Histopathologic regression in patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy is associated with favorable survival and, after metastasis, with improved progression-free survival on immune checkpoint inhibitor therapy: A single-institutional cohort study

BACKGROUND

Histopathologic regression of cutaneous melanoma is considered a favorable prognostic factor, but its significance in clinical practice remains controversial.

OBJECTIVE

To investigate the prognostic importance of regression in patients with primary cutaneous melanoma undergoing sentinel lymph node (SLN) biopsy and to assess its significance in patients progressing to an unresectable stage requiring systemic therapy.

METHODS

We retrospectively reviewed patients with newly diagnosed melanoma undergoing SLN biopsy between 2010 and 2015 and available information on histopathologic regression (n = 1179). Survival data and associations of clinical variables with SLN status were assessed.

RESULTS

Patients with regressive melanoma showed favorable relapse-free (hazard ratio [HR], 0.52; P = .00013), distant metastasis-free (HR, 0.56; P = .0020), and melanoma-specific survival (HR, 0.35; P = .00053). Regression was associated with negative SLN (odds ratio, 0.48; P = .0077). In patients who progressed to an unresectable stage, regression was associated with favorable progression-free survival under immune checkpoint inhibition (HR, 0.43; P = .031) but not under targeted therapy (HR, 1.14; P = .73) or chemotherapy (HR, 3.65; P = .0095).

LIMITATIONS

Retrospective, single-institutional design.

CONCLUSIONS

Regression of cutaneous melanoma is associated with improved prognosis in patients eligible for SLN biopsy as well as in patients with unresectable disease receiving systemic therapy with immune checkpoint inhibitors.

Baseline metastatic growth rate is an independent prognostic marker in patients with advanced BRAF V600 mutated melanoma receiving targeted therapy

BACKGROUND

Targeted therapy (TT) of BRAF V600 mutated unresectable melanoma with inhibitors of the MAPK pathway achieves response rates of up to 76%, but most patients develop secondary resistance. Albeit TT is strikingly efficacious during the first days of treatment, even in advanced cases, long-term survival is highly unlikely, especially in patients with unfavorable baseline characteristics like elevated lactate dehydrogenase (LDH). In patients treated with anti-PD-1 immune checkpoint inhibitors, elevated baseline metastatic growth rate (MGR) was the most important prognostic factor. Here, we aimed at investigating the prognostic impact of MGR in patients with unresectable melanoma receiving TT.

METHODS

Clinical records of 242 patients with at least one measurable target lesion (TL) receiving TT at seven skin cancer centers were reviewed. Baseline MGR was determined measuring the largest TL at baseline and at one earlier timepoint.

RESULTS

Overall survival (OS) and progression-free survival (PFS) were significantly impaired in patients with an MGR > 3.9 mm/month (median OS: 11.4 vs. 35.5 months, P < 0.0001; median PFS: 4.8 vs. 9.2 months, P < 0.0001). Multivariable analysis of OS and PFS revealed that the prognostic impact of elevated MGR was independent of LDH, presence of brain and liver metastases, tumor burden, and line of treatment. The prognostic significance of elevated MGR was highest in patients with normal LDH.

CONCLUSIONS

Baseline MGR is an important independent prognostic marker for OS and PFS in melanoma patients treated with TT. Its implementation in clinical routine is easy and could facilitate the prognostic stratification.

Swiss Recommendations for Cutaneous Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer in Switzerland and worldwide. Most BCCs can be treated in a curative setting. However, patients can develop locally destructive and, rarely, metastatic tumors that require a different treatment approach. The clinical subtype of individual lesions provides prognostic information and influences management decisions. Surgical excision, topical therapies, and radiotherapy are highly effective in the majority of subtypes as well as in low- and high-risk diseases. For patients with low-risk diseases and superficial tumors not amenable to surgery, several nonsurgical alternatives are available. Systemic therapy is indicated for high-risk BCCs, which are not amenable to either surgery or radiotherapy. Hedgehog pathway inhibitors (HHI) are currently approved. Other therapeutic options such as immune checkpoint inhibitors show promising results in clinical trials. This first version of Swiss recommendations for diagnosis and management of BCC was prepared through extensive literature review and an advisory board consensus of expert dermatologists and oncologists in Switzerland. The present guidelines recommend therapies based on a multidisciplinary team approach and rate of recurrence for individual lesions. Based on the risk of recurrence, two distinct groups have been identified: low-risk (easy-to-treat) and high-risk (difficult-to-treat) tumors. Based on these classifications, evidence-based recommendations of available therapies are presented herein.

Early disappearance of tumor antigen-reactive T cells from peripheral blood correlates with superior clinical outcomes in melanoma under anti-PD-1 therapy

Background

Anti-programmed cell death protein 1 (PD-1) antibodies are now routinely administered for metastatic melanoma and for increasing numbers of other cancers, but still only a fraction of patients respond. Better understanding of the modes of action and predictive biomarkers for clinical outcome is urgently required. Cancer rejection is mostly T cell-mediated. We previously showed that the presence of NY-ESO-1-reactive and/or Melan-A-reactive T cells in the blood correlated with prolonged overall survival (OS) of patients with melanoma with a heterogeneous treatment background. Here, we investigated whether such reactive T cells can also be informative for clinical outcomes in metastatic melanoma under PD-1 immune-checkpoint blockade (ICB).

Methods

Peripheral blood T cell stimulation by NY-ESO-1 and Melan-A overlapping peptide libraries was assessed before and during ICB in two independent cohorts of a total of 111 patients with stage IV melanoma. In certain cases, tumor-infiltrating lymphocytes could also be assessed for such responses. These were characterized using intracellular cytokine staining for interferon gamma (IFN-γ), tumor negrosis factor (TNF) and CD107a. Digital pathology analysis was performed to quantify NY-ESO-1 and Melan-A expression by tumors. Endpoints were OS and progression-free survival (PFS).

Results

The initial presence in the circulation of NY-ESO-1- or Melan-A-reactive T cells which became no longer detectable during ICB correlated with validated, prolonged PFS (HR:0.1; p>0.0001) and OS (HR:0.2; p=0.021). An evaluation of melanoma tissue from selected cases suggested a correlation between tumor-resident NY-ESO-1- and Melan-A-reactive T cells and disease control, supporting the notion of a therapy-associated sequestration of cells from the periphery to the tumor predominantly in those patients benefitting from ICB.

Conclusions

Our findings suggest a PD-1 blockade-dependent infiltration of melanoma-reactive T cells from the periphery into the tumor and imply that this seminally contributes to effective treatment.

