Wall ST-segment Elevation Myocardial Infarction Research Articles

Deep learning from atrioventricular plane displacement in patients with Takotsubo syndrome: lighting up the black-box.

The spatiotemporal deep convolutional neural network (DCNN) helps reduce echocardiographic readers' erroneous 'judgement calls' on Takotsubo syndrome (TTS). The aim of this study was to improve the interpretability of the spatiotemporal DCNN to discover latent imaging features associated with causative TTS pathophysiology. We applied gradient-weighted class activation mapping analysis to visualize an established spatiotemporal DCNN based on the echocardiographic videos to differentiate TTS (150 patients) from anterior wall ST-segment elevation myocardial infarction (STEMI, 150 patients). Forty-eight human expert readers interpreted the same echocardiographic videos and prioritized the regions of interest on myocardium for the differentiation. Based on visualization results, we completed optical flow measurement, myocardial strain, and Doppler/tissue Doppler echocardiography studies to investigate regional myocardial temporal dynamics and diastology. While human readers' visualization predominantly focused on the apex of the heart in TTS patients, the DCNN temporal arm's saliency visualization was attentive on the base of the heart, particularly at the atrioventricular (AV) plane. Compared with STEMI patients, TTS patients consistently showed weaker peak longitudinal displacement (in pixels) in the basal inferoseptal (systolic: 2.15 ± 1.41 vs. 3.10 ± 1.66, P < 0.001; diastolic: 2.36 ± 1.71 vs. 2.97 ± 1.69, P = 0.004) and basal anterolateral (systolic: 2.70 ± 1.96 vs. 3.44 ± 2.13, P = 0.003; diastolic: 2.73 ± 1.70 vs. 3.45 ± 2.20, P = 0.002) segments, and worse longitudinal myocardial strain in the basal inferoseptal (-8.5 ± 3.8% vs. -9.9 ± 4.1%, P = 0.013) and basal anterolateral (-8.6 ± 4.2% vs. -10.4 ± 4.1%, P = 0.006) segments. Meanwhile, TTS patients showed worse diastolic mechanics than STEMI patients (E'/septal: 5.1 ± 1.2 cm/s vs. 6.3 ± 1.5 cm/s, P < 0.001; S'/septal: 5.8 ± 1.3 cm/s vs. 6.8 ± 1.4 cm/s, P < 0.001; E'/lateral: 6.0 ± 1.4 cm/s vs. 7.9 ± 1.6 cm/s, P < 0.001; S'/lateral: 6.3 ± 1.4 cm/s vs. 7.3 ± 1.5 cm/s, P < 0.001; E/E': 15.5 ± 5.6 vs. 12.5 ± 3.5, P < 0.001). The spatiotemporal DCNN saliency visualization helps identify the pattern of myocardial temporal dynamics and navigates the quantification of regional myocardial mechanics. Reduced AV plane displacement in TTS patients likely correlates with impaired diastolic mechanics.

Pulse pressure and inferior wall ST-segment elevation myocardial infarction: investigating mortality, hospital major cardiovascular events, and long-term prognosis.

Inferior Wall ST-Segment Elevation Myocardial Infarction (INF STEMI) is a severe condition with high mortality. Rapid treatment with Primary Percutaneous Coronary Intervention (PPCI) is preferred. Pulse Pressure (PP) is a known risk factor for both cardiovascular disease and may be a valuable predictor of outcomes in these patients. The study aims to evaluate the relationship between PP and long-term prognosis, mortality, and major cardiovascular events after inferior STEMI in cases who underwent PPCI. This cross-sectional study included subjects with a confirmed diagnosis of inferior STEMI who underwent PPCI. Patient data were gathered from hospital records and analyzed for the relationship between PP and MACE during hospitalization and one-year follow-up. Statistical analysis was performed using SPSS. This cross-sectional study of 320 cases found that DM, DBP, and Cr patients had a higher incidence of MACEs (P-value #x003C;0.05). Subjects with higher LVEF and SBP had fewer MACEs (P-value #x003C;0.05). Cases with a PP of ≤50 had a higher mortality and heart failure incidence during hospitalization than those with a PP >50 (P-value #x003C;0.05). However, the two groups had no significant difference in one-year MACE rates. The study found that increasing DBP, Cr, and DM and decreasing LVEF and SBP impacted MACE incidence. PP ≤50 had more heart failure incidence and mortality during hospitalization in patients with inferior STEMI.

Echocardiographic and Angiographic Assessment of Right Ventricular Function and Right Coronary Artery Stenosis in Acute Inferior Wall Myocardial Infarction.

