1
|
Ndrepepa G, Kastrati A. Coronary No-Reflow after Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy. J Clin Med 2023; 12:5592. [PMID: 37685660 PMCID: PMC10488607 DOI: 10.3390/jcm12175592] [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: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
Coronary no-reflow (CNR) is a frequent phenomenon that develops in patients with ST-segment elevation myocardial infarction (STEMI) following reperfusion therapy. CNR is highly dynamic, develops gradually (over hours) and persists for days to weeks after reperfusion. Microvascular obstruction (MVO) developing as a consequence of myocardial ischemia, distal embolization and reperfusion-related injury is the main pathophysiological mechanism of CNR. The frequency of CNR or MVO after primary PCI differs widely depending on the sensitivity of the tools used for diagnosis and timing of examination. Coronary angiography is readily available and most convenient to diagnose CNR but it is highly conservative and underestimates the true frequency of CNR. Cardiac magnetic resonance (CMR) imaging is the most sensitive method to diagnose MVO and CNR that provides information on the presence, localization and extent of MVO. CMR imaging detects intramyocardial hemorrhage and accurately estimates the infarct size. MVO and CNR markedly negate the benefits of reperfusion therapy and contribute to poor clinical outcomes including adverse remodeling of left ventricle, worsening or new congestive heart failure and reduced survival. Despite extensive research and the use of therapies that target almost all known pathophysiological mechanisms of CNR, no therapy has been found that prevents or reverses CNR and provides consistent clinical benefit in patients with STEMI undergoing reperfusion. Currently, the prevention or alleviation of MVO and CNR remain unmet goals in the therapy of STEMI that continue to be under intense research.
Collapse
Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| |
Collapse
|
2
|
de Vries NM, Zepeda-Echavarria A, van de Leur RR, Loen V, Vos MA, Boonstra MJ, Wildbergh TX, Jaspers JE, van der Zee R, Slump CH, Doevendans PA, van Es R. Detection of Ischemic ST-Segment Changes Using a Novel Handheld ECG Device in a Porcine Model. JACC. ADVANCES 2023; 2:100410. [PMID: 38939006 PMCID: PMC11198505 DOI: 10.1016/j.jacadv.2023.100410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/20/2023] [Accepted: 05/08/2023] [Indexed: 06/29/2024]
Abstract
Background Portable, smartphone-sized electrocardiography (ECG) has the potential to reduce time to treatment for patients suffering acute cardiac ischemia, thereby lowering the morbidity and mortality. In the UMC Utrecht, a portable, smartphone-sized, multi-lead precordial ECG recording device (miniECG 1.0, UMC Utrecht) was developed. Objectives The purpose of this study was to investigate the ability of the miniECG to capture ischemic ECG changes in a porcine coronary occlusion model. Methods In 8 animals, antero-septal myocardial infarction was induced by 75-minute occlusion of the left anterior descending artery, after the first or second diagonal. MiniECG and 12-lead ECG recordings were acquired simultaneously before, during and after coronary artery occlusion and ST-segment deviation was evaluated. Results During the complete occlusion and reperfusion period, miniECG showed large ST-segment deviation in comparison to 12-lead ECG. MiniECG ST-segment deviation was observed within 1 minute for most animals. The miniECG was positive for ischemia (ie, ST-segment deviation ≥1 mm) for 99.7% (Q1-Q3: 99.6%-99.9%) of the occlusion time, while the 12-lead was only positive for 79.8% (Q1-Q3: 81.1%-98.7%) of the time (P = 0.018). ST-segment deviation reached maxima of 10.5 mm [95% CI: 6.5-14.5 mm] vs 5.0 mm [95% CI: 2.0-8.0 mm] for the miniECG vs 12-lead ECG, respectively. Conclusions MiniECG ST-segment deviation was observed early and was of large magnitude during 75 minutes of porcine transmural antero-septal infarction. The miniECG was positive for ischemia for the complete occlusion period. These findings demonstrate the potential of the miniECG in the detection of cardiac ischemia. Although clinical research is required, data suggests that the miniECG is a promising tool for the detection of cardiac ischemia.
Collapse
Affiliation(s)
- Nynke M. de Vries
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Alejandra Zepeda-Echavarria
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rutger R. van de Leur
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Vera Loen
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marc A. Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Machteld J. Boonstra
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Joris E.N. Jaspers
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rien van der Zee
- Stichting Cardiovasculaire Biologie, Delft, the Netherlands
- HeartEye B.V., Delft, the Netherlands
| | | | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- HeartEye B.V., Delft, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| |
Collapse
|
3
|
Vallelonga F, Diella FA, Smith SW. High-risk Electrocardiogram Patterns. JAMA Intern Med 2022; 182:1313-1314. [PMID: 36251314 DOI: 10.1001/jamainternmed.2022.4704] [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] [Indexed: 01/11/2023]
Abstract
This case report describes a patient in their 50s who presented to the emergency department with the presence of typical retrosternal chest pain radiating to the left scapular site.
