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Grimm K, Twerenbold R, Abaecherli R, Boeddinghaus J, Nestelberger T, Koechlin L, Troester V, Bourtzou A, Keller DI, Geigy N, Kozhuharov N, Wussler D, Wildi K, Hillinger P, Rubini Giménez M, Strebel I, Badertscher P, Puelacher C, du Fay de Lavallaz J, Osswald L, Morawiec B, Kawecki D, Miró Ò, Kühne M, Reichlin T, Mueller C. Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:857-868. [PMID: 31976746 DOI: 10.1177/2048872619853579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. METHODS We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. RESULTS Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. CONCLUSIONS The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.
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Affiliation(s)
- Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Roger Abaecherli
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Institute for Medical Engineering, Lucerne University of Applied Sciences and Arts, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Valentina Troester
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Anna Bourtzou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Servicio de Urgencias y Pneumologia, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Spain.,Leipzig Heart Center, Leipzig, Germany
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Beata Morawiec
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Damian Kawecki
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Michael Kühne
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
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Utilization of ST-segment deviation sum and change scores to identify acute myocardial infarction. Am J Emerg Med 2010; 28:790-7. [PMID: 20837256 DOI: 10.1016/j.ajem.2009.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 03/31/2009] [Accepted: 04/01/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE No information is currently available regarding the optimal cutoff values of the baseline ST-segment deviation sum (STDsum(baseline)) and 60-minute ST-segment deviation change (STDchange(60 min)) for predicting acute myocardial infarction (AMI). METHODS A retrospective study was performed in 783 admitted patients with chest pain who had suspected acute coronary syndrome and absence of left ventricular hypertrophy or bundle branch block on the initial electrocardiogram (ECG). The STDsum(baseline) was defined as the sum in millimeters (1 mm = 0.1 mV) of the absolute value of ST-segment deviations in all 12 leads at the initiation of continuous 12-lead ECG monitoring session. The STDchange(60 min) was defined as the absolute value of the difference between the baseline and 60-minute STDsum. Three cutoff values are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI was greater than or equal to 5, 10, and 20, respectively. RESULTS Acute myocardial infarction occurred in 162 (20.7%) patients. The smallest cutoff value of the STDsum(baseline) for AMI with a +LR equal to or greater than 5, 10, and 20 was 9.6, 12.4, and 14.1 mm, respectively. In the subset of 699 patients without ST-segment elevation AMI on initial ECG, the smallest cutoff value of the STDchange(60 min) for AMI with a +LR equal to or greater than 5, 10, and 20 was 2.4, 3.5, and 7.9 mm, respectively. CONCLUSIONS Clinical studies need to be performed to determine if STDsum and STDchange, in conjunction with physician pretest probability of AMI, can be used to select patients who may benefit from emergent reperfusion therapy and other aggressive medical management strategies.
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Krishnaswamy A, Lincoff AM, Menon V. Magnitude and consequences of missing the acute infarct-related circumflex artery. Am Heart J 2009; 158:706-12. [PMID: 19853686 DOI: 10.1016/j.ahj.2009.08.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 08/21/2009] [Indexed: 10/20/2022]
Abstract
Emergent reperfusion strategies are integral to providing optimal patient outcomes in the setting of acute coronary artery occlusion. ST-segment elevation on the surface 12-lead electrocardiogram, although specific as a surrogate marker, is insensitive to acute posterior circulation coronary artery occlusion. Studies of non-ST-segment elevation acute coronary syndrome consistently identify patients who have epicardial vessel occlusion at the time of initial angiography, which is usually delayed for hours or days after the initial presentation. In addition, studies of ST-segment elevation myocardial infarction often divulge a disparity in identification of the infarct-related artery, with an underrepresentation of the left circumflex artery. Taken together, it is likely that many patients with left circumflex artery occlusion are "missed" during the early phases of myocardial infarction due to the electrocardiographically silent nature of the posterior territory, resulting in delayed myocardial salvage and worse cardiovascular outcomes. In this review, we report on the magnitude of missed left circumflex infarction and the consequences of this delay in diagnosis. We review the electrocardiographic findings of left circumflex occlusion and discuss strategies to enhance early identification. Heightened awareness of this clinical scenario and the available methods to avoid missing this elusive diagnosis are imperative in our quest to further improve the outcomes of patients with acute myocardial infarction.
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Wang J, Wang X, Ren L, Wang Q, Li L, Liu W, Wan Z, Yang L, Sun P, Ren L, Li M, Wu H, Wang J, Zhang L. Conjugation of Biomolecules with Magnetic Protein Microspheres for the Assay of Early Biomarkers Associated with Acute Myocardial Infarction. Anal Chem 2009; 81:6210-7. [DOI: 10.1021/ac9007418] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jinyi Wang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Xueqin Wang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Li Ren
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Qiang Wang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Li Li
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Wenming Liu
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Zongfang Wan
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Linyan Yang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Peng Sun
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Lili Ren
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Manlin Li
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Heng Wu
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Jinfeng Wang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
| | - Lei Zhang
- College of Veterinary Medicine and College of Science, and Shaanxi Key Laboratory of Molecular Biology for Agriculture, Northwest A&F University, Yangling, Shaanxi 712100, P.R. China
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Owens C, McClelland A, Walsh S, Smith B, Adgey J. Comparison of value of leads from body surface maps to 12-lead electrocardiogram for diagnosis of acute myocardial infarction. Am J Cardiol 2008; 102:257-65. [PMID: 18638583 DOI: 10.1016/j.amjcard.2008.03.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 03/17/2008] [Accepted: 03/17/2008] [Indexed: 11/18/2022]
Abstract
We aimed to develop 12-lead electrocardiographic (ECG) models testing ST-elevation criteria with QRST variables and compare their performance with the 80-lead body surface map (BSM) in detection of acute myocardial infarction (AMI). Because the prevalence of non-ST-elevation AMI is increasing worldwide, advances in early ECG detection of AMI are urgently needed. The study population was 755 consecutive patients presenting with ischemic chest pain from January 2002 to June 2004. All patients had electrocardiography and body surface mapping performed at initial presentation. AMI occurred in 519 patients (69%, cardiac troponin T or I level > or =0.1 ng/ml). Of these 519 patients, 303 (58%) had no ST-elevation on the initial 12-lead electrocardiogram. Ten patients were classified as having an "aborted AMI" and were included in the AMI analysis. The American College of Cardiology/European Society of Cardiology criteria for ST-elevation on 12-lead electrocardiogram identified 236 patients with AMI (sensitivity 45%, specificity 92%). Additional QRST features improved sensitivity (51% to 68%) but with decreased specificity (71% to 89%), with the optimal multivariate ECG model having a c-statistic of 0.75. The optimal BSM model identified 402 patients as having AMI (sensitivity 76%, specificity 92%, c-statistic 0.84). This improvement in sensitivity over the 12-lead electrocardiogram was due mainly to detection of ST-elevation in the high right anterior, posterior, and right ventricular territories and AMI in the presence of left bundle branch block. In conclusion, QRST variables added to criteria for ST-elevation result in improvement in sensitivity of the 12-lead electrocardiogram, although with decreased specificity. The BSM is superior in detecting AMI and demonstrates the importance of electroanatomic evaluation of patients with acute coronary syndromes.
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Affiliation(s)
- Colum Owens
- Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, Northern Ireland.
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