Josefa Cortadellas

Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction.

Background—ST-segment elevation in lead aVR has been associated with severe coronary artery lesions in patients with acute coronary syndromes, but the prognostic significance of this finding is unknown. Methods and Results—We analyzed the initial ECG in 775 consecutive patients admitted to our center with a first acute myocardial infarction without ST-segment elevation in leads other than aVR or V1. The rates of in-hospital death in patients without (n=525) and with 0.05 to 0.1 mV (n=116) or ≥0.1 mV (n=134) of ST-segment elevation in lead aVR were 1.3%, 8.6%, and 19.4%, respectively (P <0.001). After adjustment for the baseline clinical predictors and for ST-segment depression on admission, the odds ratios for death in the last 2 groups were, respectively, 4.2 (95% CI, 1.5 to 12.2) and 6.6 (95% CI, 2.5 to 17.6). The rates of recurrent ischemic events and heart failure during hospital stay also increased in a stepwise fashion among the groups, whereas creatine kinase–MB levels were similar. Among the 437 patients that were catheterized within 6 months, the prevalence of left main or 3-vessel coronary artery disease in the 3 groups was 22.0%, 42.6%, and 66.3%, respectively (P <0.001). Conclusions—Lead aVR contains important short-term prognostic information in patients with a first non–ST-segment elevation acute myocardial infarction. Because the poorer outcome predicted by ST-segment elevation in lead aVR seems to be related to a more severe coronary artery disease, an early invasive approach might be especially beneficial in patients presenting with this finding.

Changes in Hospital Mortality Rates in 425 Patients With Acute ST-Elevation Myocardial Infarction and Cardiac Rupture Over a 30-Year Period

Background— Possible changes in the incidence and outcome of cardiac rupture in patients with ST-elevation myocardial infarction over a long period of time have not been investigated. Methods and Results— The incidence of cardiac rupture in ST-elevation myocardial infarction patients and its mortality rate were investigated during a 30-year period divided into 5 intervals (1977 to 1982, 1983 to 1988, 1989 to 1994, 1995 to 2000, and 2001 to 2006). Of a total of 6678 consecutive patients, 425 experienced a free wall rupture (280 with cardiac tamponade: 227 with electromechanical dissociation and 53 with hypotension) or a septal rupture (145). After the exclusion of referrals from other centers (n=44), the incidence of definite cardiac rupture (septal rupture, anatomic evidence of free wall rupture, or electromechanical dissociation) declined progressively (6.2% in 1977 to 1982 to 3.2% in 2001 to 2006; P<0.001) in parallel with a progressive use of reperfusion therapy (0% to 75.1%; P<0.001). In addition, among patients with cardiac rupture, there was a progressive fall in the rate of death (94% to 75%; P<0.001) despite a trend toward increasing age (66±8 to 75±8 years; P<0.054) in conjunction with better control of systolic blood pressure at 24 hours (130±24 versus 110±18 mm Hg; P<0.001); an increased use of reperfusion therapy (0% to 59%; P<0.001), β-blockers (0% to 45%; P<0.001), angiotensin-converting enzyme inhibitors (0% to 38%; P<0.001), and aspirin (0% to 96%; P<0.001); and a lower use of heparin (99% to 67%; P<0.001). Conclusion— The decline in the incidence in cardiac rupture and its rate of death over the last 30 years appears to be associated with the increasing use of reperfusion strategies and adjunct medical therapy.

Simultaneous dipyridamole/maximal subjective exercise with 99mTc-MIBI SPECT: improved diagnostic yield in coronary artery disease.

