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Stensjøen AL, Hommerstad A, Halvorsen S, Arheden H, Engblom H, Erlinge D, Larsen AI, Sejersten Ripa M, Clemmensen P, Atar D, Hall TS. Worst lead ST deviation and resolution of ST elevation at one hour for prediction of myocardial salvage, infarct size, and microvascular obstruction in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Ann Noninvasive Electrocardiol 2020; 25:e12784. [PMID: 32592427 PMCID: PMC7679835 DOI: 10.1111/anec.12784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background ECG changes after revascularization predicts improved outcome for patients with ST‐elevation myocardial infarction (STEMI). Worst lead residual (WLR) ST deviation and resolution of worst lead ST elevation (rST elevation) are simple measures that can be obtained early after PCI. The objective of the current study was to investigate whether simple ECG measures, obtained one hour following PCI, could predict cardiac magnetic resonance (CMR)‐derived myocardial salvage index (MSI), infarct size (IS), and microvascular obstruction (MVO) in patients with STEMI included in the MITOCARE trial. Methods The MITOCARE trial included 165 patients with a first‐time STEMI presenting within six hours of symptom onset. The current analysis included patients that had an ECG recorded at baseline and one hour after PCI and underwent CMR imaging after 3–5 days. Independent core laboratories determined WLR ST deviation, rST elevation, and the CMR variables (MSI, IS, and MVO). Results 83 patients with a mean age of 61 years were included. 83.1% were males and 41% had anterior infarctions. In logistic regression models, WLR ST deviation was a statistically significant predictor of IS (OR 2.2, 95% CI 1.3–3.8) and MVO (OR 2.8, 95% CI 1.5–5.2), but not of MSI (OR 0.8, 95% CI 0.5–1.2). rST elevation showed a trend toward a significant association with IS (OR 0.3, 95% CI 0.1–1.0), but not with the other CMR variables. Conclusion WLR ST deviation one hour after PCI was a predictor of IS and MVO. WLR ST deviation, a measure easily obtained from ECGs following PCI, may provide important prognostic information in patients with STEMI.
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Affiliation(s)
| | - Anders Hommerstad
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Håkan Arheden
- Department of Clinical Sciences, Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Sciences, Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Alf-Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Maria Sejersten Ripa
- Novo Nordisk A/S, Søborg, Denmark.,Department of Cardiology, The Heart Centre, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Cardiology, The Heart Centre, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark.,Department of Medicine, Division of Cardiology, Nykoebing-Falster Hospital, University of Southern Denmark, Odense, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of General and Intervention Cardiology, University Heart Center, Hamburg-Eppendorf, Germany
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Trygve S Hall
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
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Du YT, Pasupathy S, Air T, Neil C, Beltrame JF. Validation of contemporary electrocardiographic indices of area at risk and infarct size in acute ST elevation myocardial infarction (STEMI). Int J Cardiol 2020; 303:1-7. [PMID: 31759688 DOI: 10.1016/j.ijcard.2019.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/16/2019] [Accepted: 10/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) methods to assess area at risk (AAR) and infarct size (IS) in patients with ST-elevation myocardial infarction (STEMI) have been previously established but not validated against contemporary benchmark Cardiac Magnetic Resonance (CMR) measures. We compared ECG-determined and CMR-determined measures for (a) AAR, (b) IS, and (c) myocardial salvage. METHODS Sixty patients with ECG evidence of STEMI and CMR imaging performed within 13 days were included. The ECG-determined (a) AAR scores (Aldrich and Wilkins), (b) IS (Selvester score), and (c) myocardial salvage (i.e. [AAR-IS] / AAR × 100%), were compared with CMR-determined measures. RESULTS Compared with CMR-determined AAR, both the Wilkins & Aldrich scores underestimated AAR, although the Wilkins (r = 0.72, p < 0.001) showed a better correlation than the Aldrich (r = 0.54, p < 0.001). Bland-Altman analysis revealed a bias of 2.6% (95% limits of agreement: 18.5%, -13.3%) for the Wilkins and 5.9% (95% limits of agreement: 25.6%, -13.8%) for the Aldrich. Estimation of IS was similar between the Selvester score and CMR, with good correlation (r = 0.77, p < 0.001) and agreement (fixed bias 0.4%, 95% limits of agreement 20.8%, -15.5%). However, ECG-determined myocardial salvage significantly underestimated CMR-determined myocardial salvage, with an inverse correlation (r = -0.33, p = 0.01). CONCLUSIONS The Wilkins score is superior to Aldrich score as an ECG-AAR index, Selvester score is a reasonable ECG estimate of infarct size, though ECG derived myocardial salvage does not have enough accuracy to be used in the clinical setting; it may be an inexpensive surrogate for myocardial salvage in large research studies. Further validation and prognostic studies are required.
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Affiliation(s)
- Yang Timothy Du
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Sivabaskari Pasupathy
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tracy Air
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher Neil
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia; Department of Cardiology, Western Health, Melbourne, Australia
| | - John F Beltrame
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia.
