ST-segment Elevation In Electrocardiogram Research Articles

Comparative efficacy of sweated and non-sweated Salvia miltiorrhiza Bge. extracts on acute myocardial ischemia via regulating the PPARα/RXRα/NF-κB signaling pathway

Salvia miltiorrhiza Bge. (S. miltiorrhiza) is a well-known traditional Chinese medicine for the treatment of cardiovascular diseases. The processing of S. miltiorrhiza requires the raw herbs to sweat first and then dry. The aim of this study was to investigate the anti-acute myocardial ischemia (AMI) of S. miltiorrhiza extracts (including tanshinones and phenolic acids) before and after sweating, and to further explore whether the “sweating” primary processing affected the efficacy of S. miltiorrhiza. The AMI animal model was established by subcutaneous injection of isoprenaline hydrochloride (ISO). After treatment, the cardiac function of rats was evaluated by electrocardiogram (ECG), biochemical, and histochemical analysis. Moreover, the regulation of S. miltiorrhiza extracts on the peroxisome proliferator-activated receptor α (PPARα)/retinoid X receptor α (RXRα)/nuclear transcription factor-kappa B (NF-κB) signaling pathway of rats was assessed by the Western blotting. The results showed that sweated and non-sweated S. miltiorrhiza extracts including tanshinones and phenolic acids significantly reduced ST-segment elevation in ECG and the myocardial infarction area in varying degrees. Meanwhile, sweated and non-sweated S. miltiorrhiza reversed the activities of aspartate transaminase (AST), lactic dehydrogenase (LDH), creatine kinase-MB (CK-MB), and superoxide dismutase (SOD), as well as the levels of interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-α (TNF-α) in AMI rats. Concurrently, the results of Western blotting revealed that S. miltiorrhiza extracts regulated the PPARα/RXRα/NF-κB signaling pathway to exert an anti-inflammatory effect. Most importantly, sweated S. miltiorrhiza tanshinones extracts are more effective than the non-sweated S. miltiorrhiza, and the anti-inflammatory efficacy of tanshinones extract was also better than that of phenolic acid extract. Although phenolic acid extracts before and after sweating were effective in anti-AMI, there was no significant difference between them. In conclusion, both tanshinones and phenolic acids extracts of sweated and non-sweated S. miltiorrhiza promote anti-oxidative stress and anti-inflammatory against AMI via regulating the PPARα/RXRα/NF-κB signaling pathway. Further, the comparations between sweated and non-sweated S. miltiorrhiza extracts indicate that sweated S. miltiorrhiza tanshinones extracts have better therapeutic effects on AMI.

Predictive factors for type A aortic dissection mortality based on electrocardiogram parameters and clinical presentations.

Aortic dissection is a rare but potentially lethal disorder and may be associated with electrocardiogram (ECG) changes. In this study, we aim to investigate ECG-related parameters alongside clinical presentations of type A aortic dissection to come up with the predictive factors for the severity of the disease and its mortality rate. In this retrospective study, 201 patients with type A aortic dissection were studied between March 2015 and March 2020. Two expert cardiologists blinded to the diagnosis studied former and new patients' ECGs and recorded changes. Two-hundred and one patients, including 143 (71.1%) men and 58 (28.9%) women, presented with acute dissection of the aorta, were studied. Forty-four (21.8%) and 84 (41.7%) patients had ST-segment elevation and depression in ECG, respectively. Bivariate analysis revealed that higher heart rate (p=0.006), longer QTc (p=0.044), and ST-segment elevation in aVR lead (p=0.044) were associated with mortality in the patients. Multivariate regression showed higher heart rate (OR=1.022, CI=1.003-1.041, p=0.012) and ST-segment elevation in aVR (OR=4.854, CI=2.255-10.477, p<0.001) were independently associated with increased odds of mortality in aortic dissection patients. ROC curve analysis showed heart rate equal to or >60 per minute (AUC=0.625, sensitivity=86%, specificity=10%, p=0.019) and ST-segment elevation in aVR >0.5mm (AUC=0.854, sensitivity=75%, specificity=92%, p<0.001) were associated with a higher mortality rate. Heart rate equal or >60 and ST-segment elevation >0.5mm in aVR lead can be used as predictive factors for mortality of patients with type A aortic dissection.

