Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction.

STUDY OBJECTIVE: The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap. METHODS: T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity. RESULTS: Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves. CONCLUSION: Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample.

Association between troponin and outcome in patients with chest pain and rapid atrial fibrillation: a retrospective study of a single-center 10-year cohort.

BACKGROUND AND OBJECTIVE: The prognosis of myocardial infarction in patients with rapid atrial fibrillation (RAF) is poorly known. We sought to ascertain if troponin concentrations are associated with a higher risk of major adverse cardiovascular events (MACE) in patients with RAF and chest discomfort suggestive of coronary origin. METHODS: We retrospectively reviewed all consecutive patients attending an emergency department of a single-center (2008-2017) with chest pain suggestive of coronary origin who had RAF and at least one troponin determination. Patients were classified as having normal/increased troponin. They were followed until December 2019 to detect MACE (primary outcome), which included acute coronary syndrome (ACS), revascularization, stroke, or all-cause death. In addition to cardiovascular death and type I myocardial infarction, these were considered secondary outcomes. The adjusted risk was determined by Cox regression, and sensitivity analysis were run. Relationship between troponin as a continuous variable and outcomes was also evaluated, as well as interaction by sex. RESULTS: We included 574 patients (median = 76.5 years, IQR = 14, women 56.8%, increased troponin 34.1%) followed by a median of 3.8 years (IQR = 4.8). MACE occurred in 200 patients (34.8%). Increased troponin was independently associated with MACE (adjusted hazard ratio, 1.502, 95% CI, 1.130-1.998), ACS (adjusted hazard ratio, 2.488, 95% CI, 1.256-4.928), type I myocardial infarction (adjusted hazard ratio, 2.771, 95% CI, 1.212-6.333) and stroke (adjusted hazard ratio, 3.580, 95% CI, 1.888-6.787) but not with death, cardiovascular death or revascularization. Sensitivity analyses were consistent with these results. There was no interaction by sex. When assessed continuously, an increase in troponin concentrations was lineally associated with a steady increase in the risk of MACE. CONCLUSIONS: In patients with RAF who complain of chest pain, increased troponin levels are related to adverse cardiovascular outcomes.

Clinical presentation of patients with prior coronary artery bypass grafting and suspected acute myocardial infarction.

AIMS: Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG). METHODS AND RESULTS: Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75-0.84) vs. AUC 0.87 (95% CI 0.86-0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215-525) min vs. 300 (192-435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653). CONCLUSIONS: Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients. CLINICALTRIALS.GOV REGISTRY: Number NCT00470587.

Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations: an outlook through the NOVICA cohort.

OBJECTIVES: We investigated the natural history of patients after a first episode of acute heart failure (FEAHF) requiring emergency department (ED) consultation, focusing on: the frequency of ED visits and hospitalisations, departments admitting patients during the first and subsequent hospitalisations, and factors associated with difficult disease control. METHODS AND RESULTS: We included consecutive patients diagnosed with FEAHF (either with or without previous heart failure diagnosis) in four EDs during 5 months in three different time periods (2009, 2011, 2014). Diagnosis was adjudicated by local principal investigators. The clinical characteristics of the index event were prospectively recorded, and all post-discharge ED visits and hospitalisations [related/unrelated to acute heart failure (AHF)], as well as departments involved in subsequent hospitalisations were retrospectively ascertained. 'Uncontrolled disease' during the first year after FEAHF was considered if patients were attended at ED (≥ 3 times) or hospitalised (≥ 2 times) for AHF or died. Overall, 505 patients with FEAHF were included and followed for a mean of 2.4 years. In-hospital mortality was 7.5%. Among 467 patients discharged alive, 288 died [median survival 3.9 years, 95% confidence interval (CI) 3.5-4.4], 421 (90%) revisited the ED (2342 ED visits; 42.4% requiring hospitalisation, 34.0% AHF-related) and 357 (77%) were hospitalised (1054 hospitalisations; 94.1% through ED, 51.4% AHF-related). AHF-related hospitalisations were mainly in internal medicine (28.0%), short-stay unit (26.3%), cardiology (20.8%), and geriatrics (14.1%). Only 47.4% of AHF-related hospitalisations were in the same department as the FEAHF, and internal medicine involvement significantly increased with subsequent hospitalisations (P = 0.01). Uncontrolled disease was observed in 31% of patients, which was independently related to age > 80 years [odds ratio (OR) 1.80, 95% CI 1.17-2.77], systolic blood pressure < 110 mmHg at ED arrival (OR 2.61, 95% CI 1.26-5.38) and anaemia (OR 2.39, 95% CI 1.51-3.78). CONCLUSION: In the present aged cohort of AHF patients from Barcelona, Spain, the natural history after FEAHF showed different patterns of hospital department involvement. Advanced age, low systolic blood pressure and anaemia were factors related to uncontrolled disease during the year after debut.

