Analysis Of ST-segment Resolution Research Articles

Higher admission glycaemia independently of diagnosed or unrecognised diabetes mellitus is a risk factor for failed myocardial tissue reperfusion and higher mortality after primary angioplasty.

Admission hyperglycaemia worsens reperfusion in ST-segment elevation myocardial infarction (STEMI). ST-segment elevation resolution parallels myocardial tissue reperfusion and predicts the outcome of primary percutaneous coronary intervention (pPCI). We investigated whether higher glycaemia on admission impairs tissue-level reperfusion after pPCI for STEMI, as-sessed with the single-lead Schröder method of ST-segment resolution analysis (maxSTE). Among 323 patients (60.4 ± 11.5 years, 27.8% female), 13.4% of nondiabetic subjects and 58.2% of those with known diabetic history (17%) were admitted with glycaemia > 11.1 mmol/L. Failed tissue reperfusion, recognised if high-risk maxSTE criteria were fulfilled, was present among 25% of patients. The overall 180-day mortality rate was 6.8% (n = 22). Admission glycaemia ≥ 8.75 mmol/L appeared as the single risk factor for failed tissue reperfusion (ROC area = 0.638, standard error = 0.038, p < 0.001). Even after adjustment for diabetes history, patients with admission glycaemia ≥ 8.75 mmol/L (44.5%) had 2.36-fold higher risk (95% confidence interval [CI] 1.25-4.46, p = 0.008) of failed tissue reperfusion. After exclusion of patients with known diabetes and those with acute blood glucose level > 11.1 mmol/L (28%), admission glycaemia remained an independent predictor of failed tissue reperfusion (odds ratio [OR] 1.32, 95% CI 1.03-1.69, p = 0.028). Admission glycae-mia and failed tissue reperfusion (high- vs. low-risk maxSTE category) were the independent predictors of 180-day mortality (OR 1.18, 95% CI 1.05-1.32, p = 0.004 and OR 3.84, 95% CI 1.12-13.21, p = 0.033, respectively). Higher admission glycaemia in patients treated with pPCI for STEMI predicts failed myocardial tissue reperfusion and 180-day mortality, independently of prior or acute diabetic status.

Além da recanalização do vaso culpado no infarto com supradesnivelamento do segmento ST

A useful, simple, and inexpensive tool to assess microvas-cular reperfusion is the analysis of ST-segment resolution on the electrocardiogram (ECG) after reperfusion therapy in patients with ST-segment elevation myocardial infarc-tion (STEMI), as recommended by the North American, European, and Brazilian guidelines.

Predictive Value of ST Resolution Analysis Performed Immediately Versus at Ninety Minutes After Primary Percutaneous Coronary Intervention

ST segment resolution (STR) predicts epicardial and microvascular reperfusion after primary percutaneous coronary intervention (PPCI) or thrombolysis for ST-elevation myocardial infarction. Immediate restoration of epicardial coronary flow, with improved microvascular perfusion, is much more likely with PPCI. However, the predictive value of immediate STR compared to 90 minutes after PPCI remains unknown. In 622 consecutive patients with ST-elevation myocardial infarction (mean age 59 +/- 13 years), 217 had complete STR immediately after PPCI (group A), 188 had complete STR only at 90 minutes (group B), and 217 had incomplete STR at either point (group C). The primary end point was mortality and adverse cardiovascular events ([MACE] death, nonfatal repeat myocardial infarction, and heart failure). Group A had a greater left ventricular ejection fraction (53%, 47%, and 46%, p <0.001) and lower all-cause mortality (1.8%, 3.2%, and 6%, p = 0.07), lower heart failure (1.8%, 4.3%, and 7.8%, p <0.001), and MACE (5.1%, 9.6%, and 16.1%, p = 0.001) at 30 days compared to groups B and C, respectively. The rate of MACE at 1 year was 7.6%, 17.1%, and 20.2% in groups A, B, and C, respectively (p <0.001). Immediate STR independently predicted MACE (adjusted hazard ratio 0.36, 95% confidence interval 0.21 to 0.61, p = 0.001, group A vs C), and STR at 90 minutes did not. In conclusion, STR analysis performed immediately after PPCI provided superior differentiation for adverse cardiovascular events compared to STR at 90 minutes. Immediate STR should be the contemporary goal of reperfusion with PPCI.