Histological and Immunohistochemical Changes of Congenital Melanocytic Nevi With Age

ABSTRACT

Clinical but not histological changes of congenital melanocytic nevi (CMN) with age are well characterized. Our objective was to analyze histological changes of CMN with age and discuss possible clinical implications of our findings. We investigated serial excisions of 21 patients with CMN and compared histological and immunohistochemical features over time. The median number of serial excisions was 6 [interquartile range (IQR) 5-7], the median age at the first excision was 12 months (IQR 5-98), and the median time between the first and last analyzed excision was 53 months (IQR 45-64). The projected adult size of the excised CMN was "large" or "giant" in 14 of the 21 CMN (67%) and "medium" in the remaining lesions (33%). Nineteen CMN (90%) involved the subcutaneous fat, and 16 of the 21 CMN (76%) reached the lower surgical margin. The histological pattern and depth did not change over time but the cellularity and HMB-45 expression of dermal melanocytes decreased in 16 of the 21 patients (76%) and in 15 of the 21 patients (71%), respectively (both P < 0.001). Patients with decreasing HMB-45 expression were significantly younger at the first excision (median 6 months, IQR 4-28) than patients with unchanged HMB-45 expression (median 176 months, IQR 12-186; P = 0.018). The expression of Ki-67 and p16 did not change significantly with age. Our study demonstrates that (1) the cellularity and pigment production of CMN decreases with age, (2) the histological pattern and extension in depth remain stable, and (3) clear resection margins can rarely be achieved in larger CMN.

Serum S100B and LDH at Baseline and During Therapy Predict the Outcome of Metastatic Melanoma Patients Treated with BRAF Inhibitors

BACKGROUND

Despite impressive response rates, most patients with advanced melanoma ultimately progress following therapy with B-Raf proto-oncogene (BRAF) inhibitors (BRAFi). Therefore, frequent radiologic assessments are necessary, and reliable serum biomarkers would be beneficial for disease monitoring.

OBJECTIVE

This study investigated the ability of lactate dehydrogenase (LDH) and S100 calcium-binding protein B (S100B) to detect response and disease progression during treatment with BRAFi.

PATIENTS AND METHODS

Baseline levels of LDH and S100B and repeated measurements during therapy were recorded retrospectively in 191 patients with metastatic melanoma. LDH and S100B levels were compared between distinct time points (baseline, first follow-up visit [FV], best objective response [BR], and progressive disease [PD]). The prognostic ability of the serum biomarkers in relation to disease-specific survival (DSS) was assessed with univariable and multivariable Cox regression analysis.

RESULTS

Elevated baseline LDH and S100B correlated with impaired DSS. In contrast with LDH (P = 0.12), S100B levels at FV correlated with response (P = 0.0030). Both markers significantly decreased during the first weeks of BRAFi treatment (LDH, P = 0.00034; S100B, P < 0.0001) and increased between BR and PD (LDH, P = 0.016; S100B, P < 0.0001). Patients with elevated S100B (P = 0.00062) but not with elevated LDH (P = 0.067) at the time point of radiologically confirmed PD showed significantly impaired DSS after PD. Interestingly, DSS after PD differed significantly according to S100B levels determined as early as 8 weeks (median) before PD (P = 0.0024).

CONCLUSIONS

LDH and S100B are suitable serum biomarkers during therapy with BRAFi. S100B shows stronger correlation with response and exhibits more accuracy in predicting PD. Close biomarker monitoring with S100B is recommended during treatment with BRAFi to detect PD early.

Expression of DNA Methyltransferase 1 Is a Hallmark of Melanoma, Correlating with Proliferation and Response to B-Raf and Mitogen-Activated Protein Kinase Inhibition in Melanocytic Tumors

Aberrant DNA methylation is an epigenetic hallmark of melanoma, but the expression of DNA methyltransferase (Dnmt)-1 in melanocytic tumors is unknown. Dnmt1 expression was analyzed in primary melanocytes, melanoma cell lines, and 83 melanocytic tumors, and its associations with proliferation, mutational status, and response to B-Raf and mitogen-activated protein kinase kinase (MEK) inhibition were explored. Dnmt1 expression was increased incrementally from nevi [mean fluorescence intensity (MFI), 48.1; interquartile range, 41.7 to 59.6] to primary melanomas (MFI, 68.8; interquartile range, 58.4 to 77.0) and metastatic melanomas (MFI, 87.5; interquartile range, 77.1 to 114.5) (P < 0.001). Dnmt1 expression was correlated with Ki-67 expression (Spearman correlation, 0.483; P < 0.001) and was independent of BRAF mutation status (P = 0.55). In BRAF-mutant melanoma, Dnmt1 was down-regulated during response to B-Raf and MEK inhibition and was again up-regulated on drug resistance in vitro and in vivo. Degradation of Dnmt1 by the histone deacetylase inhibitor suberoylanilide hydroxamic acid was associated with decreased cell viability in B-Raf inhibitor-sensitive and -resistant cell lines. This study demonstrates that Dnmt1 expression is correlated with proliferation in melanocytic tumors, is increased with melanoma progression, and is associated with response to B-Raf and MEK inhibition. Given its strong expression in metastatic melanoma, Dnmt1 may be a promising target for combined epigenetic and immunotherapy.

Absolute and relative differential blood count predicts survival of AJCC stage I-II melanoma patients scheduled for sentinel lymph node biopsy

BACKGROUND/OBJECTIVES

Elevated neutrophil-to-lymphocyte ratio (NLR) in peripheral blood is associated with poor overall survival (OS) in metastatic melanoma patients receiving immunotherapy. However, the impact of peripheral blood cells in patients undergoing sentinel lymph node biopsy (SLNB) is still unclear. This study was intended to characterize the impact of peripheral blood leukocytic cells on overall survival (OS) in melanoma patients undergoing SLNB.

METHODS

A total of 1412 AJCC stage I-II melanoma patients scheduled for SLNB at a single institution in the period 2010-2015 with available perioperative blood tests were randomly assigned to two independent cohorts. Associations of peripheral blood leukocytes with OS were analysed using Kaplan-Meier estimator and multivariate Cox proportional hazards model.

RESULTS

NLR >4.26, absolute neutrophil count >5800/µL, relative neutrophil count >69.7% and relative lymphocyte count ≤ 17.5% were significantly associated with reduced OS in both cohorts. Absolute monocytes >810/µL, absolute eosinophils ≤200/µL, relative monocytes >6.6%, relative eosinophils ≤2.7% and relative basophils ≤0.6% were significantly associated with reduced OS in one cohort each. On multivariate analysis, a combined score including absolute levels of neutrophils, lymphocytes, monocytes and eosinophils was significantly associated with OS in both cohorts. The hazard ratio of patients with a risk score of 3-4 was 5.42 (95% confidence interval: 1.52-19.42, P = 0.0094) in cohort 1 and 9.42 (2.06-43.06, P = 0.0038) in cohort 2, respectively.

