Risk Stratification of Patients With Acute Anterior Myocardial Infarction and Right Bundle-Branch Block

Predictors of In-Hospital Death in Patients With Acute Myocardial Infarction

OBJECTIVE

Factors such as age, vital signs, renal function, Killip class, cardiac arrest, elevated cardiac biomarker levels, and ST deviation predict survival in patients with acute myocardial infarction (AMI). However, the existing risk assessment tools lack comprehensive consideration of catheter-related factors, and short-term prognostic predictors are unknown. This study aimed to clarify in-hospital prognostic predictors in hospitalized patients with AMI.

METHODS

Five hundred and thirty-six patients who underwent percutaneous coronary intervention (PCI) for AMI were divided into non-survivor (n = 36) and survivor (n = 500) groups. Coronary risk factors, laboratory findings, angiographic findings, and clinical courses were compared between the two groups. Multiple logistic regression was used to analyze in-hospital death in pre- and post-PCI phases.

RESULTS

In the pre-PCI phase, multiple logistic regression analysis revealed several predictors of in-hospital death, including systolic blood pressure [odds ratio (OR) = 0.985, p = 0.023)], Killip class ≥2 (OR = 14.051, p <0.001), and chronic kidney disease (OR = 4.859, p = 0.040). In the post-PCI phase, multiple logistic regression analysis revealed additional predictors of in-hospital death, including Killip class ≥2 (OR = 5.982, p = 0.039), presence of lesions in the left main trunk (OR = 51.381, p = 0.044), utilization of intra-aortic balloon pumps and percutaneous cardiopulmonary support (OR = 6.141, p = 0.016), and presence of multi-vessel disease (OR = 6.323, p = 0.022).

CONCLUSION

Predictors of in-hospital death in AMI extend beyond conventional risk factors to include culprit lesions, mechanical support, and multi-vessel disease that manifest post-PCI.

Inferior and precordial ST-segment elevation myocardial infarction due to large wrap-around left anterior descending artery occlusion

Left anterior descending artery (LAD) occlusion normally develops into precordial ST-segment elevation; however, we describe a case of a 50-year-old man with inferior and precordial ST-segment elevation myocardial infarction that resulted from proximal occlusion of the wrap-around LAD perfusing the anterior and inferior wall. We performed early and prompt reperfusion and were able to save the patient without any complications. A wrap-around LAD perfuses a large myocardial area; therefore, this type of coronary occlusion causes severe myocardial damage and has a poor prognosis. The rates of new-onset heart failure and heart failure rehospitalization are also high. Simultaneous inferior and precordial ST-segment elevations on electrocardiography suggest acute myocardial infarction with a wrap-around LAD lesion, which requires prompt revascularization. More careful medications for heart failure and follow-up should be also required even after discharge in such case.

Electrocardiographic QRS Findings Upon Admission Can Predict Prognosis of Acute Myocardial Infarction Caused by Occlusion of Left Main Coronary Artery

BACKGROUND

Acute myocardial infarction (AMI) caused by left main coronary artery (LMCA) occlusion is associated with a severe clinical course and catastrophic consequences.

HYPOTHESIS

We sought to clarify ECG predictors of prognosis in AMI caused by LMCA occlusion.

METHODS

We examined 20 consecutive patients with AMI caused by LMCA occlusion that was treated by primary stenting. The patients were assigned to either a group that survived (S) and was discharged from hospital, or a group that did not survive (NS) and died in hospital. We compared ECG findings upon admission, angiographic findings, laboratory data and clinical outcomes.

RESULTS

The rate of having Thrombolysis In Myocardial Infarction (TIMI) grade > 2 coronary flow before PCI and of achieving TIMI grade 3 after PCI was significantly lower in the NS than the S group (14.3% vs. 83.3%, p = 0.003 and 35.7% vs. 100%, p = 0.008). The ECG findings showed longer QRS interval in the NS than in the S group (150.5 ± 37.9 vs. 105.2 ± 15.4, p = 0.022). A QRS interval ≥ 120 msec predicted in-hospital mortality with sensitivity, specificity and positive and negative predictive values of 78.5%, 100%, 100% and 66.7%, respectively, in this population.

CONCLUSIONS

The QRS duration upon admission was a good predictor of in-hospital mortality among patients with AMI caused by LMCA occlusion. This ECG sign could be useful in the emergency clinical setting.

Application of machine learning to predict the occurrence of arrhythmia after acute myocardial infarction

Background

Early identification of the occurrence of arrhythmia in patients with acute myocardial infarction plays an essential role in clinical decision-making. The present study attempted to use machine learning (ML) methods to build predictive models of arrhythmia after acute myocardial infarction (AMI).

