Yama Fakhri

Evaluation of acute ischemia in pre-procedure ECG predicts myocardial salvage after primary PCI in STEMI patients with symptoms >12hours

BACKGROUND Primary percutaneous coronary intervention (pPCI) is recommended in patients with ST Elevation Myocardial Infarction (STEMI) and symptom duration <12hours. However, a considerable amount of myocardium might still be salvaged in STEMI patients with symptom durations >12hours (late-presenters). The Anderson-Wilkins score (AW-score) estimates the acuteness of myocardial ischemia from the electrocardiogram (ECG) in STEMI patients. We hypothesized that the AW-score is superior to symptom duration in identifying substantial salvage potential in late-presenters. METHODS The AW-score (range 1-4) was obtained from the pre-pPCI ECG in 55 late-presenters and symptoms 12-72 hours. Myocardial perfusion imaging was performed to assess area at risk before pPCI and after 30days to assess myocardial salvage index (MSI). We correlated both the AW-score and pain-to-balloon with MSI and determined the salvage potential (MSI) according to AW-score ≥3 (acute ischemia) and AW-score <3 (late ischemia). RESULTS Late-presenters had median MSI 53% (inter quartile range (IQR) 27-89). The AW-score strongly correlated with MSI (β=0.60, R(2)=0.36, p<0.0001), while pain-to-balloon time did not (β=-0.21, R(2)=0.04, p=0.14). Patients with AW-score ≥3 (n=16) compared to those with AW-score <3 (n=27) had significant larger MSI (82.7% vs 41.5%, p=0.014). MSI>median was observed in 79% in patients with AW-score ≥3 vs 32% in patients with AW-score <3 (adjusted OR 6.74 [95% CI 1.35-33.69], p=0.02). CONCLUSION AW-score was strongly associated with myocardial salvage while pain-to-balloon time was not. STEMI patients with symptom duration between 12 -72hours and AW-score ≥3 achieved substantial salvage after pPCI.

Clinical use of the combined Sclarovsky Birnbaum Severity and Anderson Wilkins Acuteness scores from the pre-hospital ECG in ST-segment elevation myocardial infarction

This review summarizes the electrocardiographic changes during an evolving ST segment elevation myocardial infarction and discusses associated electrocardiographic scores and the potential use of these indices in clinical practice, in particular the ECG scores developed by Anderson and Wilkins estimating the acuteness of myocardial ischemia and Sclarovsky-Birnbaums grades of ischemia evaluating the severity of ongoing ischemia.

Algorithm for the automatic computation of the modified Anderson–Wilkins acuteness score of ischemia from the pre-hospital ECG in ST-segment elevation myocardial infarction☆

BACKGROUND The acuteness score (based on the modified Anderson-Wilkins score) estimates the acuteness of ischemia based on ST-segment, Q-wave and T-wave measurements obtained from the electrocardiogram (ECG) in patients with ST Elevation Myocardial Infarction (STEMI). The score (range 1 (least acute) to 4 (most acute)) identifies patients with substantial myocardial salvage potential regardless of patient reported symptom duration. However, due to the complexity of the score, it is not used in clinical practice. Therefore, we aimed to develop a reliable algorithm that automatically computes the acuteness score. METHODS We scored 50 pre-hospital ECGs from STEMI patients, manually and by the automated algorithm. We assessed the reliability test between the manual and automated algorithm by interclass correlation coefficient (ICC) and Bland-Altman plot. RESULTS The ICC was 0.84 (95% CI 0.72-0.91), P<0.0001. The mean difference between manual and automated acuteness score was 0.17±0.66. In only two cases, there was a major disagreement between the two scores. There was an excellent agreement between the scores for the remaining 48 ECGs, all within the upper (1.46) and lower (-1.12) limits of agreement. CONCLUSION In conclusion, we have developed an automated algorithm for measurement of the modified Anderson-Wilkins ECG acuteness score from the pre-hospital ECG in STEMI patients. This automated algorithm is highly reliable, can be applied in daily practice for research purposes and may be implemented in commercial automated ECG analysis programs to achieve practical use for decision support in the acute phase of STEMI.

Prehospital electrocardiographic acuteness score of ischemia is inversely associated with neurohormonal activation in STEMI patients with severe ischemia.

BACKGROUND Elevated levels of N-terminal pro brain natriuretic peptide (NT-proBNP) are associated with adverse cardiovascular outcome after ST elevation myocardial infarction (STEMI). We hypothesized that decreasing acuteness-score (based on the electrocardiographic score by Anderson-Wilkins acuteness score of myocardial ischemia) is associated with increasing NT-proBNP levels and the impact of decreasing acuteness-score on NT-proBNP levels is substantial in STEMI patients with severe ischemia. METHODS In 186 STEMI patients treated with primary percutaneous coronary intervention (pPCI), the severity of ischemia (according to Sclarovsky-Birnbaum severity grades of ischemia) and the acuteness-score were obtained from prehospital ECG. Patients were classified according to the presence of severe ischemia or non-severe ischemia and acute ischemia or non-acute ischemia. Plasma NT-proBNP (pmol/L) was obtained after pPCI within 24hours of admission and was correlated with the acuteness-score. RESULTS NT-proBNP levels were median (25th-75th interquartile) 112 (51-219) pmol/L in patients with non-severe ischemia (71.5%) and 145 (79-339) in patients with severe ischemia (28.5%) (p=0.074). NT-proBNP levels were highest in patients with severe and non-acute ischemia compared to those with severe and acute ischemia (182 (98-339) pmol/L vs 105 (28-324) pmol/L, p=0.012). There was a negative correlation between acuteness-score and log(NT-proBNP) in patients with severe ischemia (r=0.395, p=0.003), which remained significant in multilinear regression analysis (β=-0.155, p=0.007). No correlation was observed between the acuteness-score and log(NT-proBNP) in patients with non-severe ischemia (p=0.529) or in the entire population (p=0.187). CONCLUSION In STEMI patients with severe ischemia, neurohormonal activation is inversely associated with ECG patterns of acute myocardial ischemia.