Cardiovascular diseases (CVDs) are a global concern. CVD remains a primary cause of death despite reduced coronary heart disease death rates. Acute coronary syndrome (ACS) involves myocardial infarction (MI) and unstable angina, sharing mechanisms such as plaque instability. Our study assesses the right ventricular (RV) function's predictive value in acute inferior wall MI (IWMI) to identify high-risk patients with an elevated likelihood of experiencing severe cardiac complications, hemodynamic instability, or a higher mortality risk following an acute IWMI. The research was conductedin the Department of Cardiology at theRajendra Institute of Medical Sciences (RIMS), Ranchi, from July 2021 to June 2022, following the necessary ethical approval. A cohort of 140 patients with IWMI, carefully chosen according to rigorous criteria, clearly understood the study's objectives before providing informed consent. The evaluations were conducted in the following order: clinical assessments, followed by blood testing, then echocardiography, and finally, coronary angiography. Furthermore, the study examined risk factors and utilized statistical methods to elucidate the associations between qualities and results. The study included 140 participants, with 61% being male and 39% female. Among the participants, 14% were aged 30-45, 50% were aged 46-60, and 30% were over 60. Age shows significant proportions in different categories. Diabetes, dyslipidemia, hypertension, and smoking/tobacco addiction did not differ among stenosis groups. Proximal right coronary artery (RCA) stenosis patients had elevated jugular venous pressure (JVP). The echocardiograms were performed within 48 hours of post-percutaneous coronary intervention, and significant differences between groups were observed. Participants with proximal stenosis had lower tricuspid annular plane systolic excursion (TAPSE) and right ventricular fractional area change (RVFAC), which showedcompromised RV systolic function. Proximal stenosis patients had reduced systolic motion velocity (Sm), indicating impaired myocardial contraction. Echocardiographic parameters such as early diastolic velocity (Em), atrial contraction velocity (Am), Em/Am ratio (a marker of diastolic function), isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET) between groups were different, indicating distinct cardiac functions. Proximal stenosis increased the myocardial performance index (MPI), indicating cardiac impairment. The left ventricular ejection fraction (LVEF) was comparable in the two stenosis groups, indicating similar left ventricular performance. Echocardiography showed significant RV function differences in acute inferior wall ST-segment elevation myocardial infarction (STEMI) patients with proximal and distal RCA lesions. RV dysfunction is linked to right ventricle myocardial infarction (RVMI), and echocardiographic markers can provide valuable insights. Results emphasizethat acute inferior wall STEMI is diagnosed by electrocardiogram (ECG) criteria, particularly ST-segment elevation. However, these markers emphasize the importance of RV assessment in RCA involvement assessment. These findings suggest that RV function can help diagnose acute inferior wall STEMI RCA involvement. In acute inferior STEMIs, RV function echocardiography is essential for RCA lesion location.

Influencing factors and prognostic value of left ventricular systolic dysfunction in patients with complete occlusion of the left anterior descending artery reperfused by primary percutaneous coronary intervention

BackgroundThe aim of this study was to perform a retrospective analysis of patients with acute anterior wall ST-segment elevation myocardial infarction (AAW-STEMI) whose left anterior descending (LAD) artery was completely occluded and reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influencing factors and prognostic value of left ventricular systolic dysfunction (LVSD) in the acute phase of acute myocardial infarction (AMI).MethodsA total of 304 patients with AAW-STEMI were selected. The selected patients were divided into two groups: the preserved left ventricular ejection fraction (pLVEF) group (LVEF ≥ 50%, n = 185) and the reduced left ventricular ejection fraction (rLVEF) group (LVEF < 50%, n = 119). The influencing factors of LVSD and their predictive value for LVSD were analyzed. Patients were followed up by examining outpatient records and via telephone. The predictive value of LVSD for the cardiovascular mortality of patients with AAW-STEMI was analyzed.ResultsAge, heart rate (HR) at admission, number of ST-segment elevation leads (STELs), peak creatine kinase (CK) and symptom to wire-crossing (STW) time were independent risk factors for LVSD (P < 0.05). The receiver operating characteristic (ROC) analysis showed that the peak CK had the strongest predictive value for LVSD, with an area under the curve (AUC) of 0.742 (CI, 0.687 to 0.797) as the outcome. At a median follow-up of 47 months (interquartile range, 27 to 64 months), the Kaplan‒Meier survival curves up to 6-year follow-up revealed a total of 8 patients succumbed to cardiovascular disease, with 7 (6.54%) in the rLVEF group and 1 (0.56%) in the pLVEF group, respectively (hazard ratio: 12.11, [P = 0.02]). Univariate and multivariate Cox proportional hazards regression analysis demonstrated that rLVEF was an independent risk predictor of cardiovascular death in patients with AAW-STEMI discharged after PPCI (P < 0.01).ConclusionsAge, HR at admission, number of STELs, peak CK, and STW time may be used to identify patients with a high risk of heart failure (HF) in a timely manner and initiate early standard therapy for incident LVSD in the acute phase of AAW-STEMI reperfused by PPCI. A trend toward increased cardiovascular mortality at follow-up was significantly linked to LVSD.