Collapse
Affiliation(s)
- Fabrizio Vallelonga
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy.,Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Francesco A Diella
- Department of Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy
| | - Stephen W Smith
- Hennepin County Medical Center, Department of Emergency Medicine, University of Minnesota, Minneapolis
| |
Collapse
|
4
|
Bhattad PB, Sherif AA, Mishra AK, Jha A, Pacifico L, Angelis D. Critical Stenosis in Left Anterior Descending Artery: Beware of T- Wave Inversions. Cureus 2022; 14:e29412. [PMID: 36304346 PMCID: PMC9586420 DOI: 10.7759/cureus.29412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 12/03/2022] Open
Abstract
Wellens’ syndrome (WS) is a pattern on an electrocardiogram (ECG) characterized by biphasic T waves or deeply inverted T waves in leads V2-V3 with a recent clinical history of angina. Wellens’ pattern on the ECG is particular for critical left anterior descending artery (LAD) stenosis. Wellens’ sign and WS have been used interchangeably in the literature. However, the typical patterns of ECG changes noted are mostly represented by Wellens’ sign. These ECG changes have been crucial in identifying this subset of patients with severe LAD disease.
Collapse
|
5
|
Pantea-Roșan LR, Bungau SG, Radu AF, Pantea VA, Moisi MI, Vesa CM, Behl T, Nechifor AC, Babes EE, Stoicescu M, Gitea D, Iovanovici DC, Bustea C. A Narrative Review of the Classical and Modern Diagnostic Methods of the No-Reflow Phenomenon. Diagnostics (Basel) 2022; 12:diagnostics12040932. [PMID: 35453980 PMCID: PMC9029120 DOI: 10.3390/diagnostics12040932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 02/06/2023] Open
Abstract
The incidence of the no-reflow (NR) phenomenon varies depending on the diagnostic criteria used. If just the angiographic criteria are considered (i.e., a degree of thrombolysis in myocardial infarction ≤2), it will be found that the incidence of NR is quite low; on the other hand, when the myocardial NR is taken into account (i.e., a decrease in the quality of myocardial reperfusion expressed by the degree of myocardial blush), the real incidence is higher. Thus, the early establishment of a diagnosis of NR and the administration of specific treatment can lead to its reversibility. Otherwise, regardless of the follow-up period, patients with NR have a poor prognosis. In the present work, we offer a comprehensive perspective on diagnostic tools for NR detection, for improving the global management of patients with arterial microvasculature damage, which is a topic of major interest in the cardiology field, due to its complexity and its link with severe clinical outcomes.
Collapse
Affiliation(s)
- Larisa Renata Pantea-Roșan
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Simona Gabriela Bungau
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Andrei-Flavius Radu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Vlad Alin Pantea
- Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Mădălina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Tapan Behl
- Department of Pharmacology, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India;
| | - Aurelia Cristina Nechifor
- Analytical Chemistry and Environmental Engineering Department, Polytechnic University of Bucharest, 011061 Bucharest, Romania;
| | - Elena Emilia Babes
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Diana Carina Iovanovici
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| |
Collapse
|
6
|
Dindas F, Koyuncu I, Candan O, Abacioglu OO, Yildirim A, Dogdus M. Predictive role of Frontal QRS-T angle and Selvester QRS Score in determining angiographic slow flow phenomenon following percutaneous coronary intervention in patients with Non-ST elevation myocardial infarction. J Electrocardiol 2021; 69:20-26. [PMID: 34517255 DOI: 10.1016/j.jelectrocard.2021.09.001] [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: 04/13/2021] [Revised: 08/20/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
AIM Slow flow (SF) that develops after percutaneous coronary intervention (PCI) is significantly associated with poor prognosis in Non-ST elevation myocardial infarction (Non-STEMI) patients. Increased Selvester QRS score and Frontal QRS-T angle [f(QRS-T)] are related to adverse cardiovascular outcomes. We aimed to investigate the predictive role of the Selvester QRS score and f(QRS-T) for the development of post-PCI SF in patients with Non-STEMI. METHOD AND RESULTS In a retrospective study, 210 patients with Non-STEMI were divided into two groups as SF (29) and Non-SF (181) according to their TIMI coronary flow grade. For all patients the Selvester QRS score and f(QRS-T) were calculated from automatic electrocardiography (ECG) reports. The mean age of the study population was 63 (55-75) years and 102 (68.6%) of patients were male. The Selvester QRS score and f(QRS-T) were higher in the SF group than in the Non-SF group [(5[3-8], 3[2-5]); (67° [42°-88°], 39° [24°-59°]), respectively, all p <0.01]. In a logistic regression analysis, the Selvester QRS score (OR = 4,862; 95% (CI) = 1,131-20,904, p =0.03) and f(QRS-T) (OR = 5,489; 95% (CI)= 11,433-21,034, p =0.01) were found independent predictors of post-PCI SF in Non-STEMI patients. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic values of the Selvester QRS score [86% sensitivity; 44% specificity; cut off 2; (AUC, 0.693)] and f(QRS-T) [62% sensitivity; 73% specificity; cut off 58°; (AUC, 0.778)]. CONCLUSION The Selvester QRS score and f(QRS-T), both easy-to-calculate ECG parameters, are predictors of post-PCI SF in Non-STEMI patients.