Automatic electrocardiographic algorithm for assessing severity of ischemia in ST-segment elevation myocardial infarction

BACKGROUND Terminal QRS distortion on the electrocardiogram (ECG) is a sign of severe ischemia in patients with STEMI and can be quantified by the Sclarovsky-Birnbaum Severity of Ischemia. Due to score complexity, it has not been applied in clinical practice. Automatic scoring of digitally recorded ECGs could facilitate clinical application. We aimed to develop an automatic algorithm for the severity of ischemia. METHODS Development set: 50 STEMI ECGs were manually (Manual-score) and automatically (Auto-score) scored by our designed algorithm. The agreement between Manual- and Auto-score was assessed by kappa statistics. Test set: ECGs from 199 STEMI patients were assigned a severity grade (severe or non-severe ischemia) by the Auto-score. Infarct size estimated by median peak Troponin T (TnT) and Creatinine Kinase Myocardial Band (CKMB) was tested between the groups. RESULTS The agreement between Manual- and Auto-score was 0.83 ((95% CI 0.55-1.00), p < 0.0001), sensitivity 75% and specificity 100%, PPV 100% and NPV 94.6%. In the test set 152 (76%) patients were male, mean age 61 ± 12 years. The Auto-score designated severe ischemia in 42 (21%) and non-severe ischemia in 157 (79%) patients. Patients with ECG signs of severe vs. non-severe ischemia had significantly higher levels of biomarkers of infarct size. In multiple linear regression, ECG sign of severe ischemia was an independent predictor for higher TnT and CKMB levels. CONCLUSION The automatic ECG algorithm for severity of ischemia in STEMI performs adequately for clinical use. Severe ischemia obtained by the Auto-score was associated with biomarker estimated larger infarct size.

The significance of ST-elevation in aVL in anterolateral myocardial infarction : An assessment by cardiac magnetic resonance imaging

Anterolateral myocardial infarction (MI) is traditionally defined on the electrocardiogram by ST‐elevation (STE) in I, aVL, and the precordial leads. Traditional literature holds STE in lead aVL to be associated with occlusion proximal to the first diagonal branch of the left anterior descending coronary artery. However, concomitant ischemia of the inferior myocardium may theoretically lead to attenuation of STE in aVL. We compared segmental distribution of myocardial area at risk (MaR) in patients with and without STE in aVL.

Myocardium at risk assessed by electrocardiographic scores and cardiovascular magnetic resonance - a MITOCARE substudy

INTRODUCTION The myocardium at risk (MaR) represents the quantitative ischemic area destined to myocardial infarction (MI) if no reperfusion therapy is initiated. Different ECG scores for MaR have been developed, but there is no consensus as to which should be preferred. OBJECTIVE Comparisons of ECG scores and Cardiac Magnetic Resonance (CMR) for determining MaR. METHODS MaR was determined by 3 different ECG scores, and by CMR in ST-segment elevation MI (STEMI) patients from the MITOCARE cardioprotection trial. The Aldrich score (AL) is based on the number of leads with ST-elevation for anterior MI and the sum of ST-segment elevation for inferior MI on the admission ECG. The van Hellemond score (VH) considers both the ischemic and infarcted component of the MaR by adding the AL and the QRS score, which is an estimate of final infarct size. The Hasche score is based on the maximal possible infarct size determined from the QRS score on the baseline ECG. RESULTS Ninety-eight patients (85% male, mean age 61years) met STEMI criteria on their admission ECG and underwent CMR within 3-5days after STEMI. Mean MaR by CMR was 41.2±10.2 and 30.3±7.2 for anterior and inferior infarcts, respectively. For both anterior and inferior infarcts the Aldrich (18.2±5.1 and 18.6±6.0) and Hasche (25.3±9.8 and 26.4±8.8) scores significantly underestimated MaR compared to MaR measured by CMR. In contrast, MaR by the van Hellemond score (37.0±14.2 and 31.7±12.8) was comparable to CMR. CONCLUSION We tested the performance of the electrocardiographic estimation of myocardium area at risk by Aldrich, Hasche and van Hellemond ECG scores in comparison to MaR measured by CMR in STEMI patients. MaR by the van Hellemond score and CMR were comparable, while Aldrich and Hasche underestimated MaR.