OBJECTIVES We attempted to demonstrate that simultaneous dipyridamole administration and maximal subjective exercise in patients who are unable to achieve a good exercise level can improve the diagnostic efficacy of technetium-99m methoxy isobutyl isonitrile (99mTc-MIBI) myocardial single-photon emission computed tomography (SPECT). BACKGROUND The results of myocardial perfusion scintigraphy are unsatisfactory if the level of exercise achieved by the patient is insufficient. The use of dipyridamole with maximal subjective stress testing has been shown to improve the quality of the thallium-201 myocardial perfusion images, but there are no studies demonstrating that this combination improves the diagnostic accuracy of myocardial perfusion SPECT. METHODS Two hundred thirty-one consecutive patients, without a previous myocardial infarction, were classified into three groups: group 1, 91 patients with an adequate exercise test; group 2, 68 patients with an inadequate exercise test; group 3, 72 patients with an inadequate exercise test who then received intravenous dipyridamole (0.56 mg/kg body weight over 4 min) simultaneously with exercise. RESULTS Results for sensitivity (89%) and negative predictive value (83%) in group 3 were significantly better than those in group 2 (71% [p = 0.03] and 56% [p = 0.002], respectively) and not significantly different from those in group 1. The polar maps of 20 patients studied with an without dipyridamole at the same exercise level revealed a significantly greater extent of ischemia in each territory and in a global assessment (19 + 20% vs. 8 + 11%, p < 0.0001) when dipyridamole was administered during physical exercise. CONCLUSIONS Intravenous dipyridamole administration during exercise testing is advisable in all patients who are unable to achieve an adequate exercise level. This approach permits physicians to avoid missing ergometric information while optimizing myocardial SPECT results.

Medical management of selected patients with left ventricular free wall rupture during acute myocardial infarction

OBJECTIVES This study sought to evaluate the effects of prolonged rest and blood pressure control on survival of patients in whom left ventricular free wall rupture (LVFWR) was strongly suspected. BACKGROUND Left ventricular free wall rupture in myocardial infarction is often fatal, and only a few patients may undergo operation. However, survival without surgical repair has not yet been evaluated. METHODS Eighty-one consecutive patients with a first transmural acute myocardial infarction in Killip class I or II who presented with acute hypotension due to cardiac tamponade, with electromechanical dissociation (EMD) in 72, were prospectively evaluated. Patients with early recovery were managed with prolonged bed rest and blood pressure control with beta-blockade as tolerated. RESULTS Forty-seven patients died within 2 h of acute tamponade, and autopsy in 21 showed LVFWR in all. In 15 others, an emergency surgical repair resulted in 2 survivors. The remaining 19 patients, 10 with EMD, had early recovery with dobutamine and colloid solution, and 15 required pericardiocentesis. Shortly thereafter, these 19 patients still showed a paradoxic pulse > or = 20 mm Hg, relevant pericardial effusion (24 +/- 7 mm [mean +/- SD]) and comparable elevation of right and left ventricular filling pressures (15.8 +/- 3.9 and 15.9 +/- 3.8 mm Hg, respectively). Subsequent management included bed rest (8.2 +/- 4.8 days) and control of systolic blood pressure (< or = 120 mm Hg) with beta-adrenergic blocking agents as tolerated (n = 12). Four patients died, and autopsy in three revealed a rupture that was sealed in two. A sealed rupture was also seen at thoracotomy in 2 other patients who, like the remaining 13, survived for 52.5 +/- 35.2 months. CONCLUSIONS Long-term survival of selected patients with prompt hemodynamic recovery after LVFWR is possible without surgical repair. Prolonged bed rest and blood pressure control are likely to contribute favorably to their initial outcome.

