The Selvester 32-point QRS score for evaluation of myocardial infarct size after primary coronary angioplasty

Selvester score and myocardial performance index in acute anterior myocardial infarction

BACKGROUND

The simplified Selvester QRS score is a parameter for estimating myocardial damage in ST-elevation myocardial infarction. ST-elevation myocardial infarction leads to varying degrees of impairment in left ventricular systolic and diastolic function. Myocardial performance index is a single parameter that can predict combined left ventricular systolic and diastolic performance.

OBJECTIVE

We investigated the relationship between Selvester score and myocardial performance index in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction.

METHODS

The study included 58 patients who underwent primary percutaneous coronary intervention for acute anterior myocardial infarction. Selvester score of all patients was also calculated at 72 h. Patients were categorized into two groups according to the Selvester score. Those with a score <6 (low score) were considered group 1 and those with a score ≥6 (high score) were considered group 2.

RESULTS

When compared with group 1, patients in group 2 were older (p=0.01) and had lower left ventricular ejection fractions (50.3±4 vs. 35.6±6.9, p=0.001), and conventional myocardial performance index (0.52±0.06 vs. 0.69±0.08, p=0.001), lateral tissue Doppler-derived myocardial performance index (0.57±0.08 vs. 0.72±0.08, p=0.001), and septal tissue Doppler-derived myocardial performance index (0.62±0.07 vs. 0.76±0.08, p=0.001) were higher. There was a high correlation between lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index and Selvester score (r=0.80, p<0.001; r=0.86, p<0.001, respectively) and a moderate correlation between septal tissue Doppler-derived myocardial performance index and Selvester score (r=0.67, p<0.001).

CONCLUSIONS

The post-procedural Selvester score can predict lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index with high sensitivity and acceptable specificity in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction.

Impact of hypertension on postreperfusion left ventricular recovery in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease

OBJECTIVE

The aim of this study was to investigate the impact of admission systolic blood pressure (ASBP) and left ventricular (LV) mass on the postreperfusion LV recovery in patients with ST-segment elevation myocardial infarction (STEMI) and concomitant coronary multivessel disease (MVD).

MATERIALS AND METHODS

A retrospective analysis of 12-month postreperfusion LV recovery was performed in 104 patients after primary percutaneous coronary intervention (PPCI). Patients with elevated ASBP (>140mmHg) were assigned to the first group (n=58); with normal ASBP (<140mmHg), to the second group (n=46); with increased myocardial mass index (MMI) (>100g/m(2)), to the third group (n=70); and with normal MMI (<100g/m(2)), to the fourth group (n=34). Severity of MVD was evaluated by the Syntax score. The LV recovery was assessed by evolution of quantitative characteristics of electrocardiography (QRS score, ST score, ECG STEMI stage) and echocardiography (LV ejection fraction, volume and mass indices) registered before and after PPCI, at discharge, and after 1, 6, and 12 months.

RESULTS

There were no significant differences in the baseline QRS and ST scores, ECG STEMI stage, LVEF, MMI, and Syntax score comparing all the patients' groups. The serial ECG criteria showed only a very small impact of ASBP on postreperfusion LV recovery. Only ECG STEMI stage progression was slower in the patients with elevated ASBP. In patients with different MMI, the QRS and ST scores were higher and ECG STEMI stage was lower in patients with increased MMI. LVEF after 1 year was significantly lower in the third group as compared to the fourth group (42.58%±8.25% vs. 46.8%±7.13%, P=0.018).

CONCLUSION

Postreperfusion LV recovery was more related not to ASBP but to the increased LV mass assessed by echocardiography in patients with STEMI and MVD.

Usefulness of the QRS score as a strong prognostic marker in patients discharged after undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

The prognostic value of myocardial infarct size estimation by QRS scoring in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is unclear. The standard 32-point Selvester QRS score on the discharge electrocardiogram (each point approximately 3% left ventricular mass) was calculated in 4,113 patients with STEMI who underwent primary PCI and survived to hospital discharge in the APEX-AMI trial. QRS scores were divided into tertiles, i.e., < or =3 (<10% myocardium), 4 to 7 (10% to 21% myocardium), and > or =8 (>21% myocardium). Adjusted associations between QRS score and 90-day outcomes (death and composite of death/congestive heart failure (CHF)/shock) were examined. Higher QRS scores were associated with male gender, higher heart rate, worse Killip class, noninferior infarct location, greater ST-segment deviation, and longer times to reperfusion. Higher QRS scores were also associated with impaired culprit artery flow before and after PCI and more frequent multivessel disease. Adverse outcomes occurred more often in patients with higher QRS scores (90-day death: 1.9%, QRS score 0 to 3; 3.4%, 4 to 7; 4.9%, > or =8; 90-day death/shock/CHF: 4.5%, 0-3; 7.8%, 4 to 7; 12.1%, > or =8). After multivariable adjustment, patients with higher QRS scores remained more likely to develop an adverse outcome versus those with QRS scores < or =3 (score 4 to 7, hazard ratios [HR] for death 2.08, 95% confidence interval [CI] 1.26 to 3.41; HR for death/CHF/shock 2.00, 95% CI 1.26 to 3.17; score > or =8, HR for death 2.57, 95% CI 1.56 to 4.24, HR for death/CHF/shock 2.93, 95% CI 1.84 to 4.67). In conclusion, infarct size as estimated by QRS scoring at hospital discharge is an independent and prognostically relevant metric in patients with STEMI undergoing primary PCI.

