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Alkhalil M, De Maria GL, Akbar N, Ruparelia N, Choudhury RP. Prospects for Precision Medicine in Acute Myocardial Infarction: Patient-Level Insights into Myocardial Injury and Repair. J Clin Med 2023; 12:4668. [PMID: 37510783 PMCID: PMC10380764 DOI: 10.3390/jcm12144668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
The past decade has seen a marked expansion in the understanding of the pathobiology of acute myocardial infarction and the systemic inflammatory response that it elicits. At the same time, a portfolio of tools has emerged to characterise some of these processes in vivo. However, in clinical practice, key decision making still largely relies on assessment built around the timing of the onset of chest pain, features on electrocardiograms and measurements of plasma troponin. Better understanding the heterogeneity of myocardial injury and patient-level responses should provide new opportunities for diagnostic stratification to enable the delivery of more rational therapies. Characterisation of the myocardium using emerging imaging techniques such as the T1, T2 and T2* mapping techniques can provide enhanced assessments of myocardial statuses. Physiological measures, which include microcirculatory resistance and coronary flow reserve, have been shown to predict outcomes in AMI and can be used to inform treatment selection. Functionally informative blood biomarkers, including cellular transcriptomics; microRNAs; extracellular vesicle analyses and soluble markers, all give insights into the nature and timing of the innate immune response and its regulation in acute MI. The integration of these and other emerging tools will be key to developing a fuller understanding of the patient-level processes of myocardial injury and repair and should fuel new possibilities for rational therapeutic intervention.
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Affiliation(s)
- Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | | | - Naveed Akbar
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Neil Ruparelia
- Cardiology Department, Hammersmith Hospital, Imperial College London, London W12 0HS, UK
| | - Robin P Choudhury
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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2
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Sarda AK, Thute P. Importance of ECG in the Diagnosis of Acute Pericarditis and Myocardial Infarction: A Review Article. Cureus 2022; 14:e30633. [DOI: 10.7759/cureus.30633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022] Open
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3
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Electrocardiogram to predict reperfusion success in late presenters with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Electrocardiol 2020; 59:74-80. [PMID: 32007909 DOI: 10.1016/j.jelectrocard.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/08/2020] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical decision-making in patients with ST-segment elevation myocardial infarction (STEMI) presenting beyond 12 h of symptom onset (late presenters) is challenging. However, the electrocardiogram (ECG) may provide helpful information. We investigated the association between three ECG-scores and myocardial salvage and infarct size in late presenters treated with primary percutaneous coronary intervention (primary PCI). METHODS Sixty-six patients with STEMI and ongoing symptoms presenting 12-72 h after symptom onset were included. Cardiac magnetic resonance was performed at day 1 (interquartile range [IQR], 1-1) and at follow-up at day 93 (IQR, 90-98). The pre-PCI ECG was analyzed for the presence of pathological QW (early QW) as well as Anderson-Wilkins acuteness score (AW-score), the classic Sclarovsky-Birnbaum Ischemia Grading System (classic SB-IG-score) and a modified SB-IG-score including any T-wave morphologies. RESULTS Early QW was associated with a larger myocardium at risk (39 ± 12 versus 33 ± 12; p = 0.030) and final infarct size (20 ± 11 versus 14 ± 9; p = 0.021) as well as a numerical lower final myocardial salvage (0.52 ± 0.19 versus 0.61 ± 0.23; p = 0.09). The association with final infarct size disappeared after adjusting for myocardium at risk. An AW-score < 3 showed a trend towards a larger final infarct size (18 ± 11 versus 11 ± 11; p = 0.08) and was not associated with salvage index (0.55 ± 0.20 versus 0.65 ± 0.30; p = 0.23). The classic and modified SB-IG-score were not associated with final infarct size (modified SB-IG-score, 17 ± 10 versus 21 ± 13; p = 0.28) or final myocardial salvage (0.53 ± 0.20 versus 0.53 ± 0.26; p = 0.96). CONCLUSION Of three well-established ECG-scores only early QW and AW-score < 3 showed association with myocardium at risk and infarct size to some extent, but the association with myocardial salvage was weak. Hence, neither of the three investigated ECG-scores are sufficient to guide clinical decision-making in patients with STEMI and ongoing symptoms presenting beyond 12 h of symptom onset.
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4
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Tiller C, Reindl M, Holzknecht M, Innerhofer L, Wagner M, Lechner I, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Relationship between admission Q waves and microvascular injury in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Int J Cardiol 2019; 297:1-7. [PMID: 31629564 DOI: 10.1016/j.ijcard.2019.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/12/2019] [Accepted: 10/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Using comprehensive cardiac magnetic resonance (CMR) imaging in patients suffering from ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), we sought to investigate the association of admission Q waves with microvascular injury (microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)). METHODS This prospective observational study included 195 STEMI patients treated with pPCI. Admission 12-lead electrocardiography was evaluated for the presence of pathological Q waves, defined as a Q wave duration of >30 ms and a depth of >0.1 mV. CMR was performed at 3 (interquartile range: 2-5) days after pPCI to determine infarct characteristics including MVO (late gadolinium enhancement) and IMH (T2* mapping). RESULTS Admission Q waves were observed in 53% of patients (n = 104). These patients had a significantly lower BMI (p = 0.005), more frequent left anterior descending artery as culprit lesion (p = 0.005), were less frequent smokers (p = 0.048) and had higher rates of pre-interventional TIMI flow 0 (p = 0.018). Patients with Q waves showed a significantly larger infarct size (19%vs.12% of left ventricular mass,p < 0.001), lower ejection fraction (49%vs.54%,p = 0.001), worse global strain parameters (all p < 0.005) and more severe microvascular injury (MVO: 68%vs.34%,p < 0.001; IMH: 40%vs.20%,p = 0.002). Q waves remained associated with both MVO (odds ratio: 5.23, 95% confidence interval: 2.58 to 10.58,p < 0.001) and IMH (odds ratio: 3.94, 95% confidence interval: 1.83 to 8.46,p < 0.001) after adjusting for potential confounders (culprit lesion, pre-interventional TIMI flow 0, total ischemia time, ST-segment elevation). CONCLUSIONS Admission Q waves, derived from the readily available ECG, emerged as independent early markers of CMR-determined microvascular injury in STEMI patients undergoing pPCI.
