Sum Of ST-segment Elevation Research Articles

Correlation Between Magnitude of ST Segment Elevation and the Proximal Right Coronary Artery Lesion in Acute Inferior Myocardial Infarction

Introduction: The determination of the probable site of occlusion within RCA in acute inferior MI is very important because proximal occlusions are likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Furthermore, identification of infarct-related artery and its site in acute inferior myocardial infarction not only guide decision regarding the urgency of revascularization but also guide to avoid therapy that may adversely affect the outcome. Objective: To predict the site of lesion in right coronary artery in acute inferior myocardial infarction by the magnitude of ST segment elevation in inferior leads (II, III and aVF). Methodology: This cross-sectional study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, from January 2014 to December 2015. A total of 50 consecutive patients with inferior MI who present within 12 hours of symptom onset and received fibrinolytic therapy were selected according to inclusion and exclusion criteria. Using 12-lead ECG, height of ST segment elevation in leads II, III and aVF were measured & coronary angiography(CAG) was performed during index hospital period .CAG which showed culprit lesion in RCA were only taken for the study. The sum of STsegment elevation in inferior leads were then correlated with the proximal lesion in RCA. Results: The age of the patients ranged from 31 to 70 years with the mean age of 51.1 (SD 9.2) years. Majorities (88%) of the patients were male and ratio of male to female was 7.33:1.Out of 50 patients, 26(52%) had the lesion in proximal, 19 (38%) in mid and 05 (10%) in distal RCA. Patients with proximal RCA lesion showed a mean ST segment elevation of 12.5(SD 1.07) mm, with mid RCA lesion 8.5 (SD 0.80) mm and distal RCA lesion 6.5(SD 0.42) mm. There was a positive correlation of sum of ST segment elevation in inferior leads II, III and aVF to the proximal lesion in RCA (r=0.923, P < 0.05). Conclusion: From the study it is concluded that the magnitude of ST segment elevation in inferior leads (II,III, aVF) can predict site of lesion in RCA in acute inferior wall myocardial infarction; the greater the sum of the height of ST segment elevation in inferior leads, the higher is the probability of lying the lesion in proximal right coronary artery. Bangladesh Heart Journal 2024; 39(1): 44-48

Combining qualitative and quantitative ECG criteria with the ESC 0/1h-hs-cTn-algorithm in the early diagnosis of non-ST-elevation myocardial infarction

Abstract Background The electrocardiogram (ECG) is one of the three main diagnostic tools for the assessment of patients with suspected non-ST-elevation myocardial infarction (NSTEMI). However, it is unknown how established qualitative or novel quantitative ECG criteria can best be combined with high-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms, such as the ESC 0/1h-algorithm, for the early diagnosis of NSTEMI. Methods ST-segment depression, T-wave inversion, and a novel modified ST-segment deviation score (1), defined as the sum of ST-segment elevation in aVR plus absolute, unsigned ST-segment depressions in the remaining leads, were assessed blinded to all clinical data among unselected patients presenting with acute chest discomfort to the emergency department in an international multicentre prospective diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists based on complete cardiac work-up, cardiac imaging and serial hs-cTn. Direct rule-in thresholds for the modified ST-segment deviation score, achieving a positive predictive value (PPV) of >70% justifying early monitorization and management, were derived, validated and compared to ST-segment depression and T-wave inversion and applied 1) alone and 2) in combination with the ESC 0/1h-hs-cTnT/I-algorithms. Results Among 3299 eligible patients, NSTEMI was present in 581 (17.6%) patients. ST-segment depression identified 243/3299 patients (7.4%) with a specificity of 96.5% (95% CI 95.7–97.1) and a PPV of 60.5% (95% CI 54.2–66.4) for the rule-in of NSTEMI, while T-wave inversion had a low PPV (38.0%; 95% CI 33.1–43.1). A modified ST-segment deviation score ≥6mm triaged 108/3299 patients (3.3%) towards direct rule-in upon ED arrival, resulting in a PPV of 71.3% (95% CI 62.1–79.0) and a specificity of 98.9% (95% CI 98.4–99.2), Figure 1. Bootstrap internal validation confirmed the robustness of these findings. Most patients ruled-in by ST-segment depression or a modified ST-segment deviation score ≥6mm would have been also ruled-in by the ESC 0/1h-hs-cTnT/I-algorithm, albeit 1–2h later. Combining ST-segment depression or a modified ST-segment deviation score ≥6mm with the ESC 0/1h-hs-cTnT-algorithm (Figure 2) accelerated the rule-in in those identified already by the ECG-criteria, and resulted in a modest number of reclassifications from rule-out or observe to rule-in. These results were confirmed in a secondary analysis assessing the combination of these ECG signatures with two ESC 0/1h-hs-cTnI-algorithms (Architect and Centaur). Conclusion Combining either ST-segment depression or a modified ST-segment deviation Score ≥6mm with the ESC 0/1h-hs-cTnT/I-algorithms accelerated and improved the early diagnosis of NSTEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss Heart Foundation (SHF) and Swiss National Science Foundation (SNSF)