The Diagnostic Accuracy of Electrocardiogram in Differentiating Takotsubo Cardiomyopathy in Patients Presenting as Anterior Wall St-Segment Elevation Myocardial Infarction and Taking Coronary Angiography as Gold Standard

Myocardial infarction: Myocardial infarction is the irreparable damage to heart muscles resulting in necrosis &amp; is the leading cause of death; resulting in 500,000-700,000 important deaths related to the coronary artery occur each year. Cardiovascular disease is the most common reason resulting in premature mortality as well as morbidity among various ethnic group of white, black and Hispanic populations. Takotsubo Cardiomyopathy: TCM is a condition that affects the heart reversible syndrome, characteristic of decrease(hypokinesia)/ near absent movement (akinesia) of distal half of interventricular septum &amp; cardiac apex showed as apical ballooning on echocardiogram with absence of an obstructive defect in epicardial coronary arteries following an emotional disturbance. Objective: To determine the diagnostic accuracy of electrocardiographic findings (elevation &lt; 1mm Takotsubo cardiomyopathy can be identified in lead V1 in patients who have anterior wall ST-segment elevation myocardial infarction by taking coronary angiography as gold standard. Design: Cross-sectional survey Subjects &amp; Methods: Using 250 incidences in the sample, and a 95% confidence level, a 13% error margin, and the anticipated percentage of Takotsubo cardiomyopathy i.e, 18% by using 74.2% sensitivity and 80.6% specificity of electrocardiographic findings i.e, ST-elevation of &gt; 1mm in V1 in the detection of Takotsubo cardiomyopathy when myocardial infarction with ST-elevation in the anterior wall is the presenting symptom and coronary angiography as gold standard2. Results: The patients were 49 + 13 years old on average. Sensitivity &amp; specificity of ECG criteria were 40.78% &amp; 78.65%. The positive &amp; negative predictive values were 43.28% &amp; 76.5% respectively. Practical Implication: Our study showed negative association of ST-elevation of &gt;1mm in ECG lead V1 to differentiate TC from anterior wall myocardial infarction. Further studies should be done to probe into the diagnostic accuracy of ECG in differentiating TC from acute anterior wall myocardial infarction. Conclusion: Electrocardiography is not diagnostic for distinguishing acute anterior wall pain from Takotsubo cardiomyopathy myocardial infarction so additional investigations need to be performed to diagnose the Takotsubo Cardiomyopathy. Keywords: Myocardial infarction, Takotsubo cardiomyopathy, Electrocardiogram, diagnostic accuracy Coronary angiography.

Identifying the culprit artery via 12-lead electrocardiogram in inferior wall ST-segment elevation myocardial infarction: Ameta-analysis.

Inferior wall ST-segment elevation myocardial infarction (STEMI) is mostly caused by acute occlusion of right coronary artery (RCA) and left circumflex artery (LCX). Several methods and algorithms using 12-lead ECG were developed to localize the lesion in inferior wall STEMI. However, the diagnostic properties of these methods remain under-recognized. The aim of this meta-analysis is to compare the diagnostic properties among the methods of identifying culprit artery in inferior wall STEMI using 12-lead ECG. We performed a meta-analysis to calculate the pooled sensitive, specificity, area under the curve (AUC) and diagnostic odds ratio (DOR) of each method. Thirty-three studies with 4414 participants were included in the analysis. Methods using double leads had better diagnostic properties, especially ST-segment elevation (STE) in III > II [with pooled sensitivity 0.89 (0.84-0.93), specificity 0.68 (0.57-0.79), DOR 17 (9-32), AUC 0.88 (0.85-0.91)], ST-segment depression (STD) in aVL > I [with pooled sensitivity 0.82 (0.72-0.90), specificity 0.69 (0.48-0.86), DOR 11 (4-29), AUC 0.85 (0.81-0.88)], and STD V3/STE III ≤1.2 [with pooled sensitivity 0.88 (0.78-0.95), specificity 0.59 (0.42-0.75), DOR 12 (5-27), AUC 0.82 (0.78-0.85)]. Diagnostic algorithms, including Jim score[pooled sensitivity 0.70 (0.55-0.85), specificity 0.88 (0.75-0.96)], Fiol's algorithm [pooled sensitivity 0.54 (0.44-0.62), specificity 0.92 (0.88-0.96)] and Tierala's algorithm [pooled sensitivity 0.60 (0.49-0.71), specificity 0.91 (0.86-0.96)], were not superior to these simple methods. Our meta-analysis indicated that diagnostic methods using double leads had better properties. STE in III > II together with STD in aVL > I may be the most ideal method, for its accuracy and convenience.

