial infarction: Findings from the CRUSADE initiative

Prompt reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is a class I guideline recommendation and has been shown to reduce mortality. However, many STEMI patients in contemporary practice still do not receive any form of reperfusion therapy. We evaluated 8,578 patients with STEMI from 226 US hospitals participating in the CRUSADE quality improvement initiative from September 2004 to December 2006 to determine the proportion of eligible patients who received an attempt at reperfusion therapy and factors associated with lack of reperfusion among patients without a contraindication to reperfusion. STEMI patients were classified into 3 groups: (1) patients eligible for reperfusion and for whom reperfusion was attempted; (2) patients eligible for reperfusion and for whom reperfusion was not attempted; and (3) patients who were ineligible for reperfusion because of identified contraindications. We compared patient characteristics, treatments, and outcomes among the groups and identified factors independently associated with lack of reperfusion use among eligible patients. Of the 8,578 patients with STEMI, 881 patients (10.3%) had a documented contraindication to reperfusion, 7,080 (82.5%) received fibrinolysis or underwent an attempt at primary percutaneous coronary intervention, and 617 reperfusion-eligible patients (7.2%) had no attempt to administer reperfusion. Primary reasons for contraindications were identified as absence of an ischemic indication (n = 474; 53.8%), bleeding risk (n = 147; 16.7%), patient-related reasons (n = 223; 25.3%), and other (n = 37; 4.2%). The strongest factors associated with not attempting reperfusion among the reperfusion-eligible population were older age, heart failure at presentation, noncardiac surgical center, prior stroke, and female sex. Compared with patients receiving an attempt at reperfusion, adjusted in-hospital mortality rates were higher for patients with a documented reperfusion contraindication (adjusted odds ratio 1.77, 95% CI 1.28-2.45) and in eligible patients who did not receive reperfusion (adjusted odds ratio 1.64, 95% CI 1.07-2.50). More than 7% of STEMI patients without a reperfusion contraindication did not have an attempt to administer reperfusion therapy, and this was associated with greater in-hospital mortality. Age, sex, and comorbidity were factors related to lack of attempting reperfusion among apparently eligible patients. Quality improvement efforts should focus on maximizing reperfusion use among all eligible STEMI patients and in addressing the processes by which contraindications are defined, clinically determined, and reported.

Improved mortality after STEMI over two decades

Results A total of 335 patients in 1986, 351 in 1996 and 178 patients in 2006 comprise the total study population of 864 STEMI patients. In addition 25 (6,9%) patients died within the first 24 hours of hospital admission in 1986, 33(15,6%) in 1996 and 5 (2,7%) in 2006. One-year mortality decreased from 26.3% in 1986 and 19.7% in 1996 to 12.9% in 2006 (p = 0.001). Cox proportional hazard analysis showed aspirin (HR 0.29), the use of reperfusion therapy (HR 0.51) and beta blockers at hospital discharge (HR 0.53) to be the strongest factors to explain the mortality reduction while the use of diuretics (HR 1.42) and age (HR 1.06) were related to increased one year mortality.

Resultados del III registro IAM CAT de pacientes con infarto de miocardio con elevación del segmento ST en Cataluña. Comparación con los registros IAM CAT I y II

To analyze the use of reperfusion therapy in patients with ST elevation myocardial infarction (STEMI) in Catalonia in a registry performed in 2006 (IAM CAT III) and its comparison with 2 previous registries Frequency of reperfusion therapy and time intervals between symptom onset - reperfusion therapy were the principal variables investigated. The IAM CAT I (June-December 2000) included 1,450 patients, the IAM CAT II (October 2002-April 2003) 1,386, and the IAM CAT III (October-December 2006) 367. The proportion of patients treated with reperfusion increased progressively (72%, 79% and 81%) as the use of primary angioplasty (5%, 10% and 33%). In the III registry the transfer system most frequently used was the SEM/061 (17%, 32% and 47%, respectively) but the time interval symptom onset-first contact with the medical system did not improve (II, 90 vs III, 105 min), the interval symptom onset-thrombolytic therapy did hardly change (178, 165 and 177 min) and the interval hospital arrival-trombolysis (needle-door) tended to improve (59, 42 and 42 min). Thirty day mortality in STEMI patients declined progressively through the 3 registries (12.1, 10.6 and 7.4%, p=0.012). The proportion of STEMI patients treated with reperfusion has improved but the interval to its application has not been shortened. To improve the latter it is mandatory an earlier contact with the medical system, a shortening of the intervals door-needle and door-balloon through better coordination between the 061, the sanitary personnel and the hospital administration, and to consider the subject as a real sanitary priority.