Predictors Of Left Ventricular Remodelling In Patients With ST-Elevation Myocardial Infarction

Background: Left ventricular (LV) remodelling is still the leading cause of heart failure (HF) and death in patients surviving ST-segment elevation myocardial infarction (STEMI). Despite improvement in treatments of STEMI yet the outcomes did not change and remodelling occur in about 30% of patients after STEMI. Predictors for LV remodelling are still under investigated, early prediction of LV remodelling is a necessity.Aims: We aimed to identify factors that help in early prediction of LV remodelling after STEMI using standard history, examination, laboratory results, echocardiographic study, and angiographic data collection.Patients and Methods: We included 107 patients with 1st acute STEMI treated by primary percutaneous coronary intervention (PCI) or by thrombolysis then PCI within 24 hours. Patients were divided into two groups according to remodelling after six months; defined as ≥20% increase in left ventricular end diastolic volume (LVEDV). Patients were subjected to history taking, cardiac examination, electrocardiography, standard investigations, echocardiography, and angiography with PCI. After 6 months another echocardiography was done.Results: There was statistically significant positive correlation between the study groups regarding; time till target treatment, hsTroponin T, sum of ST segment elevation, number of leads involved (p˂0.001), AST level (p˂0.031), initial LVEDV (p=0.003), initial presence of akinesia, and a negative correlation with myocardial blush grade (p˂0.001), All were independent predictors of remodelling. Conclusions: Time till target treatment, hsTroponin, AST, sum of ST segment elevation, number of leads involved, MBG score, initial LVEDV and initial presence of akinesia are independent predictor of LV remodelling

Diagnostic Performance of Selected Baseline Electrocardiographic Parameters for Prediction of Left Ventricular Remodeling in Patients with ST-Segment Elevation Myocardial Infarction.

Objective: To evaluate the diagnostic performance of selected baseline electrocardiographic (ECG) parameters as predictors of left ventricular remodeling (LVR) in patients with a first ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Methods: The study was performed as a single-center cohort study, with 249 patients (74.7% males) included in the final analysis. Nine baseline ECG parameters were evaluated, with respect to occurrence of LVR 6 months after STEMI (defined as an echocardiography-assessed relative >20% increase in end-diastolic left ventricular volume compared with the value at discharge from hospital). Results: The baseline ECG predictors of LVR, identified in univariate analysis, included the number of leads with ST-segment elevation (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.03–1.38, p = 0.0212), number of leads with Q-waves (OR 1.21, 95% CI 1.07–1.37, p = 0.0033), sum of ST-segment elevation (OR 1.04, 95% CI 1.00–1.08; p = 0.0253) and maximal ST-segment elevation (OR 1.14; 95% CI 1.00–1.29; p = 0.0446). When added to demographic, clinical and angiographic data, the number of leads with ST-segment elevation (OR 1.17, 95% CI 1.01–1.36; p = 0.0413), number of leads with Q-waves (OR 1.15, 95% CI 1.01–1.32; p = 0.0354) and the sum of ST-segment elevation (OR 1.04, 95% CI 1.00–1.08; p = 0.0331) successfully predicted development of LVR in multivariate logistic regression models. However, after inclusion of biochemical data in multivariate models, none of the electrocardiographic parameters, but increasing body weight, TIMI flow after PCI < 3 and higher maximal values of myocardial necrosis biomarker, was independently associated with the occurrence of LVR 6 months after STEMI. Conclusions: Our study demonstrates modest utility of pre-reperfusion ECG for the prediction of LVR occurrence after six months of STEMI.

P4617Early electrocardiographic changes as markers of coronary microvascular obstruction in acute myocardial infarction with ST segment elevation

