The asymptomatic patient with the Wolff-Parkinson-White electrocardiogram.

Sudden death can be the first manifestation of the Wolff-Parkinson-White (WPW) syndrome. The underlying mechanism being atrial fibrillation with a very high ventricular rate, because of a short anterograde refractory period of the accessory atrioventricular pathway (AP), deteriorating into ventricular fibrillation. Information on the anterograde refractory period of the AP is therefore important to recognize asymptomatic people with the WPW ECG at risk for dying suddenly. Several noninvasive tests are available to identify the low risk patient. Decision making when to interrupt the AP in asymptomatic WPW patients not at low risk requires an invasive study to document the electrophysiological properties of the AP and to determine its exact location.

Long-term prognostic significance of atrioventricular block in inferior acute myocardial infarction.

Among 477 consecutive patients admitted for inferior acute myocardial infarction (AMI), 2nd or 3rd degree atrioventricular (AV) block developed in 88 (20%). Compared with the 359 without AV block, these 88 patients presented a higher incidence of Killip class greater than 1 (52% vs 28%, P less than 0.001), pericarditis (30% vs 17%, P less than 0.01), atrial fibrillation (26% vs 11%, P less than 0.01), complete bundle branch block (12% vs 4%, P less than 0.01) and in-hospital mortality (24% vs 4%, P less than 0.001). The 3-year post-hospital mortality was not significantly different in the two groups (12% vs 15%). Among the 88 patients with AV block, those who died at hospital were older (66 +/- 11 vs 59 +/- 11 years, P less than 0.05), had a higher incidence of Killip class greater than 1 (86% vs 42%, P less than 0.001) and bundle branch block (29% vs 7%, P less than 0.05). Thus, patients with inferior AMI who developed AV block had a poor hospital outcome but long-term prognosis was similar in hospital survivors who had AV block and in those without this complication.

Prediction of mortality after myocardial infarction by simple clinical variables recorded during hospitalization.

Simple clinical variables obtainable in any coronary care unit and in any patient were recorded in 769 consecutive patients who were admitted with acute myocardial infarction (AMI) and who were discharged from the hospital and followed for up to 3 years. To identify the patients at highest and lowest risk of posthospital mortality, a prognostic index was established from a stepwise logistic discriminant analysis of variables obtained in a consecutive series of 418 patients discharged alive from one of two coronary care units admitting new patients on alternate days. This prognostic index was validated by applying it to a comparison group of 351 consecutive control patients discharged from the other coronary care unit. In the training group, 59 of the 418 patients (14%) died during the first year after hospital discharge and 34 (8%) died during the second or third year. The stepwise logistic discriminant analysis made it possible to distinguish between 1-year survivors and nonsurvivors, but not between the patients who died during the second and third years and the 3-year survivors. Four variables were selected for obtaining a 1-year prognostic index: the maximum grade of left ventricular function during hospitalization (0 to 4), history of previous AMI (1 or 0), predischarge cardiothoracic ratio (0 to 0.99), and complete bundle branch block (1 or 0). Prognostic index = 7.0196-0.6515 function - 1.6623 previous AMI - 0.0729 cardiothoracic ratio - 1.0813 bundle branch block. This index was validated in the comparison group.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of angina pectoris before first acute myocardial infarction.

To delineate the clinical significance and prognostic importance of a history of chronic or new onset angina pectoris before acute myocardial infarction (AMI), 732 consecutive patients admitted for a first AMI were studied and divided into 3 groups. Two hundred patients (27%) had chronic angina before AMI (greater than 1 month); 247 patients (34%) had new onset angina before AMI (less than 1 month) and the 285 remaining patients (39%) never had angina before AMI. All clinical characteristics were similar in the group of patients with chronic angina and in the group of patients with new onset angina, including in-hospital mortality (10 vs 9%) and 3-year post-hospital mortality (16 vs 16%). Compared to the 285 patients without angina, the 447 patients with angina before AMI were older, more likely to be women, and had a higher frequency of anterior AMI and early post-infarction angina. Both groups had a similar in-hospital mortality (10 vs 8%, not significant), but patients with angina had a higher 3-year post-hospital mortality (16 vs 7%, p less than 0.001). In the group of patients with angina before AMI who were discharged from the hospital, the comparison of nonsurvivors and survivors showed that the patients who died were older, presented more frequently with a non-Q-wave myocardial infarct and more often had left ventricular failure and complete bundle branch block during hospital stay. Chronic and new onset angina before AMI have the same clinical characteristics and deleterious long-term prognostic significance.