Utilization and Impact of Pre-Hospital Electrocardiograms for Patients With Acute ST-Segment Elevation Myocardial Infarction: Data From the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry

This study sought to determine the association of pre-hospital electrocardiograms (ECGs) and the timing of reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI). Pre-hospital ECGs have been recommended in the management of patients with chest pain transported by emergency medical services (EMS). We evaluated patients with STEMI from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry who were transported by EMS from January 1, 2007, through December 31, 2007. Patients were stratified by the use of pre-hospital ECGs, and timing of reperfusion therapy was compared between the 2 groups. A total of 7,098 of 12,097 patients (58.7%) utilized EMS, and 1,941 of these 7,098 EMS transport patients (27.4%) received a pre-hospital ECG. Among the EMS transport population, primary percutaneous coronary intervention was performed in 92.1% of patients with a pre-hospital ECG versus 86.3% with an in-hospital ECG, whereas fibrinolytic therapy was used in 4.6% versus 4.2% of patients. Median door-to-needle times for patients receiving fibrinolytic therapy (19 min vs. 29 min, p = 0.003) and median door-to-balloon times for patients undergoing primary percutaneous coronary intervention (61 min vs. 75 min, p < 0.0001) were significantly shorter for patients with a pre-hospital ECG. A suggestive trend for a lower risk of in-hospital mortality was observed with pre-hospital ECG use (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01). Only one-quarter of these patients transported by EMS receive a pre-hospital ECG. The use of a pre-hospital ECG was associated with a greater use of reperfusion therapy, faster reperfusion times, and a suggested trend for a lower risk of mortality.

The impact of fibrinolytic therapy for ST-segment-elevation acute myocardial infarction.

As privileged witnesses of the initiation and widespread use of reperfusion therapy the authors review the history of fibrinolytic therapy and of tissue-plasminogen activator (t-PA) more particularly and the current indications for its use in the era of mechanical reperfusion.

Changes in Hospital Mortality Rates in 425 Patients With Acute ST-Elevation Myocardial Infarction and Cardiac Rupture Over a 30-Year Period

Possible changes in the incidence and outcome of cardiac rupture in patients with ST-elevation myocardial infarction over a long period of time have not been investigated. The incidence of cardiac rupture in ST-elevation myocardial infarction patients and its mortality rate were investigated during a 30-year period divided into 5 intervals (1977 to 1982, 1983 to 1988, 1989 to 1994, 1995 to 2000, and 2001 to 2006). Of a total of 6678 consecutive patients, 425 experienced a free wall rupture (280 with cardiac tamponade: 227 with electromechanical dissociation and 53 with hypotension) or a septal rupture (145). After the exclusion of referrals from other centers (n=44), the incidence of definite cardiac rupture (septal rupture, anatomic evidence of free wall rupture, or electromechanical dissociation) declined progressively (6.2% in 1977 to 1982 to 3.2% in 2001 to 2006; P<0.001) in parallel with a progressive use of reperfusion therapy (0% to 75.1%; P<0.001). In addition, among patients with cardiac rupture, there was a progressive fall in the rate of death (94% to 75%; P<0.001) despite a trend toward increasing age (66+/-8 to 75+/-8 years; P<0.054) in conjunction with better control of systolic blood pressure at 24 hours (130+/-24 versus 110+/-18 mm Hg; P<0.001); an increased use of reperfusion therapy (0% to 59%; P<0.001), beta-blockers (0% to 45%; P<0.001), angiotensin-converting enzyme inhibitors (0% to 38%; P<0.001), and aspirin (0% to 96%; P<0.001); and a lower use of heparin (99% to 67%; P<0.001). The decline in the incidence in cardiac rupture and its rate of death over the last 30 years appears to be associated with the increasing use of reperfusion strategies and adjunct medical therapy.

