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EKG and angiographic correlation in patients with acute anteroseptal versus extensive anterior STEMI
ISCE 2013 Poster Session 1 / Journal of Electrocardiology 46 (2013) 616–620 ventricle not only on the QRS complex, but also on the ST segment. In myocardial infarction a localized slowing of impulse propagation—the periinfarction block refers to an electrocardiographic abnormality caused by delayed activation of the myocardium in the affected region. In this study we simulated the effects of localized changes in impulse propagation on the QRS and ST-segment patterns, using computer modeling. Material and methods: The model defines the geometry of cardiac ventricles analytically as parts of ellipsoids and allows to change the velocity of impulse propagation in the myocardium. The following changes were introduced in anteroseptal and posterolateral locations: intramural electrically inactive area (infarct), encircled by a transmural area with slowed impulse propagation velocity (peri-infarction block). The effects of sole infarct and peri-infarction blocks, as well the effects of their combinations on the QRS complex and the ST segment are presented. Results: A sole intramural infarct caused QRS changes typical for corresponding locations which were further considerably modified by slowed impulse propagation velocity in the surrounding area. Additionally, the areas of slowed impulse propagation velocity in both locations caused ST-segment deviations, shifting the ST segment toward the affected areas. Conclusion: Using computer modeling we showed that the localized slowing in impulse propagation (peri-infarction block) not only modified the QRS complex, but produced also changes in the ST segment that are consistent with changes that are usually interpreted as effect of the “injury current.” http://dx.doi.org/10.1016/j.jelectrocard.2013.09.011
Novel electrocardiographic pre-hospital salvage score outperforms reperfusion delay for prediction of left ventricular function in patients with ST-elevation myocardial infarction Said Yama Fakhri,a Mads Ersbøll,a Lars Køber,a Christian Hassager,a Rasmus Hesselfeldt,a Jacob Steinmetz,a Galen S. Wagner,b Peter Clemmensen,a Mikkel Malby Schoosa a Department of Cardiology, Rigshospitalet, University Hospital, Copenhagen, Denmark b Department of Medicine, Duke University Medical Center, Durham, NC, USA Background: Increased system delay (time from alarm call to balloon) is associated with adverse outcomes in ST-elevation myocardial infarction (STEMI). In current guidelines, allocation to a reperfusion strategy is entirely based on anticipated time delay to primary percutaneous coronary intervention (pPCI). We hypothesized that an objective “electric” ischemia time assessed in the pre-hospital electrocardiogram (pECG) would improve the impact of time delay in predicting myocardial function as assessed by left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Methods: We included 262 patients with STEMI and pECG, and performed echocardiography with measurements of LVEF and GLS within 48 hours of admission. ECGs were scored according to the previously validated Anderson–Wilkins acuteness score (AW 1–4) and Sclarovsky–Birnbaum grading of ischemia (GI2 or GI3). Patients were categorized by the novel Pre-Hospital Salvage Score (PHSS): PHSS1 = AW b 3 and GI3, PHSS2 = AW b 3 and GI2, PHSS3 = AW N 3 and GI2 and PHSS4 = AW N 3 and GI3, and system delay was assessed by PHSS for the prediction of LVEF and GLS. Results: System delay correlated weakly with GLS (r = 0.133, p = 0.031) and LVEF (r = 0.152, p = 0.014), but not with infarct size estimated by peak TnT (r = 0.056, p = 0.366). Lower PHSS was significantly associated with impaired GLS [PHSS1 (n = 42, mean ± SD − 11.8 ± 3.5), PHSS2 (n = 110, − 13.7 ± 3.2), PHSS3 (n = 90, − 13.8 ± 3.6), PHSS4 (n = 20, − 14.1 ± 3.7) (p = 0.008)], increasing peak TnT [PHSS1 (8.3 ± 6.6), PHSS2 (5.6 ± 5.2), PHSS3 (5.0 ± 4.0), PHSS4 (5.1 ± 5.5) (p = 0.006)] and there was a non-significant trend with impaired LVEF across PHSS [PHSS1 (47.6 ± 9.0), PHSS2 (48.8 ± 9.1), PHSS3 (50.9 ± 9.4), PHSS4 (52.7 ± 13.1) (p = 0.104)]. After adjusting for age, sex, Killip class, LAD culprit and pre-procedural TIMI flow, system delay independently predicted GLS (p = 0.002) and LVEF (p = 0.005) in PHSS4, whereas no adjusted time dependency was found for GLS and LVEF in PHSS 1–3.