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Affiliation(s)
- Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Lukas Innerhofer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Miriam Wagner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
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5
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Stankovic S, Obradovic S, Dzudovic B, Djenic N, Romanovic R, Jovic Z, Spasic M, Djuric O, Malovic D, Stavric M, Subota V. Lower plasma protein C activity is associated with early myocardial necrosis and no-reflow phenomenon in patients with ST elevation myocardial infarction. Acta Cardiol 2019; 74:331-339. [PMID: 30204553 DOI: 10.1080/00015385.2018.1494116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Activity of protein C has important role in the development of early necrosis and no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI). Methods: We examined association between plasma activity of protein C, antithrombin, coagulation factors II, VII, VIII and fibrinogen to early formation of new Q-waves (myocardial necrosis) before pPCI and early ST-segment resolution (microcirculatory reperfusion) after pPCI in patients with acute STEMI. According to ischaemic time, patients were considered as early or late presenters. 12-lead ECG was analysed for the presence of new Q-wave at admission and for significant ST-segment resolution 60 minutes after primary PCI. Results: In early presenters' group, protein C activity was significantly lower in patients who did not achieve significant ST-segment resolution after pPCI compared to patients who did (1.11 IU/L vs. 0.99 IU/L, p = .006) and in patients who had new Q-waves compared to group who had not (1.04 UI/l vs. 1.11 IU/L, p = .038). There was significant negative correlation between protein C activity and maximal CK-MB levels (R2 = 0.06, p = .009) and BNP levels (R2 = 0.109, p = .003) and significant positive correlation between protein C activity with LVEF (R2 = 0.065, constant = 33.940, b = 11.968, p = .007) in early STEMI presenters. There were no differences between the activity of other examined haemostasis factors. Conclusion: Therefore we concluded that STEMI patients with early myocardial necrosis and no-reflow phenomenon after pPCI have lower activity of plasma protein C levels.
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Affiliation(s)
- Suncica Stankovic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Slobodan Obradovic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Boris Dzudovic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Nemanja Djenic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Radoslav Romanovic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Zoran Jovic
- Clinic for cardiology, Military Medical Academy, Belgrade, Serbia
| | - Marijan Spasic
- Clinic for cardiology, Military Medical Academy, Belgrade, Serbia
| | - Obrad Djuric
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Dragana Malovic
- Clinic for Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Milena Stavric
- Institute for Biochemistry, Military Medical Academy, Belgrade, Serbia
| | - Vesna Subota
- Institute for Biochemistry, Military Medical Academy, Belgrade, Serbia
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6
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Meloni L, Marchetti MF, Cacace C, Congia M, Scotto R, Caddeo P, Montisci R. Prognosis and first diagnostic ECG in STEMI patients referred to the emergency medical system for primary PCI. J Electrocardiol 2018; 51:1131-1134. [PMID: 30497744 DOI: 10.1016/j.jelectrocard.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pathological Q waves (QWs) in the first ECG recorded at hospital admission has been found to correlate with myocardial damage and mortality in STEMI patients. We investigated the association between new QWs recorded in the pre-hospital setting and adverse outcome during the hospital stay. METHODS A pre-hospital ECG was recorded in 248 patients with STEMI who underwent primary PCI. Patients were divided into two groups based on the presence (n = 44, QWs) or absence (n = 204, non-QWs) of new QWs. RESULTS Patients with new QWs had a higher prevalence of anterior infarct, cardiogenic shock and a lower LV ejection fraction. In-hospital mortality was higher in patients with new QWs. The percentage of patients with new QWs increased progressively with increasing pain to ECG time. CONCLUSIONS New QWs provide rapid prognostic information in the pre-hospital phase of STEMI by identifying patients at risk of adverse outcome during the hospital stay.
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Affiliation(s)
- Luigi Meloni
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy.
| | - Maria Francesca Marchetti
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Cristina Cacace
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Michela Congia
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Roberta Scotto
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Piero Caddeo
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Sciences and Public Health, University of Cagliari, Italy
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7
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Koivula K, Nikus K, Viikilä J, Lilleberg J, Huhtala H, Birnbaum Y, Eskola M. Comparison of the prognostic role of Q waves and inverted T waves in the presenting ECG of STEMI patients. Ann Noninvasive Electrocardiol 2018; 24:e12585. [PMID: 30191632 DOI: 10.1111/anec.12585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/15/2018] [Accepted: 06/23/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients. METHODS We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts. RESULTS The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-. CONCLUSION Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification.
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Affiliation(s)
- Kimmo Koivula
- South Karelia Central Hospital, Lappeenranta, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kjell Nikus
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
| | - Juho Viikilä
- Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jyrki Lilleberg
- Department of Internal Medicine, Hyvinkää Hospital, Hyvinkää, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Markku Eskola
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
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8
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Topal DG, Lønborg J, Ahtarovski KA, Nepper-Christensen L, Helqvist S, Holmvang L, Pedersen F, Clemmensen P, Saünamaki K, Jørgensen E, Kyhl K, Ghotbi A, Schoos MM, Göransson C, Bertelsen L, Høfsten D, Køber L, Kelbæk H, Vejlstrup N, Engstrøm T. Association Between Early Q Waves and Reperfusion Success in Patients With ST-Segment–Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004467. [DOI: 10.1161/circinterventions.116.004467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/10/2017] [Indexed: 11/16/2022]
Abstract
Background—
Pathological early Q waves (QW) are associated with adverse outcomes in patients with ST-segment–elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) may therefore be less beneficial in patients with QW than in patients without QW. Myocardial salvage index and microvascular obstruction (MVO) are markers for reperfusion success. Thus, to clarify the benefit from primary PCI in STEMI patients with QW, we examined the association between baseline QW and myocardial salvage index and MVO in STEMI patients treated with primary PCI.
Methods and Results—
The ECG was assessed before primary PCI for the presence of QW (early) in 515 STEMI patients. The patients underwent a cardiac magnetic resonance imaging scan at day 1 (interquartile range [IQR], 1–1) and again at day 92 (IQR, 89–96). Early QW was observed in 108 (21%) patients and was related to smaller final myocardial salvage index (0.59 [IQR, 0.39–0.69] versus 0.65 [IQR, 0.46–0.84];
P
<0.001) and larger MVO (1.4 [IQR, 0.0–5.4] versus 0.0 [IQR, 0.0–2.4];
P
<0.001) compared with non-QW. QW remained associated with both final myocardial salvage index (β=−0.12;
P
=0.03) and MVO (β=0.18;
P
=0.001) after adjusting for potential confounders.
Conclusions—
Patients presenting with their first STEMI and early QW in the ECG had smaller myocardial salvage index and more extensive MVO than non-QW despite treatment within 12 hours after symptom onset. However, final myocardial salvage index in patients with QW was substantial, and patients with QW still benefit from primary PCI.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01435408.
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Affiliation(s)
- Divan Gabriel Topal
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Jacob Lønborg
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Kiril Aleksov Ahtarovski
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Lars Nepper-Christensen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Steffen Helqvist
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Lene Holmvang
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Frants Pedersen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Peter Clemmensen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Kari Saünamaki
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Erik Jørgensen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Kasper Kyhl
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Ali Ghotbi
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Mikkel Malby Schoos
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Christoffer Göransson
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Litten Bertelsen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Dan Høfsten
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Lars Køber
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Henning Kelbæk
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Niels Vejlstrup
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
| | - Thomas Engstrøm
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (D.G.T., J.L., K.A.A., L.N.-C., S.H., L.H., F.P., K.S., E.J., K.K., A.G., M.M.S., C.G., L.B., D.H., L.K., N.V., T.E.); Department of Medicine, Nykøbing F Hospital, University of Southern Denmark, Odense (P.C.); Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Germany (P.C.); and Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (M.M.S., H.K.)
