Current barriers and recommendations on the diagnosis of transthyretin amyloid cardiomyopathy: a Delphi study.

Objectives: This study has been conducted to investigate the non-invasive diagnostic journey of patients with a transthyretin amyloid cardiomyopathy (aTTR-CM) in Turkey, identify the challenges and uncertainties encountered on the path to diagnosis from the perspectives of expert physicians, and develop recommendations that can be applied in such cases. Methods: This study employed a three-round modified Delphi method and included 10 cardiologists and five nuclear medicine specialists. Two hematologists also shared their expert opinions on the survey results related to hematological tests during a final face-to-face discussion. A consensus was reached when 80% or more of the panel members marked the "agree/strongly agree" or "disagree/strongly disagree" option. Results: The panelists unanimously agreed that the aTTR-CM diagnosis could be established through scintigraphy (using either 99mTc-PYP, 99mTc-DPD, or 99mTc-HMPD) in a patient with suspected cardiac amyloidosis (CA) without a further investigation if AL amyloidosis is ruled out (by sFLC, SPIE and UPIE). In addition, scintigraphy imaging performed by SPECT or SPECT-CT should reveal a myocardial uptake of Grade ≥2 with a heart-to-contralateral (H/CL) ratio of ≥1.5. The cardiology panelists recommended using cardiovascular magnetic resonance (CMR) and a detailed echocardiographic scoring as a last resort before considering an endomyocardial biopsy in patients with suspected CA whose scintigraphy results were discordant/inconclusive or negative but still carried a high clinical suspicion of aTTR-CM. Conclusion: The diagnostic approach for aTTR-CM should be customized based on the availability of diagnostic tools/methods in each expert clinic to achieve a timely and definitive diagnosis.

Effects of weight loss after bariatric surgery on atrial electromechanical delay in obese subjects.

Background: The authors investigated the relationship between weight loss after sleeve gastrectomy and change in atrial electromechanical delay values. Methods: A total of 41 patients were included. The primary end point was any effect of total weight loss on atrial electromechanical delay parameters. Results: The mean loss of body weight was 25.50 ± 11.07 kg. There was a significant correlation between mean body weight change and change in interatrial and left intra-atrial electromechanical delays (Pearson's correlation coefficient: 0.575 and 0.871, respectively; p < 0.001). Only change in body weight was significantly related to change in interatrial electromechanical delay (regression coefficient: 0.707; p < 0.01). Conclusion: In this study, a significant relationship was found between amount of body weight loss and decrease in atrial electromechanical values.

Obesity is associated with heart rhythm disturbances. Synchrony between the electrical and mechanical activities of the heart is adversely affected in people with obesity. In this study, the authors aimed to show the effect of amount of weight loss after weight loss surgery on the coupling properties of electrical and mechanical activities of heart chambers called atria. The authors included 41 participants. Heart ultrasound was done before and after weight loss surgery. Statistical analyses were performed to show the effect of total body weight loss on the heart's electrical and mechanical atrial functions. Significant weight loss was observed in participants during short-term follow-up after surgery and was found to be related to the electrical and mechanical functions of the atria. In the authors' study, weight loss achieved in the short term after weight loss surgery improved the electrical and mechanical coupling of the atria. This may translate into decreased rhythm disturbance risk in these patients.

Cardiovascular disintegration: A conceptual, model-based approach to heart failure hemodynamics.