CONCLUSIONS

We conclude that peripheral blood leukocytes are independently associated with OS in stage I-II melanoma patients and should be considered as prognostic markers in these patients. Eosinophils and basophils deserve more attention in future investigations.

Tumor microenvironment-derived S100A8/A9 is a novel prognostic biomarker for advanced melanoma patients and during immunotherapy with anti-PD-1 antibodies

BACKGROUND

Predicting metastasis in melanoma patients is important for disease management and could help to identify those who might benefit from adjuvant treatment. The aim of this study was to investigate whether the tumor microenvironment-derived protein S100A8/A9 qualifies as prognostic marker for melanoma patients, also in the setting of immunotherapy.

METHODS

S100A8/A9 gene and protein expression were analyzed on melanocytic nevi, primary melanomas and metastases using a cDNA library and three independent tissue-microarrays (TMA). Serum levels of S100A8/A9 were measured using a specific ELISA in two independent cohorts of 354 stage III and stage IV melanoma patients as well as in two independent cohorts of patients treated with the PD-1 antibody pembrolizumab.

RESULTS

cDNA analysis revealed an upregulation of S100A8 and S100A9 gene expression in melanoma metastases compared to primary melanomas. Significantly higher numbers of infiltrating S100A8/A9 positive cells were found in tissue samples of metastasizing primary melanomas compared to non-metastasizing melanomas (P < .0001) and in melanomas of short-term survivors compared to long-term survivors (P < .0001). Serum S100A8/A9 levels > 5.5 mg/l were associated with impaired overall survival in two independent cohorts (both P < .0001). Importantly, patients with serum elevated S100A8/A9 treated with pembrolizumab showed significantly impaired survival compared to patients with lower S100A8/A9 levels (cohort 1: P = .0051; cohort 2: P < .0001).

CONCLUSIONS

The tumor microenvironment-associated protein S100A8/A9 serves as a novel prognostic marker for metastasis and survival of metastatic melanoma patients and predicts response to immunotherapy with pembrolizumab. These data underscore the significance of tumor microenvironment-derived factors as suitable biomarkers for melanoma.

S100B and LDH as early prognostic markers for response and overall survival in melanoma patients treated with anti-PD-1 or combined anti-PD-1 plus anti-CTLA-4 antibodies

Background

Immunotherapy with PD-1 antibodies has greatly increased prognosis of patients with advanced melanoma. Identifying biomarkers that predict overall survival (OS) and response to immunotherapy is important.

Methods

OS and best overall response according to RECIST version 1.1 were analysed, and S100B and lactate dehydrogenase (LDH) serum levels were assessed retrospectively in 152 patients treated with anti-PD-1, and in 86 patients treated with anti-PD-1 plus anti-CTLA-4 antibodies at University Hospital Tuebingen, Germany.

Results

In the pembrolizumab group, patients with elevated baseline S100B or LDH exhibited significantly impaired OS compared with patients with normal S100B (1-year OS: 51.1% vs 83.1%, log-rank P < .0001) and normal LDH (1-year OS: 44.4% vs 80.8%, P = .00022), respectively. LDH increases of >25% and S100B increases of >145% compared to baseline were significantly associated with impaired OS (both P < .0001). In patients treated with ipilimumab and nivolumab, baseline S100B and increasing S100B levels of >145% as well as baseline LDH were associated with impaired OS (P < .0001, P = .00060, and P = .0050, respectively), whereas increasing LDH of >25% was not (P = .64).

Conclusions

S100B could serve as a strong baseline marker for OS in melanoma patients receiving anti-PD-1 therapy. Rising S100B levels during the first weeks of therapy could help guide treatment decisions.

Diminished levels of the soluble form of RAGE are related to poor survival in malignant melanoma

RAGE is a central driver of tumorigenesis by sustaining an inflammatory tumor microenvironment. This study links the soluble forms of RAGE (sRAGE and esRAGE) with clinical outcome of melanoma patients. Moreover, tissue expression of RAGE was analyzed using immunohistochemistry on two independent tissue microarrays (TMA) containing 35 or 257 primary melanomas, and 41 or 22 benign nevi, respectively. Serum concentrations of sRAGE and esRAGE were measured in 229 Stage III-IV patients using ELISA and plasma concentrations of sRAGE were analyzed in an independent second cohort with 173 samples of Stage I-IV patients. In this cohort, three well-described SNPs in the RAGE gene were analyzed. RAGE protein expression was highly upregulated in primary melanomas compared to benign nevi in the two TMA (p < 0.001 and p = 0.005) as well as in sun-exposed melanomas (p = 0.046). sRAGE and esRAGE were identified as prognostic markers for survival as diminished sRAGE (p = 0.034) and esRAGE (p = 0.012) serum levels correlated with poor overall survival (OS). Multivariate Cox regression analysis showed that diminished serum sRAGE was independently associated with poor survival (p = 0.009). Moreover, diminished sRAGE was strongly associated with impaired OS in the second cohort (p < 0.001). Multivariate Cox regression analysis including the investigated SNPs revealed an independent correlation of the two interacting promoter SNPs with impaired OS. In conclusion, the soluble forms of RAGE and variants in its genetic locus are prognostic markers for survival in melanoma patients with high risk for progression.

Evolution of electrocardiographic and echocardiographic abnormalities during the 4 years following first acute myocardial infarction

Therapies aimed at salvaging jeopardized myocardium in patients with acute myocardial infarction (MI) are now routine. The success of these therapies must often be estimated by non-invasive tests, such as the 12-lead electrocardiogram (ECG) or two-dimensional echocardiography. To monitor QRS changes and left ventricular (LV) function over time in patients who have received therapies aimed at myocardial salvage, it is important to know the 'spontaneous' evolution of these estimates. Consecutive MI survivors admitted in the pre-thrombolytic era with their first MI were re-studied at 4 years. Patients were excluded if they had experienced reinfarction, coronary revascularization or bundle branch block in the acute or follow-up period. A standard ECG and a two-dimensional echocardiogram were obtained prior to discharge and at follow-up. The quantitative ECG analysis was performed according to the Selvester QRS scoring method. During the two-dimensional echocardiogram each of the 20 segments of the LV were assessed to provide a wall motion score. Eighty patients with a median age of 64 years (range 40-79) were included in the study. Thirty-two had anterior and 48 inferior MI. A significant decrement in median QRS score-estimated AMI size occurred between pre-discharge and follow-up ECGs in the entire group (18.3% vs 10.5%; P<0.0001). This difference occurred in both anterior (21.6% vs 10.5%; P<0.0001) and inferior-posterior (16.5 vs 10.5%; P<0.0001) MI locations. In the anterior MI group ther was a trend towards a greater total decrease of QRS points than in the inferior-posterior MI group (42% vs 27%; P=0.10). Within the anterior MI group, more QRS points awarded in the anteroseptal leads (V1-V3) remained follow-up than in the anterosuperior and apical leads (I, aVL and V4-V6), (80% vs 49%; P=0,03).