Collapse
Affiliation(s)
- Ferhat Dindas
- Usak University, Training and Research Hospital, Department of Cardiology, Usak, Turkey.
| | - Ilhan Koyuncu
- Usak University, Training and Research Hospital, Department of Cardiology, Usak, Turkey
| | - Ozkan Candan
- Usak University, Training and Research Hospital, Department of Cardiology, Usak, Turkey
| | - Ozge Ozcan Abacioglu
- University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
| | - Arafat Yildirim
- University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
| | - Mustafa Dogdus
- Usak University, Training and Research Hospital, Department of Cardiology, Usak, Turkey
| |
Collapse
|
7
|
Kumar J, O’Connor CT, Kumar R, Arnous SK, Kiernan TJ. Coronary no-reflow in the modern era: a review of advances in diagnostic techniques and contemporary management. Expert Rev Cardiovasc Ther 2019; 17:605-623. [DOI: 10.1080/14779072.2019.1653187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jathinder Kumar
- Department of Cardiology University Hospital Limerick, GEMS, University of Limerick, Limerick, Ireland
| | - Cormac T O’Connor
- Department of Cardiology University Hospital Limerick, GEMS, University of Limerick, Limerick, Ireland
| | - Rajesh Kumar
- Department of Cardiology University Hospital Limerick, GEMS, University of Limerick, Limerick, Ireland
| | - Samer Khalil Arnous
- Department of Cardiology University Hospital Limerick, GEMS, University of Limerick, Limerick, Ireland
| | - Thomas J. Kiernan
- Department of Cardiology University Hospital Limerick, GEMS, University of Limerick, Limerick, Ireland
| |
Collapse
|
8
|
Driver BE, Shroff GR, Smith SW. Posterior reperfusion T-waves: Wellens' syndrome of the posterior wall. Emerg Med J 2016; 34:119-123. [DOI: 10.1136/emermed-2016-205852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/30/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
|
9
|
Khan A, Nadeem S, Kokane H, Thummar A, Lokhandwala Y, Mahajan AU, Nathani PJ. Is accelerated idioventricular rhythm a good marker for reperfusion after streptokinase? Indian Heart J 2016; 68:302-5. [PMID: 27316481 DOI: 10.1016/j.ihj.2015.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/07/2015] [Accepted: 09/11/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Accelerated idioventricular rhythm (AIVR) is a common arrhythmia observed in patients with ST segment elevation myocardial infarction (MI). It is not clear how much value AIVR has in predicting successful reperfusion, since there have been conflicting data regarding this in the past. Streptokinase (STK) even today is the commonest thrombolytic agent used in the public health care set-up in India.(1) Most data for the use of STK are from the 1990s, which had showed that at best it is effective in only 50% of patients in restoring adequate flow.(2) It is probable that with the current dual-antiplatelet loading dose regimen and other newer medications, this figure could be higher. Also, rescue angioplasty for failed thrombolysis is the standard of care now, unlike before. Hence, we need reliable non-invasive markers to judge successful reperfusion in the present era. While ST segment resolution is the standard marker for reperfusion used in thrombolytic trials, in several instances it is not definitive. An additional marker would thus be very useful, especially in such cases. METHODS This was a prospective observational study carried out at a public teaching hospital. 200 consecutive patients with a diagnosis of acute MI who were given STK within 12h of index pain were included. The STK dose was 1.5 million units, infused over 30min; the ECG was again recorded after 90min of completion of the infusion. Continuous ECG monitoring for the first 24h of ICCU stay was performed and AIVRs during this period were documented. Early AIVR was defined as that occurring within 2h of completing the STK infusion. Echocardiography was performed 24h after presentation. The time course of AIVR was studied vis-a-vis the outcome of thrombolysis. RESULTS AIVR was seen in 41% of the patients. Though AIVR was found to have low sensitivity (45%) and specificity (64%) as a predictor of successful thrombolysis, early AIVR was a reliable sign of successful thrombolysis (p<0.05). The sensitivity (45%) of early AIVR was low; however, the specificity (94%) and positive predictive value (94%) were very good. CONCLUSION AIVR is a common arrhythmia in the setting of STEMI receiving thrombolytic therapy. Early AIVR is more common with successful thrombolysis, with an excellent positive predictive value. Thus, early AIVR can be used as an additive criterion to ST segment resolution as a non-invasive marker of successful thrombolysis with STK.
