Modern management of acute myocardial infarction

Does hormonal status influence the clinical presentation of acute coronary syndromes in women?

BACKGROUND

Previous studies suggest that the clinical presentation of acute coronary syndromes (ACS) may differ between women and men. It is not known if different clinical presentations may be explained by hormonal status in women with ACS. Our objective was to compare the clinical presentation of ACS between premenopausal (PRE) women and post-menopausal women with hormone replacement therapy (HRT) and without (POST).

METHODS

This was a prospective study of consecutive women admitted with a diagnosis of ACS (myocardial infarction [MI] or unstable angina). All women answered a detailed questionnaire that included a list of 27 clinical symptoms. Symptom results were adjusted for age and current coronary event diagnosis.

RESULTS

Seventy-three Caucasian women were studied. No differences were found in terms of the frequency of reported typical symptoms of ACS between PRE (n = 23), HRT (n = 32), and POST (n = 18). However, PRE more often reported atypical chest symptoms than HRT and POST women (57% vs. 31% vs. 22%, PRE vs. HRT vs. POST, respectively, p = 0.05). HRT and POST women experienced substernal chest pain more frequently than PRE (44% vs. 78% vs. 83%, p = 0.03). In contrast, PRE more frequently tended to experience chest pressure (57% vs. 31% vs. 39%, p = 0.2) or chest pain in other locations (22% vs. 3% vs. 6%, p = 0.06). HRT and POST groups reported more frequent indigestion-like pain/discomfort (22% vs. 50% vs. 56%, p = 0.04) and midback pain (35% vs. 63% vs. 72%, p = 0.04) during ACS compared with PRE women. POST experienced sudden fatigue more frequently than PRE and HRT (61% vs. 53% vs. 89%, p = 0.03).

CONCLUSIONS

Our results suggest that almost all women admitted with ACS experienced typical chest symptoms but frequently reported both typical and atypical symptoms. Independently of age, atypical chest symptoms occurred more frequently in premenopausal women than in postmenopausal women with or without HRT.

Predicting mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PAMI risk score)

We performed a pooled analysis of the Primary Angioplasty in Myocardial Infarction (PAMI) trials to examine predictors of death after primary percutaneous coronary intervention. Using these data, we developed a risk score with a range of 0 to 15 points. The PAMI risk score was found to be a strong predictor of late mortality.

Clinical utility of ST-segment depression in lead AVR in acute myocardial infarction

The present study evaluated the prevalence and significance of ST-segment depression (STD) in lead aVR on the admission 12-lead electrocardiogram in 307 consecutive patients with an acute myocardial infarction (AMI) with ST-segment elevation. STD in aVR was present in a significantly higher proportion of patients with inferior/posterior AMIs. Within inferior/posterior AMIs those with STD in aVR had significantly more concomitant STD in V(1), V(2), V(3) and more concomitant STesegment elevation in V(5), V(6) and right precordial leads. These data suggests that STD in aVR may point to a coronary artery with a large area of supply as the culprit vessel responsible for the AMI.