Heart Failure After Acute Myocardial Infarction

Improvements in the treatment of acute myocardial infarction (AMI), especially use of reperfusion therapy, have led to larger numbers of survivors. In patients who would have survived despite reperfusion therapy, use of this treatment should lead to greater myocardial salvage and a reduced extent of ventricular injury in many. However, others who might not have survived previously may now do so, but with substantial left ventricular damage.1,2 The net consequence of these 2 opposing effects on the early and later risk of developing heart failure after AMI is uncertain. There has been concern, however, that an increasing pool of survivors of AMI might fuel an “epidemic” of heart failure. Article p 2057 Although we have a substantial amount of data on the rates of heart failure overall, rates of heart failure after AMI have been less well studied. Furthermore, the clinical trials, registries and epidemiological studies that have reported the rate of heart failure after AMI have used different case ascertainment and diagnostic criteria. Examination of 4 of the major trials of fibrinolysis (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries [GUSTO I], Global Use of Strategies to Open Occluded Coronary Arteries [GUSTO IIb and GUSTO III], and the Assessment of the Safety and Efficacy of a New Thrombolytic trial [ASSENT II]) in AMI revealed that heart failure was present at admission in 12.5% of the 61 041 participants, with 29.4% having evidence of heart failure at any time during admission.3 The rate was similar in the 15 078 patients enrolled in the Intravenous nPA for the Treatment of Infarcting Myocardium Early II study (InTIME II), where 23% presented with heart failure.4 However, clinical trials can only be cautiously generalized to the community because of the selection of participants.5 Registries provide further …

What can mitochondrial proteomics tell us about cardioprotection afforded by preconditioning?

In 2008, acute myocardial infarction (AMI) remains a major source of mortality and morbidity, notwithstanding the aggressive use of reperfusion therapy [1]. To researchers in cardiology intent on d...

Changing strategies in the management of acute myocardial infarction in modern China

Summary Ischaemic heart disease (IHD) is a common condition in China, accounting for more than 700,000 deaths each year mainly due to acute myocardial infarction (MI). Currently there is no nationally representative registry in China to provide data about the epidemiology, clinical management and prognosis of patients with MI. The present review has used information from a few large nationwide randomised trials and some small regional registries to assess the patterns of management of MI in China. As in many other countries, the management of acute MI in China has undergone a significant transformation during recent decades, due chiefly to an evidence-based approach to cardiovascular medicine. Antiplatelet therapy is now routinely given to almost all patients admitted with acute MI, using not only aspirin but increasingly combining it with clopidogrel. The overall use of reperfusion therapy is also consistent with that reported in Western populations, even though primary PCI is much less frequently used and the type of fibrinolytic agents commonly used may be less optimal in terms of the achieved patency rate of the infarct related artery. Anticoagulant therapy and ACE inhibitors are also used routinely in hospital, with about three-quarters of patients receiving such treatments consistently across different types of hospitals or regions. The use of beta-blocker therapy for acute MI in China has conventionally involved oral agents with little use of initial intravenous regimens, and this approach seems adequate for most patients with acute MI given the findings of the large COMMIT/CCS-2 trial in China. As a result of improved treatments, the hospital mortality for acute MI has declined significantly since the early 1990s. Despite a significant improvement in the general care of MI, there is still substantial under-, over- and inappropriate treatment of many patients in China. Further improvements, especially with respect to long-term management after MI, will rely not only on better implementation of the many established cost-effective treatments but also on improvements in the medical care system and more active engagement of the medical profession to improve risk factor management, such as smoking cessation.

Progress in the management of ST-segment elevation myocardial infarction during economic transition in Poland between 1992 and 2006

Implementation of new therapeutic strategies is intended to decrease morbidity and mortality in patients with acute coronary syndromes (ACS). The aim of this study is to evaluate progress in the treatment of ST-segment elevation myocardial infarction (STEMI) in 1992–2006 based on data from Polish National ACS Registry. A total of 881 STEMI patients in 1992–1996 and 889 in 2005–2006 were enrolled. The use of reperfusion therapy resulted in marked reduction in in-hospital and post-discharge mortality with the best results achieved in the invasive arm. Low invasive approach rate in high-risk patients resulted in no reduction in global mortality.

Reduction in Door-to-Needle Time to Meet Clinical Guideline Recommendations. Outcomes After 1 Year

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P< .01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.