Methods

A total of 2084 patients with acute myocardial infarction were enrolled in this study. (All data is available on Github: https://github.com/wangsuhuai/AMI-database1.git). The primary outcome is whether tachyarrhythmia occurred during admission containing atrial arrhythmia, ventricular arrhythmia, and supraventricular tachycardia. All data is randomly divided into a training set (80%) and an internal testing set (20%). Apply three machine learning algorithms: decision tree, random forest (RF), and artificial neural network (ANN) to learn the training set to build a model, then use the testing set to evaluate the prediction performance, and compare it with the model built by the Global Registry of Acute Coronary Events (GRACE) risk variable set.

Results

Three ML models predict the occurrence of tachyarrhythmias after AMI. After variable selection, the artificial neural network (ANN) model has reached the highest accuracy rate, which is better than the model constructed using the Grace variable set. After applying SHapley Additive exPlanations (SHAP) to make the model interpretable, the most important features are abnormal wall motion, lesion location, bundle branch block, age, and heart rate. Among them, RBBB (odds ratio [OR]: 4.21; 95% confidence interval [CI]: 2.42–7.02), ≥ 2 ventricular walls motion abnormal (OR: 3.26; 95% CI: 2.01–4.36) and right coronary artery occlusion (OR: 3.00; 95% CI: 1.98–4.56) are significant factors related to arrhythmia after AMI.

Conclusions

We used advanced machine learning methods to build prediction models for tachyarrhythmia after AMI for the first time (especially the ANN model that has the best performance). The current study can supplement the current AMI risk score, provide a reliable evaluation method for the clinic, and broaden the new horizons of ML and clinical research.

Trial registration Clinical Trial Registry No.: ChiCTR2100041960.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01667-8.

Acute myocardial infarction with right bundle branch block at presentation: Prevalence and mortality

AIMS

Right Bundle Branch Block (RBBB) has been reported in 5-11% of the acute myocardial infarctions (AMI), and it could be the only electrocardiographic abnormality in this group of patients. We investigated the mortality in patients with AMI and the presence of RBBB.

MATERIALS AND METHODS

A retrospective cohort study was conducted between January 2011 to December 2017 at a university hospital in Bogotá, Colombia. Records were obtained from all patients who presented at the emergency department with AMI; patients with early transfer and incomplete follow-up were excluded.

RESULTS

1015 patients were included, the mean age was 66 years, 67% of the patients were men, and 38% had STEMI. RBBB was documented in 8% of patients and LBBB in 4% of patients. In-hospital mortality was higher in the group of patients with RBBB vs. patients without RBBB (8.64% vs. 3.74%, p = 0.034). The percentage of patients with Killip ≥II classification was higher in patients with new RBBB vs. patients with old or unknown duration RBBB (23% vs. 13%, p = 0.216).

CONCLUSIONS

In patients with AMI, the presence of RBBB was associated with a statistically significant increase of in-hospital mortality.

Right bundle brunch block in patients with acute myocardial infarction is associated with a higher in-hospital arrhythmic risk and mortality, and a worse prognosis after discharge

INTRODUCTION

Recently, the presence of right bundle brunch block (RBBB) in patients with persistent ischaemic symptoms has been suggested as an indication for emergent coronary angiography.

OBJECTIVE

The aim of this study was to assess the prognostic impact of RBBB in patients with acute myocardial infarction (AMI) before the implementation of the recent recommendations.

METHODS

We retrospectively studied consecutive patients admitted with AMI between 2011 and 2013. Patients with left bundle brunch block, pacemaker, or nonspecific intraventricular conduction delay were excluded. Patients with RBBB were compared with those without RBBB. Clinical characteristics, in-hospital evolution, and major adverse cardiovascular events (MACE) during follow-up, defined as cardiovascular death, sustained ventricular arrhythmias, acute heart failure syndromes, recurrent myocardial infarction, or acute stroke, were analysed.

RESULTS

The analysis included 481 patients. Thirty two patients (6.7%) had RBBB. Patients with RBBB were older. During hospital admission, RBBB patients had a higher rate of sustained ventricular tachycardia and death. Survival curve analysis showed that patients with RBBB had a lower in-hospital survival rate (Log-rank, p = 0.004). After discharge, during a mean follow-up time of 24.3 ± 11.6 months, 53 patients (12%) died. Survival curve analysis showed a lower survival rate free of MACE for those patients with RBBB (Log-rank, p = 0.011). RBBB was independently associated with MACE occurrence (HR 2.17, 95% CI 1.07-4.43; p = 0.033), after adjusting for demographic data, coronary angiography findings, treatment performed, echocardiographic evaluation, and medical therapy.

CONCLUSION

Patients with RBBB had a higher rate of in-hospital mortality and arrhythmic events, and an increased risk of MACE during follow-up.

Long-term outcome of pre-specified ECG patterns in acute coronary syndrome

BACKGROUND

Long-term outcome of real-life acute coronary syndrome (ACS) patients with selected ECG patterns is not well known.

PURPOSE

To survey the 10-year outcome of pre-specified ECG patterns in ACS patients admitted to a university hospital.