Incremental diagnostic and prognostic value of the QRS-T angle, a 12-lead ECG marker quantifying heterogeneity of depolarization and repolarization, in patients with suspected non-ST-elevation myocardial infarction.

BACKGROUND: The value of the 12-lead ECG in the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is limited due to insufficient sensitivity and specificity of standard ECG criteria. The QRS-T angle reflects depolarization-repolarization heterogeneity and might assist in detecting patients with a NSTEMI (diagnosis) as well as predicting patients with an increased mortality risk (prognosis). METHODS: We prospectively enrolled 2705 consecutive patients with symptoms suggestive of NSTEMI. The QRS-T angle was automatically derived from the standard 10 s 12-lead ECG recorded at presentation to the ED. Patients were followed up for all-cause mortality for 2 years. RESULTS: NSTEMI was the final diagnosis in 15% (n = 412) of patients. QRS-T angles were significantly greater in patients with NSTEMI compared to those without (p < 0.001). The use of the QRS-T angle in addition to standard ECG criteria indicative of ischemia improved the diagnostic accuracy for NSTEMI as quantified by the area under the ROC curve from 0.68 to 0.72 (p < 0.001). An algorithm for the combined use of standard ECG criteria and the QRS-T angle improved the sensitivity of the ECG for NSTEMI from 45% to 78% and the specificity from 86% to 91% (p < 0.001 for both comparisons). The 2-year survival rates were 98%, 97% and 87% according to QRS-T angle tertiles (p < 0.001). CONCLUSION: In patients with suspected NSTEMI, the QRS-T angle derived from the standard 12-lead ECG provides incremental diagnostic accuracy on top of standard ECG criteria indicative of ischemia, and independently predicts all-cause mortality during 2 years of follow-up.

Diagnostic and prognostic value of QRS duration and QTc interval in patients with suspected myocardial infarction.

BACKGROUND: While prolongation of QRS duration and QTc interval during acute myocardial infarction (AMI) has been reported in animals, limited data is available for these readily available electrocardiography (ECG) markers in humans. METHODS: Diagnostic and prognostic value of QRS duration and QTc interval in patients with suspected AMI in a prospective diagnostic multicentre study were prospectively assessed. Digital 12-lead ECGs were recorded at presentation. QRS duration and QTc interval were automatically calculated in a blinded fashion. Final diagnosis was adjudicated by two independent cardiologists. The prognostic endpoint was all-cause mortality during 24 months of follow-up. RESULTS: Among 4042 patients, AMI was the final diagnosis in 19% of patients. Median QRS duration and median QTc interval were significantly greater in patients with AMI compared to those with other final diagnoses (98 ms [IQR 88-108] vs. 94 ms [IQR 86-102] and 436 ms [IQR 414-462] vs. 425 ms [IQR 407-445], p < 0.001 for both comparisons). The diagnostic value of both ECG signatures however was only modest (AUC 0.56 and 0.60). Cumulative mortality rates after 2 years were 15.9% vs. 5.6% in patients with a QRS > 120 ms compared to a QRS duration ≤ 120 ms (p < 0.001), and 11.4% vs. 4.3% in patients with a QTc > 440 ms compared to a QRS duration ≤ 440 ms (p < 0.001). After adjustment for age and important ECG and clinical parameters, the QTc interval but not QRS duration remained an independent predictor of mortality. CONCLUSIONS: Prolongation of QRS duration > 120 ms and QTc interval > 440 ms predict mortality in patients with suspected AMI, but do not add diagnostic value.

Long-term benefits of education by emergency care nurses at discharge of patients with atrial fibrillation.

INTRODUCTION AND OBJECTIVE: Health education improves the prognosis of many diseases. A previous study in patients with atrial fibrillation (AF) showed that an educational intervention by nurses at discharge from the emergency room (ER) decreased AF-related complications at 3-month follow-up. Our objective was to determine whether this intervention had a long-term effect. PATIENTS AND METHODS: A prospective study assessed the outcomes of an intervention carried out upon discharge from the ER. Patients with a diagnosis of AF were randomized into two groups: the intervention group and the control group. The intervention consisted of a basic explanation about the arrhythmia and its treatment, precautions and warning signs, a training to take their pulse, and an individualized informational leaflet. At one year of follow-up, the clinical records for all participants were reviewed. The primary variable was the combined endpoint of AF-related or treatment-related complications and death. RESULTS: The study included 240 patients (116 intervention and 124 control), mean age 76.1±10.9years. The primary variable was significantly lower in the intervention group (31.9% vs 48.4%; p=0.005). CONCLUSION: Education by ER nurses at patient discharge helped to decrease AF-related complications at one year of follow-up.

