Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STUDY OBJECTIVE: Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS: In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS: There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION: For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.

Coronary bypass surgery in young adults. A long-term survey.

OBJECTIVES: There is little information in the literature on the long-term outcome of young patients undergoing coronary bypass grafting surgery. The aim of this study is to analyze the long-term clinical outcome of this technique when performed in young adults. METHODS: We included in this retrospective study all patients aged 40 years or younger undergoing coronary bypass surgery in our unit between January, 1989 and December, 2006. Relevant clinical data were retrieved from the patients' clinical records. Follow-up data were obtained by means of personal or telephone interviews with the patients themselves or with their relatives. RESULTS: There were 42 patients (3 females, 39 males), mean age 36.9 years (range 29-40 years). Nineteen of them suffered a previous myocardial infarction. Left ventricular function was impaired (ejection fraction lower than 50%) in six instances. Twenty-two patients underwent surgery in a state of unstable angina. The indication for surgery was 3-vessel disease in 17 patients, 2-vessel disease in 17 patients and single-vessel disease in seven instances, and in six cases the main steam of the left coronary artery was affected. A total of 102 grafts were constructed (mean 2.4 grafts per patient), 56 (54.9%) of them being arterial. There were no hospital deaths. Mean hospital stay was of 8.1 days. Four patients suffered relevant perioperative complications. One patient (2.3%) was lost for follow-up. Cumulative follow-up was 389.1 years, with a mean of 9.5 years per patient. There were five late deaths, all of them of cardiac origin, with an estimated actuarial probability of survival of 81.4%. Thirteen patients suffered 17 major cardiac non-lethal complications, with an estimated actuarial freedom from cardiac morbidity of 43.9%. Major peripheral vascular morbid events occurred in nine patients, the estimated actuarial probability of freedom from peripheral vascular complications being of 62.1%. Overall actuarial freedom from any cardiovascular lethal or morbid event was estimated at 27.7%. CONCLUSIONS: Peri-operative mortality and morbidity is low in young patients undergoing coronary bypass surgery. However, these patients present a high risk of suffering major adverse events of cardiovascular origin in the long-term.