Current approaches to risk assessment of chronic heart failure after myocardial infarction

In the last decade, there has been an increase in the number of survivors of myocardial infarction (MI). However, the risk of developing chronic heart failure (CHF) remains high in this category of patients. Population aging and comorbidity further contribute to adverse outcomes. Optimization of approaches to identify predictors of postinfarction CHF is an important clinical task of modern medicine.The aim of the investigation is to develop a method to assess the risk of CHF development after MI.Material and Methods. The present analysis included 186 patients who underwent MI from January 2019 to January 2020: 86 patients with signs of CHF above functional class (FC) 2 (NYHA) (mean age 64.3 years) and 100 patients without signs of CHF or with CHF 1 (NYHA) (mean age 62.6 years) by day 30 of MI. A mathematical model of CHF risk after MI was built by factor and correlation analysis methods.Results. A method for assessing CHF risk after a previous MI was developed. The proposed formula is programmed in Excel table processor and includes 5 indicators: presence of atrial fibrillation, Killip class of acute heart failure, triglycerides level, ST-segment elevation of electrocardiogram, left ventricular ejection fraction less than 45 %. The authors’ approach allows long-term personalized monitoring, taking into account the ranked contribution of each factor in a particular patient; it is characterized by high sensitivity, specificity, and accuracy.Conclusion. The present study investigated the factors of formation of postinfarct chronic heart failure syndrome. An original mathematical formula for CHF risk estimation, including routine indices of MI patients, has been proposed. The approach allows personalized management of selected cohorts of patients – with increased and standard risk of postinfarction CHF.

Subepicardial burn injuries in bullfrog heart induce electrocardiogram changes mimicking inferior wall myocardial infarction.

Using bullfrog hearts, we previously reproduced a ST segment elevation in electrocardiogram (ECG), mimicking human ischemic heart disease. In the present study, by inducing subepicardial burn injuries on the inferior part of the frog heart ventricle, we could reproduce typical ECG changes observed in human inferior wall myocardial infarction, such as the marked elevation of the ST segments in inferior limb leads (II, III, aVF) and their reciprocal depression in the opposite limb leads (I, aVL). Due to the decrease in Na+/K+-ATPase protein expression, the resting membrane potential of injured cardiomyocytes shifted toward depolarization. Such induced electrical difference between the injured and intact cardiomyocytes was thought to be responsible for the creation of “currents of injury” and the subsequent ST segment changes.

The association of early diarrhea after successful resuscitation following out-of-hospital cardiac arrest with neurological outcome: A retrospective observational study.

Gastrointestinal ischemia with reperfusion tissue injury contributes to post-cardiac arrest syndrome. We hypothesized that diarrhea is a symptom of intestinal ischemia/reperfusion injury and investigated whether the occurrence of early diarrhea (≤12 hours) after successful cardiopulmonary resuscitation is associated with an unfavorable neurological outcome.We analyzed data from the Vienna Clinical Cardiac Arrest Registry. Inclusion criteria comprised ≥18 years of age, a witnessed, non-traumatic out-of-hospital cardiac arrest, return of spontaneous circulation (ROSC), initial shockable rhythm, and ST-segment elevation in electrocardiogram after ROSC with consecutive coronary angiography. Patients with diarrhea caused by other factors (e.g., infections, antibiotic treatment, or chronic diseases) were excluded. The primary endpoint was neurological function between patients with or without “early diarrhea” (≤12 hours after ROSC) according to cerebral performance categories.We included 156 patients between 2005 and 2012. The rate of unfavorable neurologic outcome was higher in patients with early diarrhea (67% vs 37%). In univariate analysis, the crude odds ratio for unfavorable neurologic outcome was 3.42 (95% confidence interval, 1.11–10.56, P = .03) for early diarrhea. After multivariate adjustment for traditional prognostication markers the odds ratio of early diarrhea was 5.90 (95% confidence interval, 1.28–27.06, P = .02).In conclusion, early diarrhea within 12 hours after successful cardiopulmonary resuscitation was associated with an unfavorable neurological outcome.