T wave amplitudes in normal populations. Variation with ECG lead, sex, and age

Consideration of increased T wave amplitude (tall T waves), either alone or in association with other electrocardiographic (ECG) parameters, may be beneficial for the early detection of acute transmural ischemia, and quantification of the increase might be used in quantifying the ischemic area. The primary purpose of this study was to quantify normal T wave amplitude limits according to ECG lead, sex, and age. One thousand nine hundred thirty-five subjects in two normal populations were analyzed, and the 98th percentile of the positive T wave amplitude for each ECG lead (including -aVR) was considered the upper limit of normal. Normal T wave amplitude was two times greater in the precordial than in the limb leads, and it was approximately 25% greater in men than in women in all leads. There was approximately a 10% decrease in normal T wave amplitude between 18-39- and 40-59-year-old patients and a 15% decrease between 40-59- and 60-79-year-old patients. The upper limit of normal T wave amplitudes identified in this study confirm those developed by Lepeschkin for use as means for each lead when age and sex are not considered. These limits might be incorporated into both normograms and automated ECG analysis systems to determine the presence or absence of tall T waves in patients presenting with symptoms of acute transmural ischemia.

Impact of infarct artery patency on the relationship between electrocardiographic and ventriculographic evidence of acute myocardial ischaemia

Routine invasive evaluations are being abandoned, and thus simple non-invasive methods for estimating the extent of jeopardized myocardium during evolving myocardial infarction are needed for risk stratification to guide the appropriate therapeutic intervention. With this in mind the aim of the paper was to evaluate the association between ischaemic changes in the standard electrocardiogram and the function of acutely infarcted myocardium in relation to infarct artery patency status. Forty consecutive patients with a first acute myocardial infarction, admitted within 6 h of symptom onset and without bundle branch or fascicular block were included. Summated ST segment elevation in 11 electrocardiographic leads (aVR excluded) was measured to the nearest 0.05 mV and compared to regional wall motion, estimated by the centreline method (SD/chord) and global left ventricular ejection fraction (% LVEF) after thrombolytic therapy. Acute angiographic and ST segment measurements were performed at a median 254 min (range 70-485) after the onset of symptoms. Patients were grouped according to infarct artery patency status after intravenous thrombolysis. Of the 40 patients, 27 had a patent (Thrombolysis In Acute Myocardial Infarction trial (TIMI) grade 2-3 flow) and 13 had persistently occluded (TIMI 0-1 flow) infarct arteries. Anterior myocardial infarction was present in 13 and seven patients in the two groups. In the TIMI 2-3 group, the summated ST elevation did not correlate with % LVEF or SD/chord (rs = -0.08; and rs = -0.17, respectively). In the TIMI0-1 group the summated ST elevation correlated inversely with both % LVEF and SD/chord (rs = -0.70; and rs = -0.56, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Importance of early and complete reperfusion to achieve myocardial salvage after thrombolysis in acute myocardial infarction

The importance of the timing and completeness of coronary artery reperfusion for limitation of acute myocardial infarction (AMI) size after intravenous thrombolytic therapy was studied in 39 patients. All had electrocardiographic epicardial injury and acute coronary angiography performed < 8 hours after symptom onset. Acutely jeopardized myocardium was estimated at baseline, and before and after angiography by quantitative ST-segment analysis. The AMI size was estimated on the final electrocardiogram by the Selvester QRS score. Left ventricular ejection fraction was measured at the time of acute angiography and before discharge in 31 of these patients. In the 21 patients with normal flow (Thrombolysis in Myocardial Infarction [TIMI] trial grade 3) in the infarct-related artery, the amount of jeopardized myocardium decreased from baseline to that before and after angiography (17 to 11 and 11%, respectively; p < 0.00005), and the median final AMI size was reduced (17 to 9%; p = 0.0004). In 6 patients with suboptimal flow (TIMI grade 2), the median amount of jeopardized myocardium decreased slightly from baseline to that before to after angiography (15 to 12%); however, the median final AMI size was not reduced (17%). In 12 patients with no reperfusion (TIMI 0 to 1) flow, the median amount of jeopardized myocardium remained unchanged from baseline to that before angiography (21%), and the final AMI size was not significantly reduced. There was a significant inverse correlation between the change in global left ventricular function and the difference between electrocardiographic estimated jeopardized and final AMI size (rs = -0.53; p = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the 12-lead ECG to detect myocardial reperfusion and salvage during acute myocardial infarction

In this era of thrombolytic therapy, the standard 12-lead electrocardiogram (ECG) is easily available and noninvasive and could provide indicators of myocardial reperfusion and salvage. Previous reports have proposed that a decrease of total ST-segment elevation of > or = 20% from the pre- to the immediate posttreatment ECG is indicative of reperfusion, and that a > or = 20% decrease from the initial infarct size predicted by ST-segment deviation on the admission ECG to the final infarct size estimated by QRS score on the predischarge recording is indicative of myocardial salvage. This prospective study of 29 patients with myocardial infarction and angiographically documented reperfusion shows that the > or = 20% threshold for ST resolution achieved 79% sensitivity and 70% specificity in patients receiving intravenous therapy and 90% sensitivity in those receiving rescue intracoronary therapy. However, it should be noted that 21% of patients with successful intravenous therapy failed to achieve even this threshold of ST resolution. Regarding myocardial salvage, 63% of patients receiving intravenous and 90% of those receiving rescue intracoronary therapy achieved the threshold of > or = 20% decrease in infarct size.

Correlation of the complete version of the Selvester QRS scoring system with quantitative anatomic findings for multiple left ventricular myocardial infarcts

The correlation between myocardial infarct size estimated by the complete version of the Selvester QRS scoring system and that documented by pathoanatomic studies has been reported for single anterior, inferior and posterolateral infarcts. Although previous studies described electrocardiographic changes in patients with multiple infarcts, no quantitative documentation of the ability of such changes to estimate the total amount of left ventricular infarction has been reported. This study of 32 patients with anatomically documented multiple infarcts shows a significant correlation between QRS-estimated and anatomically documented sizes (r = 0.44; p = 0.01), which is less than that previously reported for single infarcts in the anterior, inferior and posterolateral locations. Several of the 54 electrocardiographic criteria were never satisfied. Criteria for posterior infarction were seldom present, suggesting "cancellation effect" of coexisting anterior infarction. These results will be the basis for future modification of QRS criteria for estimating myocardial infarct size.