Collapse
Affiliation(s)
- Ashar Khan
- Resident in Cardiology, Department of Cardiology, LTMMC & GH, Sion, Mumbai, India.
| | - Shoeb Nadeem
- Resident in Cardiology, Department of Cardiology, LTMMC & GH, Sion, Mumbai, India
| | - Hemant Kokane
- Resident in Cardiology, Department of Cardiology, LTMMC & GH, Sion, Mumbai, India
| | - Ankur Thummar
- Resident in Cardiology, Department of Cardiology, LTMMC & GH, Sion, Mumbai, India
| | - Yash Lokhandwala
- Visiting Consultant, Department of Cardiology, LTMMC & GH, Sion, Mumbai 22, India
| | - Ajay U Mahajan
- Professor, Department of Cardiology, LTMMC & GH, Sion, Mumbai 22, India
| | - Pratap J Nathani
- Professor and Head, Department of Cardiology, LTMMC & GH, Sion, Mumbai 22, India
| |
Collapse
|
10
|
Lønborg J, Kelbæk H, Engstrøm T, Helqvist S, Kløvgaard L, Holmvang L, Vejlstrup N, Jørgensen E, Saunamäki K, Dridi NP, Kaltoft A, Bøtker HE, Clemmensen P, Terkelsen CJ. ST peak during percutaneous coronary intervention serves as an early prognostic predictor in patients with ST-segment elevation myocardial. EUROINTERVENTION 2015; 10:466-74. [PMID: 25138184 DOI: 10.4244/eijv10i4a80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the clinical importance of the ST peak phenomenon during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS Continuous ST monitoring was performed in 942 STEMI patients from arrival until 90 minutes after revascularisation. ST peak was defined as ≥1 mm increase in the ST-segment during PCI compared with the ST elevation before intervention. ST peak was observed in 26.9% of patients. During median follow-up of 4.1 years, 20.7% of patients experienced a major adverse cardiac event (MACE). ST peak was associated with higher rates of mortality (13.4% versus 9.3%; p=0.044), admission for heart failure (10.6% versus 5.2%; p=0.002) and MACE (26.9% versus 18.2%; p=0.002), but not reinfarction (7.1% versus 5.2%; p=0.14). In two different Cox regression analyses, adjusting for predictors of MACE and ST peak including ST resolution and epicardial flow, ST peak remained significantly associated with MACE: adjusted hazard ratio (HR) 1.40 (95% confidence interval [CI] 1.01-1.95) and 1.41 (95% CI: 1.02-1.96). CONCLUSIONS In the largest study hitherto evaluating the ST peak phenomenon during primary PCI, we demonstrated that ST peak is a strong predictor of adverse long-term outcome and provides independent prognostic information beyond that provided by ST resolution and epicardial flow.
Collapse
Affiliation(s)
- Jacob Lønborg
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Kessler EL, van Veen TAB. A fishing trip to cure arrhythmogenic cardiomyopathy? ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:90. [PMID: 26015932 DOI: 10.3978/j.issn.2305-5839.2015.01.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/16/2015] [Indexed: 11/14/2022]
Abstract
The paper entitled "Identification of a New Modulator of the Intercalated Disc in a Zebrafish Model of Arrhythmogenic Cardiomyopathy", as published in 2014 in Science Translational Medicine, examined the effects of the newly discovered drug SB216763 (SB21) on arrhythmogenic cardiomyopathy (ACM). In this paper, the authors focused on mechanisms underlying ACM and the accompanying molecular and cellular alterations. Most importantly they showed that SB21 was able to rescue and partly reverse the ACM phenotype in three different experimental models: (I) a zebrafish model of Naxos disease induced by the overexpression of the 2057del2 mutation in plakoglobin (PKG); (II) neonatal rat cardiomyocytes overexpressing the same mutation in PKG; (III) cardiomyocytes derived from induced pluripotent stem cells expressing two different forms of mutations in plakophilin-2. This editorial will focus on the potency and possible restrictions concerning SB21 treatment as a potential intervention for ACM and the usefulness of the applied zebrafish models in general.