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Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications. J Electrocardiol 2017; 50:47-73. [DOI: 10.1016/j.jelectrocard.2016.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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10
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Shibutani H, Akita Y, Yutaka K, Yamamoto S, Matsui Y, Yoshinaga M, Karakawa M, Mori Y. Acute myocardial infarction with "wrap around" right coronary artery mimicking Takotsubo cardiomyopathy: a case report. BMC Cardiovasc Disord 2016; 16:71. [PMID: 27102232 PMCID: PMC4840957 DOI: 10.1186/s12872-016-0249-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 04/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background Takotsubo cardiomyopathy (TC) is a cardiomyopathy that shows distinctive clinical conditions first described more than 20 years ago. Because clinical features of TC mimic those of anterior acute myocardial infarction (AMI), the differential diagnosis is important in selecting the appropriate treatment strategy in the acute phase. But it was difficult to differentiate those two diseases because the TC-like findings; such as the electrocardiogram (ECG) changes and left ventricular wall motion abnormality can occur in AMI especially with the anatomical variance of the coronary artery. Case presentation A 63-year-old man was admitted due to sudden onset of chest pain and was in a cardiogenic shock state. His ECG showed ST-segment elevation in precordial (V2–6) and inferior leads (II, III, and aVF) and ST-segment depression in lead aVR. Blood biochemistry showed that cardiac enzymes were not elevated. Ultrasonic cardiography showed that the left ventricular apical level was akinetic, papillary muscle level was severely hypokinetic, and basal level was hyperkinetic, mimicking TC. However, coronary angiogram showed total occlusion of his right coronary artery wrapping around the cardiac apex. Successful percutaneous coronary intervention reversed his critical status. Conclusion To our knowledge, the present case is the first report described AMI with wrap-around RCA, mimicking TC. Although TC is increasingly recognized as a true but relatively infrequent clinical entity, it is still important to carefully rule out obstructive coronary artery disease.
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Affiliation(s)
- Hiroki Shibutani
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan.
| | - Yuzo Akita
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Kotaro Yutaka
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Satoshi Yamamoto
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Yumie Matsui
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Masahiro Yoshinaga
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Masahiro Karakawa
- Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
| | - Yasukiyo Mori
- Division of Nephrology, Osaka Saiseikai Izuo Hospital, 3-4-5 Kitayama, Taisho-ku, Osaka, 551-0032, Japan
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11
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Klein LR, Shroff GR, Beeman W, Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med 2015; 33:786-90. [DOI: 10.1016/j.ajem.2015.03.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022] Open
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12
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Mugnai G, Pasqualin G, Benfari G, Bertagnolli L, Mugnai F, Vassanelli F, Marchese G, Pesarini G, Menegatti G. Acute electrocardiographic differences between Takotsubo cardiomyopathy and anterior ST elevation myocardial infarction. J Electrocardiol 2014; 48:79-85. [PMID: 25465858 DOI: 10.1016/j.jelectrocard.2014.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to compare ECG findings between anterior ST elevation myocardial infarction (STEMI) and Takotsubo cardiomyopathy (TC) in a similar sample of postmenopausal women. METHODS Between 2008 and 2011, 27 patients with TC were retrospectively enrolled and matched with 27 STEMI patients with the same age and sex taken from the prospective database of our laboratory. RESULTS The absence of abnormal Q waves, the ST depression in aVR and the lack of ST elevation in V1 were significantly associated with TC (respectively: 52% vs 18%, p=0.01; 47% vs 11%, p=0.01; 80% vs 41%, p=0.01). The combination of these ECG findings identified TC with a specificity of 95% and a positive predictive value of 85.7%. CONCLUSIONS The ECG on admission may be useful to distinguish TC from anterior STEMI. The combination of three ECG findings identifies patients with TC with high specificity and positive predictive value.
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Affiliation(s)
- Giacomo Mugnai
- Division of Cardiology, University Hospital of Verona, Verona Italy.
| | - Giulia Pasqualin
- Division of Cardiology, University Hospital of Verona, Verona Italy
| | - Giovanni Benfari
- Division of Cardiology, University Hospital of Verona, Verona Italy
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Waks JW, Sabatine MS, Cannon CP, Morrow DA, Gibson CM, Wiviott SD, Giugliano RP, Sloan S, Scirica BM. Clinical implications and correlates of Q waves in patients with ST-elevation myocardial infarction treated with fibrinolysis: observations from the CLARITY-TIMI 28 trial. Clin Cardiol 2014; 37:160-6. [PMID: 24452727 DOI: 10.1002/clc.22235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/27/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The relationships between Q waves that appear during the acute phase of ST-elevation myocardial infarction (STEMI), clinical characteristics, ST-segment resolution (STRes), and clopidogrel therapy in patients treated with fibrinolysis are not well described. HYPOTHESIS We hypothesized that Q waves would be associated with less successful reperfusion and increased cardiovascular events. METHODS In the CLARITY-TIMI 28 trial, 3491 STEMI patients treated with fibrinolysis were randomized to clopidogrel or placebo. Electrocardiograms were evaluated for STRes post-fibrinolysis and the presence of pathologic Q waves during the index hospitalization in 3322 patients. RESULTS Q waves were identified in 2045 patients (61.6%) prior to discharge and were associated with increased odds of congestive heart failure (CHF) (adjusted odds ratio [ORadj ]: 2.10, P = 0.002) or the composite of cardiovascular death/CHF at 30 days (ORadj : 2.08, P ≤ 0.001). Q waves were associated with lower odds of Thrombolysis in Myocardial Infarction [TIMI] flow grade 2 to 3 (ORadj : 0.78, P = 0.028), TIMI myocardial perfusion grade 3 (ORadj : 0.83, P = 0.029), and complete STRes at 90 minutes (ORadj : 0.80, P = 0.030). Patients with both a Q wave and incomplete STRes 90 minutes after fibrinolysis were at higher risk for cardiovascular death or CHF (11.1%) than patients with no Q wave and at least partial STRes (1.9%). Overall, clopidogrel tended to be equally or more effective in patients without Q waves compared to those with Q waves. CONCLUSIONS Among STEMI patients treated with fibrinolysis, evaluating for Q waves prior to discharge is a simple method of assessing for less successful reperfusion and an increased risk of adverse 30-day cardiovascular outcomes. The combination of Q waves and 90-minute STRes allows additional risk refinement.