Performance of the automated complete Selvester QRS scoring system in normal subjects and patients with single and multiple myocardial infarctions

The automated version of the complete Selvester QRS scoring system for estimation of myocardial infarct size was evaluated in 1,344 normal subjects, 706 patients with a single myocardial infarction (366 with inferior infarction, 277 with anterior infarction and 63 with posterolateral infarction) and 131 patients with combined inferior and anterior infarction. The presence and location were determined by angiographic and ventriculographic criteria. The performance of the overall 32-point system, each of the 19 criteria and the 13 criteria sets and each of the 35 criteria within the 13 sets was examined. The mean point scores were 1.7 for normal subjects, 3.7 for posterolateral infarction, 4.1 for inferior infarction, 6.3 for anterior infarction and 6.9 for multiple infarcts. A score greater than 4 yielded a sensitivity of 67% for anterior infarction, 41% for inferior infarction, 32% for posterolateral infarction and 72% for multiple infarcts. However, 7 of 32 criteria failed to achieve 95% specificity and 10 of 35 criteria in criteria sets had a sensitivity that was even lower than their false positive rate. The automated Selvester QRS scoring system currently has limitations that are attributable to development of the original system, which used manual scoring techniques and established criteria limits from middle-aged men. Future automated analysis should use gender- and age-dependent criteria limits.

Evaluation of changes in standard electrocardiographic QRS waveforms recorded from activity-compatible proximal limb lead positions

Proximal limb lead positions are currently used for activity-compatible electrocardiographic monitoring of myocardial ischemia. Two previously described systems for alternate limb lead placement were studied in patients with and without QRS evidence of healed anterior or inferior myocardial infarction. An innovative method was used to simultaneously record 6 standard and 6 modified limb leads, and 3 standard and 3 modified precordial leads on a standard digital electrocardiograph. Both alternate lead placement systems showed rightward frontal plane axis shift and diminished Q-wave durations in lead aVF compared with those of their simultaneous standard controls. Furthermore, potential differences between the standard distal limb lead sites and 5 more proximal sites were explored along each limb. Differences along the left arm were accentuated relative to those along the right arm owing to differences in proximity of the arms to the myocardium. Along the lower limb, and anterior site showed less deviation from standard than did a more lateral site. It is imperative that recordings from alternate sites be labeled accordingly so that their output cannot be confused with that obtained from standard sites.

Evaluation of a QRS scoring system for estimating myocardial infarct size. VIII. Specificity in a control group with left ventricular hypertrophy and proposal of a new scoring system for use with this confounding factor

Electrocardiographic differentiation between left ventricular hypertrophy (LVH) and myocardial infarction (MI) is often difficult because both diagnoses are based primarily on QRS changes on the electrocardiogram (ECG). The specific goal of this study was the development of ECG criteria that could be used with the complete Selvester QRS scoring system for MI size in patients with LVH. A study population of 127 patients had significant aortic valve disease verified by cardiac catheterization. Inclusion in the study required no significant coronary artery disease, no focal contraction abnormality on the left ventriculogram, and no documented MI. Quantitative criteria for LVH developed by Bonner (IBM) and also those developed by the Cornell group were used to determine the ECG evidence for LVH in each patient. One or both sets of criteria were met in 110 (87%) of the 127 patients. This group was compared to a previously evaluated control population of 500 normal subjects. The complete 54-criteria, 32-point QRS MI size scoring system was applied to the 12-lead ECG of both groups. The score was 98% specific in the normal controls and 73% specific in the LVH group using a score of greater than 3 points as diagnostic for MI. Of the 54 individual QRS criteria, 16 failed to achieve 95% specificity in the LVH population: 13 were for anterior (and apical), 2 for inferior, and 1 for posterior locations. Of these 16, minor modifications to 11 were sufficient to achieve the 95% specificity standard.(ABSTRACT TRUNCATED AT 250 WORDS)

Specificity and sensitivity of QRS criteria for diagnosis of single and multiple myocardial infarcts

A subset of 3 criteria from the complete Selvester scoring system has been proposed earlier for electrocardiographic screening of healed myocardial infarcts. This subset yielded 95% specificity and high sensitivity for single anterior and inferior infarcts. In the present study, an automated version of these criteria was applied to 1,344 electrocardiograms from normal subjects (473 normal subjects as determined by cardiac catheterization and 871 apparently normal subjects by history and physical examination), to 706 from subjects with single myocardial infarction, and to 131 from subjects with combined anterior and inferior myocardial infarcts. Of the single infarcts, 366 had inferior, 277 anterior and 63 posterolateral locations. Presence and location of infarcts were judged from left ventriculograms and coronary angiograms. Overall specificity was only 86%, whereas overall sensitivity for the infarct population was 77%. Specificity was lower in men than in women; it was also lower in older than in younger subjects. One of the screening criteria (R greater than or equal to 40 ms in V1) may possibly be eliminated to augment specificity; this can be done with only minor loss of sensitivity. Differences in wave form measurements between the manual and computer methods account for a large part of the deterioration of specificity in this study compared with previously published results. Computer application of the screening criteria requires altered criteria limits in comparison with those used in manual application. Probably sex- and age-dependent criteria limits should be used.

Indices of reperfusion in patients with acute myocardial infarction using characteristics of the CK-MB time-activity curve

The purpose of this study was to identify indices of coronary artery reperfusion in patients treated with thrombolytic therapy for acute myocardial infarction (AMI) by means of characteristics from the serum creatine kinase (CK) isoenzyme MB time-activity curve. Frequent blood sampling as performed in three groups with a first AMI: 29 patients treated with intravenous thrombolytic therapy who had a patent infarct-related artery with normal flow (TIMI-3) at acute catheterization (reperfusion group); four patients with a persistently closed infarct-related artery (no reperfusion group); and 44 patients who did not receive any therapy aimed at coronary reperfusion (no thrombolytic therapy group). In the latter group we prospectively estimated that 25% would have spontaneous reperfusion. A physiologically based computer-calculated multi-compartment method was used to determine the characteristics of the serum CK-MB time-activity curve. In addition to demonstrating an earlier increase, a shorter time to peak of serum CK-MB and a lower estimated infarct size in the reperfusion group (p = 0.025 to 0.00001), the appearance rate constant (k1) and time from estimated initial increase to peak of CK-MB in the blood stream (tRP) were significantly different from those values in the no thrombolytic therapy group (p less than 00001). A cutoff level indicating reperfusion if k1 was greater than 0.185 or tRP was less than 16.5 hours demonstrated overlapping values between these two groups in only four patients (k1), two patients (tRP), and six patients with a combination.(ABSTRACT TRUNCATED AT 250 WORDS)

Performance of new criteria for right ventricular hypertrophy and myocardial infarction in patients with pulmonary hypertension due to cor pulmonale and mitral stenosis