Abstract Background Coronary microvascular obstruction (CMVO), occurs frequently even after a quickly epicardial revascularization of the infarct-related artery (IRA), and has been associated with an increased risk of adverse cardiovascular events and poor prognosis in patients with ST-segment myocardial infarction (STEMI). After primary coronary intervention (PCI), incomplete ST-segment elevation (STE) resolution in the ECG has been related to CMVO and worse clinical outcome. However, there is lack of information regarding other ECG changes. The aim of this study is to describe the initial ECG changes in STEMI and evaluate their association with CMVO. Methods From January 2007 to December 2017, all patients with the diagnosis of STEMI that underwent urgent coronary angiography were retrospectively included. Clinical, echocardiographic, and electrocardiographic data were taken from medical records. A univariate and multivariate analysis was performed to evaluate the relationship between initial ECG changes (before PCI) and CMVO defined as final TIMI &lt;3 in the IRA. Results 1022 patients were included; the mean age was 67.8 years (±14), 73.7% were male and 14.4% had previous coronary artery disease. The most frequent IRA was the anterior descending artery in 43.2% of the cases and CMVO was found in 18.3% of the patients. The mean value of STE sum (defined as the sum of STE in V1-V6, I and aVL in anterior STEMI and the sum of II, III, aVF, V5 and V6 in non-anterior STEMI), maximum STE in one lead and number of leads with STE was 11.36mm (± 8.2), 3.65mm (± 2.3) and 4.14mm (± 1.4), respectively. After a univariate analysis, STE sum, maximum STE in one lead and number of leads with STE were associated with CMVO, while only STE sum remained significantly associated with the presence of CMVO after a multivariate analysis (Table). The resolution of STE in the first 2 hours after PCI was a protector factor for CMVO. Univariate and Multivariate Analysis Univariate Multivariate Variables OR 95% CI p OR IC 95% p Sum of STE 1.03 1.01–1.04 0.013 1.03 1.01–1.05 0.005 Number of leads with STE 1.13 1.02–1.26 0.021 1.04 0.87–1.23 0.67 Maximum STE 1.09 1.02–1.16 0.016 1.04 0.92–1.17 0.49 Resolution of STE 0.35 0.25–0.49 &lt;0.001 0.36 0.25–1.18 &lt;0.001 STE, ST-segment elevation. Conclusion Initial ECG changes such as STE sum, number of leads with STE and maximum STE in one lead can be used as early predictors of CMVO and poor prognosis. STE resolution in the first 2 hour was associated with a lower incidence of CMVO as reported in previous studies. Acknowledgement/Funding None

Utility of ST score on admission as a marker for outcome in acute myocardial infarction in a resource constrained setting

Introduction: An early and specific indicator is needed to prognosticate acute myocardial infarction (MI). This indicator should be simple, quick, reliable, non-invasive, inexpensive, and easily applicable to all the patients especially in a resource-constrained setting. The present study tried to evaluated efficacy of ST score on electrocardiography as a prognostic indicator in acute ST-elevated MI (STEMI). Materials and Methods: A prospective study was conducted on consecutive thrombolysed patients of STEMI admitted in teaching hospital. ST score defined as sum of ST-segment elevation in all leads related to infarct location was calculated in standard 12-lead electrocardiographic tracings immediately on admission and then serially postthrombolysis at 90 min, 6 h, 24 h, and day 3 and 5 of admission. Primary end-point was all-cause mortality at 30 days. Results: The mean ST score between survivor and nonsurvivor was 19.27 mm and 16.16 mm, respectively. The score on admission in patients who had poor outcome was significantly higher than those who had good outcome (poor = 20.27 mm vs. good outcome = 12.47 mm; P = 0.002). This difference persisted throughout but was maximum at 90-min postthrombolysis (13.82 mm vs. 7.39 mm; P = 0.0001). The optimal cutoff point maximizing sensitivity and specificity was found at 11 mm for both anterior- and inferior wall MI (IWMI) with a sensitivity of 73% and specificity of 58%. Conclusion: This study concludes that an increase of 1 mm in ST score increased the odds of complications by 1.06 (95% confidence interval [CI], 1.01–1.2) for anterior-wall MI and by 1.09 (95% CI, 0.96–1.2) for IWMI. In a resource-constrained health facility where electrocardiography may be the only available equipment, ST score can easily and effectively be used to stratify patients into high-risk and low-risk categories.

Clinical Markers of Reperfusion in Patients with Acute Myocardial Infarction and Its Prognostic Significance

Abstract Introduction: Coronary artery disease (CAD) is a major cause of mortality worldwide. Thrombolysis in the treatment of acute myocardial infarction (AMI) is a landmark event in the management as it has changed the outcomes. Clinical signs after thrombolysis in AMI may have a better correlation with functional reperfusion than the isolated image of angiographic patency. Aims and objectives: To study successful clinical reperfusion (SCR) noninvasively using clinical markers of reperfusion. To evaluate the prognostic value of clinical markers of reperfusion in predicting early (30 days) prognosis after thrombolysis in AMI. To observe the effect of age, location of MI, presence of previous infarction, Killip's class at admission, and presence of clinical reperfusion assessed noninvasively on early (30 days) prognosis after AMI. Materials and methods: All the patients were thrombolyzed (using streptokinase). Successful clinical reperfusion was defined by the presence of at least two of the following criteria at 2 hours of starting treatment: (1) Significant relief of pain (50% or more), (2) 50% or more reduction in sum of ST segment elevation, (3) abrupt initial rise of creatine kinase MB (CK-MB) level, more than two-fold over upper normal or baseline values. Results: Duration of symptoms (min) mean ± SD was nearly the same in two groups (94.80 ± 13.68 vs 96.19 ± 17) but early thrombolysis resulted in better outcome (0.01 S, p &lt; 0.05). killips class at admission (KAD) &gt; OR = 2, n (%) led to worsened fate of thrombolysis. Death n (%) occurred in 7 (8.75%) patients with 1 (1.25%) from SCR (+) group and 6 (7.5%) from SCR (–) group (0.01 S, p &lt; 0.05). Conclusion: It is concluded that Killip's class at admission of more than or equal to two and absence of SCR are the predictors of mortality after thrombolysis. Absence of SCR defines a group of patients with poorer prognosis after thrombolysis and in such patients alternative strategies of reperfusion should be considered.