METHODS

A total of 1184 consecutive acute coronary syndrome patients in 2002-2003 were included and followed up for 10 years. The patients were classified into nine pre-specified ECG categories: 1) ST elevation; 2) pathological Q waves without ST elevation; 3) left bundle branch block (LBBB); 4) right bundle branch block (RBBB) 5) left ventricular hypertrophy (LVH) without ST elevation except in leads aVR and/or V₁; 6) global ischemia ECG (ST depression ≥0.5 mm in 6 leads, maximally in leads V_4-5 with inverted T waves and ST elevation ≥0.5 mm in lead aVR); 7) other ST depression and/or T wave inversion; 8) other findings and 9) normal ECG.

RESULTS

Any abnormality in the ECG, especially Q waves, LBBB, LVH and global ischemia, had negative effect on outcome. In age- and gender adjusted Cox regression analysis, pathological Q waves (HR 2.28, 95%CI 1.20-4.32, p = .012), LBBB (HR 3.25, 95%CI 1.65-6.40, p = .001), LVH (HR 2.53, 95%CI 1.29-4.97, p = .007), global ischemia (HR 2.22, 95%CI 1.14-4.31, p = .019) and the combined group of other findings (HR 3.01, 95%CI 1.56-6.09, p = .001) were independently associated with worse outcome.

CONCLUSIONS

During long-term follow-up of ACS patients, LBBB, ECG-LVH, global ischemia, and Q waves were associated with worse outcome than a normal ECG, RBBB, ST elevation or ST depression with or without associated T-wave inversion. LBBB was associated with the highest mortality rates.

In the transition from fibrinolysis to primary PCI, the HERO trials help refine STEMI ECG interpretation and Q wave analysis potentially alters future management

Electrocardiogram sub-studies from the Hirulog Early Reperfusion/Occlusion 1 and 2 trials, which tested bivalirudin as an adjunctive anticoagulant to fibrinolysis in ST-elevation myocardial infarction, have contributed to the literature. The concept of using the presence of infarct lead Q waves to determine reperfusion benefit has subsequently been explored in multiple primary percutaneous coronary intervention studies. The angiographic findings before percutaneous coronary intervention combine with the baseline electrocardiogram to accurately diagnose ST-elevation myocardial infarction and evaluate its potential territory. This review discusses the relative merits of the presence of infarct lead Q waves versus time duration from symptom onset using observational data from cohorts of patients from multiple clinical trials. The presence of infarct lead Q waves at presentation has been repeatedly shown to be superior to time duration from symptom onset in determining prognosis, despite that continuous variable (time duration) statistically should be more powerful than dichotomous variable (Q wave). If quantitative or semi-quantitative measurement of Q waves correlates well with irreversible myocardial injury in vivo (a research goal of many cardiac magnetic resonance imaging studies), Q waves measurements by mirroring ST-elevation myocardial infarction evolution better than the current metric of time duration of symptoms will impact future ST-elevation myocardial infarction reperfusion management. Newer methodology will more quickly capture and transmit electrocardiogram information including infarct lead Q waves potentially before first medical contact, and help differentiate new evolving Q waves of the ongoing ST-elevation myocardial infarction from old changes. Q waves as the new metric in ST-elevation myocardial infarction reperfusion should be tested in upcoming trials.

Simplifying electrocardiographic assessment in STEMI reperfusion management: Pros and cons

Current guidelines on STEMI reperfusion management do not incorporate further electrocardiographic details over the presence of significant ST elevation. Fibrinolysis is considered an alternative therapy to primary PCI if there is a long PCI-related delay, but the 2 therapies should not be combined. Meanwhile, reperfusion for ischemic stroke has evolved on mechanistic understanding - reperfusion benefit being greatest in the patient with small "core" infarct and large ischemic "penumbra". Fibrinolysis is not regarded as an alternative to mechanical thrombectomy, and the 2 therapies can be combined. In this article describing how reperfusion regimes have evolved along different paths for STEMI and for ischemic stroke, a new concept is made that in STEMI infarct lead Q waves can be the counterpart of the "core" and ST elevation the "penumbra". Suggestions to modify STEMI treatment algorithms are made, exploring further the relative role of (pre-hospital) fibrinolysis versus PCI particularly in younger patients presenting at the onset of their STEMI (no Q waves). In contrast, some patients particularly the older ones with more evolved STEMI (large Q waves present) may be much more suited for PCI despite expecting a long delay. The article finishes by describing potential future alterations in the method of reperfusion. Despite primary PCI being the well-established therapy, there are rooms for further research to optimize STEMI outcomes.

Troponin I Assay for Identification of a Significant Coronary Stenosis in Patients with Suspected Acute Myocardial Infarction and Wide QRS Complex

Background

Common ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI.

Methods

In 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission.

Results

Patients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99^th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99^th percentile threshold.

Conclusion

cTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.