Prognostic value of ST-segment resolution after rescue percutaneous coronary intervention. Data from the RICO survey

The goal of the present study was to test the impact of ST segment resolution (STR) after rescue percutaneous coronary intervention (PCI) on the short-term prognosis. The prognostic value of STR after rescue PCI for acute ST elevation myocardial infarction (STEMI) remains undetermined. From the French regional database, we analyzed 168 consecutive patients with STEMI and failed lysis, defined by <50 percent STR, who underwent rescue PCI. Patients were classified into two groups according to the degree of STR from the maximal ST-elevation measured on the single worst ECG lead before lysis and after rescue PCI: the without STR group (<50% STR) vs. the with STR group (> or =50%). After rescue PCI, 26 (15%) patients did not have STR and 142 (85%) patients did. No difference was observed between the two groups regarding baseline characteristics, risk factors, and median time delay either from symptom onset to thrombolysis or from failed lysis to rescue PCI. We observed a lower proportion of patients with TIMI 2/3 flow post PCI in the without STR group (respectively 61% vs. 97%, P < 0.001) but an increased use of intra-aortic balloon counterpulsation (34% vs. 8%, P < 0.001) in this group. Thirty-day mortality was markedly higher in the without STR group than in the with STR group (27% vs. 9% respectively, P = 0.025). Moreover, multivariate analysis showed that absence of STR (OR: 5.65; 95% CI: 1.24-25.67), was an independent prognostic factor for mortality. We showed for the first time that analysis of ST-segment resolution may be a simple reliable tool to identify patients at high risk after rescue PCI, and may provide useful information for the elaboration of therapeutic strategies.

Comparison of Different Methods of ST Segment Resolution Analysis for Prediction of 1‐Year Mortality after Primary Angioplasty for Acute Myocardial Infarction

Resolution of ST segment elevation corresponds with myocardial tissue reperfusion and correlates with clinical outcome after ST elevation myocardial infarction. Simpler method evaluating the extent of maximal deviation persisting in a single ECG lead was an even stronger mortality predictor. Our aim was to evaluate and compare prognostic accuracy of different methods of ST segment elevation resolution analysis after primary percutaneous coronary intervention (PCI) in a real-life setting. Paired 12-lead ECGs were analyzed in 324 consecutive and unselected patients treated routinely with primary PCI in a single high-volume center. ST segment resolution was quantified and categorized into complete, partial, or none, upon the (1) sum of multilead ST elevations (sumSTE) and (2) sum of ST elevations plus reciprocal depressions (sumSTE+D); or into the low-, medium-, and high-risk groups by (3) the single-lead extent of maximal postprocedural ST deviation (maxSTE). Complete, partial, and nonresolution groups by sumSTE constituted 39%, 40%, and 21% of patients, respective groups by sumSTE+D comprised 40%, 39%, and 21%. The low-, medium-, and high-risk groups constituted 43%, 32%, and 25%. One-year mortality rates for rising risk groups by sumSTE were 4.7%, 10.2%, and 14.5% (P = 0.049), for sumSTE+D 3.8%, 9.6%, and 17.6% (P = 0.004) and for maxSTE 5.1%, 6.7%, and 18.5% (P = 0.001), respectively. After adjustment for multiple covariates only maxSTE (high vs low-risk, odds ratio [OR] 3.10; 95% confidence interval [CI] 1.11-8.63; P = 0.030) and age (OR 1.07; 95% CI 1.02-1.11; P = 0.002) remained independent predictors of mortality. In unselected population risk stratifications based on the postprocedural ST resolution analysis correlate with 1-year mortality after primary PCI. However, only the single-lead ST deviation analysis allows an independent mortality prediction.

Prognostic significance of residual cumulative ST-segment deviation after mechanical reperfusion in patients with ST-segment elevation myocardial infarction