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Affiliation(s)
- Jonathan W Waks
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Taboulet P, Smith SW, Brady WJ. Diagnostic ECG du syndrome coronarien aigu. Partie 3. Les anomalies des complexes QRS. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0279-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Electrocardiographic Differentiation of Early Repolarization From Subtle Anterior ST-Segment Elevation Myocardial Infarction. Ann Emerg Med 2012; 60:45-56.e2. [DOI: 10.1016/j.annemergmed.2012.02.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 01/17/2012] [Accepted: 02/06/2012] [Indexed: 11/17/2022]
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16
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Fontanelli A, Bonanno C. Primary percutaneous coronary intervention in ‘early’ latecomers with ST-segment elevation acute myocardial infarction: the role of the infarct-related artery status. J Cardiovasc Med (Hagerstown) 2011; 12:13-8. [DOI: 10.2459/jcm.0b013e32834038d8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Kumar S, Hsieh C, Sivagangabalan G, Chan H, Ryding ADS, Narayan A, Ong ATL, Sadick N, Kovoor P. Prognostic impact of Q waves on presentation and ST resolution in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol 2009; 104:780-5. [PMID: 19733711 DOI: 10.1016/j.amjcard.2009.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 05/05/2009] [Accepted: 05/05/2009] [Indexed: 11/18/2022]
Abstract
Q waves can develop early in infarction and indicate infarct progression better than symptom duration. ST resolution (STR) is a predictor of reperfusion success. Our aim was to assess the prognostic impact of Q waves on presentation and STR after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction. The combined end point was of mortality and adverse cardiovascular events (MACE; death, repeat myocardial infarction, or heart failure). Q waves on presentation (Q wave, n = 332; no Q wave, n = 337) was associated with significantly less mean STR, greater incidence of akinetic, dyskinetic, or aneurysmal regional wall motion, lower left ventricular ejection fraction, and worse in-hospital and 1-year MACEs (1 year 24% vs 8.2%, p <0.001). In addition, Q waves on presentation compared to no Q waves were associated with worse 1-year MACE regardless of infarct presentation in < or =3 hours, infarct location, and adequate STR (> or =70%). Q waves on presentation and inadequate STR (<70%), but not symptom duration, were independent predictors of MACE by multivariable analysis (adjusted hazard ratios of 2.7 and 2.4 for Q waves and STR, respectively). Compared to group A (no Q waves on presentation with STR), patients in group B (no Q waves with inadequate STR), group C (Q waves with STR), and group D (Q waves with inadequate STR) had hazard ratios of 3.0, 3.6, and 7.7, respectively (p <0.05) for the occurrence of MACE. In conclusion, assessment of Q-wave status on presentation and STR immediately after PPCI provides a simple and early clinical predictor of outcomes in ST-elevation myocardial infarction.
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Affiliation(s)
- Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
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18
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Nable JV, Brady W. The evolution of electrocardiographic changes in ST-segment elevation myocardial infarction. Am J Emerg Med 2009; 27:734-46. [DOI: 10.1016/j.ajem.2008.05.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2008] [Accepted: 05/25/2008] [Indexed: 11/16/2022] Open
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19
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Armstrong PW, Fu Y, Westerhout CM, Hudson MP, Mahaffey KW, White HD, Todaro TG, Adams PX, Aylward PE, Granger CB. Baseline Q-Wave Surpasses Time From Symptom Onset as a Prognostic Marker in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2009; 53:1503-9. [DOI: 10.1016/j.jacc.2009.01.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 01/23/2009] [Accepted: 01/25/2009] [Indexed: 10/20/2022]
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20
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Birnbaum Y, Chetrit A, Sclarovsky S, Zlotikamien B, Herz I, Olmer L, Barbash GI. Abnormal Q waves on the admission electrocardiogram of patients with first acute myocardial infarction: prognostic implications. Clin Cardiol 2009; 20:477-81. [PMID: 9134281 PMCID: PMC6655437 DOI: 10.1002/clc.4960200515] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Q waves developed in the subacute and persisting into the chronic phase of myocardial infarction (MI) usually signify myocardial necrosis. However, the mechanism and significance of Q waves that appear very early in the course of acute MI (< 6 h from onset of symptoms), especially if accompanied by ST elevation, are probably different. HYPOTHESIS This study assesses the prognostic implications of abnormal Q waves on admission in 2,370 patients with first acute MI treated with thrombolytic therapy < 6 h of onset of symptoms. RESULTS Patients with abnormal Q waves in > or = 2 leads with ST-segment elevation (n = 923) were older than patients without early Q waves (n = 1,447) (60.6 +/- 11.9 vs. 58.8 +/- 11.9 years, respectively; p = 0.0003), and had a greater incidence of hypertension (34.3 vs. 30.5%; p = 0.05) and anterior MI (60.6 vs. 41.1%; p < 0.0001). Time from onset of symptoms to therapy was longer in patients with Q waves upon admission (208 +/- 196 vs. 183 +/- 230 min; p = 0.01). Peak serum creatine kinase (2235 +/- 1544 vs. 1622 +/- 1536 IU; p < 0.0001), prevalence of heart failure during hospitalization (13.8 vs. 7.0%, p < 0.0002), hospital mortality (8.0 vs. 4.6%; p = 0.02), and cardiac mortality (6.6 vs. 4.5%, p = 0.11) were higher in patients with anterior MI and with abnormal Q waves than in those without abnormal Q waves upon admission. There was no difference in peak creatine kinase, prevalence of heart failure, in-hospital mortality, and cardiac mortality between patients with and without abnormal Q waves in inferior MI. Multivariate regression analysis confirmed that mortality is independently associated with presence of Q waves on admission (odds ratio 1.61; 95% CI 1.04-2.49; p = 0.04 for all patients; odds ratio 1.65; 95% CI 0.97-2.83; p = 0.09 for anterior wall MI. CONCLUSION Abnormal Q waves on the admission electrocardiogram (ECG) are associated with higher peak creatine kinase, higher prevalence of heart failure, and increased mortality in patients with anterior MI. Abnormal Q waves on the admission ECG of patients with inferior MI are not associated with adverse prognosis.
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Affiliation(s)
- Y Birnbaum
- Beilinson Medical Center, Petah-Tiqva, Israel
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21
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Galcerá-Tomás J, Melgarejo-Moreno A, Alonso-Fernández N, Padilla-Serrano A, Martínez-Hernández J, Gil-Sánchez FJ, del Rey-Carrión A, de Gea JH, Rodríguez-García P, Martínez-Baño D, Jiménez-Sánchez R, Murcia-Hernández P, del Saz A. El sexo femenino se asocia de forma inversa e independiente a la marcada elevación del segmento ST. Estudio en pacientes con infarto agudo de miocardio con ST elevado e ingreso precoz. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)70017-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Acute Coronary Syndromes and Acute Myocardial Infarction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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23
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Kusama I, Hibi K, Kosuge M, Nozawa N, Ozaki H, Yano H, Sumita S, Tsukahara K, Okuda J, Ebina T, Umemura S, Kimura K. Impact of plaque rupture on infarct size in ST-segment elevation anterior acute myocardial infarction. J Am Coll Cardiol 2007; 50:1230-7. [PMID: 17888839 DOI: 10.1016/j.jacc.2007.07.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 06/06/2007] [Accepted: 07/03/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We sought to assess whether coronary plaque rupture at culprit lesions is associated with infarct size in patients with anterior acute myocardial infarction (AMI). BACKGROUND Some patients with AMI have large infarcts despite early reperfusion. Whether culprit plaque morphology impacts infarct size or not remains unknown. METHODS Patients who had a first anterior AMI with reperfusion within 6 hours after onset were enrolled and divided into 2 groups according to the presence or absence of plaque rupture at the culprit lesion as defined by preintervention intravascular ultrasound (IVUS): patients with rupture (n = 54) and without rupture (n = 37). RESULTS Patients with plaque rupture had a higher incidence of no-reflow phenomenon (15% vs. 3%; p = 0.08) and a lower myocardial blush grade (1.5 vs. 2.3; p < 0.05) after percutaneous coronary intervention. The IVUS analysis showed that patients with plaque rupture had a higher incidence of soft plaque and positive remodeling. Peak creatine kinase levels were higher (4,707 vs. 2,309 IU/l; p < 0.0001) and left ventricular ejection fraction in the chronic phase was lower (54% vs. 63%; p < 0.01) in patients with plaque rupture. A multivariate logistic regression analysis revealed that plaque rupture and the proximal lesion site correlated with a left ventricular ejection fraction of <50% in the chronic phase (odds ratios 6.5 and 17.5, respectively; p < 0.05). CONCLUSIONS Plaque rupture is associated with morphologic characteristics of vulnerable lesions, as well as with larger infarcts and a higher incidence of no-reflow phenomenon, suggesting that plaque embolism contributes to the progression of myocardial damage in patients with anterior AMI.
