Comparative prognostic significance of simultaneous versus independent resolution of ST segment depression relative to ST segment elevation during acute myocardial infarction

Predictors of ST Depression Resolution in STEMI Patients Undergoing Primary PCI and Its Clinical Significance

Purpose

ST depression resolution (STD-R) in ECG is a prognostic factor indicative of successful fibrinolysis or angioplasty in the treatment of ST elevation myocardial infarction (STEMI) and subsequent mortality. We conducted this study to determine the clinical significance of STD-R and its predictors in patients with anterior STEMI undergoing primary percutaneous intervention (PPCI).

Methods

Admission documents of all patients with diagnosis of anterior STEMI who were admitted to a specialty heart center and underwent PPCI since July 2018 until July 2019 were examined. The amount of ST elevation and depression in all 12 leads of a standard ECG at admission and 90 minutes after PPCI was measured and resolution was determined. All patients were followed-up for 10.8±4.0 months.

Results

A total of 179 patients had ST depression besides elevation in the first ECG. Female gender, diabetes, not smoking, lower hemoglobin, and higher platelet counts were significantly more common in the group with less than 50% resolution of ST depression. STD-R <50% was significantly associated with the incidence of in-hospital acute heart failure and major adverse cardiac events (MACE) (p value: 0.025 and 0.012, respectively) and resolution of ST elevation ≥50% was associated with reduced in-hospital mortality (p value <0.0001). According to Kaplan-Meier curve, survival in the two groups of STE-R ≥50% and STE-R <50% was significantly different (Log rank: 31.18, p value<0.0001).

Conclusion

STD-R can be considered to have high predictive power, like STE-R for predicting incidence of in-hospital acute heart failure and major adverse cardiac events.

Combination of electrocardiographic and angiographic markers of reperfusion in the prediction of infarct size in patients with ST-segment elevation myocardial infarction undergoing successful primary angioplasty

BACKGROUND

Optimal epicardial recanalization does not guarantee optimal myocardial perfusion. The aim of the current study was to evaluate angiographic and electrocardiographic markers of reperfusion in the prediction of infarct size in patients with STEMI undergoing successful primary angioplasty.

METHODS

Our population is represented by 270 STEMI patients with ST successful primary angioplasty (postprocedural TIMI 3 flow and residual stenosis <50%) with available corrected TIMI frame count (cTFC), myocardial blush grade (MBG), ST-segment resolution and enzymatic infarct size (peak CK-MB) analyses.

RESULTS

A significant linear relationship with enzymatic infarct size was observed for all markers of reperfusion, except for ST-segment resolution. These data were confirmed even when analyzed as continuous variables in case of cTFC (r=0.13, p=0.035), postprocedural residual cumulative ST-segment elevation (r=0.41, p<0.0001) and deviation (r=0.45, p<0.0001). At multivariate analysis applied to postprocedural angiographic and electrocardiographic markers of reperfusion, cumulative residual ST-segment deviation, myocardial blush grade, and corrected TIMI frame count were independent predictors of enzymatic infarct size.

CONCLUSIONS

This study showed that, among patients with STEMI treated by primary angioplasty, cTFC, MBG and cumulative residual ST-segment deviation are independent predictors of infarct size. Therefore, angiography and electrocardiography may provide complementary information in the evaluation of myocardial perfusion.

Acute coronary syndromes

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.

Prognostic significance of residual cumulative ST-segment deviation after mechanical reperfusion in patients with ST-segment elevation myocardial infarction

BACKGROUND

The analysis of ST-segment resolution is a well established and easy method to assess myocardial perfusion after reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify an easy and practical instrument for patients' prognostic stratification after angioplasty for STEMI by the use of only postprocedural ST-segment analysis.

METHODS

Our population is represented by a total of 1286 patients treated with primary angioplasty for STEMI. Residual ST-segment elevation and deviation were analyzed at 3 hours after revascularization. One-year follow-up data were collected prospectively in all patients.

RESULTS

Patients with impaired ST-segment normalization were older, with larger prevalence of diabetes, anterior infarction, hypertension, signs of heart failure at presentation, lower rate of postprocedural thrombolysis in myocardial infarction 3 flow, myocardial blush grades 2 to 3, and successful reperfusion. A linear relationship was found between both residual cumulative ST-segment elevation and deviation with 1-year mortality. At multivariate analysis, postprocedural residual cumulative ST deviation (RR 1.31, 95% CI 1.06-1.63, P = .014), but not residual cumulative ST elevation (RR 0.95, 95% CI 0.55-1.67, P = .87), was an independent predictor of 1-year mortality. Furthermore, we found that residual cumulative ST-segment deviation provides better prognostic information (area receiver operating characteristic [ROC] = 0.733) than ST-segment elevation resolution (area ROC = 0.636) or ST-segment deviation resolution (area ROC = 0.660) in terms of 1-year mortality. These data were confirmed for both anterior and nonanterior infarct location.