Historically, electrocardiographic criteria for right ventricular (RV) hypertrophy has achieved high specificity but low sensitivity. Recently, however, Butler-Leggett et al. have introduced three criteria that attained a 66% sensitivity in a population with RV hypertrophy due to mitral stenosis while maintaining a 95% specificity in an extensive normal control group. Electrocardiographic diagnosis of RV hypertrophy is principally dependent on changes in the QRS complex that may be masked or mimicked by myocardial infarction (MI). This dilemma has been confirmed by documentation of the low specificity of both the Selvester QRS scoring system for MI size estimation (greater than 3 points) and its screening subset (greater than 0 points) in a pure mitral stenosis population. This study introduces the population characterized by RV hypertrophy due to cor pulmonale, which has a mean pulmonary arterial systolic pressure that is higher than the mean for the mitral stenosis population and consequently suggests more severe RV hypertrophy. When compared, the Butler-Leggett criteria for RV hypertrophy are more sensitive in the new population than in the mitral stenosis population (89% versus 60%) and the Selvester QRS scoring system is less specific (12% versus 60%). Three sequential steps are suggested for electrocardiographic analysis: (1) diagnosis of RV hypertrophy using the Butler-Leggett criteria, (2) diagnosis of MI using the Selvester screening criteria in those patients with step 1 negative, and (3) estimation of MI size using the complete Selvester scoring system in patients with step 1 negative and step 2 positive.

Changes in standard electrocardiographic ST-segment elevation predictive of successful reperfusion in acute myocardial infarction

The ability of the electrocardiographic ST segment to predict successful reperfusion after thrombolytic therapy remains controversial. To evaluate whether angiographically determined reperfusion could be predicted from changes in ST-segment elevation, the sum of ST-segment elevation in affected leads of the electrocardiogram was compared before and after thrombolytic therapy in 53 patients with acute myocardial infarction (AMI). Reperfusion status of the infarct-related artery was determined angiographically less than 8 hours from onset of symptoms. According to the Thrombolysis in Myocardial Infarction trial (TIMI) criteria, 33 patients had successful reperfusion (TIMI grade 2 to 3 flow) after thrombolytic therapy and 20 patients did not (TIMI grade 0 to 1 flow). Logistic multiple regression analysis showed that the proportional value for the shift in the sum of ST elevation, termed the "% ST change," was more strongly associated with reperfusion than the absolute measured difference in millimeters (chi-square = 11.34 vs 9.22). The entire spectra of sensitivities and specificities were determined to identify a level of the percent ST change with simultaneous high sensitivity and specificity. A 20% decrease in ST elevation provided such a level (88% sensitivity, 80% specificity). The positive and negative predictive values of a 20% decrease in ST elevation were 88 and 80%, respectively. These results suggest that a decrease of only 20% in the sum of ST elevation in the standard electrocardiogram after thrombolytic therapy is a useful noninvasive predictor of reperfusion status in patients with evolving AMI.

Effect of intravenous streptokinase on the relation between initial ST-predicted size and final QRS-estimated size of acute myocardial infarcts

Thrombolytic therapy has been documented to reduce acute myocardial infarct size. The previously established relation between initial ST segment elevation and final electrocardiographic (ECG) myocardial infarct size in patients without coronary reperfusion might therefore be altered by thrombolytic therapy. The effect of intravenous streptokinase on this relation was therefore studied in 73 patients with initial acute myocardial infarction who had participated in the Second International Study of Infarct Survival (ISIS-2). Patients who received streptokinase were considered as one group and patients who did not receive streptokinase as a control group. Final myocardial infarct size, which was estimated from the QRS score, was predicted from the admission standard ECG by previously developed formulas based on ST segment elevation. In the 40 control patients there was no change from ST-predicted to final QRS-estimated infarct size (median 17.7% versus 18.3%; p = NS). In the 33 patients in the streptokinase group, there was a highly significant decrease from predicted to final myocardial infarct size (median 21.9% versus 16.2%; p less than 0.0002). This decrease was found for both anterior (median 23.7% versus 19.5%; p less than 0.03) and inferior (median 21.9% versus 12.0%; p = 0.001) infarct locations. Multiple regression analysis adjusting for differences in predicted infarct size confirmed the significance of streptokinase on the difference in infarct size (p = 0.006). Based on the variability of the percent change from predicted to final infarct size in the control group, a threshold decrease greater than or equal to 20% is required for identification of salvage.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity of a set of myocardial infarction screening criteria in patients with anatomically documented single and multiple infarcts

A subset of 3 screening criteria (Q wave greater than or equal to 30 ms in lead aVF, any Q or R wave less than or equal to 10 ms and less than or equal to 0.1 mV in lead V2, and R wave greater than or equal to 40 ms in V1) has been proposed to identify single nonacute myocardial infarcts. Cumulatively, these 3 criteria achieved 95% specificity, and 84 and 77% sensitivities for inferior and anterior myocardial infarcts, respectively, among patients identified by coronary angiography and left ventriculography. This study establishes the true sensitivities of the set of screening criteria in 71 patients with anatomically proven single myocardial infarcts and 32 patients with multiple myocardial infarcts. In the single inferior infarct group, the aVF criterion was 90% sensitive. The V2 criterion (any Q or R wave less than or equal to 10 ms and less than or equal to 0.1 mV) was 67% sensitive in the single anterior infarct group. No single criterion proved sensitive in identifying a posterolateral infarct. The set of screening criteria performed just as well for multiple infarcts as it did for single infarcts, with a cumulative sensitivity of 72%. The overall sensitivity of the screening set in the 103 patients in all groups was 71%.

Prognostic use of a QRS scoring system after hospital discharge for initial acute myocardial infarction in the Framingham cohort

Myocardial infarct size is an important risk factor for survival after acute myocardial infarction (AMI). The purpose of this study was to determine the prognostic value of myocardial infarct size, as estimated by the Selvester 54-criteria/32-point QRS scoring system, in the Framingham cohort. During the first 30 years of the Framingham Heart Study, a total of 384 participants developed an AMI requiring hospitalization; from this group, 243 patients met the following inclusion criteria: (1) no electrocardiographic changes due to a previous infarction, (2) survival greater than 3 days after discharge from the AMI hospitalization and (3) no electrocardiographic evidence of conduction disturbances or ventricular hypertrophy at the time of their final in-hospital electrocardiogram. Univariate and multivariate analyses were performed to test the association of the QRS score, and other associated risk factors, with time until coronary heart disease-related death. QRS score was found to be significantly associated with outcome (p = 0.03), as was the systolic blood pressure before infarction (p greater than 0.001). Both univariate and multivariate analysis showed that a history of systolic hypertension was the variable most strongly associated with coronary heart disease-related death. Thus, identification of AMI survivors at high risk for subsequent mortality can be improved by routine blood pressure measurement before AMI, and QRS scoring of the electrocardiogram taken at hospital discharge.

