RESUMO
BACKGROUND: Identification of the culprit artery can be helpful in the management of inferior infarction with ST-segment elevation myocardial infarction. Some studies suggest that previously published algorithms intended to help identify the infarct-related artery are suboptimal. Our aim is to develop a better method to localise the culprit artery on the basis of the 12-lead ECG. PATIENTS AND METHODS: We analysed the ECG and coronary angiograms of two different cohorts of patients with inferior ST-segment elevation myocardial infarction. Patients from the first cohort were labelled the derivative cohort (group A), whereas patients in the second cohort were labelled the validation cohort (group B). ST-segment elevation was measured in each lead, and a multiple logistic regression analysis was carried out to determine the best equation to predict the culprit artery. A derived algorithm was then applied to the validation cohort. Next, our algorithm was applied to the total cohort of both groups and compared with four different previously published algorithms. We analysed differences in sensitivity, specificity and area under the curve (AUC). RESULTS: We included 252 patients in the derivative group and 90 in the validation group. The multiple models analysis concluded that the best model should include five leads. This model was validated by internal bootstrapping with 1000 repetitions in group A and externally in group B. The resultant algorithm was as follows: (ST-elevation in III + aVF + V3) - (ST-elevation in II + V6) less than 0.75 mm means that the culprit artery is the left circumflex artery (Cx). If the result is at least 0.75, the culprit artery is the right coronary artery. The total group of both cohorts comprised 342 patients, aged 61.2 ± 12.4 years, of whom 19.6% were female and 80.4% were male. The Cx was the culprit artery in 67 (19.6%) patients. Our algorithm had a sensitivity of 72.3, a specificity of 80.9 and an AUC of 0.766. The AUC value was better compared with the other algorithms. CONCLUSION: The best algorithm to localise the culprit artery includes ST-elevation in leads II and V6 related to Cx, and ST-elevation in leads III, aVF and V3 related to right coronary artery. Our algorithm has been validated internally and externally, and works better than other previously published algorithms.
Assuntos
Oclusão Coronária/diagnóstico , Estenose Coronária/diagnóstico , Eletrocardiografia , Infarto Miocárdico de Parede Inferior/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Idoso , Algoritmos , Angioplastia/métodos , Área Sob a Curva , Angiografia Coronária , Oclusão Coronária/fisiopatologia , Oclusão Coronária/terapia , Estenose Coronária/fisiopatologia , Estenose Coronária/terapia , Vasos Coronários , Feminino , Humanos , Infarto Miocárdico de Parede Inferior/fisiopatologia , Infarto Miocárdico de Parede Inferior/terapia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapiaRESUMO
INTRODUCTION: Some studies suggest that ST elevation in aVR (aVR-STE) can predict the presence of left main or multivessel disease (MVD) and relates to prognosis. Our purpose was to analyze the relationship of aVR-STE to MVD disease or cardiogenic shock (CS) in patients with inferior myocardial infarction (inferior STEMI). METHODS: We analyzed two cohorts of consecutive patients admitted for inferior STEMI in the Coronary Unit of two university hospitals. ST elevation and ST depression in each derivation were compared between patients with and without MVD and with and without CS. RESULTS: We included 342 patients-19.6% women and 80.4% men-with a median age of 60 (52, 70); 18 patients (5.2%) had MVD, and 25 (7.3%) patients presented CS. There was no relationship between ST elevation or ST depression in either derivation and MVD. In contrast, CS was associated with aVR-STE, ST-segment depression in lead aVL, and the sum of ST-segment depression. aVR-STE of 0.25 mm had a sensitivity of 24.0% and a specificity of 95.9% for CS. After multivariate analysis including clinical variables, aVR-STE was independently associated with CS. CONCLUSIONS: In patients with inferior STEMI, ST-segment analysis was not useful in predicting multivessel disease. aVR-STE was an independent predictor of CS, with high specificity but low sensitivity.