New Right Bundle Branch Block as a Criterion for Emergent Coronary Angiography

Context:

ST-segment elevations in two or more contiguous leads or new left bundle branch block (LBBB) on electrocardiography (ECG) in a patient with acute onset chest pain are diagnostic criteria for acute myocardial infarction (AMI) and generally warrant urgent coronary angiography and cardiac catheterization. However, the significance of new right bundle branch block (RBBB) without other acute ECG changes is unclear and is currently not considered a criterion.

Case Report:

We present a patient with chest pain, positive biomarkers of myocardial necrosis and isolated new right bundle block on ECG. He was diagnosed with AMI but did not undergo urgent reperfusion therapy in the absence of ST-segment elevations or new LBBB. However, angiography ultimately demonstrated complete coronary occlusion.

Conclusion:

The established criteria for emergent catheterization may prove to be more sensitive with the inclusion of the presence of new RBBB on ECG.

Clinical Characteristics, Management, and Outcomes of Acute Coronary Syndrome in Patients With Right Bundle Branch Block on Presentation

We examined the relations between right bundle branch block (RBBB) and clinical characteristics, management, and outcomes among a broad spectrum of patients with acute coronary syndrome (ACS). Admission electrocardiograms of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) electrocardiogram substudy and the Canadian ACS Registry I were analyzed independently at a blinded core laboratory. We performed multivariable logistic regression analysis to assess the independent prognostic significance of admission RBBB on in-hospital and 6-month mortality. Of 11,830 eligible patients with ACS (mean age 65; 66% non-ST-elevation ACS), 5% had RBBB. RBBB on admission was associated with older age, male sex, more cardiovascular risk factors, worse Killip class, and higher GRACE risk score (all p <0.01). Patients with RBBB less frequently received in-hospital cardiac catheterization, coronary revascularization, or reperfusion therapy (all p <0.05). The RBBB group had higher unadjusted in-hospital (8.8% vs 3.8%, p <0.001) and 6-month mortality rates (15.1% vs 7.6%, p <0.001). After adjusting for established prognostic factors in the GRACE risk score, RBBB was a significant independent predictor of in-hospital death (odds ratio 1.45, 95% CI 1.02 to 2.07, p = 0.039), but not cumulative 6-month mortality (odds ratio 1.29, 95% CI 0.95 to 1.74, p = 0.098). There was no significant interaction between RBBB and the type of ACS for either in-hospital or 6-month mortality (both p >0.50). In conclusion, across a spectrum of ACS, RBBB was associated with preexisting cardiovascular disease, high-risk clinical features, fewer cardiac interventions, and worse unadjusted outcomes. After adjusting for components of the GRACE risk score, RBBB was a significant independent predictor of early mortality.

Bundle branch blocks and the risk of mortality in the Atherosclerosis Risk in Communities study

AIMS

The main objective of our study was to evaluate the associations between different categories of bundle branch blocks (BBBs) and mortality and to consider possible impact of QRS prolongation in these associations.

METHODS

This analysis included 15 408 participants (mean age 54 years, 55.2% women, and 26.9% blacks) from the Atherosclerosis Risk in Communities study. We used Cox regression to examine associations between left BBB (LBBB), right BBB (RBBB) and indetermined type of ventricular conduction defect [intraventricular conduction defect (IVCD)] with coronary heart disease (CHD) death and all-cause mortality.

RESULTS

During a mean 21 years of follow-up, 4767 deaths occurred; of these, 728 were CHD deaths. Compared to No-BBB, LBBB and IVCD were strongly associated with increased CHD death (hazard ratios 4.11 and 3.18, respectively; P < 0.001 for both). Furthermore, compared to No-BBB with QRS duration less than 100 ms, CHD mortality risk was increased 1.33-fold for the No-BBB group with QRS duration 100-109 ms, and 1.48-fold with QRS duration 110-119 ms, 3.52-fold for pooled LBBB-IVCD group with QRS duration less than 140 ms and 4.96-fold for pooled LBBB-IVCD group with QRS duration at least 140 ms (P < 0.001). However, mortality risk was not significantly increased for lone RBBB. For all-cause mortality, trends similar to those for CHD death were observed within the BBB groups, although at lower levels of risk.

CONCLUSION

Prevalent LBBB and IVCD, but not RBBB, are associated with increased risk of CHD death and all-cause mortality. Mortality risk is further increased as the QRS duration is prolonged above 140 ms.

Ventricular conduction defects and the risk of incident heart failure in the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

We evaluated the risk of incident heart failure (HF) associated with various categories of ventricular conduction defects (VCDs) and examined the impact of QRS duration on the risk of HF.