CONCLUSION

This study showed that postprocedural residual cumulative ST-segment deviation is an independent prognostic parameter in patients treated with primary angioplasty, providing even better prognostic information than ST-segment resolution.

Impact of ST-segment depression resolution on mortality after successful mechanical reperfusion in patients with ST-segment elevation acute myocardial infarction

The aim of the present study was to evaluate the additional prognostic effect of ST-depression resolution in 610 patients who had ST-elevation myocardial infarction and underwent successful primary angioplasty (postprocedural Thrombolysis In Myocardial Infarction 3 flow and complete resolution of ST-segment elevation). Incomplete resolution of ST-segment depression (<70%) was observed in 50 patients (8.2%). These patients were older, had a higher Killip's class at presentation, had larger infarcts, and had an increased 1-year mortality (10% vs 2%, p = 0.0004). At multivariate analysis, incomplete resolution of ST-segment depression was an independent predictor of 1-year mortality (p = 0.028).

Characteristics of presenting electrocardiograms of acute myocardial infarction from a community-based population predict short- and long-term mortality

To investigate the relevance of presenting electrocardiographic (ECG) patterns to short- and long-term mortality in nonreferral patients with acute myocardial infarction (AMI), 6 ECG patterns were analyzed. A consecutive series of 907 patients from Olmsted County, Minnesota, admitted to the Mayo Clinic Cardiac Care Unit from January 1, 1988 to March 31, 1998 for acute myocardial infarction comprised the study population. ECG patterns and distribution in the population were: (1) ST elevation alone (20.8%), (2) ST elevation with ST depression (35.2%), (3) normal or nondiagnostic electrocardiograms (18.5%), (4) ST depression alone (11.8%), (5) T-wave inversion only (10.7%), and (6) new left bundle branch block (LBBB) (3.0%). Seven- and 28-day mortalities varied significantly (p <0.01) among the 6 ECG groups. Respective mortalities were 3.0% and 6.0% for patients with normal or nondiagnostic electrocardiograms, 3.1% and 5.2% for T-wave inversion only, 7.4% and 10.6% for ST elevation alone, 9.4% and 13.1% for ST depression alone, 10.3% and 13.8% for ST elevation with ST depression, and 18.5% and 22.2% for new LBBB. Length of hospital stay (LOS) also varied among the ECG pattern groups (p <0.001) with the longest average LOS being in the new LBBB group (12.5 days). Long-term survival was similar among 5 ECG pattern groups (45% to 55% at 8 years from discharge) with the exception of LBBB (20% at 8 years). Among non-LBBB groups, ST-segment depression with or without ST elevation was associated with increased short-term mortality. Also, in this community-based population, 18.5% of patients had normal or nondiagnostic electrocardiograms.

The influence of the resolution of reciprocal ST segment changes on in-hospital complications of acute myocardial infarction after percutaneous coronary angioplasty

We studied 120 patients (M:F 105:15, mean age 57.5 +/- 10.1 years) with acute myocardial infarction (MI) successfully treated with percutaneous coronary angioplasty (PTCA) to analyze the influence of the resolution of the ST segment elevation and depression after intervention to 1 month composite endpoints of reinfarction or reocclusion, development of congestive heart failure (CF) and death. Sum of preintervention and postintervention ST segment elevation and depression and the rate of resolution of these ST segment elevations and depressions were recorded for every patient. A total of 17 (14.2%) composite endpoint events (events group) were recorded (7 reocclusion or recurrent MI, 9 CF, and 1 death). On univariate analysis, events group patients were older (53.3 +/- 9.9 vs. 58.8 +/- 9.1 years, P = 0.032), had lesser resolution of ST segment elevations (85 +/- 24% vs. 44 +/- 55%, P = 0.017) and depression (72 +/- 26% vs. 52 +/- 30%, P = 0.009), had greater preintervention ST segment elevation (17.49 +/- 12.95 mm vs. 28.38 +/- 20.41 mm, P = 0.045), had lower ejection fraction (59.3 +/- 10.2% vs. 43.6 +/- 9.4%, P < 0.001), and had more frequent multivessel disease (71% vs. 47%, P = 0.048) compared to the nonevents group. Time from angina to reperfusion, residual stenosis, sex, infarct location and infarct-related vessel distribution were similar. On multivariate analysis (logistic regression with backward likelihood ratio) only older age (P = 0.0752), lesser rate of resolution of ST segment depression (P = 0.0262) and lower ejection fractions (P = 0.0014) were retained as predictors of the composite endpoints. Relative risk conferred by less than 50% resolution of ST segment depressions for composite endpoints were 3.78 (95% CI 1.63-8.73). We conclude that the lack of resolution of the sum of reciprocal ST segment depressions identifies a subgroup of acute MI patients with greater morbidity after primary PTCA.