Left ventricular free wall rupture: clinical presentation and management

In patients with acute myocardial infarction, left ventricular free wall rupture is an infrequent complication (2–4%) but it is associated with a high mortality from pericardial tamponade.1-8 It accounts for 5–24% of all in hospital deaths related to acute myocardial infarction.4 6 9 10 To reduce this high mortality it is important to improve the way in which these patients are classified, as this may help clinicians anticipate myocardial rupture, prevent it occurring, and achieve better therapeutic results when it does occur. In this paper, we provide an update on the clinical, electrocardiographic, echocardiographic, and angiographic features of these patients, identifying the different forms in which free wall rupture presents. We also review the management of these cases and suggest a conservative strategy that may be applied successfully to a selected subgroup of patients. The clinical characteristics of patients with free wall rupture are summarised in table 1. Characteristically, free wall rupture occurs in relatively elderly patients, generally older than 55 years and usually between 65 and 70,1 3-5 11-13 without any apparent sex bias3 14-17—although it may be relatively more common in female patients in view of the lower incidence of acute myocardial infarction in women.4 5 In most cases the myocardial infarct is the first one recorded and it is usually transmural2 4 12-14 18 but without overt heart failure.2 13 14 18 There is an infrequent history of angina pectoris.2 13 14 19 The incidence of diabetes is not particularly high, though arterial hypertension is common—often more than 50%, but with some exceptions.1 5 6 12 14 18 These patients present with a rather prolonged episode of anginal pain, often lasting for four to six hours or more,1 2 4 5 15 16 20 21 …

Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction : Study in 225 patients with free wall, septal or papillary muscle rupture

OBJECTIVES We analyzed the possible relation between the presence of a hospital admission delay (> or =24 h), undue physical effort or recurrence of anginal pain, alone or in combination, with the development of free wall rupture (FWR), septal rupture (SR) or papillary muscle rupture (PMR) in patients with an acute myocardial infarction (AMI). BACKGROUND Physical activity as a trigger of FWR in AMI remains controversial, and its contribution to SR or PMR remains unknown. Moreover, the role of ischemia or reinfarction as an additional cause of rupture has not been explored. METHODS The incidence of hospital admission delay > or =24 h with maintenance of some ambulatory activity and the incidence of postinfarction angina were analyzed in consecutive patients with a first AMI with (n = 225) or without rupture (n = 1,012 [control group]) over different time periods. RESULTS An admission delay > or =24 h occurred in 27 (27.6%) of 98 patients with FWR, 47 (47.0%) of 100 with SR and 14 (51.9%) of 27 with PMR but in only 81 (8%) of 1,012 control patients (p < 0.0001). Information on undue in-hospital effort preceding rupture was available for 111 patients and was present in 17 (32.7%) of 52 with FWR, 9 (18.4%) of 49 with SR and 3 (30%) of 10 with PMR versus only 76 (7.5%) of 1,012 control patients (p < 0.001). Information on postinfarction anginal pain was available for 114 patients with rupture and occurred in 30 (56.6%) of 53 with FWR, 30 (60%) of 50 with SR and 4 (36.4%) of 11 with PMR versus 120 (11.9%) of 1,012 control patients (p < 0.0001). Mean age and incidence of male gender, hypertension, absence of heart failure, single-vessel disease or occlusion of the infarct-related artery were comparable among the groups with FWR, SR or PMR. CONCLUSIONS Delayed hospital admission or undue in-hospital physical activity appears to increase the risk of rupture in patients prone to this complication (i.e., a first transmural AMI, absence of overt heart failure and advanced age); recurrence of ischemia/infarction emerges as a potential additional trigger in a proportion of these patients.

Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation

OBJECTIVES We sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation. BACKGROUND ST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear. METHODS In 432 patients with a first acute MI without Q waves or > or = 0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death. RESULTS The presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V5, or V6) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 +/- 96 vs. 122 +/- 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 +/- 12% vs. 66 +/- 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001). CONCLUSIONS In patients with a first non-ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.