METHODS AND RESULTS

This analysis included 14,478 participants from the Atherosclerosis Risk in Communities (ARIC) study who were free of HF at baseline. VCDs (n = 377) were categorized into right and left bundle branch blocks (RBBB and LBBB, respectively), bifascicular BBB (RBBB with fascicular block), indeterminate-type VCD (IVCD), and pooled VCD group excluding lone RBBB. During an average of 18 years' follow-up, 1,772 participants were hospitalized for incident HF. Compared with no VCD, LBBB and pooled VCD were strongly associated with increased risk of incident HF (multivariable hazard ratios 2.87 and 2.29, respectively). Compared with no VCD with QRS duration <100 ms, HF risk was 1.17-fold for the no VCD group with QRS duration 100-119 ms, 1.97-fold for the pooled VCD group with QRS duration 120-139 ms, and 3.25-fold for the pooled VCD group with QRS duration ≥140 ms. HF risk for the pooled VCD group remained significant (1.74-fold for QRS duration 120-139 ms and 2.81-fold for QRS duration ≥140 ms) in the subgroup free from cardiovascular disease at baseline. Lone RBBB was not associated with incident HF.

CONCLUSIONS

VCDs except for isolated RBBB are strong predictors of incident HF, and HF risk is further increased as the QRS duration is prolonged >140 ms.

Reperfusion therapy for ST-segment elevation myocardial infarction: has ECG information been underutilized?

This perspective makes a contentious viewpoint that ECG information is underutilized in ST-segment elevation myocardial infarction (STEMI) and the next breakthrough rests on its full utilization. This is to better diagnose difficult cases such as ST changes during bundle branch block, posterior ST elevation and right-sided ST elevation during normal conduction, and aVR ST elevation. More importantly, this is to better characterize the STEMI for tailored reperfusion. The proposal is to develop a system capable of recording from multiple electrodes that one can apply onto oneself, and having analysis coordinated centrally via phone-internet transmission. This provides 'longitudinal' in addition to 'cross-sectional' ECG information. STEMI will be classified on a gray-scale according to its potential size and speed of Q wave evolution. The hypothesis is that large rapidly progressive STEMI is best treated by on-site fibrinolysis with prompt transferral to a percutaneous coronary intervention center; while small stuttering STEMI is best treated by primary percutaneous coronary intervention despite a long delay.

Potent P2Y1 urea antagonists bearing various cyclic amine scaffolds

A number of new amine scaffolds with good inhibitory activity in the ADP-induced platelet aggregation assay have been found to be potent antagonists of the P2Y1 receptor. SAR optimization led to the identification of isoindoline 3c and piperidine 4a which showed good in vitro binding and functional activities, as well as improved aqueous solubility. Among them, the piperidine 4a showed the best overall profile with favorable PK parameters.

New ST-depression: an under-recognized high-risk category of 'complete' ST-resolution after reperfusion therapy

AIM

It is not known if there is an association between resolution of ST-elevation to ST-depression following fibrinolysis and 30-day mortality.

METHODS

In an ECG substudy of HERO-2, which compared bivalirudin to unfractionated heparin following streptokinase in 12,556 patients with ST-elevation myocardial infarction ECGs were recorded at baseline and at 60 minutes after commencing fibrinolysis. The main outcome measure was 30-day mortality.

RESULTS

Using summed ST-segment elevation and five categories of changes in the infarct leads, further ST-elevation, 0-30% ST-resolution, >30-70% (partial) ST-resolution, >70% (complete) ST-resolution, and new ST-depression occurred in 21.7, 24.9, 36.8, 14.8, and 1.8% of patients, with 30-day mortality of 12.3, 11.7, 8.0, 4.2, and 8.1%, respectively. For the comparison of new ST-depression with complete ST-resolution and no ST-depression, p<0.01 with 24-hour mortality 4.5 vs. 1.3%, respectively (p=0.0003). Patients with new ST-depression had similar peak cardiac enzyme elevations as patients with complete ST-resolution without ST-depression. On multivariate analysis including summed ST-elevation at baseline, age, sex, and infarct location, new ST-depression was a significant predictor of 30-day mortality (OR 1.82, 95% CI 1.42-4.29).

CONCLUSIONS

In patients with complete ST-resolution following fibrinolysis, new ST-depression at 60 minutes developed in 10.8% of patients. These patients had higher mortality than patients with complete ST-resolution without ST-depression and represent a high-risk group which could benefit from rapid triage to early angiography and revascularization as appropriate.

Different patterns of bundle-branch blocks and the risk of incident heart failure in the Women's Health Initiative (WHI) study

BACKGROUND

We evaluated the risk of incident heart failure (HF) associated with bundle-branch blocks (BBBs) in postmenopausal women.

METHODS AND RESULTS

Cox's regression was used to evaluate hazard ratios with 95% confidence intervals for HF among 65975 participants of the Women's Health Initiative (WHI) study during an average follow-up of 14 years. BBBs observed in 1676 women at baseline were categorized into left, right, and indetermined-type BBBs (LBBB, RBBB, and intraventricular conduction defect, respectively). Compared with women with no BBB, LBBB, and intraventricular conduction defect were strong predictors of incident HF in multivariable-adjusted risk models (hazard ratio, 3.79; confidence interval, 2.95-4.87 for LBBB and hazard ratio, 3.53; confidence interval, 2.14-5.81 for intraventricular conduction defect). RBBB was not a significant predictor of incident HF in multivariable-adjusted risk model, but the combination of RBBB and left anterior fascicular block was a strong predictor (hazard ratio, 2.96; confidence interval, 1.77-4.93). QRS duration was an independent predictor of incident HF only in LBBB, with more pronounced risk at QRS ≥ 140 ms than at <140 ms. QRS nondipolar voltage (RNDPV) was an independent predictor in both RBBB and LBBB and, in addition, in LBBB, QRS/STT angle and ST J-point depression in aVL were independent predictors.