Collapse
Affiliation(s)
- Elise L Kessler
- Department of Medical Physiology, Division of Heart & Lungs, University Medical Center Utrecht Utrecht, The Netherlands
| | - Toon A B van Veen
- Department of Medical Physiology, Division of Heart & Lungs, University Medical Center Utrecht Utrecht, The Netherlands
| |
Collapse
|
12
|
Andersson H, Christensen T, Ahtarovski K, Bang L, Hasbak P, Vejlstrup N, Pedersen F, Holmvang L, Grande P, Clemmensen P, Wagner G. Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease. J Electrocardiol 2014; 47:459-64. [DOI: 10.1016/j.jelectrocard.2014.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Indexed: 12/16/2022]
|
13
|
Poon KL, Brand T. The zebrafish model system in cardiovascular research: A tiny fish with mighty prospects. Glob Cardiol Sci Pract 2013; 2013:9-28. [PMID: 24688998 PMCID: PMC3963735 DOI: 10.5339/gcsp.2013.4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/29/2013] [Indexed: 12/26/2022] Open
Affiliation(s)
- Kar Lai Poon
- Harefield Heart Science Centre, National Heart and Lung Institute, Imperial College London, Hill End Road, Harefield, Middlesex, UB9 6JH, United Kingdom
| | - Thomas Brand
- Harefield Heart Science Centre, National Heart and Lung Institute, Imperial College London, Hill End Road, Harefield, Middlesex, UB9 6JH, United Kingdom
| |
Collapse
|
14
|
Arrhythmias following revascularization procedures in the course of acute myocardial infarction: are they indicators of reperfusion or ongoing ischemia? ScientificWorldJournal 2013; 2013:160380. [PMID: 23431252 PMCID: PMC3572688 DOI: 10.1155/2013/160380] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 01/16/2013] [Indexed: 12/24/2022] Open
Abstract
Objective. The most important step in the treatment of ST elevation myocardial infarction is to sustain myocardial blood supply as soon as possible. The two main treatment methods used today to provide myocardial reperfusion are thrombolytic therapy and percutaneous coronary intervention. In our study, reperfusion arrhythmias were investigated as if they are indicators of coronary artery patency or ongoing ischemia after revascularization. Methods. 151 patients with a diagnosis of acute ST elevation myocardial infarction were investigated. 54 patients underwent primary percutaneous coronary intervention and 97 patients were treated with thrombolytic therapy. The frequency of reperfusion arrythmias following revascularization procedures in the first 48 hours after admission was examined. The relation between reperfusion arrhythmias, ST segment regression, coronary artery patency, and infarct related artery documented by angiography were analyzed. Results. There was no statistically significant difference between the two groups in the frequency of reperfusion arrhythmias (P = 0.355). Although angiographic vessel patency was higher in patients undergoing percutaneous coronary intervention, there was no significant difference between the patency rates of each group with and without reperfusion arrythmias. Conclusion. Our study suggests that recorded arrhythmias following different revascularization procedures in acute ST elevation myocardial infarction may not always indicate vessel patency and reperfusion. Ongoing vascular occlusion and ischemia may lead to various arrhythmias which may not be distinguished from reperfusion arrhythmias.
Collapse
|
15
|
Lønborg J, Kelbæk H, Holmvang L, Vejlstrup N, Jørgensen E, Helqvist S, Saunamäki K, Dridi NP, Ahtarovski KA, Terkelsen CJ, Bøtker HE, Kim WY, Treiman M, Clemmensen P, Engstrøm T. ST peak during primary percutaneous coronary intervention predicts final infarct size, left ventricular function, and clinical outcome. J Electrocardiol 2012; 45:708-16. [PMID: 22832151 DOI: 10.1016/j.jelectrocard.2012.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE One third of patients treated with primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction develop a secondary increase in electrocardiographic ST segment (ST peak) during reperfusion. The purpose was to determine the clinical importance of ST peak during primary PCI. METHODS A total of 363 patients with ST-elevation myocardial infarction were stratified to no ST peak or ST peak. Final infarct size and ejection fraction (EF) were assessed by cardiovascular magnetic resonance. RESULTS Patients with ST peak had a larger infarct size (14% vs 10%; P = .003) and lower EF (53% vs 57%; P = .022). Rates of cardiac mortality (8% vs 3%; P = .047) and cardiac events (cardiac mortality and admission for heart failure; 19% vs 10%; P = .018) were higher among patients with ST peak, but not all-cause mortality (8% vs 5%; P = .46). In a multivariable Cox regression analysis, ST peak remained significantly associated with cardiac events (adjusted hazard ratio, 2.03 [1.08-3.82]). CONCLUSION ST peak during primary PCI is related to larger final infarct size, a reduced EF, and adverse cardiac clinical outcome.