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Affiliation(s)
- Ikuyoshi Kusama
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
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Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic Markers of Reperfusion in ST-elevation Myocardial Infarction. Cardiol Clin 2006; 24:367-76, viii. [PMID: 16939829 DOI: 10.1016/j.ccl.2006.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The outcome of patients who fail to reperfuse with thrombolytic therapy or percutaneous coronary intervention (PCI) for ST-elevation acute myocardial infarction (STEMI) may be improved with additional pharmacologic and mechanical interventions such as rescue PCI or intravenous glycoprotein IIb/IIIa infusion. The standard 12-lead ECG is the most commonly available and suitable tool for routine bedside evaluation of the success of reperfusion therapy for STEMI. This article reviews and discusses the current data on the four ECG markers for prediction of the perfusion status of the ischemic myocardium: ST-segment deviation, T-wave configuration, QRS changes, and reperfusion arrhythmias.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555, USA
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25
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Abstract
The ECG is an essential part of the initial evaluation of patients who have chest pain, especially in the immediate decision-making process in patients who have ST-elevation myocardial infarction. This article reviews and summarizes the current information that can be obtained from the admission ECG in patients who have ST-elevation acute myocardial infarction, with an emphasis on: (1) prediction of final infarct size, (2) estimation of prognosis, and (3) the correlations between various ECG patterns and the localization of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555, USA
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26
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Abstract
Despite technologic advances in many diagnostic fields, the 12-lead ECG remains the basis for early identification and management of an acute coronary syndrome. This article reviews the use of the ECG in acute coronary syndromes.
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Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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Atar S, Birnbaum Y. Ischemia-induced ST-segment elevation: classification, prognosis, and therapy. J Electrocardiol 2005; 38:1-7. [PMID: 16226066 DOI: 10.1016/j.jelectrocard.2005.06.098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) remains the most useful tool for the diagnosis, early risk stratification, triage, and guidance of therapy in patients with acute coronary syndromes. However, the initial and the terminal part of the QRS complex, the ST segments, and the T waves are influenced by anatomical and metabolic factors such as the "myocardium at risk" and "severity" and "duration" of ischemia. Moreover, there are complex interactions between all these factors. The ECG can identify potential candidates for reperfusion therapy as well as the completeness and success of reperfusion, whereas it can also identify those patients who will have no benefit from reperfusion because of either late arrival or nonischemic etiologies of ECG changes. These patients may have a "pseudo" ST-elevation acute myocardial infarction (STEAMI) or "pseudo-pseudo" STEAMI. The presence of Q waves and additional ST-segment depression and T-wave inversion on the admission ECG in patients with STEAMI may provide us information regarding the potential myocardial reserves, and various ECG scoring systems are in current use for that purpose. The pattern and timing of changes in Q waves, ST segment, and T waves may all be markers of the patency status of the infarct-related artery. We review and discuss each of the dynamic ECG variables during ischemia and reperfusion: the initial QRS (Q and R waves), the terminal QRS (Sclarovsky-Birnbaum score), the ST segment, and the T waves.
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Affiliation(s)
- Shaul Atar
- The Division of Cardiology, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
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Birnbaum Y, Ware DL. Electrocardiogram of acute ST-elevation myocardial infarction: the significance of the various "scores". J Electrocardiol 2005; 38:113-8. [PMID: 15892020 DOI: 10.1016/j.jelectrocard.2005.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Electrocardiogram has extensively been used for evaluation and triage of patients with acute chest pain. The clinician admitting a patient with ST elevation acute myocardial infarction should be able to estimate the size and location of the ischemic area at risk, how much of the ischemic myocardium has already undergone irreversible necrosis by the time of presentation, and the "severity of ischemia" (or what is the rate of progression of necrosis as long as ischemia continues). The electrocardiographic variables that are used to make these estimates are the initial portion of the QRS (Q and R waves), the terminal portion of the QRS (the S waves and the J-point), the ST segment, and the configuration of the T waves. This editorial discuss the ability to predict each of the "physiological" parameters using the above mentioned electrocardiographic variables.
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Affiliation(s)
- Yochai Birnbaum
- Division of Cardiology, Department of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA.
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29
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Cosić Z, Tavcioski D, Jovelić A, Romanović R. Late ventricular potentials in risk assessment of the occurrence of complex ventricular arrhythmia in patients with myocardial infarction and heart failure. VOJNOSANIT PREGL 2005; 61:589-97. [PMID: 15717719 DOI: 10.2298/vsp0406589c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIM To determine the prognostic significance of late ventricular potentials on signal-averaged electrocardiogram and left ventricular ejection fraction for the occurrence of complex ventricular arrhythmia in patients treated with accelerated tissue-type plasminogen activator, using the rapid protocol, within six months of acute myocardial infarction. METHODS In this analytic observational prospective study patients were divided into four groups: patients with left ventricular ejection fraction bellow 40% and late ventricular potentials, patients with left ventricular ejection fraction bellow 40% and without late ventricular potentials, patients with left ventricular ejection fraction over 40% and late ventricular potentials, and patients with left ventricular ejection fraction over 40% and without late ventricular potentials. Complex ventricular arrhythmias (Lown grade IVa, IVb, and V) were recorded using standard electrocardiography and 24-hour Holter monitoring 21, 60, and 90 days after acute myocardial infarction, respectively. Serial recordings of signal-averaged electrocardiogram were obtained 30, 90, and 180 days after acute myocardial infarction. Left ventricular ejection fraction was determined by echocardiography between 15 and 21 days after acute myocardial infarction. Multivariant logistic regression analysis was used to evaluate the relation between late ventricular potentials and left ventricular ejection fraction with the occurrence of complex ventricular arrhythmias. Sensitivity, specificity, positive and negative predictive values of late ventricular potentials and left ventricular ejection fraction for the occurrence of complex ventricular arrhythmias were determined. RESULTS The prospective study included 80 patients (73% men), mean age 64 +/- 3.5 years. Complex ventricular arrhythmias were recorded in 34 (42.5%) of patients, all 17 (50%) of which were from the first group (p < 0.01). Complex ventricular arrhythmias were recorded in 25 (73.5%) patients with late ventricular potentials, and in 23 (67.6%) patients with left ventricular ejection fraction bellow 40%. Left ventricular ejection fraction bellow 40% and late ventricular potentials represented independent predictors for the occurrence of complex ventricular arrhythmias (RR = 14.33, p < 0.01). When combined with left ventricular ejection fraction bellow 40%, late ventricular potentials had sensitivity (0.50), specificity (0.93), and positive predictive accuracy (0.85) higher than late ventricular potentials alone (0.44, 0.67, and 0.37, respectively) for the occurrence of complex ventricular arrhythmias following acute myocardial infarction. CONCLUSION In this study, late ventricular potentials in patients with left ventricular ejection fraction bellow 40% represented the independent predictor for the occurrence of complex ventricular arrhythmias in the first six months after the first myocardial infarction treated with accelerated tissue-type plasminogen activator, using the rapid protocol.