Reliability of electromechanical dissociation in the diagnosis of left ventricular free wall rupture in acute myocardial infarction

The reliability of electromechanical dissociation (EMD) in diagnosing acute left ventricular free wall rupture (LVFWR) was assessed in 479 consecutive patients with acute myocardial infarction (AMI). EMD was the mechanism of death in 193 patients, 140 without heart failure (group A, 74%), and 53 with heart failure (group B, 26%). Autopsies performed on 121 patients with EMD showed LVFWR in 81 (95%) of 85 from group A and in 7 (17%) of 36 from group B. Of the 106 patients without EMD (group C) autopsied, 5 (4.7%) had LVFWR. Excluding the eight patients with associated septal rupture, LVFWR occurred in 79 (95.2%) of 83 patients from group A, 4 (12.1%) of 33 from group B, and 2 (1.9%) of 103 from group C. Predictive accuracy of EMD for LVFWR in group A was 95% but only 17% in group B. Moreover, in 13 consecutive cases with a first AMI without heart failure and EMD, emergency surgery demonstrated LVFWR in all. Thus EMD has a highly predictive accuracy in diagnosing LVFWR in patients with a first AMI without overt heart failure.

Relevance of electrocardiographic findings, heart failure, and infarct site in assessing risk and timing of left ventricular free wall rupture during acute myocardial infarction

Clinical and electrocardiographic features of 227 patients who died of an acute myocardial infarction (AMI) were compared with those of 150 survivors of a first AMI. Left ventricular (LV) free wall rupture was found in 93 patients aged > 50 years, but not in 134. The incidence of healed infarct (4 [4%] vs 50 [37%], p < 0.001), heart failure (11 [12%] vs 112 [84%], p < 0.001), and bundle branch block (11 [12%] vs 54 [40%], p < 0.001) was lower in patients with than without LV rupture. In patients with anterior AMI and early rupture (1 day), admission ST elevation was higher than in those with late LV rupture (> 1 day, 6.8 +/- 4.0 vs 4.0 +/- 2.7 mm, p < 0.01). However, lateral wall AMI had minimal ST elevation and accounted for 10% of ruptures. On day 2, the decrease in ST segment in patients with late LV rupture was less than in survivors (0.5 +/- 1.6 vs 3.2 +/- 2.9 mm, p < 0.001). Admission systolic blood pressure in patients who had early rupture was higher than in survivors (155 +/- 22 vs 137 +/- 22 mm Hg, p < 0.001) and in those with late rupture (135 +/- 23 mm Hg, p < 0.001). Late rupture was associated with infarct thinning and triggered by a physical strain in 18 of 45 patients (40%); infarct thinning, however, was present only in 4 of 48 patients (8%) with early rupture (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital Outcome of Moderate to Severe Pericardial Effusion Complicating ST-Elevation Acute Myocardial Infarction

Background— Hospital prognosis of moderate to severe pericardial effusion (MPE; ≥10 mm) in ST-elevation myocardial infarction is largely unknown. Methods and Results— Data from 446 ST-elevation myocardial infarction patients, 228 with MPE—88 with cardiac tamponade (CT) and electromechanical dissociation (EMD), 44 with CT without EMD (w/oEMD), and 96 without initial CT—and 218 with small PE (5 to 9 mm), were compared. Patients with MPE without initial CT were also compared with 96 patients without PE. CT patients showed larger PE (P<0.001) than those without initial CT; 85% of those with CT+EMD and 86% with CTw/oEMD were treated with pericardiocentesis and 10% and 21% were treated with a surgical repair, respectively. Among MPE patients, 30-day mortality was 43% and was higher in those with CT+EMD (operated, 89%; and nonoperated, 85%) than in those with CTw/oEMD (22% and 11%, respectively; P<0.001) and those without initial CT (17%; P<0.001). It was also higher than in patients with small PE (10%; P<0.001) or those without PE (6%; P=0.001). Death was attributable to cardiac rupture in 83% of patients with CT+EMD, 7% with CTw/oEMD, and 8% with MPE without initial CT and occurred late (≥7 days) in 14%, 67%, and 100%, respectively. Conclusions— MPE carries an increased mortality that is highest in patients with CT+EMD. In those with CTw/oEMD, however, mortality is considerably low after pericardiocentesis, and subsequent management may be individualized because a conservative approach is often successful. Importantly, MPE patients without initial CT are not free from late rupture and deserve further investigation.