Clinical Case 31—Active gastrointestinal bleeding during STEMI: a management dilemma

Abstract A man in his 40s presented to the emergency department with chest pain for 8 hours. ECG showed an anterior wall ST-segment elevation myocardial infarction (MI). He received a loading dose of both aspirin and ticagrelor. Coronary angiography demonstrated occlusion of the proximal left anterior descending artery, and primary percutaneous coronary intervention (PCI) with one drug-eluting stent was performed. The patient also presented melena for 5 days. At admission, his hemoglobin was 6.3 g/dL and he was stable. He received a blood transfusion and was started on IV pantoprazole. Endoscopic study was postponed due to concerns related to performing such exam in the setting of a recent MI. The day after PCI, the patient presented major bleeding and hypotension, leading to interruption of the P2Y12 inhibitor. On day 3 of hospitalization, while on single antiplatelet therapy with aspirin, the patient presented new onset of chest pain. He was diagnosed with subacute stent thrombosis (type 4b MI), and thrombus aspiration and balloon angioplasty were performed (Figure 1A, and B). Dual antiplatelet therapy was immediately restarted. Echocardiography revealed worsened left ventricular disfunction (LVEF of 20%). Endoscopy showed tears in the esophagogastric junction (Mallory-Weiss syndrome). This case challenged clinical decision-making, especially the antithrombotic strategy after primary PCI in a patient with major bleeding. Learning points Management of a bleeding patient with acute MI should be individualized. The decision to withhold antithrombotic treatment should weigh the risks related to ongoing bleeding and stent thrombosis. Early endoscopy for acute gastrointestinal bleed in recent MI appears to be a safe procedure for hemorrhage control, although evidence is lacking. Figure 1 Coronary angiography. A—Total occlusion with in-stent thrombus in the proximal left anterior descending artery. B—After thrombus aspiration and angioplasty with paclitaxel-coated balloon of stent thrombosis in the proximal left anterior descending artery, remaining a residual lesion of 50–70%, and distal flow TIMI grade 3.

The Value of Sacubitril/Valsartan in Acute Anterior Wall ST-Segment Elevation Myocardial Infarction before Emergency Percutaneous Coronary Intervention

Background: Many patients present with heart failure with reduced ejection fraction (HFrEF) after acute anterior wall ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to evaluate the effect of preprocedural sacubitril/valsartan on N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and left ventricular ejection fraction (LVEF) in patients with acute anterior STEMI undergoing percutaneous coronary intervention (PCI). Methods: We enrolled patients with acute anterior wall STEMI who underwent emergency PCI at The Affiliated Hospital of Putian University from January 2019 to January 2021. Prior to PCI, patients were randomized to receive sacubitril/valsartan or valsartan. Nonculprit lesion vessels that require PCI were excluded. The primary endpoints included changes in NT-pro-BNP, LVEF, and rehospitalization for heart failure (HF) during the follow-up period. Results: Out of 109 patients who were randomized, 55 were assigned to receive sacubitril/valsartan and 54 were assigned to receive valsartan. The decrease in NT-pro-BNP concentrations and the increase in LVEF were significantly greater in the sacubitril/valsartan group than in the valsartan group. Conclusions: In patients with acute anterior wall STEMI undergoing emergency PCI, preprocedural initiation of sacubitril/valsartan therapy increased LVEF and lower NT-pro-BNP concentrations compared with valsartan therapy.

Shark Fin Electrocardiogram in the Intensive Care Unit.

Shark Fin Electrocardiogram in the Intensive Care Unit.

Outcomes of a Newly Established Electromagnetic Navigation Bronchoscopy Service in the Middle East.

Electromagnetic Navigation Bronchoscopy (EMNB) is a useful tool for the bronchoscopist to target peripheral pulmonary lesions. It has a well-established efficacy and safety profile; however, there are no studies describing its utility in a Middle Eastern population. In this paper, we describe the efficacy and safety outcomes of a newly established EMNB service. The diagnosis of peripheral pulmonary lesions presents a significant challenge to the bronchoscopist, especially in the era of increased thoracic imaging with computerized tomography (CT) scans. EMNB is a relatively novel technique that utilizes an image-guided localization system akin to Global Positioning Satellite (GPS) technology, offering the bronchoscopist an accurate navigational pathway to sample peripheral pulmonary targets. We present our initial experience of performing EMNB and report our diagnostic and safety outcomes with EMN bronchoscopy. We conducted a retrospective review of the medical notes of all patients booked for EMNB from May 2015 to December 2019 at our tertiary care center using the electronic medical record system. Fifty-five patients were scheduled for EMNB, and 47 patients (24 males, 23 females) had EMNB-guided sampling between May 2015 and December 2019. The median age of the patients was 61 years (IQR 49.5-74.3). A bronchus sign was present on the CT chest in 29 (61.7%) cases. Thirty-one (66%) patients had positive EMNB guided samples. There was a weak correlation between the lesion size and the positive EMNB guided sampling (r: 0.34). Twenty-one of 29 (72%) patients with positive bronchus signs had positive EMNB guided samples, compared to 10/18 (56%) patients without bronchus signs; however, the difference was not statistically significant (p-value 0.335). When the presence or absence of rapid onsite examination of cytopathological specimens (ROSE) was compared during the procedure, a trend favoring the presence of ROSE could be seen, but this was statistically non-significant (p-value 0.078). In this series, one patient with pre-existing triple vessel coronary artery disease developed an inferior wall ST-segment elevation myocardial infarction (STEMI), likely secondary to spasm. This patient recovered completely and was discharged from the hospital. This study demonstrates that EMNB can be safely performed in a Middle Eastern population with results similar to those reported in major international studies. The highest diagnostic yield was in patients with a bronchus sign on a CT scan, and combining EMNB with ROSE can increase the chances of having a positive diagnostic bronchoscopy. However, patients and physicians need to be aware of the need to follow up with the patients with negative biopsies to ensure that false negatives are not missed.