OBJECTIVE: The current understanding of heart failure (HF) largely centers round left ventricular (LV) function; however, disorders in serial integration of cardiovascular system may cause a hemodynamic picture similar to left-sided HF. Therefore, focusing only on LV function may be a limited and misleading approach. We hypothesized that cardiovascular system has four major integration points, and disintegration in any of these points may produce the hemodynamic picture of HF. METHODS: We used a computational model in which mechanical properties of each chamber were characterized using time-varying elastance, and vascular beds were modeled by series of capacitances and resistances. The required percent changes in stressed volume (Vstressed) was presented as a measure of congestion susceptibility. RESULTS: As mean systemic pressure is closely correlated with pulmonary capillary wedge pressure (PCWP), arteriovenous disintegration can create a diastolic dysfunction pattern, even without any change in diastolic function. For 10%, 20%, 30%, 40%, and 50% interventricular disintegration, required Vstressed for reaching a PCWP over 20 mmHg was decreased by 42.0%, 31.2%, 22.5%, 15%, and 8.3%, respectively. Systolodiastolic disintegration, namely combined changes in the end-diastolic and systolic pressure-volume curves and ventriculoarterial disintegration significantly decreases the required percent change in Vstressed for generating congestion. CONCLUSION: Four disintegration points can produce the hemodynamic picture of HF, which indicates that combination of even seemingly mild abnormalities is more important than an isolated abnormality in a single function of a single chamber. Our findings suggest that a "cardiovascular disintegration" perspective may provide a different approach for assessing the HF syndrome.

Investigation of Circulating miRNA-133, miRNA-26, and miRNA-378 as Candidate Biomarkers for Left Ventricular Hypertrophy.

BACKGROUND/AIM: Left ventricular hypertrophy (LVH) involves increased muscular mass of the left ventricle due to increased cardiomyocyte size and is caused by cardiomyopathies. Several microRNAs (miRNAs) have been implicated in processes that contribute to heart disease. This study aimed to examine miRNA-133, miRNA-26 and miRNA-378 as candidate biomarkers to define prognosis in patients with LVH. PATIENTS AND METHODS: The study group consisted of 70 patients who were diagnosed with LVH and 16 unaffected individuals who served as the control group. Real-time polymerase chain reaction (RT-PCR) was used to analyze serum miRNA-133, miRNA-26, and miRNA-378 expression levels in LVH patients and the control group. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic capability of miRNA-378. RESULTS: When crossing threshold (CT) values were compared between patient and control samples, we found that there were no statistically significant differences in miRNA-133 and miRNA-26 CT values, while the miRNA-378 expression was significantly increased in LVH patients. ROC analysis demonstrated that the expression levels of miRNA-378 (AUC=0.484, p=0.0013) were significantly different between groups. CONCLUSION: We observed a statistically significant relationship between miRNA-378 expression levels and LVH, suggesting that circulating miRNA-378 may be used as a novel biomarker to distinguish patients who have LVH from those who do not.

The Association between Serum Heme Oxygenase-1 Levels and Coronary SYNTAX Score.

AIM: The relationship between heme oxygenase-1 (HO-1) levels and atherosclerosis was investigated in multiple studies. The aim of this study was to establish the relationship between HO-1 levels and coronary SYNergy between percutaneous coronary intervention with TAXus and Cardiac Surgery (SYNTAX) score in patients with stable coronary artery disease (CAD). METHODS: Patients who had been planned to undergo invasive coronary angiography due to a suspected CAD, between the dates of September and December 2019, were included in the study. Serum HO-1 levels were measured from peripheral venous blood. The SYNTAX score was calculated using standard coronary angiography images. Regression analysis was performed to establish the relationship between HO-1 levels and the SYNTAX score. RESULTS: In total, 137 patients were included. The median age was 63 years (IQR: 15), and most of the patients were male (75.2%). The median HO-1 level was 1.44 (IQR: 0.88) ng/mL, and the median SYNTAX score was 6 (IQR: 13). Regression analysis showed that HO-1 is the single most important variable associated with the SYNTAX score (HO-1 levels from 1.01 to 1.87 ng/mL, OR: 6.77, 95% confidence interval 5.18-8.36, p < 0.0001). CONCLUSION: In this study, serum HO-1 levels were significantly associated with the coronary SYNTAX score.

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study).

BACKGROUND: Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. METHODS: A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database. RESULTS: In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality. CONCLUSIONS: We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).