Abstract 12088: Coronary Angiography and Revascularization After Out-of-Hospital Cardiac Arrest in Coronary Artery Disease Patients Without ST-segment Elevation

Introduction: The emergent coronary angiography and revascularization after out-of-hospital cardiac arrest (OHCA) in coronary artery disease (CAD) patients without ST-segment elevation remains controversial. Methods: There were 2391OHCA patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among them, 110 patients were diagnosed CAD with no ST-segment elevation in electro-cardiogram (51%: multi-vessel disease, 33%: chronic total occlusion). To predict mortality in hospital and neurological outcome at 1-year, we investigated basic patients’ characteristics, pre-hospital information, post-hospital care including coronary angiography (CAG) and revascularization. Results: In the Cox proportional hazards model, emergent coronary angiography (hazards ratio; HR: 0.90, 95%confidence interval (CI) 0.45-1.79, P=0.758) and emergent coronary revascularization (HR: 1.51, 95%CI 0.87-2.61, P=0.142) were not associated to predict the mortality. At 1-year, VF survivor (P=0.004), younger age (P=0.010), without ECMO support (P&lt;0.001), pre-hospital ROSC (P&lt;0.001), and low lactate level on admission (P&lt;0.001) were associated with low mortality. The higher number of coronary vessel disease (P=0.020) such as multi-vessel disease (P=0.019), the coronary lesion of LAD (P=0.043), and larger infarct size (max CK level; P=0.014, max CK-MB level; P&lt;0.001) were associated with high 1-year mortality. Zero-vessel disease (VSA, P=0.007) had lower mortality. Conclusions: Emergent coronary assessment and revascularization were not associated with the prognosis.

Accuracy of Resolution of ST-Segment Elevation in Electrocardiogram to Determine the Patency of Infarct-Related Artery.

Introduction: There is very limited data comparing the accuracy of ECG to angiography in predicting reperfusion status. In this study, we will determine the accuracy of ECG change i.e. resolution of ST-segment elevation in predicting infarct-related artery (IRA) patency after thrombolysis in patients with ST-segment elevated myocardial infarction (STEMI), in comparison to angiography.Methods: Three hundred and forty-one (n = 341) patients with acute STEMI received streptokinase, a thrombolytic agent within 12 hours of symptoms, and were enrolled in the study via consecutive convenient non-probability sampling. ECG was recorded as soon as the patient arrived in the emergency unit of cardiology. Subsequent ECG was recorded three hours after the administration of streptokinase to look for resolution of ST-segment elevation. ST-segment resolution was classified as greater/equal to 50% resolved or less than 50% resolved. Coronary angiography was performed within 24 hours of hospitalization and flow in the IRA was assessed.Results: The most common site of myocardial infarction (MI) was the anterior wall (50.1%) and the commonest artery involved was the left anterior descending artery (44.2%). On ECG, ST-resolution of more than 50% was found in 242 (70.9%) participants. Thrombolysis in MI (TIMI) grade III flow in angiography was found in 211 (61.8%) participants. The sensitivity and specificity of ST-resolution to detect TIMI grade III flow was 94.79% and 67.69%, respectively, while accuracy was 84.46%.Conclusion: ST-resolution on ECG after streptokinase can predict IRA patency on coronary angiography with moderate to good accuracy. ECG can assist in predicting the impact of streptokinase early in the course of management and give an option of monitoring patient prognosis with a non-invasive test in patients not comfortable with angiography.

A novel electrocardiogram characteristic in patients with myocardial injury due to COVID-19

Background: Coronavirus disease of 2019 (COVID-19) is a respiratory disease which can lead to cardiovascular complications including myocarditis, myocardial infarction, and heart failure. Electrocardiogram (ECG) may change in patients with COVID-19 with or without heart involvement. In this study, the ECG changes were evaluated in myocardial injuries due to COVID-19. Methods: This study was done on 22 COVID-19 patients with ST segment elevation in ECG and high troponin level. COVID-19 was confirmed using reverse-transcription polymerase chain reaction test. The ECG variables were evaluated by an expert cardiologist. Statistical analyses were carried out on ECG variables where the significance level of 0.05 was assigned. Results: Of 22 patients, 17 cases (77.3%) were male and 6 cases (27.3%) had a history of coronary artery disease. The most common myocardial involvement was extensive anterior type (31.8%), followed by anterior type (22.7%). Sinus rhythm was observed in 95.5% of patients and 54.5% had low voltage ECG in limb leads. No significant correlation was found between low voltage ECG and demonstrable etiologies of low voltage. Conclusion: The prevalence of low voltage ECG was significantly high in limb leads of patients with myocardial injury due to COVID-19 which was considerably greater than that of myocarditis or myocardial infarction patients.

Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction.

Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.

Ionic mechanisms of ST segment elevation in electrocardiogram during acute myocardial infarction

ST elevation on an electrocardiogram is a hallmark of acute transmural ischemia. However, the underlying mechanism remains unclear. We hypothesized that high ischemic sensitivities of epicardial adenosine triphosphate-sensitive potassium (IKATP) and sodium (INa) currents play key roles in the genesis of ST elevation. Using a multi-scale heart simulation under moderately ischemic conditions, transmural heterogeneities of IKATP and INa created a transmural gradient, opposite to that observed in subendocardial injury, leading to ST elevation. These heterogeneities also contributed to the genesis of hyper-acute T waves under mildly ischemic conditions. By contrast, under severely ischemic conditions, although action potentials were suppressed transmurally, the potential gradient at the boundary between the ischemic and normal regions caused ST elevation without a contribution from transmural heterogeneity. Thus, transmural heterogeneities of ion channel properties may contribute to the genesis of ST–T changes during mild or moderate transmural ischemia, while ST elevation may be induced without the contribution of heterogeneity under severe ischemic conditions.

Postoperative Cardiac Ischemic Complications in Lung Cancer Patients

Background. Perioperative myocardial ischemia often complicates extracardiac surgery. The problems of its prediction, diagnostics, treatment and prevention are not solved. Frequency, structure and clinical features of cardiac ischemic complications of surgical treatment of lung cancer are not well understood.The aim of the study was to investigate the frequency of postoperative myocardial infarction and myocardial ischemia in the surgical treatment of patients with non-small cell lung cancer.Methods. The frequency (%) of myocardial infarction (MI) with and without ST segment elevation of electrocardiogram, acute myocardial ischemia in a complete sample of cancer patients (n = 2051) who underwent treatment for non-small cell lung cancer for the last 10 years was calculated. By comparing the relative indicators and calculating the Odds Ratio (OR), we studied the relationship between the cardiac ischemic events with age, type of surgery, prevalence and localization of the tumour. The clinical manifestations and pathomorphology of postoperative myocardial infarction were analysed.Results. Cardiac ischemic complications of thoracotomy for lung cancer occurred in 2.73 % (95% CI 1.98–3.48) cases. Myocardial infarction with ST segment elevation was recorded in 1.07 % (95% CI 0.58–1.57) patients, MI without ST segment elevation – in 0.54 % (95% CI 0.17–0.9), myocardial ischemia – in 1.12 % (95% CI 0.62–1.63). An increase in the frequency of ischemic events after pneumonectomy was observed compared with lobectomy (OR 6.5, 95% CI 3.5–12.2) and after right-sided pneumonectomy compared with left-sided one (OR 3.2, 95% CI 1.6–6.3), and also the age over 70. Hospital mortality from MI was 39.3 %. According to autopsies of patients who died of МI, coronary atherothrombosis was detected in 2 of 22 cases.Conclusion. In the surgical treatment of non-small cell lung cancer, cardiac ischemic events develop in 2.73 % of patients. The greatest risk is associated with right-sided pneumonectomy.

Feasibility and performance of a device for automatic self-detection of symptomatic acute coronary artery occlusion in outpatients with coronary artery disease: a multicentre observational study

Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion. Response time might be reduced by reliable self-detection. We aimed to formally assess the proof-of-concept and accuracy of self-detection of acute coronary artery occlusion by patients during daily life situations and during the very early stages of acute coronary artery occlusion. In this multicentre, observational study, we tested the operational feasibility, specificity, and sensitivity of our RELF method, a three-lead detection system with an automatic algorithm built into a mobile handheld device, for detection of acute coronary artery occlusion. Patients were recruited continuously by physician referrals from three Belgian hospitals until the desired sample size was achieved, had been discharged with planned elective percutaneous coronary intervention, and were able to use a smartphone; they were asked to perform random ambulatory self-recordings for at least 1 week. A similar self-recording was made before percutaneous coronary intervention and at 60 s of balloon occlusion. Patients were clinically followed up until 1 month after discharge. We quantitatively assessed the operational feasibility with an automated dichotomous quality check of self-recordings. Performance was assessed by analysing the receiver operator characteristics of the ST difference vector magnitude. This trial is registered with ClinicalTrials.gov, number NCT02983396. From Nov 18, 2016, to April 25, 2018, we enrolled 64 patients into the study, of whom 59 (92%) were eligible for self-applications. 58 (91%) of 64 (95% CI 81·0-95·6) patients were able to perform ambulatory self-recordings. Of all 5011 self-recordings, 4567 (91%) were automatically classified as successful within 1 min. In 65 balloon occlusions, 63 index tests at 60 s of occlusion in 55 patients were available. The mean specificity of daily life recordings was 0·96 (0·95-0·97). The mean false positive rate during daily life conditions was 4·19% (95% CI 3·29-5·10). The sensitivity for the target conditions was 0·87 (55 of 63; 95% CI 0·77-0·93) for acute coronary artery occlusion, 0·95 (54 of 57; 0·86-0·98) for acute coronary artery occlusion with electrocardiogram (ECG) changes, and 1·00 (35 of 35) for acute coronary artery occlusion with ECG changes and ST-segment elevation myocardial infarction criteria (STEMI). The index test was more sensitive to detect a 60 s balloon occlusion than the STEMI criteria on 12-lead ECG (87% vs 56%; p<0·0001). The proportion of total variation in study estimates due to heterogeneity between patients (I2) was low (12·6%). The area under the receiver operator characteristics curve was 0·973 (95% CI 0·956-0·990) for acute coronary artery occlusion at different cutoff values of the magnitude of the ST difference vector. No patients died during the study. Self-recording with our RELF device is feasible for most patients with coronary artery disease. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase Survival without overloading emergency services. Ghent University, Industrial Research Fund.

Prognostic Role of CMR and Conventional Risk Factors in Myocardial Infarction With Nonobstructed Coronary Arteries

ObjectivesThis study sought to assess the prognostic impact of cardiac magnetic resonance (CMR) and conventional risk factors in patients with myocardial infarction with nonobstructed coronaries (MINOCA). BackgroundMyocardial infarction with nonobstructed coronary arteries (MINOCA) represents a diagnostic dilemma, and the prognostic markers have not been clarified. MethodsA total of 388 consecutive patients with MINOCA undergoing CMR assessment were identified retrospectively from a registry database and prospectively followed for a primary clinical endpoint of all-cause mortality. A 1.5-T CMR was performed using a comprehensive protocol (cines, T2-weighted, and late gadolinium enhancement sequences). Patients were grouped into 4 categories based on their CMR findings: myocardial infarction (MI) (embolic/spontaneous recanalization), myocarditis, cardiomyopathy, and normal CMR. ResultsCMR (performed at a median of 37 days from presentation) was able to identify the cause for the troponin rise in 74% of the patients (25% myocarditis, 25% MI, and 25% cardiomyopathy), whereas a normal CMR was identified in 26%. Over a median follow-up of 1,262 days (3.5 years), 5.7% patients died. The cardiomyopathy group had the worst prognosis (mortality 15%; log-rank test: 19.9; p < 0.001), MI had 4% mortality, and 2% in both myocarditis and normal CMR. In a multivariable Cox regression model (including clinical and CMR parameters), CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation electrocardiogram (ECG) remained the only 2 significant predictors of mortality. Using presentation with ECG ST-segment elevation and CMR diagnosis of cardiomyopathy as risk markers, the mortality risk rates were 2%, 11%, and 21% for presence of 0, 1, and 2 factors, respectively (p < 0.0001). ConclusionsIn a large cohort of patients with MINOCA, CMR (median 37 days from presentation) identified a final diagnosis in 74% of patients. Cardiomyopathy had the highest mortality, followed by MI. The strongest predictors of mortality were a CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation ECG.

Electrocardiographic approach to classification of acute pericarditis in emergency department: Typical and atypical pericarditis