CONCLUSIONS

LBBB, intraventricular conduction defect, and RBBB combined with left anterior fascicular block are strong predictors of incident HF in multivariable-adjusted risk models, but RBBB is not a significant predictor. QRS duration ≥ 140 ms may warrant consideration in LBBB as an indication for further diagnostic evaluation for possible therapeutic and preventive action. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Discovery of diarylurea P2Y(1) antagonists with improved aqueous solubility

Preclinical data suggests that P2Y1 antagonists, such as diarylurea compound 1, may provide antithrombotic efficacy similar to P2Y12 antagonists and may have the potential of providing reduced bleeding liabilities. This manuscript describes a series of diarylureas bearing solublizing amine side chains as potent P2Y1 antagonists. Among them, compounds 2l and 3h had improved aqueous solubility and maintained antiplatelet activity compared with compound 1. Compound 2l was moderately efficacious in both rat and rabbit thrombosis models and had a moderate prolongation of bleeding time in rats similar to that of compound 1.

The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction

AIMS

ST-elevation in lead aVR is known to be associated with a worse prognosis in patients with acute ST elevation myocardial infarction (MI) but the significance of ST depression in lead aVR has been unclear. Infarction of the inferior apex of the left ventricle may not be appreciated on the standard 12-lead electrocardiogram (ECG) except by observing ST depression in lead aVR which is reciprocal to lead V(7). We therefore determined the prognostic value of the full spectrum of aVR ST changes in patients presenting with acute ST elevation MI.

METHODS AND RESULTS

Lead aVR ST level was measured on randomization and 60 min ECGs in 15 315 patients with normal conduction from the HERO-2 trial. The outcome measure was 30-day mortality. aVR ST elevation ≥1 mm was associated with higher 30-day mortality for both inferior (22.5% for ≥1.5 mm and 13.2% for 1 mm) and anterior (23.5% for ≥1.5 mm and 11.5% for 1 mm) infarction. In contrast, deeper aVR ST depression (0, 0.5, 1, and ≥1.5 mm) was associated with higher mortality for anterior infarction (9.8, 13.2, 12.8, and 16.8%, respectively, trend P-value <0.0001) but not for inferior infarction. The resolution of aVR ST depression and ST elevation 60 min after fibrinolysis was associated with lower mortality.

CONCLUSION

There is a U-shaped relationship between 30-day mortality and aVR ST level in patients presenting with anterior but not inferior ST elevation MI.

Prognostic value of lead V1 ST elevation during acute inferior myocardial infarction

BACKGROUND

Lead V(1) directly faces the right ventricle and may exhibit ST elevation during an acute inferior myocardial infarction when the right ventricle is also involved. Leads V(1) and V(3) indirectly face the posterolateral left ventricle, and ST depression ("mirror-image" ST elevation) in V(1) through V(3) may reflect concomitant posterolateral infarction. The prognostic significance of V(1) ST elevation during an acute inferior myocardial infarction may therefore be dependent on V(3) ST changes.

METHODS AND RESULTS

In 7967 patients with acute inferior myocardial infarction in the Hirulog and Early Reperfusion or Occlusion-2 (HERO-2) trial, V(1) ST levels were analyzed with adjustment for lead V(3) ST level for predicting 30-day mortality. V(1) ST elevation at baseline, analyzed as a continuous variable, was associated with higher mortality. Unadjusted, each 0.5-mm-step increase in ST level above the isoelectric level was associated with approximately 25% increase in 30-day mortality; this was true whether V(3) ST depression was present or not. The odds ratio for mortality was 1.21 (95% confidence interval, 1.07 to 1.37) after adjustment for inferolateral ST elevation and clinical factors and 1.24 (95% confidence interval, 1.09 to 1.40) if also adjusted for V(3) ST level. In contrast, lead V(1) ST depression was not associated with mortality after adjustment for V(3) ST level. V(1) ST elevation >or=1 mm, analyzed dichotomously in all patients, was associated with higher mortality. The odds ratio was 1.28 (95% confidence interval, 1.01 to 1.61) unadjusted, 1.51 (95% confidence interval, 1.19 to 1.92) adjusted for V(3) ST level, and 1.35 (95% confidence interval, 1.04 to 1.76) adjusted for ECG and clinical factors. Persistence of V(1) ST elevation >or=1 mm 60 minutes after fibrinolysis was associated with higher mortality (10.8% versus 5.5%, P=0.001).