Collapse
Affiliation(s)
- Jacob Lønborg
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Delewi R, Remmelink M, Meuwissen M, van Royen N, Vis MM, Koch KT, Henriques JPS, de Winter RJ, Tijssen JGP, Baan J, Piek JJ. Acute haemodynamic effects of accelerated idioventricular rhythm in primary percutaneous coronary intervention. EUROINTERVENTION 2011; 7:467-71. [PMID: 21764665 DOI: 10.4244/eijv7i4a76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Accelerated idioventricular rhythm (AIVR) is very frequently observed in primary percutaneous coronary intervention (PCI), however knowledge of the haemodynamic effects is lacking. METHODS AND RESULTS We studied an ST-segment elevation myocardial infarction cohort of 128 consecutive patients (aged 62±11 years) in whom AIVR occurred following reperfusion during primary PCI. Mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were determined during periods of AIVR and sinus rhythm. We grouped patients according to the infarct-related artery and the site of the coronary occlusion. AIVR caused an immediate reduction in SBP (130±27 vs. 98±22 mmHg, p<0.001) and DBP (80±19 vs. 69±16 mmHg, p<0.001) and a small increase in heart rate (78±12 vs. 83±11 bpm, p<0.001) as compared to sinus rhythm, irrespective of infarct-related artery. Both absolute as well as relative reduction in SBP were more pronounced in distal than proximal left coronary artery (LCA) occlusions (36±16 vs. 27±12 mmHg, p<0.01, respectively 25±9 vs. 20±8%, p<0.05). These haemodynamic differences between proximal and distal occlusion sites were not observed in the right coronary artery. CONCLUSIONS AIVR following reperfusion is associated with marked reduction in both SBP and DBP, irrespective of infarct-related artery. These haemodynamic effects are accompanied by only a very modest increase in heart rate during AIVR. Patients with a culprit lesion in the proximal LCA showed a smaller reduction in systolic blood pressure than distal LCA lesions.
Collapse
Affiliation(s)
- Ronak Delewi
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Demidova MM, van der Pals J, Ubachs JF, Kanski M, Engblom H, Erlinge D, Tichonenko VM, Platonov PG. ST-segment dynamics during reperfusion period and the size of myocardial injury in experimental myocardial infarction. J Electrocardiol 2011; 44:74-81. [DOI: 10.1016/j.jelectrocard.2010.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Indexed: 11/27/2022]
|
18
|
Bekkers SCAM, Yazdani SK, Virmani R, Waltenberger J. Microvascular obstruction: underlying pathophysiology and clinical diagnosis. J Am Coll Cardiol 2010; 55:1649-60. [PMID: 20394867 DOI: 10.1016/j.jacc.2009.12.037] [Citation(s) in RCA: 198] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 11/18/2009] [Accepted: 12/16/2009] [Indexed: 11/18/2022]
Abstract
Successful restoration of epicardial coronary artery patency after prolonged occlusion might result in microvascular obstruction (MVO) and is observed both experimentally as well as clinically. In reperfused myocardium, myocytes appear edematous and swollen from osmotic overload. Endothelial cell changes usually accompany the alterations seen in myocytes but lag behind myocardial cell injury. Endothelial cells become voluminous, with large intraluminal endothelial protrusions into the vascular lumen, and together with swollen surrounding myocytes occlude capillaries. The infiltration and activation of neutrophils and platelets and the deposition of fibrin also play an important role in reperfusion-induced microvascular damage and obstruction. In addition to these ischemia-reperfusion-related events, coronary microembolization of atherosclerotic debris after percutaneous coronary intervention is responsible for a substantial part of clinically observed MVO. Microvascular flow after reperfusion is spatially and temporally complex. Regions of hyperemia, impaired vasodilatory flow reserve and very low flow coexist and these perfusion patterns vary over time as a result of reperfusion injury. The MVO first appears centrally in the infarct core extending toward the epicardium over time. Accurate detection of MVO is crucial, because it is independently associated with adverse ventricular remodeling and patient prognosis. Several techniques (coronary angiography, myocardial contrast echocardiography, cardiovascular magnetic resonance imaging, electrocardiography) measuring slightly different biological and functional parameters are used clinically and experimentally. Currently there is no consensus as to how and when MVO should be evaluated after acute myocardial infarction.