Assuntos
Doença da Artéria Coronariana , Infarto Miocárdico de Parede Inferior , Infarto do Miocárdio com Supradesnível do Segmento ST , Eletrocardiografia , Feminino , Humanos , Masculino , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologiaRESUMO
BACKGROUND: There are several approaches widely used in the localization of the responsible artery in inferior myocardial infarction. However, the existing papers show differences in the point where the ST segment is measured. The purpose of our investigation is to analyse the influence of the point at which elevation of the ST segment is measured on the results of these algorithms. METHODS: We analysed the 12lead electrocardiograms of 90 consecutive patients with inferior myocardial infarction. The ST segment elevation or depression was measured at the J-point and at 80â¯ms, and three algorithms were applied to predict the culprit artery with both measurements. Sensitivity, specificity, the area under the curve, and the kappa index of agreement were analysed to compare each algorithm at the J-point and at 80â¯ms. RESULTS: The area under the curve was better at the J-point than at 80â¯ms in two algorithms (0.696 vs. 0.635, pâ¯<â¯0.043, and 0.754 vs. 0.661, pâ¯<â¯0.045) and did not change in one. Agreement between the J-point and 80â¯ms was suboptimal in all three algorithms (0.71, 0.65, and 0.58). CONCLUSIONS: The result of different algorithms to detect the culprit artery in inferior STEMI patients can change significantly depending on the point where ST elevation or depression is measured.
Assuntos
Vasos Coronários/fisiopatologia , Eletrocardiografia , Infarto Miocárdico de Parede Inferior/fisiopatologia , Idoso , Algoritmos , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeAssuntos
Aorta/patologia , Aorta/cirurgia , Doença da Artéria Coronariana/patologia , Vasos Coronários/patologia , Embolia/patologia , Átrios do Coração/patologia , Neoplasias Cardíacas/patologia , Mixoma/patologia , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Ecocardiografia , Ecocardiografia Transesofagiana , Eletrocardiografia , Embolia/diagnóstico por imagem , Embolia/cirurgia , Átrios do Coração/diagnóstico por imagem , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Humanos , Masculino , Mixoma/diagnóstico por imagem , Mixoma/cirurgia , Resultado do TratamentoAssuntos
Síndrome Coronariana Aguda/diagnóstico , Anafilaxia/diagnóstico , Anisaquíase/diagnóstico , Anisakis , Vasoespasmo Coronário/diagnóstico , Hipersensibilidade Alimentar/diagnóstico , Síndrome Coronariana Aguda/parasitologia , Adulto , Anafilaxia/parasitologia , Animais , Anisaquíase/parasitologia , Culinária , Vasoespasmo Coronário/parasitologia , Ecocardiografia , Eletrocardiografia , Eosinofilia/patologia , Peixes/parasitologia , Hipersensibilidade Alimentar/parasitologia , Humanos , Masculino , Testes Cutâneos , Tomografia de Coerência Óptica/métodosRESUMO
INTRODUCTION: Several risk scores regarding the probability of death/complications in the acute setting and during the follow-up of patients admitted with acute coronary syndromes (ACS) have been published, such as the GRACE, TIMI and ZWOLLE risk score. Our objective was to assess the prognosis of nonagenarians admitted to a coronary care unit with an ACS, as well as the usefulness of each of these scores. MATERIAL AND METHODS: A retrospective analysis was performed on nonagenarians with an ACS admitted between 2003 and 2011. Vital status was determined at 14, 30 days, and 6 months after the ACS, and later during the follow-up. The risk scores were evaluated by area under the curve ROC (AUC). RESULTS: A total of 45 patients with an ACS, 26 (57.8%) with ST-segment elevation and 19 (42.2%) with non-ST elevation. The GRACE- AUC for in-hospital mortality was excellent, 0.91, (95% CI: 0.82-1; P<.001), and for the combined event (in-hospital mortality and re-infarction) was 0.83 (95% CI: 0.66-1.0; P<.01). However, the GRACE-AUC at 6 months for mortality was 0.34 (95% CI: 0.09-0.58; P=.45), and for the combined event it was 0.51 (95% CI: 0.26-0.77; P=.95). The TIMI-AUC and ZWOLLE-AUC did not reach statistical significance. CONCLUSIONS: It is useful calculate the GRACE risk score in order to estimate risk and survival in the acute phase of ACS in nonagenarians. This can help appropriate in making invasive or conservative treatment decisions.