Prognostic value of myocardial contrast echocardiography in acute anterior wall ST-segment elevation myocardial infarction with successful epicardial recanalization.

Although myocardial contrast echocardiography (MCE) can evaluate microvascular perfusion abnormalities, its prognostic value is uncertain in acute anterior wall ST-Segment elevation myocardial infarction (STEMI) with successful epicardial recanalization. Therefore, the study aims to investigate the prognostic role of qualitative and quantitative MCE in acute anterior wall STEMI with successful epicardial recanalization. 153 STEMI patients were assessed by MCE within 7days after successful epicardial recanalization. Qualitative perfusion parameters (microvascular perfusion score index, MPSI) and quantitative perfusion parameters (A, β, and Aβ) were acquired using a 17-segment model. And corrected A and Aβ were calculated. Patients were all followed for major adverse cardiovascular events (MACEs). During median follow-up of 27 (4) months, 39 (25.49%) patients experienced MACEs, while 114 (74.51%) were free from MACEs. Patients with MACEs had higher MPSI (1.65 ± 0.13 vs. No-MACEs 1.35 ± 0.20, P < 0.001), lower β (1.09 ± 0.19s-1 vs. No-MACEs 1.34 ± 0.30s-1, P < 0.001), corrected A (0.17 ± 0.03dB vs. No-MACEs 0.19 ± 0.04dB, P = 0.039) and lower corrected Aβ (0.19 ± 0.06dB/s vs. No-MACEs 0.25 ± 0.08dB/s, P < 0.001). MPSI of 1.44 provided an area under the curve (AUC) of 0.872, while β of 1.18s-1 and corrected Aβ of 0.22dB/s provided AUCs of 0.759 and 0.724, respectively. The combination of MPSI, β and corrected Aβ provided an increased AUC of 0.964 (all P < 0.05). Time-dependent ROC analysis showed that the AUCs of the MPSI, β, corrected Aβ and the combination at 1, 1.5 and 2years indicated a strong predictive power for MACEs (AUC = 0.900/0.894/0.881 for MPSI, 0.648/0.704/0.732 for β, 0.674/0.686/0.722 for corrected Aβ, and 0.947/0.962/0.967 for the combination, respectively). Patients with MPSI < 1.44, β > 1.18s-1, or corrected Aβ > 0.22dB/s had lower event rate (all Log Rank P ≤ 0.001). MPSI, β, corrected Aβ, GLS and WBC were independent predictors of MACEs with adjusted hazard ratio of 34.41 (8.18-144.87), P < 0.001 for MPSI; 39.29 (27.46-65.44), P < 0.001 for β; 8.93 (1.46-54.55), P = 0.018 for corrected Aβ; 10.88 (2.83-41.86), P = 0.001 for GLS; and 1.43 (1.16-1.75), P = 0.001 for WBC. Qualitative and quantitative MCE can accurately predict MACEs in acute anterior wall STEMI with successful epicardial recanalization, and their combined predictive value is higher.

Index of microcirculatory resistance predicts long term cardiac systolic function in patients with STEMI undergoing primary PCI

BackgroundTo evaluate the predictive value of the index of microcirculatory resistance (IMR) for long-term cardiac systolic function after primary percutaneous coronary intervention (pPCI) in patients with acute anterior wall ST-segment elevation myocardial infarction (STEMI).MethodsA total of 53 acute anterior wall STEMI patients were included and followed up within 1-year. IMR was measured to evaluate the immediate intraoperative reperfusion. IMR > 40 U was defined as the high IMR group and ≤ 40 U was defined as the low IMR group. Left ventricular ejection fraction (LVEF) was measured by echocardiography at 24 h, 1 month, 3 months, and 1 year after PCI to analyze the correlation between IMR and cardiac systolic function. Heart failure was estimated according to classification within one year.ResultsThe ratio of TMPG (TIMI myocardial perfusion grade) 3 (85.7% vs. 52%, p = 0.015) and STR (ST-segment resolution) > 70% (82.1% vs. 48%, p = 0.019) were significantly higher in the low IMR group. The LVEF in the low IMR group was significantly higher than that in the high IMR group at 3 months (43.06 ± 2.63% vs. 40.20 ± 2.67%, p < 0.001) and 1 year (44.16 ± 2.40% vs. 40.13 ± 3.48%, p < 0.001). IMR was negatively correlated with LVEF at 3 months (r = − 0.1014, p = 0.0040) and 1 year (r = − 0.1754, p < 0.0001).ConclusionsThe IMR showed significant negative correlation with the LVEF value after primary PCI. The high IMR is a strong predictor of heart failure within 1 year after anterior myocardial infarction.