Anatomic validation of electrocardiographic estimation of the size of acute or healed myocardial infarcts

Seventeen new criteria added to the simplified version of the Selvester QRS scoring system to comprise the complete version were evaluated to determine their value in estimating the size of single infarcts. These non-Q-wave criteria might be particularly useful regarding posterolateral infarcts in the distribution of the left circumflex artery. The study population was made up of 21 anterior, 30 inferior and 20 posterolateral single myocardial infarction (MI) patients with no evidences of bundle branch or fascicular blocks, ventricular hypertrophy or previous MI on their final stable electrocardiogram. The complete system's maximum 32 points is capable of indicating MI in 96% of the left ventricle and it estimated a mean electrocardiographic MI size that better approximated the anatomic size compared with the simplified version in all MI locations. The correlation between anatomic and electrocardiographic MI size using the complete system was better and statistically significant for the posterolateral MI group (simplified r = 0.55, p less than 0.01 vs complete r = 0.70, p less than 0.0006). Criteria such as Q and S amplitude less than or equal to 0.3 mV in V1 and less than or equal to 0.4 mV in V2 were particularly helpful. This study documents the improved ability provided by the 17 additional non-Q-wave criteria which have been added in the complete version of this scoring system regarding the sizing of infarcts in the region of the left ventricle supplied by the left circumflex artery.

The portable programmable microprocessor-driven real-time 12-lead electrocardiographic monitor: a preliminary report of a new device for the noninvasive detection of successful reperfusion or silent coronary reocclusion

Successful intravenous thrombolytic therapy early in myocardial infraction has the potential to reduce patient mortality without the additional risk and cost of aggressive invasive therapy. Noninvasive detection of successful reperfusion using resolution of chest pain, ST-segment changes assessed on static electrocardiograms, arrhythmia evolution, early isoenzyme peaking or changes in ventricular perfusion or function has been hampered by poor sensitivity or specificity, or inability to provide timely information. A newly available portable programmable microprocessor-driven real-time 12-lead electrocardiographic monitor has been introduced that may address these limitations. A continuously updated precise digital record of ST-segment activity at the bedside provides valuable information both in monitoring patients during reperfusion therapy to determine the efficacy of such treatment and in the subsequent hours to signal threatened reocclusion. This report describes the salient features of the monitor and presents 4 distinct situations in which the monitor detected timely information regarding coronary patency after reperfusion.

Transient alterations of the QRS complex and ST segment during percutaneous transluminal balloon angioplasty of the right and left circumflex coronary arteries

The dynamic QRS amplitude changes that appear during 1-vessel percutaneous transluminal coronary angioplasty of the right and left circumflex coronary arteries were studied in 20 patients using continuous 3-lead electrocardiographic recordings representing leads aVF, V2 and V5. The balloon inflations that produced the greatest extent of ST-segment deviation were identified for each lead ("maximally ischemic periods"). QRS amplitude measurements were performed manually at both the PR and shifted J-ST baselines at 10-second intervals during these periods to determine that baseline from which the R and S waves most nearly maintained their control amplitudes. There was no significant baseline relation for either the R or the S waves in leads V2 and V5 during ischemia. However, the R-wave changes in lead aVF were significantly associated with the PR- versus the J-ST-segment baseline (p = 0.007); the S wave, when it occurred, had no tendency for either baseline. The electrocardiographic records were also examined visually for characteristics of left posterior (inferior) "periischemic block" likely to occur uniquely in patients with a dominant right or left circumflex occlusion. There were 2 patients with obstruction of the right circumflex artery who exhibited the characteristics of periischemic block during percutaneous transluminal coronary angioplasty, as evidenced by an increase in R-wave duration, amplitude or both in lead aVF.

Invalidation of the resting electrocardiogram obtained via exercise electrode sites as a standard 12-lead recording

The difficulty in interpreting the standard 12-lead electrocardiogram (ECG) due to the interference from muscle potentials produced by arm and leg motion makes it unsuitable during the exercise treadmill test. Likewise, the exercise lead placement ECG cannot substitute for the standard ECG due to significant errors in the former's diagnostic interpretation. This study compares the ECGs recorded via standard and exercise sites regarding frontal and horizontal plane axes, diagnosis and location of myocardial infarction and estimation of infarct size using the complete 54-criteria and 32-point Selvester QRS scoring system. The altered limb lead locations on the exercise ECG caused the QRS vectors to artifactually appear to be directed more inferiorly, posteriorly and rightward, producing a marked rightward mean frontal plane axis shift of +48 degrees (p less than 0.00001). No false positive or false negative anterior infarct was seen on the exercise lead placement ECG, whereas inferior and posterior infarcts were lost in 69% and 31% of patients, respectively. A false lateral infarct was seen in 19% of patients. Estimation of infarct size differed between the 2 ECG sets, with 11 patients increasing their infarct size by 3 to 9% and 14 others decreasing it by 3 to 15% on the exercise lead placement ECG. This study demonstrates that use of body torso positions for limb leads results in substantial QRS waveform variations that disqualify the exercise lead placement ECG as a "standard" recording. Such ECGs should therefore be labeled as "torso positioned" or "nonstandard" to prevent misuse for clinical and investigative purposes.

Effect of cetamolol on epinephrine-induced hypokalemia

The effect of cetamolol (an investigational cardioselective beta blocker with intrinsic sympathomimetic activity) on the hypokalemic response to epinephrine infusions in normal subjects was evaluated and compared with placebo and two other beta-adrenergic blocking drugs. After two daily doses of cetamolol 15 mg, atenolol (a cardioselective beta blocker) 50 mg; a long-acting propranolol preparation (a nonselective beta blocker) 80 mg; or placebo, 12 men (mean age, 26.7 years) were infused with epinephrine. The resulting average plasma epinephrine level was 1123 pg/mL, whereas average baseline serum potassium levels for the four treatment groups ranged from 3.94 to 4.07 mEq/L. Epinephrine-induced hypokalemia occurred in the placebo group (maximum potassium decrease of 1.00 mEq/L) and in the atenolol group (maximum potassium decrease of 0.59 mEq/L); potassium levels did not decrease but rose slightly in subjects receiving cetamolol or propranolol. Subjects treated with placebo or atenolol also demonstrated statistically significant prolongation of the QTc interval (0.039 seconds with placebo; 0.023 seconds with atenolol) and frequently developed T-wave flattening and U-wave appearance. After pretreatment with cetamolol or propranolol, however, the QTc interval was unaffected, T-wave abnormalities did not occur, and U waves appeared only rarely. The results of this study indicate that cetamolol blocks epinephrine-induced hypokalemia and associated electrocardiographic changes.