Assuntos
Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/mortalidade , Avaliação Geriátrica , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: The effect of ß-blockers on infarct size when used in conjunction with primary percutaneous coronary intervention is unknown. We hypothesize that metoprolol reduces infarct size when administered early (intravenously before reperfusion). METHODS AND RESULTS: Patients with Killip class II or less anterior ST-segment-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention within 6 hours of symptoms onset were randomized to receive intravenous metoprolol (n=131) or not (control, n=139) before reperfusion. All patients without contraindications received oral metoprolol within 24 hours. The predefined primary end point was infarct size on magnetic resonance imaging performed 5 to 7 days after STEMI. Magnetic resonance imaging was performed in 220 patients (81%). Mean ± SD infarct size by magnetic resonance imaging was smaller after intravenous metoprolol compared with control (25.6 ± 15.3 versus 32.0 ± 22.2 g; adjusted difference, -6.52; 95% confidence interval, -11.39 to -1.78; P=0.012). In patients with pre-percutaneous coronary intervention Thrombolysis in Myocardial Infarction grade 0 to 1 flow, the adjusted treatment difference in infarct size was -8.13 (95% confidence interval, -13.10 to -3.16; P=0.0024). Infarct size estimated by peak and area under the curve creatine kinase release was measured in all study populations and was significantly reduced by intravenous metoprolol. Left ventricular ejection fraction was higher in the intravenous metoprolol group (adjusted difference, 2.67%; 95% confidence interval, 0.09-5.21; P=0.045). The composite of death, malignant ventricular arrhythmia, cardiogenic shock, atrioventricular block, and reinfarction at 24 hours in the intravenous metoprolol and control groups was 7.1% and 12.3%, respectively (P=0.21). CONCLUSIONS: In patients with anterior Killip class II or less ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, early intravenous metoprolol before reperfusion reduced infarct size and increased left ventricular ejection fraction with no excess of adverse events during the first 24 hours after STEMI. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01311700. EUDRACT number: 2010-019939-35.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Cardiotônicos/uso terapêutico , Metoprolol/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Intervenção Coronária Percutânea , Pré-Medicação , Antagonistas Adrenérgicos beta/administração & dosagem , Biomarcadores , Cardiotônicos/administração & dosagem , Terapia Combinada , Creatina Quinase Forma MB/sangue , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/uso terapêutico , Insuficiência Cardíaca/prevenção & controle , Humanos , Imageamento por Ressonância Magnética , Masculino , Metoprolol/administração & dosagem , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Miocárdio/patologia , Necrose , Método Simples-Cego , Volume Sistólico/efeitos dos fármacos , Terapia TrombolíticaRESUMO
BACKGROUND: Infarct size predicts post-infarction mortality. Oral ß-blockade within 24 hours of a ST-segment elevation acute myocardial infarction (STEMI) is a class-IA indication, however early intravenous (IV) ß-blockers initiation is not encouraged. In recent magnetic resonance imaging (MRI)-based experimental studies, the ß(1)-blocker metoprolol has been shown to reduce infarct size only when administered before coronary reperfusion. To date, there is not a single trial comparing the pre- vs. post-reperfusion ß-blocker initiation in STEMI. OBJECTIVE: The METOCARD-CNIC trial is testing whether the early initiation of IV metoprolol before primary percutaneous coronary intervention (pPCI) could reduce infarct size and improve outcomes when compared to oral post-pPCI metoprolol initiation. DESIGN: The METOCARD-CNIC trial is a randomized parallel-group single-blind (to outcome evaluators) clinical effectiveness trial conducted in 5 Counties across Spain that will enroll 220 participants. Eligible are 18- to 80-year-old patients with anterior STEMI revascularized by pPCI ≤6 hours from symptom onset. Exclusion criteria are Killip-class ≥III, atrioventricular block or active treatment with ß-blockers/bronchodilators. Primary end point is infarct size evaluated by MRI 5 to 7 days post-STEMI. Prespecified major secondary end points are salvage-index, left ventricular ejection fraction recovery (day 5-7 to 6 months), the composite of (death/malignant ventricular arrhythmias/reinfarction/admission due to heart failure), and myocardial perfusion. CONCLUSIONS: The METOCARD-CNIC trial is testing the hypothesis that the early initiation of IV metoprolol pre-reperfusion reduces infarct size in comparison to initiation of oral metoprolol post-reperfusion. Given the implications of infarct size reduction in STEMI, if positive, this trial might evidence that a refined use of an approved inexpensive drug can improve outcomes of patients with STEMI.