CONCLUSIONS

V(1) ST elevation identifies patients with acute inferior myocardial infarction who are at higher risk.

aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction

AIM

This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI).

METHODS AND RESULTS

The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation > or =1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of > or =1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of > or =1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with > or = 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation > or =1 mm was associated with higher mortality.

CONCLUSION

aVR ST elevation is an important adverse prognostic sign in AMI.

QRS prolongation in patients with acute coronary syndromes

BACKGROUND

QRS prolongation with or without bundle branch block (BBB) has been associated with adverse outcome in myocardial infarction; we examined the relationship between QRS duration and outcome in a broad spectrum of patients with acute coronary syndrome (ACS).

METHOD AND RESULTS

Core laboratory evaluation of the presenting electrocardiogram in Canadian ACS Registry patients (n = 5,003) showed 4,289 (85.7%) had QRS <120 milliseconds, 202 (4.0%) patients had QRS > or =120 milliseconds without BBB, 262 (5.2%) had left BBB (LBBB), and 250 (5.0%) had right BBB. Compared to patients with QRS <120 milliseconds, patients with QRS > or =120 milliseconds without BBB had higher in-hospital (3.5% vs 1.9%, odds ratio [OR] 1.87, 95% CI 0.85-4.09, P = .12) and 1-year mortality (14.9% vs 7.7%, OR 2.10, 95% CI 1.38-3.18, P = .001). In-hospital and 1-year mortality was significantly higher in patients with BBB (eg, LBBB compared with QRS <120 milliseconds) (5.0% vs 1.9%, OR 2.71, 95% CI 1.49-4.94, P = .001, and 23.8% vs 7.7%, OR 3.74, 95% CI 2.72-5.13, P < .001). Analyzed as a continuous variable and after adjustment for validated prognosticators, QRS duration was an independent predictor of 1-year death (OR 1.11, 95% CI 1.06-1.16, P < .001) and death/myocardial infarction (OR 1.06, 95% CI 1.02-1.11, P = .003). However, when using clinically applicable QRS duration evaluation, only LBBB was an independent predictor of 1-year mortality (OR 1.93, 95% CI 1.28-2.90, P = .002).

CONCLUSIONS

In patients presenting with a broad spectrum of suspected ACS, QRS prolongation-particularly in the setting of LBBB-is an independent predictor of in-hospital and 1-year mortality.

Right bundle-branch block in acute coronary syndrome: diagnostic and therapeutic implications for the emergency physician

Right bundle-branch block (RBBB) in the patient with acute coronary syndrome is a marker of significant potential cardiovascular risk; the RBBB pattern in the patient with acute coronary syndrome identifies a subgroup of patients with quite high short- and long-term morbidity and mortality. Right bundle-branch block is not an uncommon finding on an electrocardiogram in the emergency department patient, noted incidentally and thus without clinical import or, conversely, encountered in the early phase of significant cardiovascular dysfunction. This review will address RBBB in the acute coronary syndrome setting.

Prognostic significance of QRS duration in patients with suspected coronary artery disease referred for noninvasive evaluation of myocardial ischemia

The purpose of this study was to evaluate the prognostic significance of QRS duration in patients with suspected coronary artery disease (CAD) referred for noninvasive evaluation of myocardial ischemia by dobutamine stress echocardiography. QRS duration is a prognostic marker in patients with previous myocardial infarction and/or heart failure. The relation between QRS duration and outcome of patients without known heart disease has not been evaluated. A total of 1,227 patients (707 men, mean age 61 +/- 14 years) with suspected CAD underwent dobutamine stress echocardiography for evaluation of myocardial ischemia. Patients were followed to determine predictors of cardiac events and to assess the incremental significance of QRS duration compared to clinical and dobutamine stress echocardiographic data. During a mean follow-up of 4.2 +/- 2.4 years, 280 patients (23%) died (129 cardiac deaths), and 60 (5%) had a nonfatal infarction. Annualized cardiac death rates were 2.0% in patients with QRS duration <120 ms and 4.4% in patients with QRS duration >or=120 ms, respectively (p <0.0001). Annualized event rates for cardiac death/nonfatal infarction were 2.8% in patients with QRS duration <120 ms and 4.8% in patients with QRS duration >or=120 ms (p = 0.0001). Multivariate models identified age, male gender, smoking, QRS duration >or=120 ms, and an abnormal dobutamine stress echocardiogram as independent predictors of cardiac death and the combined end point cardiac death/nonfatal infarction. In conclusion, QRS duration is an independent predictor of cardiac death and cardiac death/nonfatal infarction in patients with suspected CAD. This risk is persistent after adjustment for clinical variables, left ventricular function, and myocardial ischemia.