617
Conclusion: Pre-Hospital Salvage Score is a new quantitative electrocardiographic ischemia assessment method that identifies STEMI patients where time reduction to pPCI is crucial for myocardial salvage. The clinical application of this method could improve pre-hospital triage, help to risk stratify patients and select the optimal immediate reperfusion strategy. http://dx.doi.org/10.1016/j.jelectrocard.2013.09.012
EKG and angiographic correlation in patients with acute anteroseptal versus extensive anterior STEMI Arzhang Fallahi, Justin Ratcliffe, Simon Gringut, Yumiko Kanei, Paul Schweitzer Beth Israel Medical Center, New York, NY, USA Anteroseptal MI (AS-STEMI) has historically been defined as ST elevation limited to leads V(1) to V(3) and extensive anterior MI (EA-STEMI) extending to leads V(4) to (V6). AS-STEMI is thought to spare the apical segments however recent studies have shown that both AS-STEMI and EA-STEMI can similarly involve apical segments in patients with wrapping left anterior descending coronary artery (LAD). The aim of this study was to identify, in 94 consecutive patients with STEMI, the coronary angiographic anatomy of patients with AS-STEMI (n = 25) and EA-STEMI (n = 69). We looked at EKGs from 94 consecutive patients with anterior STEMI who underwent PCI from 2008 to 2012 at our institution. The ST-segment elevation in all leads was measured at 80 ms past the J-point. Angiogram films were reviewed for presence of wrapping LAD and site of occlusion: proximal (before first septal branch), mid (after first septal) or distal LAD. Our study showed patients with EA-STEMI were more likely to have wrapping LAD compared to patients with AS-STEMI (52.0% vs 82.6%, p = 0.0062). This finding is consistent with the classical paradigm of AS-STEMI sparing apical segments compared to EASTEMI. In conclusion, EA-STEMI more often involves apical segments by virtue of higher prevalence of wrapping LAD compared to AS-STEMI. http://dx.doi.org/10.1016/j.jelectrocard.2013.09.013
Transient myocardial ischemia among non-STEMI and unstable angina patients treated with invasive versus conservative treatment Michele M. Pelter, RN, PhD,a Denise Loranger, RN,a Teri M. Kozik, RN, PhD,b Mary G. Carey, RN, PhDc a University of Nevada, Reno, Orvis School of Nursing, Stockton, CA, USA b St. Joseph's Medical Center, Stockton, CA, USA c Strong Memorial Hospital, Rochester, NY, USA Background/Significance: Treatment for acute coronary syndrome (ACS) is aimed at plaque stabilization in order to prevent myocardial cellular death. There is debate, about which immediate treatment pathway is best for nonST-elevation myocardial infarction (non-STEMI) or unstable angina (UA) patients; early invasive percutaneous coronary intervention (PCI/ stent b 24 hours after admission) or conservative management (i.e., medications with cardiac catheterization N 24 hours after admission if indicated). Continuous 12-lead electrocardiographic (ECG) monitoring can identify transient myocardial ischemia (TMI), even when asymptomatic, but is typically not utilized in the hospital setting. Purpose: The purposed of this prospective study was to compare the frequency of TMI, in patients with NSTEMI/UA treated with early invasive PCI/stent to those managed conservatively, assessed with continuous 12lead ECG monitoring. Additionally, in patients with TMI to assessed if the event was detected by the bedside monitor or if symptoms were present. Method: Hospitalized patients with suspected NSTEMI/UA were recruited and continuous 12-lead ECG Holter monitor (Mortara Instruments, Milwaukee) was initiated; the ECG data were not available to the patient's clinical team. Off-line ECG analysis (H-Scribe, Mortara Instruments) was conducted blind to clinical information. All subjects had documented coronary artery disease defined by a history of myocardial infarction, PCI, coronary artery bypass graft surgery, N50% lesion on coronary angiogram, and positive troponin during current admission.
Novel electrocardiographic pre-hospital salvage score outperforms reperfusion delay for prediction of left ventricular function in patients with ST-elevation myocardial infarction Said Yama Fakhri,a Mads Ersbøll,a Lars Køber,a Christian Hassager,a Rasmus Hesselfeldt,a Jacob Steinmetz,a Galen S. Wagner,b Peter Clemmensen,a Mikkel Malby Schoosa a Department of Cardiology, Rigshospitalet, University Hospital, Copenhagen, Denmark b Department of Medicine, Duke University Medical Center, Durham, NC, USA Background: Increased system delay (time from alarm call to balloon) is associated with adverse outcomes in ST-elevation myocardial infarction (STEMI). In current guidelines, allocation to a reperfusion strategy is entirely based on anticipated time delay to primary percutaneous coronary intervention (pPCI). We hypothesized that an objective “electric” ischemia time assessed in the pre-hospital electrocardiogram (pECG) would improve the impact of time delay in predicting myocardial function as assessed by left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Methods: We included 262 patients with STEMI and pECG, and performed echocardiography with measurements of LVEF and GLS within 48 hours of admission. ECGs were scored according to the previously validated Anderson–Wilkins acuteness score (AW 1–4) and Sclarovsky–Birnbaum grading of ischemia (GI2 or GI3). Patients were categorized by the novel Pre-Hospital Salvage Score (PHSS): PHSS1 = AW b 3 and GI3, PHSS2 = AW b 3 and GI2, PHSS3 = AW N 3 and GI2 and PHSS4 = AW N 3 and GI3, and system delay was assessed by PHSS for the prediction of LVEF and GLS. Results: System delay correlated weakly with GLS (r = 0.133, p = 0.031) and LVEF (r = 0.152, p = 0.014), but not with infarct size estimated by peak TnT (r = 0.056, p = 0.366). Lower PHSS was significantly associated with impaired GLS [PHSS1 (n = 42, mean ± SD − 11.8 ± 3.5), PHSS2 (n = 110, − 13.7 ± 3.2), PHSS3 (n = 90, − 13.8 ± 3.6), PHSS4 (n = 20, − 14.1 ± 3.7) (p = 0.008)], increasing peak TnT [PHSS1 (8.3 ± 6.6), PHSS2 (5.6 ± 5.2), PHSS3 (5.0 ± 4.0), PHSS4 (5.1 ± 5.5) (p = 0.006)] and there was a non-significant trend with impaired LVEF across PHSS [PHSS1 (47.6 ± 9.0), PHSS2 (48.8 ± 9.1), PHSS3 (50.9 ± 9.4), PHSS4 (52.7 ± 13.1) (p = 0.104)]. After adjusting for age, sex, Killip class, LAD culprit and pre-procedural TIMI flow, system delay independently predicted GLS (p = 0.002) and LVEF (p = 0.005) in PHSS4, whereas no adjusted time dependency was found for GLS and LVEF in PHSS 1–3.