The Importance of Magnesium Values in Patients With STEMI Admitted to the Emergency Department.

The aim of this study is to examine the relationship between initial magnesium (Mg) levels, electrocardiographic no-reflow, and long-term mortality in patients who underwent primary percutaneous coronary intervention (pPCI) due to ST-segment elevation myocardial infarction (STEMI). A total of 111 patients with pPCI participated in the study. Magnesium and high-sensitive C-reactive protein (hs-CRP) were measured. The sum of ST-segment elevation was measured immediately before and 60 minutes after the restoration of coronary flow. The difference between the 2 measurements was taken as the amount of ST-segment resolution and defined as sum of ST-segment resolution (∑STR). The ∑STR <50% was determined as electrocardiographic sign of no-reflow phenomenon. After the patients were discharged, they were followed up for major adverse cardiac events for up to 51 months after discharge. Forty patients in the no-reflow group and 71 patients in the normal-flow group were included in the study. Magnesium value ≤1.87 mg/dL initially measured had 77% sensitivity and 59% specificity in predicting no-reflow on receiver operating characteristic curve analysis. In multivariate analyses, Mg (odds ratio [OR]: 0.01, <95% confidence interval [CI]: 0.01-0.12; P = .004), hs-CRP (OR: 1.06, <95% CI: 1.00-1.14; P = .05), left anterior descending artery lesion (OR: 6.66, <95% CI: 1.45-3.05; P = .01), and reperfusion time (OR: 1.01, <95% CI: 1.00-1.01; P = .03) were still independent predictors of electrocardiographic no-reflow, and only Mg (OR: 0.08, <95% CI: 0.01-1.03; P = .05) was still an independent predictor of long-term mortality. Serum Mg level is an independent predictor of electrocardiographic no-reflow and long-term mortality in patients with STEMI.

SYNTAX score II as a predictor of incomplete ST-segment resolution in patients with acute myocardial infarction treated with primary percutaneous intervention

Background Incomplete ST-segment resolution (STR) is a marker of impaired myocardial perfusion and adverse clinical outcome after primary percutaneous coronary intervention (PPCI). Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery score II (SS-II) has been developed combining anatomical and clinical variables. The aim of the present study was to evaluate the SS-II as a predictor of incomplete STR in patients with ST-segment elevation myocardial infarction (STEMI) treated with PPCI. Patients and methods The present study prospectively included 100 patients with STEMI treated with PPCI. SS-II was determined in all patients. The sum of ST-segment elevation was measured from standard 12-lead ECG obtained on admission and from a second ECG recorded 60 min after PPCI. STR resolution was defined as either complete (≥50%) or incomplete ( Results Patients in the negative STR group were older, had higher prevalence of peripheral vascular disease, lower creatinine clearance (CrCl), higher peak troponin, lower ejection fraction and a higher SS-II (P value = Conclusion SS-II is an independent predictor of incomplete STR in patients with STEMI treated with PPCI.