Comparison between preoperative loading dose of ticagrelor versus clopidogrel on myocardial perfusion in type ii diabetic patients presenting with anterior wall myocardial infarction

Background: Diabetes mellitus is recognized as an independent risk factor for the development of Coronary No Reflow. Ticagrelor has a faster onset of action and a stronger antiplatelet effect as compared to clopidogrel. The aim of this study is to compare between ticagrelor and clopidogrel loading doses before primary percutaneous coronary intervention (PCI) in Type II diabetic patients presenting with anterior wall ST-Segment Elevation Myocardial Infarction (STEMI) and their different effect on myocardial perfusion and in-hospital Major Adverse Cardiac Events. Methods: The study included 170 patients with Type II diabetes, who presented with acute anterior wall STEMI who underwent primary PCI. They were randomized into two groups, the1st group 85 patients received clopidogrel loading dose (600 mg) and the 2nd group 85 patients received ticagrelor loading dose (180 mg). Postinterventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded as well as in-hospital outcomes. Results: In the clopidogrel group, 80% of the patients had TIMI III flow score, 15.3% had TIMI II flow score and 2.4% had TIMI I and TIMI 0 flow score. In the ticagrelor group, 95% of the patients had TIMI III flow score, 2.4% had TIMI II flow score and 1.2% had TIMI I and TIMI 0 flow score (P = 0.01). Regarding MBG, in the clopidogrel group, 64.7% of the patients had MBG III, 13% had MBG II flow score, 2.3% had MBG 1, and 20% had MBG 0. In the ticagrelor group, 93% of the patients had MBG III, 1.1% had MBG II flow score, 1.1% had MBG 1, and 4.8% had MBG 0 (P = 0.007). In the clopidogrel group there were 3.5% in-hospital mortality, while in ticagrelor 2.4% in-hospital mortality (2.4%) (P = 0.47). In the Clopidogrel group, in-hospital MACE was 5.8% versus 3.5% in the ticagrelor group (P = 0.65). In the Clopidogrel group, in-hospital bleeding was 3.5% versus 4.7% in the ticagrelor group (P = 0.7). Conclusion: Ticagrelor loading before primary PCI resulted in improved TIMI flow and MBG in Type II diabetic patients presenting with anterior wall myocardial infarction.

"Takotsubo effect" in patients with ST segment elevation myocardial infarction.

Myocardial infarction can be a trigger of Takotsubo syndrome. We recently characterized imaging features of acute myocardial infarction-induced Takotsubo syndrome ("Takotsubo effect"). In this study, we investigate diagnostic and prognostic implications of Takotsubo effect in patients with anterior wall ST-segment elevation myocardial infarction. We enrolled 111 consecutive patients who developed anterior wall ST-segment elevation myocardial infarction and received percutaneous coronary intervention, and studied systolic/diastolic function, hemodynamic consequences, adverse cardiac events, as well as 30-day and five-year outcomes in patients with and without Takotsubo effect. Patients with Takotsubo effect showed significantly worse average peak systolic longitudinal strain (-9.5 ± 2.6% vs -11.1 ± 3.6%, p = 0.038), left ventricular ejection fraction (38.5 ± 6.8% vs 47.7 ± 8.7%, p = 0.000) and myocardial performance index (0.54 ± 0.17 vs 0.37 ± 0.15, p = 0.000) within 48 h of myocardial infarction. There was no significant difference between the two groups in diastolic ventricular filling pressures, hemodynamic consequences, and 30-day rehospitalization and mortality (Gehan-Breslow-Wilcoxon test: p = 0.157). However, patients with Takotsubo effect developed more major adverse cardiac events (log-rank test: p = 0.019) when tested at the five-year follow-up. Cox regression analysis revealed that age, hypotension, tricuspid annular plane systolic excursion, and Takotsubo effect were independent prediction factors for five-year major adverse cardiac events. The Doppler/tissue Doppler parameter E/e' correlated with MACE only in patients without Takotsubo effect. Takotsubo effect secondary to anterior ST-segment elevation myocardial infarction predicts a worse long-term prognosis.

HIGHER ST-SEGMENT ELEVATION IN LEAD III THAN LEAD II IN ACUTE INFERIOR MYOCARDIAL INFARCTION CAN BE A PREDICTOR OF SHORT-TERM MORBIDITY AND MORTALITY

