Toni Anne De Venecia

Atrial myocardial infarction: A tale of the forgotten chamber

It has been almost a century since atrial infarction was first described, yet data describing its significance remain limited. To date, there are still no universally accepted criteria for the diagnosis of atrial infarction. Atherosclerosis is the leading cause of atrial infarction but it has also been described in cor pulmonale and pulmonary hypertension. Atrial infarction almost always occurs concomitantly with ventricular infarction. Its clinical presentation depends largely on the extent and site of ventricular involvement. Atrial infarction can present with supraventricular tachyarrhythmias. Electrocardiographic (ECG) criteria for diagnosing atrial infarction have been described but none have yet to be validated by prospective studies. Atrial ECG patterns include abnormal P-wave morphologies, PR-segment deviations, as well as transient rhythm abnormalities, including atrial fibrillation, atrial flutter, atrial tachycardia, wandering atrial pacemaker (WAP) and atrioventricular (AV) blocks. Complications of atrial infarction include thromboembolic events and cardiogenic shock. There are no specific additional recommendations in the management of myocardial infarction with suspected involvement of the atria. The primary goal remains coronary reperfusion and maintenance of, or conversion to, sinus rhythm.

Psychiatric conditions as predictors of rehospitalization among African American patients hospitalized with heart failure

African Americans (AAs) have the highest risk of developing heart failure (HF) among all ethnicities in the United States and are associated with higher rates of readmissions and mortality. This study aims to determine the prevalence and relationship of common psychiatric conditions to outcomes of patients hospitalized with HF.

Prognostic significance of abnormal P wave morphology and PR-segment displacement after ST-elevation myocardial infarction

INTRODUCTION Atrial infarction is uncommonly diagnosed and data on its significance are limited. Its incidence in ST-elevation myocardial infarction (STEMI) reportedly ranges from 0.7-42%. Certain atrial ECG changes, such as abnormal P wave morphology suggestive of atrial involvement have been associated with 90-day mortality after STEMI. However, whether atrial ECG changes are associated with short (30-day) or long-term (1-year) mortality have not been studied. METHODS We examined index ECG in 224 consecutive STEMI. Demographics, clinical variables, peak troponin I, ejection fraction, and angiographic data were collected. Atrial ECG patterns were examined and correlated with mortality. RESULTS Length of stay was longer with abnormal P waves (p=0.008) or PR displacement in any lead (p=0.003). Left main coronary disease was more prevalent with abnormal P wave (p=0.045). Abnormal P wave morphology in any lead was associated with higher 30-day (OR 3.09 (1.35-7.05)) and 1-year mortality (OR 5.33 (2.74-10.36)). PR displacement in any lead was also associated with increased 30-day (OR 2.33 (1.03-5.28)) and 1-year mortality (OR 6.56 (3.34-12.86)). Abnormal P wave, PR depression in II, III and AVF, and elevation in AVR or AVL were associated with increased 1-year mortality (OR 12.49 (5.2-30.0)) as was PR depression in the precordial leads (OR 21.65 (6.82-68.66)). After adjusting for age, ejection fraction, peak troponin I, and left main disease, PR displacement in any lead was associated with increased 1-year mortality (adjusted OR 6.22 (2.33-18.64)). CONCLUSION PR segment displacement in any lead, found in 31% of patients with STEMI, independently predicted 1-year mortality.

Utility of the QT interval in predicting outcomes in patients presenting to the emergency department with chest pain.

ObjectivesThe aim of this study was to investigate whether prolongation of the heart rate-corrected QT interval (QTc) is an independent risk factor for predicting future acute coronary syndrome (ACS) occurrence or mortality in patients with at least one cardiac risk factor presenting with chest pain to the emergency department (ED). MethodsThis is a single-center, retrospective study of patients presenting with chest pain to the ED of Einstein Medical Center, Philadelphia, between 2011 and 2012. Proportional hazards models were used to calculate hazard ratios (HRs) for occurrence of ACS or death within 1 year. Kaplan–Meier curves were used to determine the time to event for QTc low (<460 ms) versus QTc high (≥460 ms) groups. ResultsA total of 595 patients met the inclusion criteria. Older age, hypertension, diabetes mellitus, and hyperlipidemia were more common in the QTc high group. Patients in the QTc high group were more likely to experience subsequent ACS or death (HR 8.12, 95% confidence interval 4.00–16.72), even after adjusting for traditional cardiac risk factors (HR 7.68, 95% confidence interval 3.57–16.61). ConclusionQTc prolongation at ED presentation with chest pain and at least one cardiac risk factor predicts subsequent ACS and death.

QRS duration and left ventricular ejection fraction (LVEF) in non-ST segment elevation myocardial infarction (NSTEMI).

BACKGROUND Non-traditional EKG parameters such as QRS pattern and QRS duration (QRSd) are being investigated in acute coronary syndrome as prognostic markers. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which eventually lowers the ejection fraction (LVEF). Our objective is to evaluate the relationship between the QRSd at the time of NSTEMI and extent of coronary artery disease (CAD) and changes in LVEF. METHODS AND RESULTS Patients admitted with NSTEMI between 08/01/2006 and 9/30/2012 were included. Patients were classified into high or low QRSd at cutoff value of 90ms noted on initial EKG after excluding bundle-branch block. A total of 536 patients with mean age of 66±14years were included. 49% were male and majority were African American (73%). Patients within the higher QRSd group had a lower LVEF at the time of the NSTEMI compared to those with QRSd <90ms (47±15% vs. 50±13%; p<0.038). The LVEF remained lower in the high QRS group on follow up to 12months (47±15% vs. 52±11%; p<0.001). The high QRSd group had a higher incidence of severe LV dysfunction at baseline (27% vs. 18%; p<0.045). Logistic regression analysis revealed that a QRSd ≥90ms was also independently associated with a severely reduced LVEF on follow-up (OR=2.7; CI 1.55-4.69; p<0.001). CONCLUSION QRSd ≥90ms at the time of NSTEMI is predictive of three-vessel/left main coronary artery involvement and a lower LVEF. This depression in LVEF is maintained for up to 12months. Thus, the QRSd at time of NSTEMI has additional prognostic significance.

Clinical Characteristics, Management, and Outcomes of Suspected Poststroke Acute Coronary Syndrome.

Background Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. Methods This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. Results Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. Conclusion Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

QRS DURATION AND LEFT VENTRICULAR EJECTION FRACTION IN NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Non-traditional EKG parameters as pattern of QRS or its duration (QRSd) have been investigated in acute coronary syndrome. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which alters the ejection fraction over time. Our objective is to evaluate the

ELECTROCARDIOGRAPHIC CHANGES CONSISTENT WITH ATRIAL INFARCTION IS A POTENTIAL INDEPENDENT PREDICTOR OF 30 DAY AND 1 YEAR MORTALITY IN PATIENTS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Atrial Infarction is an uncommonly diagnosed disease and data on its significance are limited. Its incidence in patients with ST-segment elevation myocardial infarction (STEMI) reportedly ranges from 0.7-52%. Several atrial infarction electrocardiographic (ECG) patterns have been described but none