PREDICTORS OF DEPRESSED LEFT VENTRICULAR FUNCTION IN PATIENTS PRESENTING WITH ST-ELEVATION MYOCARDIAL INFARCTION

Background: Left ventricular dysfunction after ST segment elevation myocardial infarction (STEMI) is the most important factor affecting morbidity and mortality. The primary objective of reperfusion therapy is to restore epicardial flow and to reperfuse the myocardial tissue. However, in some cases lack of microvascular reperfusion and, consequently, significant left ventricular (LV) dysfunction persist despite the rapid and sustained restoration of blood flow. Early in the course of STEMI, therapies that may harm patients who develop LV dysfunction, such as beta-blockers, are often administered. Aim of the work: construct a predictive score of the risk of developing left ventricular dysfunction in patients with STEMI. Patient and methods: This study was done in Cardiology department, Zagazig University on 100 patients; 78 males (78%) & 22 females (22%) with first acute STEMI underwent successful primary percutaneous intervention (pPCI). Within 72 hours of admission, all of the following parameters were reported: risk factors, blood pressure, heart rate, KILLIP class, need for mechanical ventilation (MV), cardiac enzymes, admission blood sugar, kidney function, lipid profile, electrocardiographic data (ST elevation in millimeters (mm), location of infarction, ST resolution, QRS width in milliseconds (ms), Selvester score), echocardiography (ejection fraction by Simpson's method, wall motion score index) and angiographic data (culprit artery, Total number of diseased vessels, severity of coronary artery disease, Gensini score and door to balloon time). Results: LV dysfunction was associated with decreased renal function (creatinine >1.1 mg/dl, p= 0.029), number of diseased vessels >2 (p=0.034), absence of complete ST segment resolution (p 2.05 (p=0.008), sum of ST segment elevation >13.5 mm (p 98.5 ms (p 3.5 (p 95 (p 1 (p=0.003). A prediction score using these variables stratified patients into low, intermediate and high-risk groups for LV dysfunction; positive likelihood ratios for LV dysfunction in these groups were 2.9, 2.1, and 2.4, respectively. Conclusions: 10 key predictors of in-hospital LV dysfunction after STEMI were identified; a risk score based on these predictors helps to quickly identify patients presenting with STEMI who are at the highest risk for developing significant LV dysfunction and could guide optimal therapeutic choices. Key words: ST-elevation myocardial infarction, left ventricular dysfunction, predictors, score, primary angioplasty.

TIMI Myocardial Perfusion Grade and ST-segment resolution in the assessment of coronary reperfusion after primary angioplasty

Angiographic coronary flow parameters and resolution of ST segment changes play an important role in the evaluation of reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). In previous studies on the relation between angiographic and electrocardiographic (ECG) parameters of coronary reperfusion, several alternative methods to assess ST segment resolution were used. Thus, the relation between the TIMI Myocardial Perfusion Grade (TMPG) and different methods to evaluate ST segment resolution seems to be of interest. To evaluate the relationship between TMPG and absolute and relative ST segment resolution after successful primary percutaneous coronary intervention (pPCI). We studied a population of STEMI patients successfully treated with pPCI. Reperfusion of the coronary microcirculation was determined using 4-grade TMPG scale in coronary angiography performed after successful pPCI. ST segment resolution was analysed in two manners: 1) by calculating the sum of ST segment elevation in infarct leads and depression in reciprocal leads after pPCI (absolute resolution, SSTD); 2) as a percent reduction of summed ST segment deviation from the baseline value (relative resolution, SSTD%). Maximum ST segment elevation in a single lead on the postprocedural ECG was measured to categorise the risk of death. ST segment elevation > 1 mm for an inferior infarct or > 2 mm for an anterior infarct was considered the criterion of high risk (high risk ECG). The study population included 183 patients treated with pPCI. We found a significant but weak negative correlation between TMPG and SSTD (r = -0.27, p = 0.0002). Significant differences in median SSTD were observed between TMPG 0 vs. TMPG 2 and TMPG 3 groups (p = 0.0034 and 0.0121, respectively) and also between TMPG 1 and TMPG 2 (p = 0.02). A significant but very weak positive correlation was found between TMPG and SSTD% (r = 0.16,p = 0.0286). However, further analyses showed that differences in median SSTD% between patients with different TMPG values were statistically insignificant (p = 0.1756). In patients with TMPG 2/3, a high risk ECG was absent considerably more often (p = 0.0007). However, angiographic features of successfully vs. unsuccessfully reperfused microcirculation did not correspond to the presence of a high risk ECG in about 34% of cases. TMPG is more closely related to absolute compared to relative ST segment resolution. A high risk ECG was absent in most patients with TMPG 2 or 3. However, in about one third of cases TMPG did not correspond to the presence of ECG high risk features. These data suggest that TMPG is complementary to ST segment resolution in the assessment of coronary reperfusion.

Correlation of Severity of ST Segment Elevation with Respect to the Site of Right Coronary Artery Lesion

Electrocardiogram a widely available tool may predict infarct related artery in acute inferior wall myocardial infarction. Severity of ST segment elevation may correlate with proximity of lesion in right coronary artery. Patient with acute ST segment elevation inferior wall myocardial infarction who underwent coronary angiogram was studied. Differences in electrocardiogram among right coronary and left circumflex groups were evaluated. Severity of ST segments elevation in relation to site of lesion in right coronary was studied. The mean age of presentation was 59.52 ± 11.01 years. Total 36 (72%) were men. A total of 42 (84%) had lesion in right and 8 (16%) in left circumflex. Age, sex,diabetes,hypertension, smoking, dyslipidemia and physical activity showed no correlation with lesion in right or circumflex coronary artery. ST segment elevation in III>II (P=0.01), ST segment depression in AVL> I (P<0.01) and ST elevation in V4R (P=0.04), correlated with right coronary lesion. Sum of ST elevation in inferior leads were 10.90 ±1.30 mm for proximal, 7.38±1.19 mm for mid and 5.50± 0.53 mm for distal right coronary with significant correlation (P<0.01). Electrocardiogram was reliable tool to difference right and left circumflex lesion. Severity of sum of ST segment elevations in inferior leads correlated with the proximity of lesion in right coronary.