Collapse
|
19
|
ST changes before and during primary percutaneous coronary intervention predict final infarct size in patients with ST elevation myocardial infarction. J Electrocardiol 2009; 42:64-72. [DOI: 10.1016/j.jelectrocard.2008.08.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2008] [Indexed: 11/24/2022]
|
20
|
Critical care aspects in the management of patients with acute coronary syndromes. Emerg Med Clin North Am 2008; 26:685-702, viii. [PMID: 18655940 DOI: 10.1016/j.emc.2008.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The spectrum of acute coronary syndromes (ACS) includes several clinical complexes that frequently cause critical instability in affected patients. This article focuses on several critical care aspects of these unstable ACS patients. The management of cardiogenic shock can be particularly challenging because the mechanical defects are varied in cause, severity, and specific treatment. Complications of fibrinolytic therapy are potentially deadly and arrhythmias are relatively common in the ACS patients. Discussions on the management of these problems should help the emergency physician more effectively to treat critically ill patients with ACS.
Collapse
|
21
|
Majidi M, Kosinski AS, Al-Khatib SM, Lemmert ME, Smolders L, van Weert A, Reiber JH, Tzivoni D, Bar FW, Wellens HJ, Gorgels AP, Krucoff MW. Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias. Europace 2008; 10:988-97. [DOI: 10.1093/europace/eun123] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
22
|
Schnell GB, Kryski AJ, Mann L, Anderson TJ, Belenkie I. Contrast echocardiography accurately predicts myocardial perfusion before angiography during acute myocardial infarction. Can J Cardiol 2007; 23:1043-8. [PMID: 17985005 DOI: 10.1016/s0828-282x(07)70871-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To determine whether myocardial contrast echocardiography (MCE) can quickly and accurately assess myocardial perfusion and infarct-related artery (IRA) patency before emergency angiography during acute myocardial infarction (AMI). BACKGROUND Despite encouraging experimental and clinical studies, the reliability and practicality of MCE in predicting IRA patency during AMI before angiography has not been proven. METHODS Two-dimensional echocardiography and MCE were performed in 51 patients with AMI just before emergency angiography. With knowledge of the electrocardiogram findings and regional wall motion, myocardial perfusion was assessed to predict IRA patency. RESULTS Myocardial perfusion studies were adequate for interpretation in 40 patients. An occluded IRA was predicted in 28 patients; the artery was occluded in 22 patients, and six patients had Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow or less. A patent IRA was predicted in 12 patients; eight patients had TIMI grade 3 flow, one patient had TIMI grade 2 flow and the IRA was occluded in three patients. In one of the three patients, the appropriate view was not obtained. In another patient, collateral flow was adequate for near-normal regional wall motion, and in the last, the findings suggested reperfusion of the proximal artery with distal embolic occlusion. Taken together, MCE accurately predicted either TIMI grade 2 flow or less, or TIMI grade 3 flow in 36 of 40 patients. Sensitivity was 87.5%, specificity and positive predictive value were 100% and negative predictive power was 66.7% (P<0.001). CONCLUSIONS MCE, together with the electrocardiogram and regional wall motion, can be used to quickly and reliably predict IRA patency early during AMI and may be useful to facilitate a management strategy.
Collapse
Affiliation(s)
- Gregory B Schnell
- Department of Cardiac Sciences and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | | | | |
Collapse
|
23
|
Ito H. No-reflow phenomenon and prognosis in patients with acute myocardial infarction. ACTA ACUST UNITED AC 2006; 3:499-506. [PMID: 16932767 DOI: 10.1038/ncpcardio0632] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 06/06/2006] [Indexed: 12/29/2022]
Abstract
The rapid restoration of coronary flow to the jeopardized myocardium has become an essential part of therapy after acute myocardial infarction. Despite an open infarct-related artery, breakdown of or obstruction to coronary microvasculature can markedly reduce blood flow to the infarct zone. This effect is known as the no-reflow phenomenon. Advances in imaging modalities have improved visualization of no reflow, showing its frequency to be higher than was estimated by clinical judgment alone. This phenomenon is important because it correlates with infarct size and provides useful prognostic information. No reflow is associated with reduced left ventricular ejection fraction, left ventricular remodeling, and poor clinical outcomes, placing patients with this effect in a high-risk group among reperfused patients. The focus of reperfusion therapy is shifting towards improved myocardial perfusion, which could promote functional recovery of viable muscle, reduce infarct expansion, and increase the delivery of blood-borne components, thereby accelerating the healing process. Various pharmacologic interventions and catheter-based devices to retrieve embolic materials have been proposed. Further studies to improve understanding of the pathophysiology of microvascular dysfunction will, however, help in the further development of preventive and therapeutic strategies. In this article, I discuss in depth the data available on the no-reflow phenomenon.
Collapse
Affiliation(s)
- Hiroshi Ito
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan.
| |
Collapse
|
24
|
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.