Short- and long-term prognostic importance of complete bundle-branch block complicating acute myocardial infarction.

Among 1013 consecutive patients with acute myocardial infarction (AMI), 104 (10%) developed complete bundle-branch block (BBB). The clinical characteristics and the short- and long-term prognosis were similar in the 53 patients with right and the 51 patients with left BBB. Compared to the 909 patients without this conduction disturbance, these 104 patients were older (64 +/- 9 vs. 58 +/- 10 years, p less than 0.001), more frequently women (26 vs. 17%, p less than 0.05), had a larger infarct (peak CK 1672 +/- 1124 vs. 1356 +/- 1089 IU/l, p less than 0.001), more frequently anterior (60 vs. 37%, p less than 0.001). They had a higher incidence of Killip class greater than 1 (63 vs. 38%, p less than 0.001), pericarditis (40 vs. 23%, p less than 0.001), atrial fibrillation or flutter (22 vs. 12%, p less than 0.01), ventricular fibrillation (15 vs. 9%, p less than 0.05), and atrioventricular block (23 vs. 11%, p less than 0.001). Both hospital mortality (32 vs 10%, p less than 0.001) and 3-year posthospital mortality (37 vs. 18%, p less than 0.001) were much higher among patients with complete BBB. Transient BBB had the same deleterious prognosis as BBB persistent at discharge (mortality 33 vs. 39%, NS). The prognostic importance of BBB was more prominent during the first 6 months after infarction (mortality between 6 and 36 months: 18% with BBB vs. 11% without BBB, NS).

Short-term risk stratification at admission based on simple clinical data in acute myocardial infarction.

Simple clinical data, available in all coronary care units, were recorded in 1,013 consecutive patients with acute myocardial infarction (AMI). In order to identify the patients at highest and lowest risk of mortality during hospital stay, a prognostic index was established from a stepwise logistic discriminant analysis of 10 clinical variables obtained at admission in a consecutive series of 477 patients hospitalized in 1 of 2 coronary care units admitting new patients on alternate days and treating them similarly. This prognostic index was applied to a comparison group of 536 consecutive patients admitted to the other coronary care unit. In the experimental group, 57 of the 477 patients (12%) died during hospital stay; 60 of the 536 patients (11%) died in the comparison group. As individual variables, age, previous history of AMI, anterior site and left ventricular function on admission were associated with increased mortality. Three variables were selected from the stepwise logistic discriminant analysis of the experimental group: age; site (anterior = 1, other = 0); and grade of left ventricular function (0 to 4). Prognostic index = 5.9019 - 0.8961 function - 0.5708 location - 0.0369 age. This index was validated in the comparison group. Patients were allocated into different classes with increasing index values associated with decreasing risk. Three subgroups of patients were identified: high risk of hospital mortality (index less than or equal to 1; mortality: 51%), intermediate risk (index 1 to 3; mortality: 18%) and low risk (index greater than 3; mortality: 4%). The use of this simple prognostic index may improve clinical management and selection of patients for intervention trials.

Incidence, clinical significance and prognosis of ventricular fibrillation in the early phase of myocardial infarction.