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Affiliation(s)
- Zoran Cosić
- Military Medical Academy, Clinic of Cardiology, Belgrade.
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30
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Barbagelata A, Califf RM, Sgarbossa EB, Knight D, Mark DB, Granger CB, Armstrong PW, Elizari M, Birnbaum Y, Grinfeld LR, Ohman EM, Wagner GS. Prognostic value of predischarge electrocardiographic measurement of infarct size after thrombolysis: insights from GUSTO I Economics and Quality of Life substudy. Am Heart J 2004; 148:795-802. [PMID: 15523309 DOI: 10.1016/j.ahj.2004.04.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current methods for risk stratification after acute myocardial infarction (MI) include several noninvasive studies. In this cost-containment era, the development of low-cost means should be encouraged. We assessed the ability of an electrocardiogram (ECG) MI-sizing score to predict outcomes in patients enrolled in the Economics and Quality of Life (EQOL) sub study of the Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries -I (GUSTO-I) trial. METHODS We classified patients by electrocardiographic Selvester QRS score at hospital discharge: those with a score 0-9 versus > or =10. Endpoints were 30-day and 1-year mortality, resource use, and quality-of-life measures. RESULTS Patients with a QRS score <10 were well-matched with those with QRS score > or =10 with the exception of a trend to more anterior MI in the higher scored group. Patients with QRS score > or =10 had increased risk of death at 30-days (8.9% vs. 2.9% P < .001), and this difference persisted at 1 year (12.6% vs. 5.4%, P = .001). Recurrent chest pain, use of angiography, and angioplasty were similar during follow-up. However, there was a trend toward less coronary bypass surgery in patients with a QRS score > or =10. Readmission rates were higher at 30 days but similar at 1 year. CONCLUSIONS Stratification of patients after acute MI by a simple measure of MI size identifies populations with different long-term prognoses; patients with a QRS score > or =10 (approximately 30% of the left ventricle infarcted) at discharge have poorer outcomes in both the short- and long-term. The standard 12-lead ECG provides a simple, economical means of risk stratification at discharge.
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Hedén B, Ripa R, Persson E, Song Q, Maynard C, Leibrandt P, Wall T, Christian TF, Hammill SC, Bell SS, Pahlm O, Wagner GS. A modified Anderson-Wilkins electrocardiographic acuteness score for anterior or inferior myocardial infarction. Am Heart J 2004; 146:797-803. [PMID: 14597927 DOI: 10.1016/s0002-8703(03)00404-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Optimal treatment of acute myocardial infarction (AMI) depends on the duration of the ischemia. The Anderson Wilkins (AW) electrocardiographic acuteness score has been shown to complement the historical timing in estimating the time interval from acute thrombotic coronary occlusion in patients presenting with chest pain and evolving myocardial infarction. The purposes of this study were to (1) compare the distributions of the previously developed AW acuteness score in a training population with either anterior or inferior AMI and (2) propose modifications to the formula to achieve distributions similar to the observed distributions of historical times from onset of pain. METHODS Two hundred three and 177 patients were included as training and testing population, respectively. All patients had an anterior or an inferior AMI and were without confounding factors on the electrocardiogram. RESULTS The training population had similar distributions of historical times from onset of pain, but differences in distributions of AW acuteness scores, between patients with anterior and inferior AMI (P <.0001). Eighty percent of the inferior AMI group had the highest possible AW acuteness score. Modification of a Q-wave criterion from > or =30 to > or =20 ms resulted in similar distributions in patients with anterior and inferior AMI both in the training and an independent testing population. CONCLUSIONS These results suggest that a modified AW acuteness score using a lower Q-wave duration criterion provides similar AMI timing information in patients with anterior and inferior locations. Clinical use of the AW acuteness score will only be practical if the calculation is automated.
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Affiliation(s)
- Bo Hedén
- Department of Clinical Physiology, Lund University, Lund, Sweden
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32
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Birnbaum Y, Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. Postgrad Med J 2003; 79:490-504. [PMID: 13679544 PMCID: PMC1742828 DOI: 10.1136/pmj.79.935.490] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The electrocardiogram is considered an essential part of the diagnosis and initial evaluation of patients with chest pain. This review summarises the information that can be obtained from the admission electrocardiogram in patients with ST elevation acute myocardial infarction, with emphasis on: (1) prediction of infarct size, (2) estimation of prognosis, and (3) the correlations between various electrocardiographic patterns and the localisation of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Y Birnbaum
- University of Texas Medical Branch, Galveston, Texas 77555-0553, USA.
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33
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Ogura R, Hiasa Y, Takahashi T, Yamaguchi K, Fujiwara K, Ohara Y, Nada T, Ogata T, Kusunoki K, Yuba K, Hosokawa S, Kishi K, Ohtani R. Specific findings of the standard 12-lead ECG in patients with 'Takotsubo' cardiomyopathy: comparison with the findings of acute anterior myocardial infarction. Circ J 2003; 67:687-90. [PMID: 12890911 DOI: 10.1253/circj.67.687] [Citation(s) in RCA: 179] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The clinical course of 'Takotsubo' cardiomyopathy closely resembles that of acute myocardial infarction (AMI) and coronary angiography (CAG) is usually performed to distinguish the 2 conditions during the acute phase. The present study was designed to determine whether the standard 12-lead electrocardiogram (ECG) findings could help to distinguish 'Takotsubo' cardiomyopathy from anterior AMI. The study group comprised 13 patients with 'Takotsubo' cardiomyopathy and 13 consecutive patients with anterior AMI. Patients with 'Takotsubo' cardiomyopathy had abnormal Q waves less frequently than patients with anterior AMI (15% vs 69%, p=0.008). No reciprocal changes were seen in the inferior leads in patients with 'Takotsubo' cardiomyopathy (p=0.0003). The ratio of ST-segment elevation in leads V(4-6) to V(1-3) (SigmaSTeV(4-6)/V(1-3)) was significantly higher in patients with 'Takotsubo' cardiomyopathy (1.55+/-0.53 vs 0.57+/-0.58, p=0.0004). The QTc interval was significantly longer in patients with 'Takotsubo' cardiomyopathy. The absence of reciprocal changes, absence of abnormal Q waves, and a SigmaSTeV(4-6)/V(1-3) >/=1 all showed a high sensitivity and specificity for diagnosing 'Takotsubo' cardiomyopathy. Furthermore, the combination of the absence of reciprocal changes and a SigmaSTeV(4-6)/V (1-3) >/=1 had a greater specificity (100%) and overall accuracy (91%) than either criteria. Therefore, the standard 12-lead ECG on admission can help to distinguish 'Takotsubo' cardiomyopathy from anterior AMI.
