Comparison of the prognostic role of Q waves and inverted T waves in the presenting ECG of STEMI patients.

BACKGROUND: Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients. METHODS: We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts. RESULTS: The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-. CONCLUSION: Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification.

Outcome of all-comers with STEMI based on the grade of ischemia in the presenting ECG.

BACKGROUND: Grade 3 ischemia (G3I) in the 12­lead electrocardiogram (ECG) predicts poor outcome in patients with ST-elevation myocardial infarction (STEMI). The outcome of G3I in "real-life" patient cohorts is unclear. METHODS: The aim of the study was to establish the prognostic significance of grade 2 ischemia (G2I), G3I and the STEMI patients excluded from ischemia grading (No grade of ischemia, NG) in a real-life patient population. We assessed in-hospital, 30-day and 1-year mortality as well as other endpoints. RESULTS: The NG patients had more comorbidities and longer treatment delays than the two other groups. Short-term and 1-year mortality were highest in patients with NG and lowest in patients with G2I. Maximum troponin level was highest in G3I, followed by NG and G2I. In logistic regression multivariable analysis, NG was independently associated with 1-year mortality. CONCLUSIONS: NG predicted poor outcome in STEMI patients. G2I predicted relatively favorable outcome.

Trends in treatment delays for patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Treatment delay is an important prognostic factor for patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We aimed to determine recent trends in these delays and factors associated with longer delays. METHODS: We compared two datasets collected in Helsinki University Central Hospital in 2007-2008 (HUS-STEMI I) and 2011-2012 (HUS-STEMI II), a total of 500 patients treated with primary PCI within 12 hours of the onset of symptoms. RESULTS: Delays of the emergency medical system (EMS) were longer in HUS-STEMI I than II (medians 81 vs. 67 min, respectively, p < 0.001). Although door-to-balloon times were longer in the later dataset (33 vs. 48 min, p < 0.001) most of the patients (75.3% vs. 62.8%, respectively, p = 0.010) were treated within the recommendation (<60 min) of the European Society of Cardiology (ESC). In HUS-STEMI II, patient arrival at the hospital during off-hours was associated with longer door-to-balloon time (40 and 57.5 min, p = 0.001) and system delay (111 and 127 min, p = 0.009). However, in HUS-STEMI I, arrival time did not impact the delays. Longer system delay was associated with higher mortality rates. CONCLUSIONS: Though the delays inside the hospital have increased they are still mostly within the ESC guidelines. Still, only about half of the patients are treated within a system delay of recommended two hours. Albeit our results are good in comparison with previous studies, further efforts for decreasing the delays particularly within the EMS should be established.

Outcome up to one year following different reperfusion strategies in acute ST-segment elevation myocardial infarction: the Helsinki-Uusimaa Hospital District registry of ST-Elevation Acute Myocardial Infarction (HUS-STEMI).

AIMS: Current guidelines prefer primary percutaneous coronary intervention (pPCI) over fibrinolysis in the treatment of acute ST-elevation myocardial infarction (STEMI). Pre-hospital fibrinolysis followed by early invasive evaluation is an alternative that we have used in patients presenting within three hours of symptom onset. We made a survey of patients suffering an acute STEMI over one year to assess mortality and adverse events following either pPCI or fibrinolysis. METHODS AND RESULTS: Of the 448 consecutive STEMI patients, 194 were treated with pPCI and 176 underwent fibrinolysis; 78 patients received no reperfusion treatment within 12 hours (NRT group). The median TIMI risk scores were 4.0, 3.0 and 4.0 in the pPCI, fibrinolysis and NRT groups, respectively (p<0.001). Mortality at one year was 14.4% following pPCI, 5.1% following fibrinolysis and 12.8% in the NRT group (p=0.011 across all groups and p=0.003 between pPCI and fibrinolysis, adjusted for differences in risk factors). The one-year composite of cardiovascular death, stroke, reinfarction and new revascularization was 20.1%, 18.2% and 26.9% for the pPCI, fibrinolysis and NRT groups, respectively (p=NS). In patients presenting within three hours of symptom onset, one-year mortality was 3.7% in the fibrinolysis group (n=163) and 15.3% in the pPCI group (n=118) (adjusted p =0.001), while the composite of adverse events was 16.6% in the former group and 19.5% in the latter (p=NS). CONCLUSION: Pre-hospital fibrinolysis followed by routine early invasive evaluation provides an excellent reperfusion strategy for low-risk STEMI patients presenting early after symptom onset.

Only modest resources are needed to improve treatment of hospitalised patients with chest pain or heart failure: rapid assessment is a safe and efficient strategy.

BACKGROUND: The objective of this study was to evaluate the safety and efficacy of rapid assessment using modest resources in hospitalised chest pain and heart failure patients. METHODS: We evaluated 81 patients hospitalised for chest pain or heart failure in a prospective rapid assessment group and 162 patients in a retrospective usual care group with 6 months' follow-up. Main outcome measures were length of hospital stay at index observation, number of days spent in hospital for all causes, chest pain or heart failure, and number of visits to the doctor. RESULTS: Chest pain patients: Length of hospital stay was significantly shorter in the rapid assessment group (1.3 vs. 3.7 days, P<0.0001). Days spent in hospital over 6 months were fewer in the rapid assessment group (2.9 vs. 8.8 days, P<0.005). Furthermore, the number of days spent in the hospital for chest pain or heart failure decreased (2.5 vs. 8.0 days, P<0.01). Heart failure patients: The length of hospital stay (8.7 vs. 9.7 days, P=ns) or days spent in the hospital over 6 months did not differ (25.7 vs. 23.1 days, P=ns). However, there were fewer days (10.5 vs. 16.7 days, P<0.01) spent in the hospital for chest pain or heart failure in the rapid assessment group. CONCLUSIONS: Rapid assessment of hospitalised chest pain and heart failure patients on the next working day is a safe strategy in a medium-sized hospital. In 6 months, rapid assessment effectively reduces days spent in the hospital in chest pain patients, but not in heart failure patients. It can easily be integrated into standard care using modest resources.

The calcium sensitizer levosimendan and cardiac arrhythmias: an analysis of the safety database of heart failure treatment studies.

BACKGROUND: Levosimendan is a calcium sensitizer that increases the contractility of the myofilaments and is considered not to affect cardiac electrophysiology. We assessed its potential to generate cardiac arrhythmias by analysing ECG recordings from clinical studies on intravenously administered levosimendan in heart failure patients. METHODS AND RESULTS: The database consisted of continuous 1-day recordings, of which 366 were during levosimendan and 142 during placebo comparison. Supraventricular (SVT) and ventricular tachycardia (VT) were defined as > or =3 premature complexes at a rate > or = 120/min. No difference appeared between levosimendan and control groups in the occurrence of atrial fibrillation (12% vs 13%), SVT (28% vs 30%), or VT (41% vs 44% of all recordings; all p = NS). Also the frequency of VT was similar (0.55 +/- 3.89 vs 0.20 +/- 1.08 episodes/h; p = NS). No torsade de pointes or sustained VT occurred. CONCLUSION: Short-term levosimendan therapy of heart failure showed no tendency to increase cardiac arrhythmias. Although assessing only surrogates of prognostically significant arrhythmias, the findings together with previously observed reduction of mortality in heart failure therapy studies support the presumption that levosimendan has an electrophysiologically neutral profile.