[Temporal evolution of treatment of patients with atrial fibrillation in a urban health care area]. / Evolución temporal del tratamiento de los pacientes con fibrilación auricular en un área sanitaria urbana.

BACKGROUND AND OBJECTIVE: To evaluate the adequacy of atrial fibrillation (AF) management 6 years after the establishment of a coordinated AF Unit. PATIENTS AND METHODS: Patients with AF attended during 14 consecutive days in the Emergency Room, Internal Medicine, Neurology and Arrhythmia departments of a tertiary hospital, and 3 primary health care centers of the same urban health care area were included. Treatment for AF and its adequacy to current clinical guidelines, tests performed and knowledge about the arrhythmia were evaluated. Results were compared with a population of 239 patients treated 6 years earlier. RESULTS: One hundred and sixty-eight patients were included. Knowledge of the arrhythmia improved. The adequacy of treatment (rate control, rhythm control and antithrombotic prophylaxis) remained at the same level as in the previous period in all areas. The adequacy of thromboprophylaxis was negatively associated with advanced age (P < .001) and positively associated with knowledge of arrhythmia (P = .026). CONCLUSION: Treatment of AF in a coordinated health area remains appropriate 6 years after the establishment of a coordinated AF unit. Elderly patients are still poorly anticoagulated. Health education may improve this deficit.

Management of acute atrial fibrillation in the emergency department: a systematic review of recent studies.

The aim of the study was to provide an overview on the current evidence on the method of cardioversion in patients presenting with recent-onset atrial fibrillation at the emergency department. ISI Web of Science and MEDLINE were explored for articles published between January 2000 and December 2011 in English or Spanish for the keywords 'acute', 'recent-onset' or 'paroxysmal' AND 'atrial fibrillation' AND 'treatment' AND 'emergency'. Original published articles were included if they enrolled patients with atrial fibrillation episodes of short duration (<48 h) and if they specifically addressed time to conversion, length of stay in the emergency department, safety, and/or relapses. Data extracted included the number of patients included, agent(s) studied, type and level of evidence of the article, rate of sinus rhythm conversion, time to conversion, discharge rate, length of stay, adverse events, embolic complications, and relapses. Fourteen papers were included in the review, eight of them prospective and randomized. Cardioversion in the emergency department had an overall high rate of conversion and few side-effects and/or embolic complications. Direct current cardioversion was the most effective therapeutic strategy in terms of sinus rhythm restoration, rate of discharge, length of stay, and safety. Class I drugs were also effective in a selected population. Amiodarone had a longer conversion time, with a similar rate of acute adverse events. Cardioversion in the emergency department is feasible and safe. Direct current cardioversion is the most effective therapeutic strategy.

Expression of scavenger receptors in glial cells. Comparing the adhesion of astrocytes and microglia from neonatal rats to surface-bound beta-amyloid.

Astrocytes and microglia associate to amyloid plaques, a pathological hallmark of Alzheimer disease. Microglia are activated by and can phagocytose beta-amyloid (Abeta). Scavenger receptors (SRs) are among the receptors mediating the uptake of fibrillar Abeta in vitro. However, little is known about the function of the astrocytes surrounding the plaques or the nature of their interaction with Abeta. It is unknown whether glial cells bind to nonfibrillar Abeta and if binding of astrocytes to Abeta depends on the same Scavenger receptors described for microglia. We determined the binding of glia to Abeta by an adhesion assay and evaluated the presence of scavenger receptors in glial cells by immunocytochemistry, immunohistochemistry of brain sections, and immunoblot. We found that astrocytes and microglia from neonatal rats adhered in a concentration-dependent manner to surfaces coated with fibrillar Abeta or nonfibrillar Abeta. Fucoidan and poly(I), known ligands for SR-type A, inhibited adhesion of microglia and astrocytes to Abeta and also inhibited Abeta phagocytosis. In contrast, a ligand for SR-type B like low density lipoprotein, did not compete glial adhesion to Abeta. Microglia presented immunodetectable SR-BI, SR-AI/AII, RAGE, and SR-MARCO (macrophage receptor with collagenous structure, a member of the SR-A family). Astrocytes presented SR-BI and SR-MARCO. To our knowledge, this is the first description of the presence of SR-MARCO in astrocytes. Our results indicate that both microglia and astrocytes adhere to fibrillar and nonfibrillar Abeta. Adhesion was mediated by a fucoidan-sensitive receptor. We propose that SR-MARCO could be the Scavenger receptor responsible for the adhesion of astrocytes and microglia to Abeta.