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de Framond Y, Schaaf M, Pichot-Lamoureux S, Range G, Dubreuil O, Angoulvant D, Claeys MJ, Dorado DG, Bochaton T, Rioufol G, Jossan C, Boussaha I, Ovize M, Mewton N. Regression of Q waves and clinical outcomes following primary PCI in anterior STEMI. J Electrocardiol 2019; 73:131-136. [PMID: 31668455 DOI: 10.1016/j.jelectrocard.2019.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 08/19/2019] [Accepted: 09/20/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pathological Q waves are correlated with infarct size, and Q-wave regression is associated with left ventricular ejection fraction improvement. There are limited data regarding the association of Q-wave regression and clinical outcomes. Our main objective was to assess the association of pathological Q wave evolution after reperfusion with clinical outcomes after anterior STEMI. METHODS Standard 12-lead electrocardiograms (ECGs) were recorded in 780 anterior STEMI patients treated with primary percutaneous coronary intervention (PCI) from the CIRCUS trial. ECGs were recorded before and 90 min following PCI, as well as at hospitalization discharge and 12 months of follow-up. The number of classic ECG criteria Q waves was scored for each ECG. Patients were classified in the Q wave regression group if they had regression of at least one Q wave between the post-PCI, the discharge and/or one year ECGs. Patients were classified in the Q wave persistent group if they had the same number or greater between the post-PCI, the discharge and/or 1 and one year ECGs. All-cause death and heart failure events were assessed for all patients at one year. RESULTS There were 323(43%) patients with persistent Q waves (PQ group), 378(49%) patients with Q wave regression (RQ group) and 60(8%) patients with non-Q wave MI (NQ group). Infarct size as measured by the peak creatine kinase was significantly greater in the PQ group compared to the RQ and NQ groups (4633 ± 2784 IU/l vs. 3814 ± 2595 IU/l vs. 1733 ± 1583 IU/l respectively, p < 0.0001). At one year, there were 22 deaths (7%) in the PQ-group, 15 (4%) in the RQ-group and none in the NQ-group (p = 0.04). There was a 4-fold increase in the risk of death or heart failure in the PQ compared to the NQ group (HR 4.7 [1.1; 19.3]; p = 0.03), but there was no significant difference between NQ and RQ groups (HR 3.3 [0.8; 13.8]; p = 0.09). CONCLUSION In a population of anterior STEMI patients, persistent Q waves defined according to the classic ECG criteria after reperfusion was associated with a 4-fold increase in the risk of heart failure or death compared to non-Q-wave MI, while Q-wave regression was associated with significantly lower risk of events.
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Affiliation(s)
- Yuni de Framond
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | | | - Sophie Pichot-Lamoureux
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | | | | | | | | | - David Garcia Dorado
- Vall d'Hebron University Hospital and Research Institut and CIBERC, Universtitat Autonoma de Barcelona, Spain
| | - Thomas Bochaton
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | - Gilles Rioufol
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | - Claire Jossan
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | - Inesse Boussaha
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | - Michel Ovize
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France
| | - Nathan Mewton
- Hopital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, Lyon, France, Centre d'Investigation Clinique de Lyon, Université Claude Bernard Lyon 1, France.
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Lindow T, Pahlm O, Olson CW, Khoshnood A, Ekelund U, Carlsson M, Swenne CA, Man S, Engblom H. Diagnostic Accuracy Of The Electrocardiographic Decision Support – Myocardial Ischaemia (EDS-MI) Algorithm In Detection Of Acute Coronary Occlusion. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:13-25. [DOI: 10.1177/2048872618768081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Electrocardiographic Decision Support – Myocardial Ischaemia (EDS-MI) is a graphical decision support for detection and localization of acute transmural ischaemia. A recent study indicated that EDS-MI performs well for detection of acute transmural ischaemia. However, its performance has not been tested in patients with non-ischaemic ST-deviation. We aimed to optimize the diagnostic accuracy of EDS-MI in patients with verified acute coronary occlusion as well as patients with non-ischaemic ST deviation and compare its performance with STEMI criteria. We studied 135 patients with non-ischaemic ST deviation (perimyocarditis, left ventricular hypertrophy, takotsubo cardiomyopathy and early repolarization) and 117 patients with acute coronary occlusion. In 63 ischaemic patients, the extent and location of the ischaemic area (myocardium at risk) was assessed by both cardiovascular magnetic resonance imaging and EDS-MI. Sensitivity and specificity of ST elevation myocardial infarction criteria were 85% (95% confidence interval (CI) 77, 90) and 44% (95% CI 36, 53) respectively. Using EDS-MI, sensitivity and specificity increased to 92% (95% CI 85, 95) and 81% (95% CI 74, 87) respectively (p=0.035 and p<0.001). Agreement was strong (83%) between cardiovascular magnetic resonance imaging and EDS-MI in localization of ischaemia. Mean myocardium at risk was 32% (± 10) by cardiovascular magnetic resonance imaging and 33% (± 11) by EDS-MI when the estimated infarcted area according to Selvester QRS scoring was included in myocardium at risk estimation. In conclusion, EDS-MI increases diagnostic accuracy and may serve as an automatic decision support in the early management of patients with suspected acute coronary syndrome. The added clinical benefit in a non-selected clinical chest pain population needs to be assessed.
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Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Sweden
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Sweden
| | - Olle Pahlm
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Sweden
| | | | - Ardavan Khoshnood
- Lund University, Department of Clinical Sciences Lund, Emergency Medicine, Skane University Hospital, Sweden
| | - Ulf Ekelund
- Lund University, Department of Clinical Sciences Lund, Emergency Medicine, Skane University Hospital, Sweden
| | - Marcus Carlsson
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Sweden
| | - Cees A Swenne
- Cardiology Department, Leiden University Medical Center, The Netherlands
| | - Sumche Man
- Cardiology Department, Leiden University Medical Center, The Netherlands
| | - Henrik Engblom
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Sweden
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