NT-proBNP level in stage 3-4 chronic kidney disease and mortality in long-term follow-up: HAPPY study subgroup analysis.

OBJECTIVE: This was an investigation of the relationship between the N-terminal pro-brain natriuretic peptide (NT-proBNP) level and mortality in patients with stage 3-4 chronic kidney disease (CKD). METHODS: This study was designed as a subgroup analysis of the Heart Failure Prevalence and Predictors in Turkey (HAPPY) study. The HAPPY study included 4650 randomly selected individuals from the 7 geographical regions of Turkey. A total of 191 subjects from the original cohort with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.1.73 m² were enrolled in this study and the relationship between NT-proBNP and mortality was investigated. Prognostic variables for total and cardiovascular mortality were also examined using Cox regression analysis. RESULTS: The mean length of follow-up was 76.12±22.45 months. The mean NT-proBNP level was 423.54±955.88 pg/mL. During follow-up, 51 subjects (26.7%) died from any cause and 36 subjects (18.8%) died from a cardiovascular cause. The presence of hypertension (hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.01-3.50; p=0.048), anemia (HR: 2.49; 95% CI: 1.20-5.15; p=0.014), male gender (HR: 2.64; 95% CI: 1.44-4.86; p=0.002) and log NT-proBNP (HR: 4.93; 95% CI: 2.83-8.58; p<0.001) were independent variables for total mortality. The presence of hypertension (HR: 2.47; 95% CI: 1.09-5.56; p=0.029), male gender (HR: 2.79; 95% CI: 1.38-5.62; p=0.004), eGFR (HR: 0.94; 95% CI: 0.91-0.98; p=0.005) and log NT-proBNP (HR: 6.31; 95% CI: 3.11-12.81; p<0.001) were independent predictors of cardiovascular mortality. CONCLUSION: NT-proBNP was found to be an independent prognostic marker in patients with stage 3-4 CKD.

Does electrocardiogram help in identifying the culprit artery when angiogram shows both right and circumflex artery disease in inferior myocardial infarction?

OBJECTIVE: In a subgroup of patients with inferior myocardial infarction (MI), both the right coronary artery (RCA) and circumflex coronary artery (Cx) show potentially culprit lesions, and angiography may be insufficient to determine which artery is responsible for the clinical presentation. Although many electrocardiographic (ECG) algorithms have been proposed for identifying the infarct-related artery in patients with inferior MI, it is unclear whether the current algorithms have the discriminative power to identify the real culprit artery in these patients. METHODS: The patients with the diagnosis of acute inferior MI and underwent coronary angiography were enrolled in the study. The prediction of the infarct-related artery was attempted from the admission ECG using published algorithms and criteria. For the angiographic definition of the infarct-related artery, multiple criteria were used. RESULTS: Total 417 inferior MI cases were enrolled during the study period; the final patient population comprised of 318 patients. Forty-five patients (14.2%) had both RCA and Cx lesions on coronary angiography. Although several criteria and algorithms are able to identify the infarct-related artery in the general inferior MI population, they lose their strength in patients with both RCA and Cx lesions. Only the Aslanger-Bozbeyoglu criterion emerges as a more powerful diagnostic test with a sensitivity, specificity, and c-statistic of 80%, 48%, and 0.650, respectively for the whole population (p<0.001) and 81%, 58%, and 0.709, respectively, for patients with both RCA and Cx lesions (p=0.019). CONCLUSION: The Aslanger-Bozbeyoglu criterion is not only helpful in differentiating the infarct territory in combined inferior and anterior ST-segment elevation as previously shown, but also valuable in identifying the infarct-related artery in patients with inferior STEMI with critical lesions in both the RCA and the Cx. (Anatol J Cardiol 2020; 23: 318-23).

A new electrocardiographic pattern indicating inferior myocardial infarction.