Predischarge QRS score and risk for heart failure after first ST-elevation myocardial infarction

BACKGROUND

The prognostic value of the QRS score, a simple index of infarct size after a first ST-elevation myocardial infarction, has not been adequately explored in the reperfusion era.

METHODS AND RESULTS

We prospectively followed up 100 consecutive survivors of a first ST-elevation myocardial infarction (aged 64 +/- 13 years, 77% were male) without bundle branch block or paced rhythm at hospital discharge for 3 months. The modified 32-point QRS score was calculated as part of the predischarge evaluation. The predefined primary endpoint was the composite of death or hospitalization for heart failure. By 3 months, 6 patients died and 16 patients were readmitted for heart failure, resulting in a 22% primary endpoint rate. Patients with a QRS score >/= 3 at hospital discharge (n = 38) had significantly more events compared with those with a QRS score < 3 (44.7% vs. 8.2%, P < .001), and all six deaths occurred among patients with a QRS score >/= 3 (P = .002). A QRS score < 3 reliably predicted heart-failure free survival during the follow-up period (negative predictive value 91.9%). In multivariate models, the QRS score was an independent predictor of the primary endpoint (hazard ratio = 1.4 per point, 95% confidence interval 1.1-1.8, P = .003).

CONCLUSION

For patients surviving a first ST-elevation myocardial infarction, the predischarge QRS score provides powerful prognostic information on short-term outcomes, including mortality and readmission for heart failure.

Size and transmural extent of first-time reperfused myocardial infarction assessed by cardiac magnetic resonance can be estimated by 12-lead electrocardiogram

BACKGROUND

The ability of the 12-lead electrocardiogram (ECG) to quantify size and transmural extent of myocardial infarction (MI) is not fully explored. Q waves are still thought of as indicative of transmural MI despite that several studies have rejected this association. We hypothesized that size and transmural extent of acute MI indeed can be estimated by QRS scoring on the 12-lead ECG using delayed, contrast-enhanced magnetic resonance imaging (DE-MRI) as gold standard and that Q waves are not predictive of transmural MI.

METHODS

Twenty-nine patients with first-time reperfused MI were studied. Delayed, contrast-enhanced magnetic resonance imaging was performed and 12-lead ECG was recorded 8 +/- 1 days after the acute event. Myocardial infarction size and transmurality were determined by DE-MRI and compared with Selvester QRS score from the ECG recorded on the same day.

RESULTS

There was a good correlation (r = 0.79, P < .001) between MI size by QRS scoring and DE-MRI. As local MI transmurality increased as assessed by DE-MRI, the local QRS score increased progressively (P < .001). There was no significant difference in the number of Q-wave-related QRS points between nontransmural and transmural MI (1.8 +/- 0.6 vs 2.9 +/- 0.4, P = .14). The global QRS score, however, differed significantly (3.1 +/- 0.8 vs 5.1 +/- 0.6, P < .05).

CONCLUSION

QRS score is significantly related to both MI size and transmurality by DE-MRI in patients with first-time reperfused MI. Presence of Q waves, however, is not indicative of transmural MI in these patients. Thus, QRS scoring could potentially be used for diagnosing and characterizing MI in patients with suspected recent MI.

Electrocardiographic infarct size assessment after thrombolysis: insights from the Acute Myocardial Infarction STudy ADenosine (AMISTAD) trial

BACKGROUND

Noninvasive methods are needed to evaluate reperfusion success in patients with acute myocardial infarction (MI). The AMISTAD trial was analyzed to compare MI size and myocardial salvage determined by electrocardiogram (ECG) with technetium Tc 99m sestamibi single-photon emission computerized tomography (SPECT) imaging.

METHODS

Of 236 patients enrolled in AMISTAD, 166 (70 %) with no ECG confounding factors and no prior MI were included in this analysis. Of these, group 1 (126 patients, 53%) had final infarct size (FIS) available by both ECG and SPECT. Group 2 (56 patients, 24%) had myocardium at risk, FIS, and salvage index (SI) assessed by both SPECT and ECG techniques. Aldrich/Clemmensen scores for myocardium at risk and the Selvester QRS score for final MI size were used. Salvage index was calculated as follows: SI = (myocardium at risk-FIS)/(myocardium at risk).

RESULTS

In group 1, FIS was 15% (6, 24) as measured by ECG and 11% (2, 27) as measured by SPECT. In the adenosine group, FIS was 12% (6, 21) and 11% (2, 22). In the placebo group, FIS was 16.5% (7.5, 24) and 11.5% (3.0, 38.5) by ECG and SPECT, respectively. The overall correlation between SPECT and ECG for FIS was 0.58 (P = .0001): 0.60 in the placebo group (P = .0001) and 0.54 (P = .0001) in the adenosine group. In group 2, myocardium at risk was 23% (17, 30) and 26% (10, 50) with ECG and SPECT, respectively (P = .0066). Final infarct size was 17% (6, 21) and 12% (1, 24) (P < .0001). The SI was 29% (-7, 57) and 46% (15, 79) with ECG and SPECT, respectively (P = .0510).