BACKGROUND: In typical pericarditis, concave ST–segment elevation can be characteristically seen in electrocardiogram (ECG). However, PR-segment depression may be the earliest ECG change in patients with acute pericarditis and in following time, from atypical pattern to typical pattern transition may be occur. Without ST-segment elevation in ECG may undergo misdiagnosed or overestimated condition, including acute coronary syndrome. Therefore, we classified acute pericarditis by highlighting ECG features to prevent any possible failure to notice acute pericarditis in emergency department (ED). METHODS: This study included 216 patients selected from the 2140 patients acute chest pain admitted into ED between 2015 and 2018. The two groups were retrospectively created by virtue of the presence or absence of typical ECG findings. Typical ECG refers to diffuse or regional concave ST-segment elevations with reciprocal ST-segment depression in aVR, and V1 in ECG, and atypical ECG refers to PR-segment depression in leads V5 to V6 in ECG. 100 patients (group I) had typical ECG, whereas 116 patients (group II) had atypical ECG changes. RESULTS: The mean age of the patients with typical pericarditis was higher than those with atypical pericarditis (P<0.05). Typical pericarditis group had higher CRP level (P<0.05). Atypical pericarditis group had more recurrence rate than typical pericarditis (P<0.05). In ECG following time, 10 patients with the atypical pericarditis pattern were transformed typical pericarditis pattern. CONCLUSION: We classified acute pericarditis as typical and atypical by highlighting ECG features to prevent any possible failure to notice acute pericarditis. Thanks to PR-segment recognition, acute pericarditis diagnosis may confirm and prevent the inappropriate coronary intervention. It is recommended that the ECG features should be examined thoroughly, especially with a focus on ST-segment elevation besides PR-segment depression.

Complete Healing of Spontaneous Coronary Artery Dissection Demonstrated by Optical Coherence Tomography in a Young Postpartum Female Presenting With Acute Coronary Syndrome

A 27-year-old primigravida presented with chest pain, ST-segment elevation in electrocardiogram leads I, aVL, and V1 to V6, positive troponin I, and apical hypokinesia with a left ventricular ejection fraction of 45%, 20 days following a cesarean section. The patient was a smoker, with no other

Role of electrocardiogram in identification of culprit vessel occlusion in acute ST elevation myocardial infarction in relation to coronary angiography

Objective: The objective of the study is to study the usefulness of electrocardiography in localizing the culprit vessel in acute ST-elevation myocardial infarction (STEMI) and to assess the diagnostic accuracy of the electrocardiogram (ECG) findings by comparing them with coronary angiographic findings. Materials and Methods: This study is prospective observational study, conducted on fifty patients in tertiary care center attached to medical college. Patients with ST-segment elevation in ECG was evaluated to identify culprit vessel and later correlated with their coronary angiography. Results: Among fifty patients in the study, 34 had anterior wall, and 16 had inferior wall myocardial infarction. ST↑ >1 mm in V4R, ST↓V3/ST↑LIII lead II was the most sensitive and ratio of ST↓V3/ST↑LIII >1.2 was the most specific criterion. In anterior wall STEMI, 52.9% patients had occlusion proximal to first septal (S1), 17.6% had occlusion proximal to first diagonal (D1), 8.8% had occlusion distal to S1, and 20.5% had occlusion distal to D1. Q wave in aVL had maximum sensitivity for identifying occlusion proximal to D1 and Q wave in leads V4-V6 for occlusion distal to S1. Conclusion: The admission ECG in patients with STEMI is valuable not only for determining early reperfusion treatment, but also provides important information to guide clinical decision-making.

Prevalence, Clinical Characteristics, and Predictors of Patients with Thromboembolic Events in Takotsubo Cardiomyopathy

BACKGROUNDSeveral acute complications related to takotsubo cardiomyopathy (TTC) have been documented recently. However, the incidence and clinical significance of acute thromboembolic events in TTC is not well established.METHODSA detailed investigation of the clinical characteristics and in-hospital complications of 114 consecutive patients diagnosed with TTC between January 2003 and September 2015 was carried out. This study was initiated to reveal the predictors, clinical significance, and short-term and long-term outcomes of patients with TTC associated with acute thromboembolic events on index presentation.RESULTSThe incidence of acute thromboembolic events related to TTC was around 12.2%, and these included ventricular thrombi, cerebrovascular events, retinal and brachial artery pathologies, renal, splenic, and aortic involvement. The most frequent complication on initial presentation was cardiogenic shock (20%) accompanied with pulmonary congestion (20%). Interestingly, patients experiencing thromboembolic events had higher C-reactive protein (CRP) levels as compared to the non-thromboembolic group (P = 0.02). Certain thromboembolic events were characterized by the presence of ST-segment elevation in electrocardiogram (P = 0.02). Chest pain was the primary symptom in these patients (P = 0.09). Furthermore, there was significant right ventricular involvement (as assessed by transthoracic echocardiography) in patients presenting with an acute thromboembolic event (P = 0.08). A Kaplan–Meier analysis indicated a significantly higher mortality rate over a mean follow-up of three years in the thromboembolic group than the non-thromboembolic group (log-rank, P = 0.02).CONCLUSIONSOur results confirmed the relative common occurrence of thromboembolic events in the setting of TTC. Inflammation might play an important role in the development of thromboembolic events, and a right ventricular involvement and ST-segment elevation could be positive predictors for this occurrence. In order to circumvent the risk of a negative outcome, it is recommended that an anticoagulation therapy be initiated in all high-risk patients.