Collapse
Affiliation(s)
- Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
| | | |
Collapse
|
25
|
|
26
|
Syed MA, Borzak S, Asfour A, Gunda M, Obeidat O, Murphy SA, Gibbons RJ, Gourlay SG, Barron HV, Weaver WD, Hudson M. Single lead ST-segment recovery: a simple, reliable measure of successful fibrinolysis after acute myocardial infarction. Am Heart J 2004; 147:275-80. [PMID: 14760325 DOI: 10.1016/j.ahj.2003.08.010] [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: 10/26/2022]
Abstract
BACKGROUND Successful reperfusion after acute ST-elevation myocardial infarction improves prognosis. Among the different electrocardiographic markers of reperfusion, sum ST resolution is considered the hallmark of reperfusion, but is cumbersome to use. METHODS To assess the usefulness of a single lead ST resolution at 90 minutes after fibrinolysis compared with the sum ST resolution in predicting Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, we used prospectively collected data from the Limitation of Myocardial Injury Following Thrombolysis in Acute Myocardial Infarction (LIMIT-AMI) study. All patients had electrocardiograms recorded at presentation and 90 minutes and a coronary angiogram 90 minutes after fibrinolysis. RESULTS Infarction artery patency was assessed in 238 patients with 4 different ST resolution criteria: single lead ST resolution > or =50% and > or =70% and sum ST resolution > or =50% and > or =70%. The most sensitive criteria for TIMI grade 3 flow was single lead ST resolution > or =50% (sensitivity rate, 70%; specificity rate, 54%), whereas sum ST resolution > or =70% was most the specific criteria (sensitivity rate, 45%; specificity rate, 79%). The proportion of patients with TIMI grade 3 flow was similar in all 4 ST resolution groups (P =.84). Pre-discharge infarction size and ejection fraction were also similar. No single lead or sum lead measure of ST resolution was significantly associated with an increased risk of death, heart failure, or reinfarction. CONCLUSION We propose that single lead ST-resolution > or =50% as an optimal electrocardiographic indicator for successful reperfusion 90 minutes after fibrinolysis. This simple electrocardiographic measure should be combined with bedside clinical and hemodynamic assessment to optimize decision making after fibrinolysis.
Collapse
Affiliation(s)
- Mushabbar A Syed
- Henry Ford Heart and Vascular Institute, Detroit, Mich 48202, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Affiliation(s)
- Peter J Zimetbaum
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston 02215, USA.
| | | |
Collapse
|
28
|
Alconero AR, Carrera M, Cobo JL, Fernández R, Labrador P, Mancebo N. Fracaso del tratamiento trombolítico: indicadores de no reperfusión y utilización de angioplastia de rescate. ENFERMERIA CLINICA 2003. [DOI: 10.1016/s1130-8621(03)73819-4] [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]
|
29
|
Abstract
BACKGROUND Failed reperfusion after thrombolysis occurs in as many as 30% of patients with acute myocardial infarction (MI). Furthermore, some patients have incomplete tissue perfusion despite reperfusion of the infarct-related artery. Close assessment of the efficacy of thrombolytic administration in people with evolving acute MI is necessary, particularly with regard to myocardial perfusion status, because some patients may benefit from incremental pharmacologic or invasive reperfusion strategies. PURPOSE AND METHOD This article reviews a number of strategies to assess infarct-related artery patency and myocardial tissue perfusion. These include coronary angiography, continuous ST-segment monitoring, serial electrocardiography, obtaining serial serum biochemical markers of myocardial necrosis, monitoring for reperfusion arrhythmias, and assessment of changes in chest pain intensity. CONCLUSION The early detection of failed reperfusion is critical if incremental strategies to enhance myocardial salvage are to be considered. Continuous ST-segment monitoring is a relatively inexpensive, reliable, and accurate tool for assessing real-time myocardial perfusion.
Collapse
Affiliation(s)
- Angela Marie Kucia
- University of South Australia School of Nursing and Midwifery, Adelaide, Australia
| | | |
Collapse
|
30
|
Significado del patrón electrocardiográfico de ingreso en el infarto agudo de miocardio tratado con trombólisis. Med Intensiva 2002. [DOI: 10.1016/s0210-5691(02)79829-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
31
|
Kosuge M, Kimura K, Ishikawa T, Nakatogawa T, Saito T, Okuda J, Sugiyama M, Tochikubo O, Umemura S. Clinical features of patients with reperfused inferior wall acute myocardial infarction complicated by early complete atrioventricular block. Am J Cardiol 2001; 88:1187-91. [PMID: 11703969 DOI: 10.1016/s0002-9149(01)02059-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M Kosuge
- The Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Greenfield JC. Increase in ST-segment elevation immediately after reperfusion: cause and meaning. Am Heart J 2000; 139:390-1. [PMID: 10689250 DOI: 10.1016/s0002-8703(00)90079-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|