Circulating microRNA-1 as a potential novel biomarker for acute myocardial infarction

Recent studies have revealed the role of microRNAs (miRNAs) in a variety of basic biological and pathological processes and the association of miRNA signatures with human diseases. Circulating miRNAs have been proposed as sensitive and informative biomarkers for multiple cancers diagnosis. We have previously documented aberrant up-regulation of miR-1 expression in ischemic myocardium and the consequent slowing of cardiac conduction. However, whether miR-1 could be a biomarker for predicting acute myocardial infarction (AMI) is unclear. In the present study, we recruited 159 patients with or without AMI for quantification of miR-1 level in plasma using real-time RT-PCR method. We performed Wilcoxon rank sum and signed rank tests for comparison. Univariable linear regression and logistics regression analyses were performed to assess the potential correlation between miR-1 and known AMI markers. We also conducted receiver-operator characteristic curve (ROC) analysis to evaluate the diagnostic ability of miR-1. We found that: miR-1 level was significantly higher in plasma from AMI patients compared with non-AMI subjects and the level was dropped to normal on discharge following medication. Increased circulating miR-1 was not associated with age, gender, blood pressure, diabetes mellitus or the established biomarkers for AMI. However, miR-1 level was well correlated with QRS by both univariable linear and logistics regression analyses. The area under ROC curve (AUC) was 0.7740 for separation between non-AMI and AMI patients and 0.8522 for separation AMI patients under hospitalization and discharge. Collectively, our results revealed that circulating miR-1 may be a novel, independent biomarker for diagnosis of AMI.

Relationship of admission QRS duration and changes in QRS duration with myocardial reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy

BACKGROUND

Although ischemia induced QRS complex changes have been described previously, their relationship with impaired reperfusion, which is known to be associated with poor clinical outcomes, is not clear.

METHODS AND RESULTS

To investigate the relationship of QRS duration changes with myocardial reperfusion, we studied 165 acute myocardial infarction (MI) patients who were administered fibrinolytic therapy for reperfusion. For each patient, 12-lead electrocardiogram (ECG) with a paper speed of 50 mm/s was recorded on admission and repeated at the 60(th) and 90(th) min following fibrinolytic therapy. Based on the myocardial blush grades obtained from a control coronary angiography, patients were divided into reperfusion (grades 2, 3) and impaired reperfusion (grades 0, 1) groups. We detected impaired reperfusion in 74 patients. The patients in the impaired reperfusion group were older, more often diabetic, and had longer pain-to-needle intervals. They also had significantly longer QRS durations at admission compared to reperfusion group patients (91+/-11 vs 79+/-11 ms, p<0.001). Reperfusion group patients showed significantly greater resolution in QRS duration at the 90(th) min post fibrinolysis ECG (18+/-5 vs 5+/-4 ms, p<0.001). In regression analysis, the pain-to-needle time (odds ratio (OR): 0.55, 95% confidence interval (CI) 0.35-0.88, p=0.012), QRS duration on admission (OR: 0.80, 95% CI 0.67-0.97, p=0.021), and change in QRS duration at the post fibrinolysis 90(th) min ECG (OR: 2.43, 95% CI, 1.29-4.60, p=0.006) were determined as independent predictors of adequate reperfusion.

CONCLUSION

The present study, for the first time, has shown that admission QRS duration and post fibrinolysis 90(th) min QRS duration changes are related to tissue reperfusion in fibrinolytic administered acute MI patients.

Incidence and clinical impact of right bundle branch block in patients with acute myocardial infarction: ST elevation myocardial infarction versus non-ST elevation myocardial infarction

BACKGROUND

Both left bundle branch block and right bundle branch block (RBBB) have been associated with increased inhospital and long-term mortality in patients with acute ST elevation myocardial infarction (STEMI). However, the prognostic role of RBBB in acute non-ST elevation myocardial infarction (NSTEMI) is not well known. Therefore, the aim of the study was to evaluate the incidence and clinical impact of RBBB in patients with NSTEMI compared to patients with STEMI.

METHODS

From the German prospective multicenter registry "Maximal Individual Therapy of Acute Myocardial Infarction" (MITRA PLUS), 6,403 consecutive patients with NSTEMI and 20,233 patients with STEMI were analyzed. Patients with left bundle branch block were excluded. The median follow-up time for NSTEMI was 378 days and for STEMI 479 days.

RESULTS

A total of 455 (7.1%) patients with NSTEMI and 894 (4.4%) patients with STEMI presented with RBBB on admission. In general, RBBB patients were older, more often had comorbidities, and less often received short-term inhospital treatment according to guidelines. In STEMI, RBBB patients had higher peak enzyme levels and lower left ventricular ejection fraction (LV-EF) than patients without BBB. Right bundle branch block in STEMI was associated with an increased inhospital and long-term mortality. In NSTEMI, however, peak enzyme levels and LV-EF were similar in both groups with and without RBBB. Right bundle branch block in NSTEMI was not independently associated with a worse outcome.

CONCLUSIONS

Unlike RBBB in STEMI, RBBB in NSTEMI is not an independent predictor of inhospital and long-term mortality.