Clinical evidence of exaggerated inflammation in patients with a cardiogenic shock complicating ST-segment elevation myocardial infarction

We characterized the degree of systemic and coronary inflammation and the impact of those on clinical state in patients with a cardiogenic shock complicating first anterior ST-segment elevation myocardial infarction (STEMI). Methods: We recruited 14 consecutive patients with cardiogenic shock (10 men, 69 ± 12 years) and 18 well-matched baseline characteristics without shock (17 men, 64 ± 9 years) undergoing percutaneous coronary intervention (PCI) for an early phase of a first anterior STEMI in whom plasma level of cardiac enzyme was less elevated. We measured systemic and coronary levels of C-reactive protein, interleukin-6, and angiotensin II, and evaluated the relation of those to myocardial tissue-level reperfusion using both angiographic myocardial blush grade from 0 to 3, with the highest grade indicating normal myocardial perfusion, and a resolution of the sum of ST-segment elevation in 12-lead electrocardiogram. Results: In-hospital mortality was 57% in patients with cardiogenic shock and 6% without shock (p = 0.005). Coronary levels of C-reactive protein (9.2 ± 6.9 vs. 1.7 ± 2.1 mg/L, p = 0.001), interleukin-6 (379 ± 137 vs. 24 ± 20 pg/mL, p = 0.003), and angiotensin II (19 ± 10 vs. 10 ± 6 pg/mL, p = 0.010) were extremely higher in patients with shock than without shock. Interleukin-6 and angiotensin II, but not C-reactive protein, revealed higher in coronary levels than in systemic levels. The presence of both myocardial blush grade el reperfusion (p = 0.012). Conclusions: The exaggerated systemic and coronary inflammation, presumably associated with myocardial mal-reperfusion, was presented in patients with a cardiogenic shock complicating first anterior STEMI.

Infarct‐like Acute Myocarditis: Relation Between Electrocardiographic Findings and Myocardial Damage as Assessed by Cardiac Magnetic Resonance Imaging

Acute myocarditis (AM) may occasionally have an infarct-like presentation. The aim of the present study was to investigate the relation between electrocardiographic (ECG) findings in this group of patients and myocardial damage assessed by cardiac magnetic resonance imaging (MRI) with the late gadolinium enhancement (LGE) technique. Myocardial damage may be associated with ECG changes in infarct-like AM. Forty-one consecutive patients (36 males; mean age, 36 ± 12 years) with diagnosis of AM according to cardiac MRI Lake Louise criteria and infarct-like presentation were included. The relation between site of ST-segment elevation (STE), sum of STE (sumSTE), time to normalization of STE, and development of negative T wave with the extent of LGE (expressed as % of left ventricular mass [%LV LGE]), was evaluated. Most (80%) patients presented with inferolateral STE; mean sumSTE was 5 ± 3 mm. Normalization of STE occurred within 24 hours in 20 (49%) patients. Development of negative T wave occurred in 28 (68%) patients. Cardiac MRI showed LGE in all patients; mean %LV LGE was 9.6 ± 7.2%. Topographic agreement between site of STE and LGE was 68%. At multivariate analysis, sumSTE (β = 0.42, P < 0.001), normalization of STE >24 hours (β = 0.39, P < 0.001), and development of negative T wave (β = 0.49, P < 0.001) were independently related to %LV LGE. Analysis of the site of STE underestimates the extent of myocardial injury among patients with infarct-like myocarditis. However, some ECG features (ie, sumSTE, normalization of STE >24 hours, and development of negative T wave) may help to identify patients with larger areas of myocardial damage.