Persistent Excessive Electrocardiogram ST-segment Elevation in a Patient with a Takotsubo Syndrome: What Could be the Cause?

Persistent Excessive Electrocardiogram ST-segment Elevation in a Patient with a Takotsubo Syndrome: What Could be the Cause?

Subacute thrombosis after primary percutaneous coronary intervention with bioresorbable vascular scaffold implantation

Everolimus-eluting bioresorbable vascular scaffold (BVS) is a promising new technology recently applied in the treatment of coronary artery lesions that might overcome the limitations of the currently used drug eluting stents. There were no scaffold thromboses reported in the first-in-human trials with BVS implantation. However, the current body of evidence on its safety and incidence of early thrombotic complications in the setting of acute coronary syndromes is still limited. We present the case of a 58-year-old male who was admitted to a coronary care unit due to typical (two-hour long) chest pain with electrocardiographic signs of anterior wall ST segment-elevation myocardial infarction. Coronary angiography revealed critical stenosis of the proximal left anterior descending artery (Fig. 1A). Subsequent primary angioplasty with manual aspiration thrombectomy, balloon predilatation, and implantation of BVS (ABSORB, 3.5/28 mm, 12 atm.) was performed, with good angiographic result (TIMI 3 flow) (Fig. 1B). Optical coherence tomography (OCT) confirmed good scaffold expansion and complete strut apposition (Fig. 1C–F). Further in-hospital course was uneventful and the patient was discharged after five days of hospitalisation. On the ninth day after BVS implantation he presented again with acute severe chest pain and anterior ST-segment elevation in electrocardiogram. The patient confirmed that he discontinued both antiplatelet drugs (aspirin and clopidogrel) after discharge. Repeat coronary angiography revealed a subacute scaffold thrombosis (Fig. 2A). Manual aspiration thrombectomy, abciximab infusion, and plain old balloon angioplasty was performed (Fig. 2B), with good final angiographic result (TIMI 3) (Fig. 2C). Echocardiography revealed an impaired left ventricular ejection fraction of 38%, compared to 50% directly after the primary index procedure. As there was appropriate scaffold expansion and strut apposition in OCT directly after the index procedure, the most likely cause of scaffold thrombosis was the cessation of antiplatelet therapy. Figure 2. A. Occlusion of the proximal left anterior descending artery in the place of bioresorbable vascular scaffold implantation (arrow); B. Plain old balloon angioplasty performed in the occluded left anterior descending artery; C. Good final angiographic result of the treatment of scaffold thrombosis (TIMI 3) Figure 1. A. Coronary angiography revealing critical stenosis of the proximal left anterior descending artery (arrow); B. Good angiographic result of primary angioplasty with bioresorbable vascular scaffold implantation (TIMI 3); C–F. Good scaffold expansion and complete strut apposition in optical coherence tomography A

Heat Stroke–Induced Sinoatrial Node Dysfunction

BackgroundHeat stroke has been associated with stress-induced cardiomyopathy and electrocardiogram ST segment elevation and depression. Laboratory studies with dogs have demonstrated heat stroke–induced sinoatrial node dysfunction in the setting of hyperkalemia. No prior case report has described heat stroke–induced complete sinoatrial node dysfunction that resolved in the emergency department. Case ReportAn 87-year-old female presented to the emergency department with heat stroke and severe bradycardia. Initial electrocardiogram demonstrated complete sinoatrial node dysfunction. The bradycardia responded to external cardiac pacing and the sinoatrial node dysfunction resolved with aggressive cooling. Emergency physicians should be aware that heat stroke can cause complete sinoatrial node dysfunction and that this bradydysthrmia can be treated with aggressive cooling.