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Affiliation(s)
- Riyo Ogura
- Division of Cardiology, Tokushima Red Cross Hospital, Komatsushima, Japan
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Sakata K, Yoshino H, Houshaku H, Koide Y, Yotsukura M, Ishikawa K. Myocardial damage and left ventricular dysfunction in patients with and without persistent negative T waves after Q-wave anterior myocardial infarction. Am J Cardiol 2001; 87:510-5. [PMID: 11230830 DOI: 10.1016/s0002-9149(00)01422-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Persistent T-wave inversions during the chronic stage of Q-wave myocardial infarction (MI) indicate the presence of a transmural infarction with a fibrotic layer pathologically. The aim of the present study was to examine the relation between left ventricular (LV) damage and changes in polarity of the T waves from the acute to chronic phase in patients with Q-wave anterior wall MI. We studied 140 patients with persistent T-wave inversions in leads with Q waves (negative T-wave group) and 158 patients with positive T waves (positive T-wave group) at 12 months after anterior MI. In the positive T-wave group, the precordial T waves reverted from a negative to a positive morphology < 3 months after MI in 21 patients (3 M-positive T-wave subgroup), 3 to 6 months in 52 patients (6 M-positive T-wave subgroup), and 6 to 12 months in 75 patients (12 M-positive T-wave subgroup). Ten patients had persistent positive T waves without initial T-wave inversion (persistent positive T-wave group). Wall motion index and LV dimension were higher and the wall thickness for the infarct area and LV ejection fraction were lower in the negative T-wave than in the positive T-wave groups, except the persistent positive T-wave group in the chronic stage (p < 0.0001). Wall motion in the infarcted area improved over the course of 1 year in the 3 M-, 6 M-, and 12 M-positive T-wave subgroups (p < 0.0001), but not in the persistent positive T-wave group. Among the patients with T-wave inversions after admission, those who had persistent negative T waves after 12 months had worse LV function. In patients with initial T-wave inversion, earlier normalization of the precordial T waves was associated with greater improvement in LV function. Patients with persistent positive T waves without initial negative T waves had poorer recovery of LV function than patients with persistent negative T waves. We conclude that the presence of inverted T waves in leads with abnormal Q waves 12 months after MI and the time required for T-wave normalization can be used to assess the degree of LV dysfunction.
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Affiliation(s)
- K Sakata
- Second Department of Internal Medicine, Kyorin Universty School of Medicine, Mitaka, Tokyo, Japan
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35
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Vaturi M, Birnbaum Y. The use of the electrocardiogram to identify epicardial coronary and tissue reperfusion in acute myocardial infarction. J Thromb Thrombolysis 2000; 10:137-47. [PMID: 11005936 DOI: 10.1023/a:1018762509887] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: (1) ST-segment measurements, (2) T-wave configuration, (3) QRS changes, and (4) reperfusion arrhythmias. Complete and stable (> or = 70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30 to 70%) or no (<30%) ST-segment resolution. Early inversion of the T waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude, and width; R-wave amplitude; and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes has not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm, are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST segments and T waves occur during reperfusion therapy and the days after. Whereas changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes is less clear, and especially whether changes in the QRS complex and T wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and reischemia should be used for therapeutic decision making in the clinical setting.
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Affiliation(s)
- M Vaturi
- The Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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Vaturi MD M, Birnbaum MD Y. The use of the electrocardiogram to identify epicardial coronary and tissue reperfusion in acute myocardial infarction. J Thromb Thrombolysis 2000; 10:5-14. [PMID: 10947909 DOI: 10.1023/a:1018794918584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The standard 12-lead ECG gives us crucial information concerning myocardial perfusion and the success of reperfusion therapy for ST-elevation acute myocardial infarction. Continuous monitoring has advantages over repeated snapshot recordings. There are four electrocardiographic markers for prediction of the perfusion status of the ischemic myocardium: 1) ST-segment measurements; 2) T-wave configuration; 3) QRS changes; and 4) reperfusion arrhythmias. Complete and stable (> or = 70%) resolution of ST-segment elevation is associated with better outcome and preservation of left ventricular function than partial (30% to 70%) or no (< 30%) ST-segment resolution. Early inversion of the T-waves after initiation of reperfusion therapy is another marker of myocardial reperfusion and a good prognostic sign. Using standard 12-lead ECG, dynamic changes in Q-wave number, amplitude and width, R-wave amplitude and S-wave appearance are detected during reperfusion therapy. However, the significance of these changes have not been clarified. Reperfusion arrhythmias, especially bradycardia and accelerated idioventricular rhythm are detected occasionally during reperfusion therapy, but the value of reperfusion arrhythmias as a marker of coronary artery patency is still debatable. Dynamic changes in the QRS complexes, ST-segments and T-waves occur during reperfusion therapy and the days after. While changes in ST-segment amplitude have been extensively studied, the significance of QRS-complex and T-wave changes are less clear, and especially whether changes in the QRS-complex and T-wave may be complementary and additive to ST-segment monitoring. It has remained unclear whether electrocardiographic signs of reperfusion and re-ischemia should be used for therapeutic decision-making in the clinical setting.
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Affiliation(s)
- M Vaturi MD
- The Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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37
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Adler Y, Zafrir N, Ben-Gal T, Lulu OB, Maynard C, Sclarovsky S, Balicer R, Mager A, Strasberg B, Solodky A, Wagner GS, Birnbaum Y. Relation between evolutionary ST segment and T-wave direction and electrocardiographic prediction of mycardial infarct size and left ventricular function among patients with anterior wall Q-wave acute myocardial infarction who received reperfusion therapy. Am J Cardiol 2000; 85:927-33. [PMID: 10760328 DOI: 10.1016/s0002-9149(99)00903-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the prethrombolytic era it was found that infarct size and left ventricular ejection fraction could be predicted using the Selvester QRS score. We evaluated whether infarct size and left ventricular ejection fraction could be predicted by the predischarge QRS score in patients who had received reperfusion therapy and whether considering the configuration of the ST segments and T waves would increase the accuracy of these predictions. We evaluated 51 patients with first anterior wall myocardial infarction who had received reperfusion therapy and predischarge resting technetium-99m-sestamibi scan. The electrocardiograms recorded on the same day of the scan were analyzed for the QRS score and were divided into 3 groups: A, isoelectric ST and negative T waves; B, ST elevation (> or =0.1 mV) and negative T waves; and C, ST elevation (> or =0.1 mV) and positive T waves. Groups A, B, and C included 12, 23, and 16 patients, respectively. The myocardial perfusion defect extent increased from groups A to C (median 21%, 37%, and 43.5% in groups A, B, and C, respectively; p = 0.023). Similarly, left ventricular ejection fraction decreased (44%, 38%, and 34%, respectively; p = 0.042) from groups A to C. Overall, the correlation between the QRS score and the myocardial perfusion defect extent (rho 0.249; p = 0.08) and ejection fraction (rho -0.229; p = 0.11) was poor. A statistically significant correlation between myocardial perfusion defect size and QRS score was found only in group A (rho 0.599, p = 0.04). Among patients with anterior myocardial infarction who received reperfusion therapy, the predischarge QRS score was predictive of infarct size only in those in whom ST elevation resolved completely. In patients with residual ST elevation there was no correlation between QRS score and infarct size.