Evaluation of a QRS scoring system for estimating myocardial infarct size. VI: Identification of screening criteria for non-acute myocardial infarcts

Each of the 54 criteria in the Selvester 32-point QRS scoring system for estimation of myocardial infarct (MI) size has attained greater than or equal to 95% specificity in normal subjects. This study was performed to identify a subset of those criteria with cumulative specificity greater than or equal to 95% and maximal sensitivity for use in screening for the presence of non-acute MI. Coronary angiography and left ventriculography were used to identify 500 normal subjects, 60 patients with isolated anterior MI and 62 patients with isolated inferior MI. Patients with the QRS confounding factors of ventricular hypertrophy, fascicular block or bundle branch block on their electrocardiogram were not included. Using stepwise logistic regression analysis, the screening criteria identified were: (1) Q greater than or equal to 30 ms in aVF, (2) R less than or equal to 10 ms and less than or equal to 0.1 mV in V2 and (3) R greater than or equal to 40 ms in V1. Cumulatively, these 3 screening criteria achieved 84% and 77% sensitivities for inferior and anterior MI groups, respectively. Thus, a set of 3 criteria from the Selvester QRS scoring system is capable of identifying single non-acute anterior or inferior MI in 80% of patients, and falsely indicating presence of MI in only 5% of normal subjects.

Development and validation of an automated method of the Selvester QRS scoring system for myocardial infarct size

The Selvester QRS score for estimation of myocardial infarct (MI) size from the standard 12-lead electrocardiogram (ECG) has not yet achieved wide recognition as a valuable tool in the routine assessment of the MI patient, primarily because of the practical limitations inherent to manual application. This study examined the ECGs of 438 patients (105 normal subjects, 161 with "possible" MI and 172 with "definite" MI based on data from cardiac catheterization) to develop software for an automated method of the Selvester system in attempts to overcome the manual constraints. After a comprehensive validation process involving extensive interactions between the manual scorer and the software developer, an automated method of the Selvester system was generated that had a high correlation with manual application (r = 0.94) and was superior regarding time, training, reader bias, reproducibility and precision of measurement. These results indicate that an automated version of the Selvester QRS scoring system would resolve many of the limitations of manual application and would provide a reliable, technically accurate estimate of MI size that could be incorporated into ECG diagnostic programs and used in standard digital ECG machines.

Use of initial ST-segment deviation for prediction of final electrocardiographic size of acute myocardial infarcts

The decision to administer thrombolytic therapy for limitation of acute myocardial infarction (AMI) size must occur when only the history, physical examination and 12-lead electrocardiogram of a patient are available. A method that could quickly assess the amount of jeopardized myocardium would greatly aid the physician. This study developed formulas from 68 anterior and 80 inferior AMI patients using the extent of initial ST-segment deviation (ST delta) to predict the final AMI size estimated by the Selvester QRS score in a population not receiving reperfusion therapy. Inclusion required: initial anterior or inferior AMI; admission electrocardiogram less than or equal to 8 hours after the onset of symptoms with evidence of epicardial injury; elevated creatine kinase-MB; a predischarge electrocardiogram taken greater than or equal to 72 hours after admission; and no AMI extension before the predischarge electrocardiogram. The extent of epicardial injury was quantified by counting the number of leads with greater than or equal to 0.1 mm ST delta, by the sum (sigma) of ST delta in all leads and by the sigma ST delta in the lead groups associated with each AMI location. These results were compared to the AMI size estimated from the predischarge electrocardiogram. Univariable and multivariable analyses generated these formulas for AMI size: anterior = 3[1.5 (number leads ST increases) - 0.4]; inferior = 3[0.6 (sigma ST increases II, III, aVF) + 2.0]. Thus, formulas based on quantitative measurements of ST delta on the admission electrocardiogram are predictive of final QRS-estimated AMI size, and may be useful in determining the efficacy of acute reperfusion therapy.

An ischemic index from the electrocardiogram to select patients with low left ventricular ejection fraction for coronary artery bypass grafting

Patients who have a decreased left ventricular (LV) ejection fraction (EF) may be denied coronary by-pass grafting (CABG) because it is assumed that improvement in function is unlikely. If the low LVEF were due to myocardial necrosis, this assumption would be valid. If the dysfunction were due to both necrosis and ischemia, however, then improvement may be possible with CABG. A method capable of identifying such patients would be useful. In this study, an "ischemic index" was determined for 37 patients based on the difference between the presurgical LVEF estimated from the standard 12-lead electrocardiogram by the Selvester QRS score (indicating the extent of dysfunction due to necrosis) and the presurgical LVEF measured from resting multigated radionuclide angiography (indicating dysfunction due to both necrosis and ischemia). It was hypothesized that a high ischemia index, that is, a large discrepancy between estimated and measured LVEF, would be associated with an improved post-surgical measured LVEF. The results showed that patients with an ischemic index of less than or equal to 0 had a mean decrease in LVEF of 8% (p = 0.02) and those with an index between 0 and 10 had no mean change. Patients with an index greater than or equal to 11, however, had a mean increase of 5% (p = 0.02), suggesting that depressed LVEF may improve following CABG among patients whose low function is due primarily to reversible ischemia as indicated by a high ischemic index.

False-positive posterior myocardial infarct criteria during left anterior descending coronary angioplasty

In reviewing ECG change during acute anterior myocardial infarction (AMI) and during transluminal coronary angioplasty of the left anterior descending (LAD) coronary artery, QRS changes mimicking posterior myocardial infarct (PMI) and false-positive points for PMI using the QRS infarct size scoring system were observed in about 20% of patients. Nineteen patients in whom a three-lead electrocardiogram (ECG) was continuously recorded during transluminal coronary angioplasty of a proximal left anterior descending (LAD) coronary artery were reviewed. All but two had significant ST-segment shifts in V2 within a few seconds of balloon occlusion of a proximal LAD. In many such patients the R wave amplitude in V2 measured from the PR segment baseline remained relatively stable and the S amplitude tracked with the J. point. However, of the 19 patients studied, 11 had transient QRS changes greater than could be accounted for by baseline shift alone and 4 had transient false-positive PMI points by QRS MI size score. Transient QRS changes were observed as follows: (1) significant increase in R waves and/or decrease in S waves in V2 due to right septal block (or conduction delay) occurred in 3 of 11 patients and was the cause of the false-positive criteria for PMI; (2) 5 of 11 patients had a major decrease in R waves in V2 due to left septal block; (3) 2 of 11 patients had both (1) and (2); and (4) 1 of 11 had transient frontal plane axis shifts with the QRS configuration of anterosuperior fascicular block plus right and left septal block.(ABSTRACT TRUNCATED AT 250 WORDS)