Of 1265 patients admitted to the CCU with the diagnosis of acute MI, 96 (7.6%) developed ventricular fibrillation within 72 hours following admission. Of these 96, 35 (36.5%) had secondary VF associated with left ventricular failure; they had a high in-hospital mortality of 57.1%. The remaining 61 (63.5%) had primary VF, i.e. VF occurring in the absence of significant LV failure. Fourteen of these (23%) died in hospital: 9 due to PVF (3 during the first episode, 6 during a recurrence). This mortality figure was significantly higher (P less than 0.001) than the mortality of 10% seen among patients who did not experience VF. Primary VF showed a recurrence rate of 20%. Compared with the 1061 patients who left the hospital without primary VF, the 61 subjects with this rhythm disorder were older, had larger infarcts and more frequent complications, such as pericarditis, conduction abnormalities, frequent ventricular premature contractions and signs of right ventricular failure. These findings, in contrast with a widely held view, suggest that primary VF may carry a guarded prognosis.

Frequency and clinical significance of pericardial friction rubs in the acute phase of myocardial infarction.

An early pericardial friction rub was noted in 23.4% of a population of 1264 consecutive patients admitted with acute myocardial infarction. The incidence of the rub did not vary with age, sex or past cardiac history. The pericardial rub, however, was more often a complication of Q- than non-Q-wave infarcts (25.5% vs 10.5%, P greater than 0.001) and of anterior than inferior infarcts (35.3% vs 20.8%, P greater than 0.001). In comparing the 297 patients with a pericardial rub to the 967 others, we noted that the former group had a higher CK peak (1706 +/- 1110 UI l-1 vs 1189 +/- 1038 UI l-1, P greater than 0.001) and a higher incidence of Killip class greater than 1 (47.5% vs 33.2%, P greater than 0.001), atrial flutter or fibrillation (22.2% vs 9.3%, P greater than 0.001), second or third degree atrioventricular blocks (16.8% vs 9.4%, P greater than 0.001) and complete bundle branch block (14.5% vs 7.1%, P greater than 0.001). In spite of this, the development of a pericardial rub did not increase the in-hospital mortality (10.8% in patients with pericardial rub; 11.3% in those without).

Does lactate dehydrogenase isoenzyme-5 contribute to the predictive power of total lactate dehydrogenase in myocardial infarction?

In 385 patients with acute myocardial infarction, lactate dehydrogenase (LD; EC 1.1.1.27) isoenzymes were determined electrophoretically 24, 48, and 72 h after admission. At those times, LD-1/LD-2 ratios exceeding 1 were recorded in 78.9, 88.8, and 92.2% of the cases, respectively. LD-1 ranged from 181 to 2674 U/L, or 21.9 to 66.1% of the total activity. On the first day of hospitalization, 27.3% of the patients demonstrated abnormal LD-5 (greater than 6% of total LD); this finding dropped to 20.5% and 17.4% in the two following days. Early increases in LD-5 were most frequently observed in patients associating inferior infarcts with posterior or lateral extension and having a previous history of myocardial infarction. On day 1, LD-5 was significantly increased in early deceased patients as compared to long-term survivors (9.7% vs 4.9% of total LD, p less than 0.01). LD-5 definitely contributes to the prognostic efficiency of total LD in acute myocardial infarction, but does not replace it as a risk predictor. This study confirms the superiority of total LD over the isoenzyme measurements to achieve short-term prognostication.

Right ventricular myocardial infarction diagnosed by 99 m technetium pyrophosphate scintigraphy: clinical course and follow-up.

Out of 178 consecutive patients with acute inferior wall myocardial infarction submitted to technetium-99 m pyrophosphate scintigraphy, 49 (27.5%) were found to have concomitant right ventricular infarction. Gated blood pool scans showed right ventricular abnormalities in 21 out of 26 patients who were submitted to this investigation (right ventricular asynergy: 16 cases; right ventricular dilatation: eight cases; decreased right ventricular ejection fraction: 16 cases). Complications were common in the acute stage. Shock was noted in 19 cases (eight related to bradycardia, three related to relative hypovolaemia and eight instances of true cardiogenic shock). Atrial fibrillation (seven patients), ventricular fibrillation (eight patients) and severe atrioventricular conduction disorders (13 patients) were also frequent. In spite of this, the in-hospital mortality was low: three deaths occurred (6.1%), one from heart failure, two others from posterior septal rupture. All patients were followed up for one year or more. Six additional deaths were noted (three from left cardiac failure, two from recurrent anterior wall infarction and one from massive pulmonary embolism). Clinical assessment, haemodynamic measurements and gated blood pool scans showed significant improvement of right ventricular function with return to normal in those cases with small right ventricular infarcts as judged from technetium-99 m pyrophosphate scintigraphy. In spite of the complications seen in the initial period, patients with a right ventricular infarction have a good overall prognosis and the long-term outcome, primarily determined by the left-sided lesions, is often favourable.