Background:The incidence of mortality and complications are high in patients with acute inferior wall ST-segment elevation myocardial infarction with right ventricular involvement, which has been reported to be an independent predictor of significant complications and in-hospital mortality. Objective:To investigate the feasibility of using electrocardiographic changes in inferior myocardial infarction represented by ST-segment elevation ratio in lead II and III as a predictor of right ventricular infarction and in-hospital morbidity and mortality. Methods:Ninety-nine patients were studied in this prospective study, their ages ranged from 19-90 years, average 58.12 (±12.7 SD). They were presented to the Coronary Care Unit of Basrah General Hospital with acute inferior ST-segment elevation myocardial infarction. The 12 leads plus right-sided precordial electrocardiograms were done to all patients within 12 hours of the onset of symptoms, and ST-segment elevation was measured. ST-segment elevation in lead III exceeding lead II was defined as a ratio of elevation in lead III: II&gt;1. Patients grouped according to ST-segment elevation III:II ratio into either &gt;1 or ≤1. In-hospital morbidity and mortality were studied in both groups. Results:ST-segment elevation ratio &gt; 1was detected in 68 patients (68.7%) with acute inferior myocardial infarction at time of admission. Right ventricular infarction was diagnosed in 33 (33.3%) patients, with the majority (32 patients) have ST-elevation ratio &gt; 1. Thirty-Six patients had at least one of the in-hospital complications with significantly higher incidence (51.4%) in patients with higher ST elevation ratio. The mortality was statistically higher when ST segment elevation level in the lead III &gt; than that in the lead II. Conclusion:In patients with inferior STEMI, ST-segment elevation in the lead III more than lead II can be a potential marker of the presence of right ventricular infarction in association with inferior myocardial infarction. Short-term prognosis is possibly worse in the presence of a higher ratio between lead III and II ST-segment elevation. However, further studies are needed to validate this conclusion. Keywords:Inferior MI, right ventricular infarction, ST-segment changes Citation:Al-Mansouri LA, Al-Obaidi FR, Al-Humrani AH. Higher ST-Segment elevation in lead III than lead II in acute inferior myocardial infarction can be a predictor of short-term morbidity and mortality. Iraqi JMS. 2019; 17(3&amp;4): 168-174. doi: 10.22578/IJMS.17.3&amp;4.2

Ischemic postconditioning improves longitudinal contractile function of the reperfused myocardium in patients with anterior wall acute myocardial infarction

To investigate whether ischemic postconditioning (IPTC) can promote the recovery of left ventricular impaired regional or global longitudinal systolic function. Methods: The trial was divided into a percutaneous coronary intervention (PCI) group, an PCI+IPTC group and a control group. Thirty-two patients with anterior acute anterior wall ST-segment elevation myocardial infarction (STEMI) underwent the first emergency PCI in the PCI group, 28 patients with anterior acute STEMI underwent the combination of PCI and IPTC in the PCI+IPTC group, while 30 patients underwent coronary angiography in the control group. Two-dimensional dynamic echocardiography was collected before operation, 0.5 h, 1 day, 3 days, 1 week, 1 month and 6 months after operation, respectively. The longitudinal strain parameters at different time points were analyzed and compared in the 3 groups. Results: The regional longitudinal strain of infracted segments in the PCI+IPTC group after the operation within 1 week was higher than that in the PCI group (P<0.05). The left ventricular global longitudinal strain in the PCI+IPTC group seemed to be higher than that in PCI group after the operation within 1 week, but there was not statistically difference (P>0.05). There was no significant difference in the long-term regional and global longitudinal strains of left ventricle between the PCI+IPTC group and the PCI group (both P>0.05). Conclusion: The IPTC can improve the short-term longitudinal systolic function of the reperfused myocardium in patients with acute anterior wall STEMI after PCI.

Myocardial dysfunction in Takotsubo syndrome: More than meets the eye?

IntroductionTakotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction, typically mimicking an anterior wall myocardial infarction (MI), without obstructive coronary artery disease. In the few published reports assessing myocardial deformation in TTS and MI, no consistent differences have been described between the two entities. We sought to characterize global and regional function in TTS and to compare it with a population with MI. MethodsClinical data, including echocardiography, were gathered from 17 TTS patients and 20 anterior wall ST-segment elevation myocardial infarction (STEMI) controls. Peak systolic longitudinal strain was determined for each LV segment using speckle tracking imaging, and global and mean apical, midventricular and basal longitudinal strain were calculated from these. ResultsBoth TTS and STEMI patients presented significant LV systolic dysfunction, and there were no significant differences in ejection fraction or global longitudinal strain. Regional longitudinal strain was more severely impaired in basal inferolateral and mid anterolateral segments in the TTS group and in apical anteroseptal segments in the STEMI group. Mean longitudinal strain was worse in the basal segments of TTS patients (-9.8±2.9 vs. -12.4±4.1%, p=0.010), with no significant differences in mid and apical segments. The basal/apical ratio was significantly lower in this group as well (1.51±0.86 vs. 2.94±1.88, p=0.006). ConclusionsWhile both TTS and STEMI feature significantly impaired global systolic function, we found a regional pattern of worse basal longitudinal strain and a lower basal/apical ratio in the former. These suggest generalized myocardial impairment in TTS, providing new clues about its pathophysiology and possible specific echocardiographic changes.

Usefulness of Myocardial Longitudinal Strain in Prediction of Heart Failure in Patients with Successfully Reperfused Anterior Wall ST-segment Elevation Myocardial Infarction.