Abstract 2805: Persistent Gender Bias in the Use of Percutaneous Coronary Intervention at the Acute Stage of MI from 1995 to 2005: Results from the French USIK, USIC 2000 and FAST-MI Registries

Percutaneous coronary intervention (PCI) is an essential step in the management of patients with STEMI or NSTEMI. Previous data have evidenced a gender bias in the use of PCI in people admitted for AMI. Aim: to assess whether PCI was used differently in men and women with AMI and if there have been changes in this regard over the last 10 years. Methods: USIK 1995, USIC 2000 and FAST-MI are 3 nationwide French registries conducted 5 years apart, using a similar methodology in patients admitted to CCU over a one-month period. For the present analysis, all 7528 patients admitted for AMI (STEMI and NSTEMI) &lt; 48 hours from symptom onset were included. Results: 2152 patients were included in 1995, 2317 in 2000 and 3059 in 2005. Women represented 29%, 27% and 32% of the populations, respectively in the 3 periods. Overall, women were 10 years older than men (no difference between the 3 periods); PCI was used in 53% of men and 39% of women (p&lt;0.001). Use of PCI during the initial hospital stay increased from 1995 to 2005, but the difference between men and women persisted (1995: 12% v. 20%; 2000: 45% v. 62%; 2005: 52% v. 69%)(p&lt;0.001 at all time points). In the whole population, female gender was an independent predictor of a lower use of reperfusion therapy (OR: 0.70; 95% CI: 0.62– 0.79, p&lt;0.001), together with older age, history of peripheral arterial disease, history of congestive heart failure, and earlier time period (1995 v 2000 v 2005) (logistic regression analysis). In each of the 3 periods, female gender remained associated with lower use of reperfusion, with odds ratios of similar magnitude (1995: OR: 0.54, 95% CI: 0.41– 0.71; 2000: OR 0.50, 95% CI: 0.41– 0.60; 2005: OR: 0.48, 95% CI: 0.41– 0.56). A striking decrease in 30-day mortality was observed in women (1995: 21%, 2000: 12%, 2005: 8.5%). This decrease, however, was found predominantly in women who underwent PCI (14%, 6% and 4%, respectively), compared with women without PCI (22%, 17%, 14%, respectively). Conclusion: In spite of a much higher use of PCI over the past 10 years, a definite gender bias persists. This finding is all the more preoccupying as the reduction in early mortality over this period of time has been observed mainly in women with PCI.

The incidence, treatment strategies and outcomes of acute coronary syndromes in the “reperfusion network” of different hospital types in the Czech Republic: Results of the Czech evaluation of acute coronary syndromes in hospitalized patients (CZECH) registry

Aims To analyze the incidence, treatment strategies and outcomes of acute coronary syndromes (ACS) in Czech population. Methods and results ACS diagnosis was confirmed in 1345 of 1921 (70%) consecutively admitted patients with suspected ACS. ACS incidence was 3248 cases/million/year and the annual incidence of confirmed myocardial infarction was 1960 per million. In-hospital mortality was 5.1% (10.0% with Q-MI, 4.4% with non-Q-MI, and 0.9% with UAP). Coronary angiography was performed in 92% of STEMI (followed by primary PCI in 83%, by CABG in 3%, by conservative therapy in 6%). Thrombolysis was used in only 1% of patients. Reperfusion therapy was thus used in 87% of all STEMI patients. Discharge medication included aspirin in 95%, a statin in 76%, a beta-blocker in 78%, an ACE inhibitor in 50%, clopidogrel in 60%, and ticlopidine in 4% of patients. Conclusions In-hospital mortality of ACS in the Czech network of PCI and non-PCI hospitals is low. Nationwide application of primary PCI strategy for STEMI is feasible and increases the overall use of reperfusion therapy.