The impact of admission red cell distribution width on the development of poor myocardial perfusion after primary percutaneous intervention

BackgroundThe purpose of this study was to evaluate the predictive value of red cell distribution width (RDW) on the electrocardiographic no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI). MethodsOne-hundred consecutive patients (mean age 61.3 ± 12.8 years and male 77%) with ST-elevation myocardial infarction, who were treated with primary PCI, were analyzed prospectively. RDW and high sensitive C reactive protein (hs-CRP) were measured. The sum of ST-segment elevation was obtained immediately before and 60 min after the restoration of coronary flow. The difference between two measurements was accepted as the amount of ST-segment resolution and was expressed as ∑STR. ∑STR < 50% was accepted as electrocardiographic sign of no-reflow phenomenon. ResultsThere were 30 patients in the no-reflow group (Group 1) and 70 patients in the normal re-flow group (Group 2). RDW and hs-CRP levels on admission were higher in Group 1. An RDW level ≥14% measured on admission had 70% sensitivity and 64% specificity in predicting no-reflow on ROC curve analysis. Mid-term cardiovascular events were significantly higher in Group 1. In multivariate analyses, RDW (OR 2.93, <95% CI 1.42–6.04; p = 0.004), and tirofiban (OR 0.16, <95% CI 0.05–0.48; p = 0.001) were independent predictors of no-reflow, and RDW (OR 5.89, <95% CI 1.63–21.24; p = 0.007), and creatine kinase-MB (CK-MB) on admission (OR 1.01, <95% CI 1.00–1.02; p = 0.006) were independent predictors of mid-term mortality. ConclusionsA greater baseline RDW value was independently associated with the presence of electrocardiographic no-reflow.

Prediction of enzymatic infarct size in ST-segment elevation myocardial infarction

Predictors of adverse outcomes following myocardial infarction (MI) are well established; however, little is known about what predicts enzymatically estimated infarct size in patients with acute ST-elevation MI. The Complement And Reduction of INfarct size after Angioplasty or Lytics trials of pexelizumab used creatine kinase (CK)-MB area under the curve to determine infarct size in patients treated with primary percutaneous coronary intervention (PCI) or fibrinolysis. Prediction of infarct size was carried out by measuring CK-MB area under the curve in patients with ST-segment elevation MI treated with reperfusion therapy from January 2000 to April 2002. Infarct size was calculated in 1622 patients (PCI=817; fibrinolysis=805). Logistic regression was used to examine the relationship between baseline demographics, total ST-segment elevation, index angiographic findings (PCI group), and binary outcome of CK-MB area under the curve greater than 3000 ng/ml. Large infarcts occurred in 63% (515) of the PCI group and 69% (554) of the fibrinolysis group. Independent predictors of large infarcts differed depending on mode of reperfusion. In PCI, male sex, no prior coronary revascularization and diabetes, decreased systolic blood pressure, sum of ST-segment elevation, total (angiographic) occlusion, and nonright coronary artery culprit artery were independent predictors of larger infarcts (C index=0.73). In fibrinolysis, younger age, decreased heart rate, white race, no history of arrhythmia, increased time to fibrinolytic therapy in patients treated up to 2 h after symptom onset, and sum of ST-segment elevation were independently associated with a larger infarct size (C index=0.68). Clinical and patient data can be used to predict larger infarcts on the basis of CK-MB quantification. These models may be helpful in designing future trials and in guiding the use of novel pharmacotherapies aimed at limiting infarct size in clinical practice.

Predictors of cardiovascular magnetic resonance-derived microvascular obstruction on patient admission in STEMI

BackgroundEarly stratification of patients according to the risk for developing microvascular obstruction (MVO) after ST-segment elevation myocardial infarction (STEMI) is desirable. We aimed to identify predictors of cardiovascular magnetic resonance (CMR)-derived MVO from clinical+ECG, laboratory and angiographic parameters available on admission. MethodsCharacteristics available on admission were documented in 97 STEMI patients referred for primary angioplasty. MVO was determined using contrast-enhanced CMR. ResultsMVO was present in 44 patients (45%). The C-statistic for predicting MVO was: clinical+ECG (.832), laboratory (.743), and angiographic parameters (.669). Adding laboratory to clinical+ECG information did not improve the C-statistic (.873 vs. .832, p=.2). Further addition of angiographic data (.904) improved the C-statistic of clinical+ECG (p=.04) but not of clinical+ECG and laboratory (p=.2). Independent predictors of MVO using clinical and ECG parameters were: Killip class >1 (OR 15.97 95%CI [1.37–186.76], p=.03), diabetes (OR 6.15 95%CI [1.49–25.39], p=.01), age <55years (OR 4.70 95%CI [1.56–14.17], p=.006), sum of ST-segment elevation >10mm (OR 4.5 95%CI [1.58–12.69], p=.005) and delayed presentation >3h (OR 3.80 95%CI [1.19–12.1], p=.02). A score was constructed assigning Killip class >1 2 points and the remaining indexes 1 point. The incidence of MVO increased with the score: 0 point: 8.7%; 1 point: 28.1%; 2 points: 71.4%; and 3+ points: 93% (p<.0001). ConclusionsMVO can be predicted using parameters already available on patient admission. We developed a clinical-ECG score allowing for early and reliable classification of STEMI patients according to the risk of MVO.