Effect of the haptoglobin phenotype on the size of a myocardial infarct.

We investigated the relation between haptoglobin (Hp) phenotypes and serum levels of various biochemical markers after myocardial infarction in 496 patients. In 122 subjects selected on the basis of short delays until hospitalization, patients with Hp 2-2 had higher cumulated creatine kinase activity than patients with Hp 1-1, or Hp 2-1 (P less than 0.05), as well as higher myoglobin concentrations (P less than 0.02) 12 to 28 hours after admission. Comparison of serum enzyme activities in the remaining 374 patients confirmed that Hp 2-2 patients had significantly higher total creatine kinase, creatine kinase isoenzyme MB fraction, aspartate aminotransferase, and lactate dehydrogenase peak levels. Complications of left ventricular failure were more frequent in these patients (P = 0.05). Our results suggest that Hp 2-2 patients have more severe myocardial infarctions than Hp 1-1 and Hp 2-1 patients, However, no difference in the distribution of haptoglobin phenotype was found between patients who had a myocardial infarction and healthy subjects, indicating that Hp 2-2 does not predispose to the occurrence of infarction.

Critical evaluation of serum uric acid levels in acute myocardial infarction.

Serial measurements of serum uric acid were performed on patients suffering from acute myocardial infarction. Nearly 80 percent of the cases demonstrated a fall in uric acid concentrations during the first two days of hospitalization and a subsequent return to initial levels within six to eight days. There was a relationship between the decrease in uric acid levels and the serum lactate dehydrogenase activity. No evidence could be found that male patients were hyperuricemic as compared to control subjects. However, female patients between 40 and 60 years of age demonstrated significantly higher uric acid levels than healthy women of corresponding ages, even after adjustment for diuretic use.

The prognostic significance of serum alpha 1-acid glycoprotein changes in acute myocardial infarction.

Serum alpha 1-acid glycoprotein and haptoglobin concentrations were evaluated in 151 patients with acute myocardial infarction (MI) during the first ten days of hospitalization. Maximum glycoprotein concentrations were found to be related to myoglobin and enzyme peak levels. Glycoprotein levels recorded upon patients' admission did not vary for acute phase survivors and early deaths (15 patients), but the latter demonstrated significantly higher alpha 1-acid glycoprotein levels (p less than 0.05) on day 1. The maximum glycoprotein concentrations were, however, reached too long after the onset of acute MI to be of interest for short-term prognosis. Comparison of the evolution of the two glycoproteins investigated in late deaths (10 patients) and in 6-month survivors indicated increased alpha 1-acid glycoprotein levels in non-survivors, with a maximum discrimination occurring on day 8 (p less than 0.001). Haptoglobin was not significantly different in the two groups and even demonstrated lower concentrations from day 4 to day 10 in non-survivors. The decrease of haptoglobin levels in patients with hepatic dysfunction could explain the divergent results given by the serum concentrations of the two glycoproteins to predict mortality. We show in this study that alpha 1-acid glycoprotein measured at the end of hospitalization can give relevant prognostic information for the 6-month period following acute MI.

Prognostic value of thallium-201 stress myocardial scintigraphy with exercise ECG after myocardial infarction.

The prognostic value of stress electrocardiogram and thallium-201 stress myocardial scintigraphy was analyzed in 224 patients 3 months after a myocardial infarction; both techniques allowed an adequate stratification based on the presence of ST depression or multivessel disease. Combining stress electrocardiogram and stress myocardial scintigraphy data improved the prognostic ability, particularly in patients who associated multivessel disease and ST depression.