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Affiliation(s)
- Y Adler
- Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Al-Mohammad A, Norton MY, Mahy IR, Patel JC, Welch AE, Mikecz P, Walton S. Can the surface electrocardiogram be used to predict myocardial viability? Heart 1999; 82:663-7. [PMID: 10573488 PMCID: PMC1729205 DOI: 10.1136/hrt.82.6.663] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate whether QRS morphology on the surface ECG can be used to predict myocardial viability. DESIGN ECGs of 58 patients with left ventricular impairment undergoing positron emission tomography (PET) were studied. (13)N-Ammonia (NH(3)) and (18)F-fluorodeoxyglucose (FDG) were the perfusion and the metabolic markers, respectively. The myocardium is scarred when the uptake of both markers is reduced (matched defect). Reduced NH(3) uptake with persistent FDG uptake (mismatched defect) represents hibernating myocardium. First, the relation between pathological Q waves and myocardial scarring was investigated. Second, the significance of QR and QS complexes in predicting hibernating myocardium was determined. RESULTS As a marker of matched PET defects, Q waves were specific (79%) but not sensitive (41%), with a 77% positive predictive accuracy and a poor (43%) negative predictive accuracy. The mean size of the matched PET defect associated with Q waves was 20% of the left ventricle. This was not significantly different from the size of the matched PET defects associated with no Q waves (18%). Among the regions associated with Q waves on the ECG, there were 16 regions with QR pattern (group A) and 23 regions with QS pattern (group B). The incidence of mismatched PET defects was 19% of group A and 30% of group B (NS). CONCLUSIONS Q waves are specific but not sensitive markers of matched defects representing scarred myocardium. Q waves followed by R waves are not more likely to be associated with hibernating myocardium than QS complexes.
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Affiliation(s)
- A Al-Mohammad
- Cardiac Department, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
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Watanabe Y, Wang J, Kondo T, Tokuda M, Chikamatsu H, Yasui T, Yamaguchi T, Kinoshita M, Kamide S, Nagai N, Abo Y, Yokoi H, Hishida H. Vectorcardiographic evaluation of myocardial infarct size: departure parameters are superior to conventional spatial parameters. JAPANESE CIRCULATION JOURNAL 1998; 62:473-8. [PMID: 9707001 DOI: 10.1253/jcj.62.473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To determine whether the departure parameters derived from a "departure loop" of a vectorcardiogram are more accurate than conventional spatial parameters in evaluating myocardial infarct size, 74 patients with first-onset myocardial infarction (MI) were studied. The correlation between the departure parameters (amplitudes in scalar leads of the departure loop) and the percent defect volume of thallium myocardial scintigrams (%DV) was compared with that of the spatial parameters (magnitude, azimuth, and elevation of the original QRS loop). In anteroseptal MI, the amplitude of a 20-msec vector in the z-axis and the azimuth of a 30-msec vector (H30) were significantly correlated with %DV (r=0.783, p<0.001 and r=0.572, p<0.05). In anteroseptal MI with involvement of the lateral wall, the amplitude of a 30-msec vector in the x-axis and H30 showed significant correlation with %DV (r=0.802, p<0.001 and r=0.772, p<0.01). In inferior and inferoposterior MI, the amplitude of a 30-msec vector in the y-axis and the elevation of a 30-msec vector were significantly correlated with %DV (r=0.920, 0.891, p<0.001 and r=0.871, 0.678, p<0.01, respectively). In conclusion, the departure parameters are more accurate than the spatial parameters for evaluation of myocardial infarct size.
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Affiliation(s)
- Y Watanabe
- Department of Internal Medicine, Fujita Health University, School of Medicine, Toyoake, Japan
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40
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Birnbaum Y, Sclarovsky S, Herz I, Zlotikamien B, Chetrit A, Olmer L, Barbash GI. Admission clinical and electrocardiographic characteristics predicting in-hospital development of high-degree atrioventricular block in inferior wall acute myocardial infarction. Am J Cardiol 1997; 80:1134-8. [PMID: 9359538 DOI: 10.1016/s0002-9149(97)00628-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study assessed the ability of simple clinical and electrocardiographic variables routinely obtained on admission to identify patients who are at high risk of developing high-degree atrioventricular (AV) block during hospitalization in 1,336 patients with inferior wall acute myocardial infarction (AMI). Patients were classified into 2 initial electrocardiographic patterns based on the J-point to R-wave amplitude ratio: pattern 1: those with J point/R wave <0.5 and pattern 2: patients with J point/R wave > or =0.5 in > or =2 leads of the inferior leads II, III, and aVF. High-degree AV block was found in 6.7% of patients (41 of 615) with pattern 1 versus 11.8% of the patients (85 of 721) with pattern 2 on admission electrocardiogram (p = 0.0008). Multivariate logistic regression analysis revealed that the only variables found to be independently associated with high-degree AV block were female gender (odds ratio [OR] 1.48; 95% confidence interval [CI] 0.98 to 2.23; p = 0.06); Killip class on admission > or =2 (OR 2.24; CI 1.43 to 3.51; p = 0.0004); initial electrocardiographic pattern 2 versus pattern 1 (OR 1.82; CI 1.22 to 2.21; p = 0.003); and absence of abnormal Q waves on admission (OR yes vs no 0.68; CI 0.44 to 1.05; p = 0.08). A simple electrocardiographic sign (J point/R wave > or =0.5 in > or =2 leads) is a reliable predictor of the development of advanced AV block among patients receiving thrombolytic therapy for inferior wall AMI.
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Affiliation(s)
- Y Birnbaum
- Beilinson Medical Center, Petah-Tiqva, Israel
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Birnbaum Y, Sclarovsky S. The Initial Electrocardiographic Pattern in Acute Myocardial Infarction. Ann Noninvasive Electrocardiol 1997. [DOI: 10.1111/j.1542-474x.1997.tb00337.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
42
|
MAYNARD CHARLES, EVERY NATHANR, MARTIN JENNYS, HALLSTROM ALFREDP, KENNEDY JWARD, WEAVER WDOUGLAS. The Western Washington and Myocardial Infarction Triage and Intervention Trials of Thrombolytic Therapy: 15 Years of Collaboration in the Pacific Northwest. J Interv Cardiol 1997. [DOI: 10.1111/j.1540-8183.1997.tb00028.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|