The analysis of ST-segment resolution is a well established and easy method to assess myocardial perfusion after reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify an easy and practical instrument for patients' prognostic stratification after angioplasty for STEMI by the use of only postprocedural ST-segment analysis. Our population is represented by a total of 1286 patients treated with primary angioplasty for STEMI. Residual ST-segment elevation and deviation were analyzed at 3 hours after revascularization. One-year follow-up data were collected prospectively in all patients. Patients with impaired ST-segment normalization were older, with larger prevalence of diabetes, anterior infarction, hypertension, signs of heart failure at presentation, lower rate of postprocedural thrombolysis in myocardial infarction 3 flow, myocardial blush grades 2 to 3, and successful reperfusion. A linear relationship was found between both residual cumulative ST-segment elevation and deviation with 1-year mortality. At multivariate analysis, postprocedural residual cumulative ST deviation (RR 1.31, 95% CI 1.06-1.63, P = .014), but not residual cumulative ST elevation (RR 0.95, 95% CI 0.55-1.67, P = .87), was an independent predictor of 1-year mortality. Furthermore, we found that residual cumulative ST-segment deviation provides better prognostic information (area receiver operating characteristic [ROC] = 0.733) than ST-segment elevation resolution (area ROC = 0.636) or ST-segment deviation resolution (area ROC = 0.660) in terms of 1-year mortality. These data were confirmed for both anterior and nonanterior infarct location. This study showed that postprocedural residual cumulative ST-segment deviation is an independent prognostic parameter in patients treated with primary angioplasty, providing even better prognostic information than ST-segment resolution.

Impact of Insulin-Requiring diabetes mellitus on effectiveness of reperfusion and outcome of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

The relation between diabetes mellitus (DM) and outcome was assessed in a series of 1,061 patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI). The efficacy of reperfusion was assessed by ST-segment resolution analysis. Of 1,061 patients, 166 had DM (15.6%), and 84 had insulin-requiring DM (51% of DM patients). The 6-month mortality rate was 26% in insulin-requiring DM patients, 7% in non-DM patients, and 4% in non–insulin-requiring DM patients (p <0.001). The early ST-segment resolution rate was lower in insulin-requiring DM patients (52%) compared with the other DM patients (78%) and non-DM patients (76%; p <0.001). Multivariate analysis showed insulin-requiring DM to be independently related to the risk for death (hazard ratio 1.94, 95% confidence interval 1.17 to 3.22, p = 0.009). Insulin-requiring DM is a strong predictor of mortality in patients who undergo PCI for AMI, and this relation may be explained by a less effective myocardial reperfusion despite the mechanical restoration of normal epicardial flow in most patients.

Shifting the open-artery hypothesis downstream: the quest for optimal reperfusion

Successful reperfusion after acute myocardial infarction (MI) has traditionally been considered to be restoration of epicardial patency, but increasing evidence suggests that disordered microvascular function and inadequate myocardial tissue perfusion are often present despite infarct vessel patency. Thus, optimal reperfusion is being redefined to include intact microvascular flow and restored myocardial perfusion, as well as sustained epicardial patency. Coronary angiography has been used as the gold standard to define failed reperfusion, according to the Thrombolysis In Myocardial Infarction (TIMI) flow grades. However, new angiographic techniques, including the corrected TIMI frame count and myocardial blush grade, have been used to show that epicardial TIMI flow grade 3 may be an incomplete measure of reperfusion success. Furthermore, evolving noninvasive diagnostic techniques, including measurement of infarct size with cardiac marker release patterns or technetium-99m–sestamibi single-photon emission computed tomographic imaging and analysis of ST segment resolution appear to be useful complements to angiography for the assessment of myocardial tissue reperfusion. Promising adjunctive therapies that target microvascular dysfunction, including platelet glycoprotein IIb/IIIa inhibitors, and agents designed to improve tissue perfusion and attenuate reperfusion injury are being evaluated to further improve clinical outcomes after acute MI. To accelerate development of these new reperfusion regimens, an integrated approach to phase II clinical trials that incorporates multiple efficacy variables, including angiography and noninvasive biomarkers of microvascular dysfunction, should be considered. Thus, as the reperfusion era moves into the next millennium, the open-artery hypothesis is expected to shift downstream and guide efforts to further improve myocardial salvage and clinical outcomes after acute MI.

Treatment strategies for microvascular dysfunction following acute myocardial infarction.

Successful reperfusion following acute myocardial infarction is considered to be restoration of epicardial infarct vessel patency, but recent studies suggest that disrupted microvascular function and inadequate myocardial tissue perfusion are often present despite epicardial patency. New angiographic techniques, including the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count and myocardial blush grade, have been used to demonstrate that restoration of downstream coronary flow and tissue perfusion may be the key links to improved clinical outcomes. Additionally, other diagnostic techniques, including infarct size measurement with cardiac marker release patterns, or (99m) Tc-sestamibi single photon emission computed tomography imaging, and analysis of ST-segment resolution have also been used to assess microvascular function and tissue perfusion. Promising adjunctive therapies that target microvascular dysfunction, including platelet glycoprotein IIb/IIIa inhibitors, anti-inflammatory agents, vasodilators, glucose-insulin-potassium, and embolization protection devices, may ameliorate microvascular dysfunction following epicardial reperfusion. However, these therapies have not yet been shown to improve clinical outcomes and are thus currently being studied together with fibrinolytics and primary angioplasty in clinical trials. Therefore, shifting the focus of reperfusion therapy to the microcirculation offers the potential to further improve myocardial salvage and clinical outcomes following acute myocardial infarction.