Assuntos
Antagonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Infarto Miocárdico de Parede Anterior/tratamento farmacológico , Metoprolol/administração & dosagem , Reperfusão Miocárdica , Administração Oral , Infarto Miocárdico de Parede Anterior/patologia , Esquema de Medicação , Humanos , Infusões Intravenosas/métodos , Imageamento por Ressonância Magnética , Método Simples-Cego , Volume SistólicoRESUMO
INTRODUCTION AND OBJECTIVES: Tako-tsubo syndrome produces a variable degree of transient left ventricular dysfunction. Our objective was to determine the short- and long-term prognosis of this syndrome, the incidence of and risk factors for the development of heart failure, and the influence on heart failure on the long-term outcome in our patient population. METHODS: We prospectively recorded the clinical features and events during the hospital stay and follow-up of 100 patients with tako-tsubo syndrome. The risk factors for heart failure during hospital stay, considered as Killip class≥II, were assessed. RESULTS: Most of the patients were women (89%), with a mean age of 68 years. The distribution according to Killip class was: Killip I, 70 patients; Killip II, 15; Killip III, 5; and Killip IV, 10. Cardiovascular risk factors, including diabetes, were common in the overall group, but were more so in the heart failure cohort. The left ventricular ejection fraction was lower in the heart failure group (51% vs 42%; P<.01). There were no differences in preadmission medications or biomarkers of necrosis. Over a median follow-up of 1380 days, the incidence of events reported during the hospital stay and long-term follow-up, both for death and the combined endpoints, was higher in the heart failure cohort. CONCLUSIONS: Although the prognosis in tako-tsubo syndrome is usually good, heart failure occurs quite frequently, mainly in patients with a greater number of comorbidities and poorer previous functional class. Moreover, heart failure is associated with a higher number of early and late adverse events. The overall long-term prognosis is good. Full English text available from:www.revespcardiol.org.
Assuntos
Insuficiência Cardíaca/etiologia , Cardiomiopatia de Takotsubo/complicações , Idoso , Eletrocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Humanos , Estimativa de Kaplan-Meier , Masculino , Necrose , Estudos Prospectivos , Fatores de Risco , Volume Sistólico , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/terapia , Resultado do Tratamento , Ultrassonografia , Função Ventricular EsquerdaRESUMO
BACKGROUND: The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. OBJECTIVE: To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. METHODS: A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. RESULTS: Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p=0.015 and p=0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00-noon period and a local minimum in the noon-18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00-noon), with an increase in peak CK and TnI concentrations of 18.3% (p=0.031) and 24.6% (p=0.033), respectively, compared with onset of STEMI in the 18:00-midnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. CONCLUSIONS: Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00-noon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMI.
Assuntos
Ritmo Circadiano , Infarto do Miocárdio/patologia , Análise de Variância , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoAssuntos
Neoplasias Cardíacas/secundário , Neoplasias Pulmonares/secundário , Infarto do Miocárdio/etiologia , Angiografia Coronária , Evolução Fatal , Neoplasias Cardíacas/diagnóstico , Humanos , Neoplasias Pulmonares/diagnóstico , Angiografia por Ressonância Magnética , Masculino , Neoplasias do Mediastino/diagnóstico , Neoplasias do Mediastino/secundário , Invasividade Neoplásica , Insuficiência Respiratória/etiologia , Adulto JovemRESUMO
Antiphospholipid syndrome has been associated with venous and arterial thrombotic events but intracardiac thrombosis is rare. We describe a case about a 30-year-old woman, admitted with a 6-month history of arthralgia, fatigue, and intermittent fever. Subsequent investigation revealed the presence of a large and calcified mass in the right ventricular outflow tract attached to the subvalvular tricuspid apparatus. Cardiac surgery was performed and histological examination demonstrated it to be composed entirely of calcified thrombus. Screening laboratory evaluation for hypercoagulable states confirmed the diagnosis of antiphospholipid syndrome.
Assuntos
Síndrome Antifosfolipídica/complicações , Calcinose/diagnóstico , Trombose/diagnóstico , Adulto , Calcinose/cirurgia , Ecocardiografia Transesofagiana , Feminino , Ventrículos do Coração , Humanos , Imageamento por Ressonância Magnética , Artéria Pulmonar , Trombose/complicações , Trombose/cirurgia , Resultado do TratamentoRESUMO
The main risk factor for contrast nephropathy is the presence of poor renal function. Plasma creatinine level is not a reliable measure of renal function as its value could lie within the normal range despite the presence of significant nephropathy. The purpose of this study was to evaluate the creatinine clearance rate as a predictor of contrast nephropathy in patients with a normal plasma creatinine level. The study included 273 consecutive patients with non-ST elevation acute coronary syndrome (NSTEACS) and a normal plasma creatinine level at admission who underwent coronary angiography. Patients who developed contrast nephropathy had a lower creatinine clearance rate at admission (66.3 mL/min vs. 83.4 mL/min; P<.001). A creatinine clearance rate < 80 mL/min had a sensitivity of 81% for predicting contrast nephropathy. Creatinine clearance should be measured routinely in patients with NSTEACS who are scheduled for coronary angiography.