Clinical Features of Early Myocardial Rupture of Acute Myocardial Infarction

We assessed the clinical features of patients with myocardial rupture within 48 to 72 hours, defined as early myocardial rupture, after percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI). Six patients (4 men, 66 ± 13 years) with early myocardial rupture were identified from 1252 consecutive patients undergoing PCI for STEMI. We evaluated the degree of microvascular reperfusion using thrombolysis in myocardial infarction (TIMI) myocardial perfusion (TMP) grade and a resolution of sum of ST-segment elevation in a 12-lead electrocardiogram (ECG). Time from PCI to myocardial rupture was 11 ± 7 hours. All patients showed TMP grade 0 or 1 and an increase in sum of ST-segment elevation after PCI (1.9 ± 0.5 vs 2.5 ± 0.7 mV; P = .032), suggesting severely failed reperfusion at the level of microcirculation as the common feature to develop early myocardial rupture after PCI for STEMI.

Comparison of Electrocardiographic Findings Between the Midventricular Ballooning Form and Apical Ballooning Form of Takotsubo Cardiomyopathy

Several reports have recently described the variant form of takotsubo cardiomyopathy exhibiting midventricular ballooning. The purpose of this study was to assess electrocardiographic (ECG) findings on admission in patients with midventricular ballooning. ECG findings are different between the midventricular ballooning form and apical ballooning form of takotsubo cardiomyopathy. We reviewed ECGs on admission in 6 patients with midventricular ballooning and 20 patients with apical ballooning. The sum of ST segment elevation in leads V1 to V3 or in leads V4 to V6 was obtained. The number of leads showing ST segment elevation and/or T wave inversion was also obtained. These ECG findings were compared between the 2 groups. In midventricular ballooning, ECG changes including ST segment elevation and/or T wave inversion were observed frequently in leads V2 and V3, and were not observed in leads II, III, -aVR, aVF, V5, and V6. On the other hand, in apical ballooning, they were found in all leads. They were most common in leads V4 and V5. The sum of ST segment elevation in leads V1 to V3 was similar (2.6 ± 2.0 mm vs 2.7 ± 2.0 mm, P = not significant), and the sum of ST segment elevation in leads V4 to V6 was significantly lower in midventricular ballooning than apical ballooning (0.4 ± 0.8 mm vs 3.5 ± 3.0 mm, P<0.05). The number of leads showing ST segment elevation and/or T wave inversion was significantly lower in midventricular ballooning than apical ballooning (3.2 ± 1.0 leads vs 6.3 ± 2.2 leads, P<0.01). Our data suggested that midventricular ballooning may show limited ECG changes despite broad wall motion abnormality.

Efficacy and safety of tirofiban treatment combined with percutaneous coronary intervention in the elderly with acute ST segment elevation myocardial infarction

Objective To analyze the efficacy and safety of tirofiban treatment combined with percutaneous coronary intervention (PCI) in the elderly with acute ST segment elevation myocardial infarction prospectively. Methods From May 2008 to May 2010, 106 patients who presented with acute STEMI within 12 hours from onset and received successful primary PCI were enrolled into the study. All patients had angiographic evidence of initial total occlusion of infarct-related artery and finally restored toTIMI3 flow after PCI. All patients were divided into tirofiban group (n = 54) and control group (n = 52) according to whether tirofiban was used or not. Assessment of myocardial perfusion included Myocardial Blush Grades (MBG), and the resolution of the sum of ST-segment elevation (sumSTR) at 90 minutes after the procedure. Left ventricular ejection fraction (EF) was measured one week later. Major adverse cardiac events in hospital and bleeding complications were also assessed. Results Baseline clinical and angiographic characteristics of the two groups were similar. Significant higher rates of MBG 3 were observed in the tirofiban group (88. 9% vs57. 7%, P ＜ 0.05). Patients received tirofiban were more likely to achieve higher sumSTR (70. 3% vs 42. 3%, P ＜0. 05). Ejection fraction was also markedly increased in tirofiban group than control group (56. 2 ± 7.6 vs 46. 7 ± 8. 5, P ＜ 0. 05). In-hospital major adverse cardiac events, it was not different between the two groups(P ＞0. 05). There were slightly more minor bleeding complications in tirofiban group compared with control(11.1% vs 6. 0%, P ＞0. 05). No patient had major bleeding or thrombocytopenia.Conclusions Tirofiban can further ameliorate microvascular perfusion and it is safe and feasible for patients with STEMI undergoing primary PCI. Key words: Angioplasty, transluminal, percutaneous coronary; Platelet membrane glycoproteins/AL/AD; Tyrosine/AA/AD; Myocardial infarction/TH