Geographic variation in the treatment of acute myocardial infarction in the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial

The VALIANT trial compared the efficacy and safety of captopril, valsartan, and their combination in patients with left ventricular systolic dysfunction, heart failure, or both after acute myocardial infarction (MI). By examining this international trial population of high-risk patients, we sought to determine geographic variations in the use of 3 key treatments for MI. We analyzed data from 14,512 high-risk patients with MI in the VALIANT trial from the 20 countries that had enrolled >100 patients. International variation in the proportion of patients receiving (1) reperfusion therapy (thrombolysis or primary percutaneous coronary intervention), (2) beta-blockers, or (3) aspirin at the time of MI was measured by using adjusted W scores. These scores correspond to the number of additional or fewer patients who received each of the therapies compared with the number expected, as estimated from multivariable regression models that account for patients' baseline characteristics. There was marked variation between countries in the use of reperfusion therapy (equivalent to a difference of up to 36/100 potentially eligible patients) and beta-blockers (41/100), whereas there was much less variation in the use of aspirin (13/100). Marked geographic variation persists in the use of standard evidence-based therapy advocated by international guidelines. Our findings have implications not only for care of patients but also for the conduct of international trials.

Gender differences in management and outcome of patients with acute myocardial infarction

Background The study objectives were to assess any gender differences in the application of diagnostic and therapeutic procedures and their impact on outcome in patients with acute myocardial infarction (AMI). Methods Prospective cohort study of patients in the PRIAMHO II registry. 58 randomly selected public hospitals in Spain included 6209 patients with AMI admitted to Coronary/Critical Care Unit from May 15 to December 15 2000 with 1-year follow-up. Data were gathered on use of coronary angiography and reperfusion procedures, on a combined outcome variable (including death, reinfarction, postinfarction angina, and stroke during hospital stay), and on 28-day and 1-year mortality rates. Results 4641 (74.75%) of the patients were male and 1568 (25.5%) female. No gender differences in coronary angiography or reperfusion therapy use were found. However, female sex alongside age, use of reperfusion therapy, diabetes mellitus, previous revascularization, previous AMI, and higher Killip class were predictors of the combined outcome variable, with an adjusted OR of 1.21 (CI 95% 1.02–1.42). Conclusions No association was observed between the gender of patients with AMI and the application of diagnostic or therapeutic procedures. Nevertheless, female sex behaved as an independent adverse short-term prognostic factor.

Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction

To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment. Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication (n = 909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood chi2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood chi2 31.6, P < 0.001), higher intracerebral haemorrhage risk (likelihood chi2 27.1, P < 0.001), higher baseline cardiovascular risk (likelihood chi2 25.4, P < 0.001), and greater number of chronic comorbid conditions (likelihood chi2 15.4, P < 0.001). The importance of each factor on non-utilization was independent, additive, not explained by age effects alone, or driven by subgroups traditionally under-represented in clinical trials. Care gaps in the use of reperfusion therapy widen with both increasing baseline cardiovascular risk and increasing intracerebral haemorrhage risk. Future studies should examine whether the implementation of clinical decision tools which allow for more accurate risk-benefit tradeoff predictions improve the treatment gaps when using life-saving therapies in this patient population.

Recording lead V 4R is associated to enhanced use of fibrinolytic therapy in acute myocardial infarction

Background ST-segment elevation in the right-sided chest lead V 4R in inferior wall myocardial infarction is recognized as a sign of proximal occlusion of the right coronary artery with evolving right ventricular myocardial infarction. Our objective is to study how often lead V 4R is recorded in clinical practice and how this might be associated with use of reperfusion therapy and outcome of patients. Methods Recording of lead V 4R in 814 consecutive patients with acute myocardial infarction, administration of therapy, and outcome of the patients during a median follow-up of 285 days (174-313 days) were studied. Results V 4R was recorded in 52% of patients with inferior ST-elevation myocardial infarction. Patients with V 4R recorded were more likely to receive fibrinolytic therapy compared with patients without recording (65% vs 51%; P = .035). In multivariate analysis, recording of lead V 4R (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.2; P = .006), along with age ( P < .001), previous myocardial infarction (OR 2.2, 95% CI 1.3-3.5; P = .002), and diabetes (OR 3.9, 95% CI 1.1-2.4; P = .03) correlated to the use of reperfusion therapy. Patients with lead V 4R recorded had less ( P = .055) reinfarction, unstable angina, stroke, and/or death during follow-up. Conclusions Lead V 4R was recorded in only half of patients with inferior ST-elevation myocardial infarction. Patients with V 4R recorded were more likely to receive thrombolytic therapy than those without recording of the additional chest lead.