CONCLUSIONS

The ECG measurement of infarct size has a moderate relationship with SPECT infarct size measurements in the population with available assessments. This ECG algorithm must further be validated on clinical outcomes.

Prognostic value of predischarge electrocardiographic measurement of infarct size after thrombolysis: insights from GUSTO I Economics and Quality of Life substudy

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.

Early Definition of Treatment Outcomes After Reperfusion Therapy for Myocardial Infarction

AIMS

Early definition of treatment outcomes, including coronary patency and infarct size, after reperfusion therapy for myocardial infarction (MI) is desirable to identify patients requiring further intervention.

METHODS AND RESULTS

Patients receiving reperfusion therapy for a first MI had continuous 12-lead ST segment monitoring to document reperfusion and ischaemia time. Infarct size was measured by 12-lead QRS score and radionuclide scintigraphy ((201)Tl single-photon emission computed tomography, SPECT) at 1 week, and left ventricular function by echocardiography at 1 week and 1 month. Resolution of ST elevation accurately detected TIMI 2 or 3 reperfusion (predictive accuracy 93%) in 55 patients undergoing immediate angioplasty, but ST recovery was delayed (17+/-14min) after angiographic reperfusion. A multivariate model, including risk region and ischaemia time, accurately predicted MI size (R(2)=0.80, P<0.00001) in these patients. The same model, prospectively applied on Day 1 to 154 patients receiving thrombolytic therapy, accurately predicted MI size, measured by QRS score (R(2)=0.88, P<0.0000001) and (201)Tl SPECT (R(2)=0.75, P<0.000001) at 1 week for individual patients. Regional myocardial wall motion at 1 month was directly correlated with MI size predicted by the model on Day 1 (r=0.73, P<0.0001).

CONCLUSIONS

Use of ST segment monitoring during reperfusion therapy facilitates early prediction of treatment outcomes, including coronary reperfusion, infarct size and ventricular function.

The predischarge electrocardiographic pattern in anterior acute myocardial infarction: relation between evolutionary ST segment and T-wave configuration and prediction of myocardial infarct size and left ventricular systolic function by the QRS Selvester score

Left ventricular systolic function, determined mainly by final infarct size, has a major influence on prognosis after acute myocardial infarction (MI). It was found that infarct size and left ventricular ejection fraction can be predicted using the Selvester QRS-score in patients not receiving reperfusion therapy. We assessed whether the predischarge QRS-score can be used for estimating infarct size and left ventricular ejection fraction in 51 patients with a first anterior MI who had received reperfusion therapy and whether considering the configuration of the ST-segments and T-waves will increase the accuracy of these predictions. All patients had received reperfusion therapy and had predischarge resting 99mTc-sestamibi scan. We determined the Selvester QRS score using the electrocardiograms performed on the same day of the scan. In addition, we divided the patients into 3 groups: A: isoelectric ST and negative T-waves (n = 12); B: ST elevation (> or =0.1 mV) and negative T-waves (n = 23); and C: ST elevation (> or =0.1 mV) and positive T-waves (n = 16). The myocardial perfusion defect extent increased from group A to C (28.5+/-16.4%, 39.4+/-14.8%, and 45.3+/-15.8% in groups A, B, and C. respectively; P = .022). Similarly, the left ventricular ejection fraction decreased (41.7+/-11.6%, 38.4+/-8.1%, and 32.0+/-9.7%, respectively; P = .042) from group A to C. Overall, the correlation between the QRS-score and the myocardial perfusion defect extent (Rho = 0.249; P = .08), and ejection fraction (Rho = -0.229; P = .11) was not good. A statistically significant correlation between the myocardial perfusion defect size and the QRS-score was found only in group A (Rho = 0.599, P = .04). In patients with a first anterior myocardial infarction who underwent reperfusion therapy, the predischarge QRS-score is predictive of infarct size only in those in whom ST elevation resolved completely. In patients with residual ST elevation the Selvester QRS-score is inaccurate in predicting infarct size and left ventricular ejection fraction upon discharge.

Computer applications in the interpretation of the exercise electrocardiogram

The exercise electrocardiogram remains the noninvasive diagnostic test of first choice in patients with coronary artery disease. While new technology offers novel diagnostic possibilities and the ability to assess patients unsuitable for exercise testing, no other investigation has to this point furnished the quality of functional information and value-for-predictive accuracy of exercise electrocardiography. In this article, we describe how this central position in the work up of the cardiac patient has been secured through the evolution of the microprocessor. Particularly important has been its ability to harness and present large volumes of raw data, to derive and manipulate multivariate equations for diagnostic prediction, and to run 'expert' systems which can pool demographic and exercise test data, calculate risk scores, and prompt the nonexpert with advice on current management. These key features explain the pivotal role of the exercise test in the diagnostic, and increasingly prognostic, armoury of the cardiovascular clinician.

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

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.