Background and ObjectivesAcute myocardial infarction-related heart failure (HF) is associated with poor outcome. This study was designed to investigate the usefulness of global longitudinal strain (GLS), global circumferential strain (GCS) and mean longitudinal strain of left anterior descending artery territory (LSant) measured by 2-dimensional speckle tracking echocardiography (2D STE) in prediction of acute anterior wall ST-segment elevation myocardial infarction (ant-STEMI)-related HF.MethodsA total of 171 patients with ant-STEMI who underwent successful primary coronary intervention and had available 2D STE data were enrolled. Patients were divided into 3 groups: in-hospital HF, post-discharge HF, and no-HF groups.ResultsIn-hospital and post-discharge HF developed in 39 (22.8%) and 13 (7.6%) of patients, respectively and 113 patients (69.6%) remained without HF. Multivariate analysis showed that GLS was the only factor significantly associated with the development of in-hospital HF. For post-discharge HF, LSant was the only independent predictor. Other echocardiographic or laboratory parameters did not show independent association with the development of ant-STEMI-related HF.ConclusionsGLS is a powerful echocardiographic parameter related to development of in-hospital HF and LSant was significantly associated with post-discharge HF in patients with successfully reperfused ant-STEMI.

Left ventricular thrombosis in acute anterior myocardial infarction: Evaluation of hospital mortality, thromboembolism, and bleeding.

Left ventricular thrombosis (LVT) is a well-known complication of acute myocardial infarction, most commonly seen in anterior wall ST-segment elevation myocardial infarction (STEMI). It is associated with systemic thromboembolism. Our aim was to evaluate the impact of LVT on in-hospital mortality, thromboembolism, and bleeding in patients with anterior STEMI. Data was collected from the Nationwide Inpatient Sample where patients with a primary diagnosis of "Anterior STEMI" [ICD9-CM code 410.1] were included. Comparisons were made between patients with LVT [ICD9-CM code 429.79] vs those without using propensity score matching (PSM). From 2002 to 2014, there were 157 891 cases of anterior STEMI. Among these, 649 (0.4%) had LVT. Post-PSM, there was no difference in in-hospital mortality between the groups with LVT and without (7.3% vs 8.6%). Thromboembolic event rate was higher with LVT compared to those without LVT (7.3% vs 2.1%). There was no difference in bleeding events between patients with LVT and those without (2.9% vs 3.2%). The baseline average length of stay in the group with LVT was longer than the group without LVT (7.9 ± 6.7 days vs 5.1 ± 6.0 days). The average hospitalization-related costs were also significantly higher among patients with LVT compared to those without (95 598 USD vs 66 641 USD per stay) at baseline. Among patients hospitalized with anterior STEMI, presence of LVT is associated with increased thromboembolic events, average length of hospital stay and average cost of hospitalization. However, it is not associated with increased in-hospital mortality or bleeding events.

Improvement in Left Ventricular Function with Intracoronary Mesenchymal Stem Cell Therapy in a Patient with Anterior Wall ST-Segment Elevation Myocardial Infarction

Background/AimsThe progression and development of congestive heart failure is still considered a large problem despite the existence of revascularization therapies and optimal, state-of-the-art medical services. An acute myocardial infarction (AMI) is a major cause of congestive heart failure, so researchers are investigating techniques to complement primary percutaneous coronary intervention (PCI) or thrombolytic therapy to prevent congestive heart failure after AMI.MethodsTwenty-six patients with successful PCI for acute ST-segment elevation anterior wall myocardial infarction were assigned to either a control group (n = 12) or a bone marrow mesenchymal stem cells (BM-MSC) group (n = 14). The control group received optimum post-infarction treatment, and the BMSC group received intracoronary delivery of autologous BMSC at 1 month after PCI with the optimum medical treatment. The primary endpoint was a left ventricular ejection fraction (LVEF) change from baseline to 4-month follow-up, as determined via myocardial single-photon emission computed tomography (SPECT).ResultsThe global LVEF at baseline (determined 3.5 ± 1.5 days after PCI) was 35.4 ± 3.0% in the control group and 33.6 ± 4.7% in the BM-MSC group. BMSC transfer enhanced left ventricular systolic function primarily in anterior wall myocardial segments adjacent to the LAD infarcted area. Four months later, via SPECT, global LVEF had increased by 4.8 ± 1.9% in the control group and 8.8 ± 2.9% in the BM-MSC group (p = 0.031). The cell transfer did not increase the risk of adverse clinical events, in-stent restenosis, or proarrhythmic effects. The echocardiographic evaluation also revealed a significant increase in the LVEF value from baseline to the 4-month (9.0 ± 4.7 and 5.3 ± 2.6%, p = 0.023) and 12-month (9.9 ± 5.2% and 6.5 ± 2.7%, p = 0.048) follow-up in the BM-MSC group but not in the control group.ConclusionsIntracoronary administration of autologous BM-MSC was tolerable and safe with significant improvement in LVEF at 4-month (SPECT and echocardiography result) and 12-month (echocardiography result only) follow-up in patients with anterior AMI.