BACKGROUND: We identified a specific pattern that does not display contiguous ST-segment elevation (STE), indicating acute inferior myocardial infarction (MI) with concomitant critical stenoses on the other coronary arteries. We sought to define the frequency, underlying anatomic substrate, diagnostic power and prognostic implications of this pattern. METHODS: One thousand patients with a diagnosis of non-STEMI were enrolled as the study group. Within the same date range, all patients with inferior STEMI and 1000 patients, who had been excluded for MI (no-MI), were also enrolled. The coronary angiograms were reviewed by two interventional cardiologists, who were blinded to the ECGs. Echocardiographic wall motion bullseye displays and coronary angiography maps were constructed for each group. The dead or alive status was checked from the electronic national database. RESULTS: The final study population consisted 2362 patients. The prespecified ECG pattern was observed in 6.3% (61/966) of the non-STEMI cohort and 0.5% (5/1000) of no-MI patients. These patients had a larger infarct size as evidenced by 24-hour troponin levels, higher frequency of angiographic culprit lesion, and higher frequency of composite acute coronary occlusion endpoint compared to their non-STEMI counterparts. On the other hand, they had a similar in-hospital (5% vs. 4%, respectively; P = 0.675) and one-year mortality compared to the patients with inferior STEMI (11% vs. 8%, respectively; P = 0.311). CONCLUSION: We here define a new ECG pattern indicating inferior MI in patients with concomitant critical lesion(s) in coronary arteries other than the infarct-related artery. Patients with this pattern have multivessel disease and higher mortality.

[Turkish Cardiology Association Consensus Report: COVID-19 Pandemic and Cardiovascular Diseases (May 13, 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (13 Mayis 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

[Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. (25th March 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (25 Mart 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Is the inferior ST-segment elevation in anterior myocardial infarction reliable in prediction of wrap-around left anterior descending artery occlusion?

OBJECTIVE: In a subgroup of patients with the anterior wall myocardial infarction (MI), the electrocardiogram (ECG) records a concomitant inferior ST-segment elevation (STE), which is generally explained by a 'wrap-around' left anterior descending (LAD) artery occlusion. However, recent evidence indicates that this may be due to a distal LAD occlusion, which may be irrelevant to the LAD length. We investigated the relationship between inferior ST-T changes in anterior MI and the presence of a wrap-around LAD. METHODS: Consecutive patients diagnosed with anterior MI due to an acute LAD occlusion were enrolled into the study. All ECGs were measured manually by a cardiologist, who was blinded to the angiographic outcomes. The site of the LAD occlusion was determined using multiple angiographic views. A wrap-around LAD was defined as a LAD artery from a post-reperfusion coronary angiogram that perfused at least one-fourth of the inferior wall of the left ventricle in the right anterior oblique projection. RESULTS: A total of 379 anterior MI cases were enrolled, and the final study population consisted of 259 patients. The presence of a wrap-around LAD was more frequent in patients presenting with inferior STE compared with patients without inferior STE (62.1% vs. 30.4%, p=0.001), however, this relationship was weak (φ=0.211). Inferior STE was more frequent in distal occlusions (22.9% vs. 4.3%, p<0.001), which showed a stronger relationship (φ=0.285). The polarity of the T-wave in lead III did not give any clues about the LAD anatomy. CONCLUSION: Contrary to the popular acceptance, our results indicate that a wrap-around LAD cannot be reliably diagnosed by ECG.

Short-term effects of sleeve gastrectomy on weight loss and diastolic function in obese patients.