617
Conclusion: Pre-Hospital Salvage Score is a new quantitative electrocardiographic ischemia assessment method that identifies STEMI patients where time reduction to pPCI is crucial for myocardial salvage. The clinical application of this method could improve pre-hospital triage, help to risk stratify patients and select the optimal immediate reperfusion strategy. http://dx.doi.org/10.1016/j.jelectrocard.2013.09.012
EKG and angiographic correlation in patients with acute anteroseptal versus extensive anterior STEMI Arzhang Fallahi, Justin Ratcliffe, Simon Gringut, Yumiko Kanei, Paul Schweitzer Beth Israel Medical Center, New York, NY, USA Anteroseptal MI (AS-STEMI) has historically been defined as ST elevation limited to leads V(1) to V(3) and extensive anterior MI (EA-STEMI) extending to leads V(4) to (V6). AS-STEMI is thought to spare the apical segments however recent studies have shown that both AS-STEMI and EA-STEMI can similarly involve apical segments in patients with wrapping left anterior descending coronary artery (LAD). The aim of this study was to identify, in 94 consecutive patients with STEMI, the coronary angiographic anatomy of patients with AS-STEMI (n = 25) and EA-STEMI (n = 69). We looked at EKGs from 94 consecutive patients with anterior STEMI who underwent PCI from 2008 to 2012 at our institution. The ST-segment elevation in all leads was measured at 80 ms past the J-point. Angiogram films were reviewed for presence of wrapping LAD and site of occlusion: proximal (before first septal branch), mid (after first septal) or distal LAD. Our study showed patients with EA-STEMI were more likely to have wrapping LAD compared to patients with AS-STEMI (52.0% vs 82.6%, p = 0.0062). This finding is consistent with the classical paradigm of AS-STEMI sparing apical segments compared to EASTEMI. In conclusion, EA-STEMI more often involves apical segments by virtue of higher prevalence of wrapping LAD compared to AS-STEMI. http://dx.doi.org/10.1016/j.jelectrocard.2013.09.013
Transient myocardial ischemia among non-STEMI and unstable angina patients treated with invasive versus conservative treatment Michele M. Pelter, RN, PhD,a Denise Loranger, RN,a Teri M. Kozik, RN, PhD,b Mary G. Carey, RN, PhDc a University of Nevada, Reno, Orvis School of Nursing, Stockton, CA, USA b St. Joseph's Medical Center, Stockton, CA, USA c Strong Memorial Hospital, Rochester, NY, USA Background/Significance: Treatment for acute coronary syndrome (ACS) is aimed at plaque stabilization in order to prevent myocardial cellular death. There is debate, about which immediate treatment pathway is best for nonST-elevation myocardial infarction (non-STEMI) or unstable angina (UA) patients; early invasive percutaneous coronary intervention (PCI/ stent b 24 hours after admission) or conservative management (i.e., medications with cardiac catheterization N 24 hours after admission if indicated). Continuous 12-lead electrocardiographic (ECG) monitoring can identify transient myocardial ischemia (TMI), even when asymptomatic, but is typically not utilized in the hospital setting. Purpose: The purposed of this prospective study was to compare the frequency of TMI, in patients with NSTEMI/UA treated with early invasive PCI/stent to those managed conservatively, assessed with continuous 12lead ECG monitoring. Additionally, in patients with TMI to assessed if the event was detected by the bedside monitor or if symptoms were present. Method: Hospitalized patients with suspected NSTEMI/UA were recruited and continuous 12-lead ECG Holter monitor (Mortara Instruments, Milwaukee) was initiated; the ECG data were not available to the patient's clinical team. Off-line ECG analysis (H-Scribe, Mortara Instruments) was conducted blind to clinical information. All subjects had documented coronary artery disease defined by a history of myocardial infarction, PCI, coronary artery bypass graft surgery, N50% lesion on coronary angiogram, and positive troponin during current admission.