Prognostic implications of TIMI flow grade in the infarct related artery compared with continuous 12-lead ST-segment resolution analysis: Reexamining the “gold standard” for myocardial reperfusion assessment

OBJECTIVETo compare the prognostic significance of reperfusion assessment by Thrombolysis in Myocardial Infarction (TIMI) flow grade in the infarct related artery and ST-segment resolution analysis, by correlating with clinical outcomes in patients with acute myocardial infarction (AMI).BACKGROUNDAngiographic assessment, based on epicardial coronary anatomy, has been considered the “gold standard” for reperfusion. The electrocardiogram (ECG) monitoring provides a noninvasive, real-time physiologic marker of cellular reperfusion and may better predict clinical outcomes.METHODSTwo hundred fifty-eight AMI patients from the Thrombolytics and Myocardia Infarction phase 7 and Global Utilization of Streptokinase tPA for Occluded coronary arteries phase 1 trials were stratified based on blinded, simultaneous reperfusion assessment on the acute angiogram (divided into TIMI grades 0 & 1, TIMI grade 2 and TIMI grade 3) and ST-segment resolution analysis (divided into: <50% ST-segment elevation resolution or reelevation and ≥50% ST-segment elevation resolution). In-hospital mortality, congestive heart failure (CHF) and combined mortality or CHF were compared to determine the prognostic significance of reperfusion assessment by each modality using chi-square and Fisher’s Exact tests for univariable correlation and logistic regression analysis for univariable and multivariable prediction models.RESULTSBy logistic regression analysis, ST-segment resolution patterns were an independent predictor of the combined outcome of mortality or CHF (p = 0.024), whereas TIMI flow grade was not (p = 0.693). Among the patients determined to have failed reperfusion by TIMI flow grade assessment (TIMI flow grade 0 & 1), the ST-segment resolution of ≥50% identified a subgroup with relatively benign outcomes with the incidence of the combined end point of mortality or CHF 17.2% versus 37.2% in those without ST-segment resolution (p = 0.06).CONCLUSIONContinuous 12-lead ECG monitoring can be an inexpensive and reliable modality for monitoring nutritive reperfusion status and to obtain prognostic information in patients with AMI.

Comparative Prognostic Significance of Simultaneous Versus Independent Resolution of ST Segment Depression Relative to ST Segment Elevation During Acute Myocardial Infarction

Objectives. We sought to determine the prognostic significance of simultaneous versus independent resolution of ST segment depression that occurs concomitant with ST segment elevation during acute myocardial infarction (AMI).Background. ST segment depression in leads other than those showing ST segment elevation during AMI is a common phenomenon. Whether this indicates adverse outcomes remains controversial. We hypothesized that the timing of ST segment depression resolution relative to ST segment elevation resolution might differentiate between a high risk group and a low risk group of patients.Methods. Continuous 12-lead ST segment monitoring was performed after thrombolytic therapy for AMI in 413 patients, 261 of whom met technical criteria for analysis. Blinded analysis of ST segment depression resolution patterns was used to group patients as follows: 1) no ST segment depression at any time (control group); 2) ST segment depression resolving simultaneously with ST segment elevation (simultaneous group); and 3) ST segment depression persisting after ST segment elevation resolution (independent group). These patterns were correlated with the outcomes—recurrent angina, reinfarction, heart failure and death—using chi-square analysis and the Fisher exact test for categoric variables and the Wilcoxon rank-sum test for continuous variables.Results. The incidence of recurrent angina, reinfarction and heart failure was similar among the three groups. In-hospital mortality, however, was significantly higher in the independent group (13%) than either the simultaneous group (1%, p < 0.001) or the control group (0%, p = 0.002).Conclusions. Continuous analysis of ST segment resolution identifies, among patients with AMI with concomitantly occurring ST segment elevation and depression, a subgroup with increased in-hospital mortality. The pathogenic mechanism of increased mortality is not currently known.