diac structure and function in obese patients. This study was an examination of the short-term effects of sleeve gastrectomy on body measurements and diastolic function. METHODS: A total of 41 consecutive obese patients who were scheduled to undergo a sleeve gastrectomy procedure were included in the study. Baseline body and echocardiographic measurements and the follow-up counterpart data, including total and excess weight loss percentages, were recorded. RESULTS: The mean age of the patients was 42.85+-11.47 years. Of the total, 21 (51.1%) patients were female. The mean body mass index (BMI) was 44.86+-5.62 kg/m². The mean duration of follow-up was 91.24+-44.48 days. The participants demonstrated statistically significant weight loss (26.64+-10.95 kg), as well as a decrease in BMI (8.84+-3.93 kg/m²) and body surface area (0.27+-0.12 m²). A significant increase in E velocity and mitral annular e velocity were observed, as well as a significant decrease in A velocity, E/e ratio, left ventricle mass, and left atrial volume (LAV). No significant correlations between the body measurement changes and changes in echocardiographic parameters were observed, with the exception that the excessive weight loss percentage was moderately correlated with a change in LAV. CONCLUSION: Sleeve gastrectomy led to a significant decrease in body weight and improved diastolic function parameters in the short-term. No significant relationship was found between the amount of weight loss and change in echocardiographic measurements.

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis.

BACKGROUND: The currently used scheme for the classification of infarct location and extent in anterior myocardial infarction (MI) is intuitive rather than being evidence-based, and recent evidence suggests that it may be misleading both in anatomic and prognostic sense. MATERIAL AND METHODS: Consecutive patients with the diagnosis of anterior MI were enrolled. All electrocardiograms (ECG) were first classified according to established scheme and then reassessed using newer criteria for angiographic site of occlusion. The site of left anterior descending (LAD) occlusion was determined using multiple angiographic views. Clinic, echocardiographic and angiographic outcomes were compared. RESULTS: A total of 379 anterior MI cases were enrolled, final study population consisted of 267 patients. The established scheme did not predict infarct size or adverse outcomes. Location of the myocardium subtended by the occluded coronary network did not match with the anatomic location as ECG classification implies. Many high-risk patients with proximal LAD were classified as "anteroseptal", whereas the majority of the patients labeled as "extensive anterior MI" had in fact distal occlusions. On the other hand, expert interpretation was fairly accurate in predicting adverse outcomes and the site of angiographic involvement. CONCLUSION: Classifying patients according to the established scheme neither gives prognostic information nor accurately localizes infarction. It should be regarded as obsolete and its use should be abandoned. Instead, the extent of infarction can be inferred from newer criteria provided by the angiographic correlation studies.

An algorithm for the differentiation of the infarct territory in difficult to discern electrocardiograms.

BACKGROUND: In a minority of the patients presenting with ST-segment elevation (STE) myocardial infarction (MI), electrocardiogram (ECG) may show a balanced STE in both anterior and inferior lead groups and may cause diagnostic confusion about involved myocardial territory. In this study, we sought ECG clues which may facilitate discriminating (1) MI location and then (2) culprit artery in patients with difficult-to-discern ECGs. MATERIAL AND METHODS: Consecutive patients with the diagnosis of STEMI were scanned and patients with ECGs displaying both anterior and inferior STE were enrolled. ECGs with obvious ST elevation in either lead group and reciprocal ST-segment depression were excluded. Predictive power of several ECG variables has been analyzed and an algorithm has been constructed. RESULTS: A total of 959 STEMI cases were scanned, the final study population was consisted of 114 patients. Our algorithm for locating MI territory had a sensitivity, specificity, positive and negative predictive value of 72.1%, 92.5%, 91.7% and 74.2% for inferior versus anterior location, respectively (P < 0.001, φ = 0.652). As anterior MI was strictly reserved for left anterior descending (LAD) artery occlusion, these diagnostic values were also valid for discriminating circumflex artery [Cx]/right coronary artery [RCA] versus LAD as the culprit artery. In patients classified as having inferior MI, an STE in lead III greater than STE in lead II favored RCA over Cx as the culprit artery with a sensitivity, specificity, positive and negative predictive value of 97%, 46.6%, 80% and 87.5%, respectively (P < 0.001; φ = 0.544). CONCLUSION: Our algorithm can be used in difficult-to-discern ECGs for defining involved myocardial territory and culprit artery.

NT-proBNP levels and mortality in a general population-based cohort from Turkey: a long-term follow-up study.

AIM: We investigated the relationship between NT-ProBNP and mortality in a general population-based cohort. METHODS & RESULTS: A total of 2021 out of 4650 participants from previously published HAPPY study were included. Mean follow-up was 84.5 ± 10.4 months. After adjusting for risk factors, high levels of LogNT-proBNP predicted all-cause death (HR: 3.23; 95% CI: 2.20-4.75; p < 0.001) and cardiovascular death (HR: 3.85; 95% CI: 2.37-6.26; p < 0.001). Regression analysis revealed that LogNT-proBNP was an independent predictor of all-cause death (HR: 2.85; 95% CI: 1.91-4.24; p < 0.001) and cardiovascular death (HR: 3.02; 95% CI: 1.84-4.95; p < 0.001). Conclusion: Our study showed that in long term follow-up, NT-proBNP is associated with increased all-cause and cardiovascular mortality.

A Simplified Formula Discriminating Subtle Anterior Wall Myocardial Infarction from Normal Variant ST-Segment Elevation.

Benign variant (BV) ST-segment elevation (STE) is present in anterior chest leads in most individuals and may cause diagnostic confusion in patients presenting with chest pain. Recently, 2 regression formulas were proposed for differentiation of BV-STE from anterior ST-elevation myocardial infarction (MI) on the electrocardiogram, computation of which is heavily device-dependent. We hypothesized that a simpler visual-assessment-based formula, namely (R-wave amplitude in lead V4 + QRS amplitude in V2) - (QT interval in millimeters + STE60 in V3), will be noninferior to these formulas. Consecutive cases of proven left anterior descending occlusion were reviewed, and those with obvious ST elevation MI were excluded. First 200 consecutive patients with noncardiac chest pain and BV-STE were also enrolled as a control group. Relevant electrocardiographic parameters were measured. There were 138 anterior MI and 196 BV-STE cases. Our simple formula was superior to the 3- and noninferior to the 4-variable formulas. This new practical formula had an excellent area-under curve of 0.963 (95% confidence interval, 0.946 to 0.980, p<0.001). It also had a sensitivity, specificity and diagnostic accuracy of 86.9%, 92.3%, and 90.1%, respectively. In conclusion, a simple visual assessment-based formula can reliably differentiate STE MI from BV-STE. Also, our results emphasize that focusing only on STE for diagnosing acute coronary occlusion is extremely insensitive and even puts the term "STEMI" itself into question.

A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation.

BACKGROUND: It may sometimes be difficult to differentiate subtle ST-segment elevation (STE) due to anterior myocardial infarction (MI) from benign variant (BV) STE. Recently, two related formulas were proposed for this purpose. However, they have never been tested in an external population. MATERIALS AND METHODS: Consecutive patients from May 2017 to January 2018, who were admitted with the diagnosis of acute anterior STEMI, were enrolled. Electrocardiograms were systematically reviewed and only subtle ones were included. First 200 consecutive patients with noncardiac chest pain were also enrolled as a control group. Relevant electrocardiographic parameters were measured. RESULTS: A total of 379 anterior MI and 200 BV-STE cases were enrolled during study period. A total of 241 patients in STEMI group were excluded for not matching subtleness criteria, four patients in control group were also excluded because of prior left-anterior descending artery intervention. The three-variable formula, with recommended cut-point of 23.5, had a sensitivity, specificity, and diagnostic accuracy of 73.9%, 86.7%, and 81.4%, respectively. The four-variable formula, with the published cut-point of 18.2, had a sensitivity, specificity, and diagnostic accuracy of 83.3%, 87.7%, and 85.9%, respectively. CONCLUSION: Three- and four-variable formulas with recommended cutoffs have a reasonable sensitivity, specificity, and diagnostic accuracy in differentiating subtle STEMI with BV-STE. Although both perform well, the four-variable formula has a higher sensitivity, specificity, and diagnostic accuracy and should be preferred.