Acute coronary syndrome with a totally occluded culprit artery: relation of the ST injury vector with ST-elevation and non-ST elevation ECGs.

BACKGROUND: In acute coronary syndrome (ACS), ST-segment elevation (STE), often associated with a completely occluded culprit artery, is an important ECG criterion for primary percutaneous coronary intervention (PCI). However, several studies showed that in ACS a completely occluded culprit artery can also occur with a non-ST-elevation (NSTE) ECG. In order to elucidate reasons for this discrepancy we examined ST injury vector orientation and magnitude in ACS patients with and without STE, all admitted for primary PCI and having a completely occluded culprit artery. METHODS: We studied the ECGs of 300 ACS patients (214/86 STE/NSTE; 228/72 single/multivessel disease) who had a completely occluded culprit artery during angiography prior to primary PCI. The J+60 injury vector orientation and magnitude were computed from Frank XYZ leads derived from the 10-s standard 12-lead ECG. RESULTS: Demographic and anthropomorphic characteristics of the STE and NSTE patients did not differ. STE patients had a higher rate of right coronary artery occlusions, and a lower rate of left circumflex occlusions than NSTE patients (43 vs. 31%, and 13 vs. 22%, respectively; P<0.05). Injury vector elevation and magnitude were larger in STE than in NSTE patients (32° ± 37° vs. 6° ± 39°, and 304 ± 145 µV vs. 134 ± 72 µV, respectively; P<0.0001). CONCLUSION: STE criteria favor certain injury vector directions and larger injury vector magnitudes. Obviously, several ACS patients with complete culprit artery occlusions requiring primary PCI do not fulfill these criteria. Our study suggests that STE-NSTE-based ACS stratification needs further enhancement.

Pacemaker follow-up: are the latest guidelines in line with modern pacemaker practice?

AIMS: Guidelines regarding pacemaker (PM) follow-up (FU) are not precisely defined. The study aim is to describe long-term routine in-hospital FU, evaluate compliance to guidelines, and assess the portion of visits-with-an-action (VWA). METHODS AND RESULTS: The multicentre prospective FOLLOWPACE study collected data in the period 2003-2010, regarding FU of 1517 patients with a first PM for bradycardia indications in 23 Dutch hospitals. A total of 15 472 visits were analysed with a median FU of 4.9 years, adding up to 6750 patient years. The median time to the first three visits was 35, 127, and 303 days, respectively. Thereafter the median interval between visits was 180 days. Most patients had 2 FU/year, 22% had 1 FU/year, and 18% had >3 FU/year. Seventy-three percent of patients with single-chamber PMs had at least 1 FU/year, whereas 36% of patients with dual-chamber PMs received at least 2 FU/year. During the first year, 52% of visits were VWA, as opposed to 17% after 6 years. Battery status was assessed in 98%, and stimulation and sensing thresholds in 90% and 77% of visits, respectively. Reprogramming markedly declined from ≈ 60% in the first FU visit to 10-20% after the fifth visit. CONCLUSION: Although the measurements during PM FU are according to guidelines, the frequency of FU is not. Moreover, in the vast majority of performed FU, PM programming is left unchanged. This suggests that a large portion of FU visits is redundant, such that their frequency after the first year can be diminished, or replaced by remote FU.

Is the myocardial blush grade scored by the operator during primary percutaneous coronary intervention of prognostic value in patients with ST-elevation myocardial infarction in routine clinical practice?

BACKGROUND: Multiple trials have documented that myocardial blush grade (MBG) after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) has prognostic value for long-term clinical outcome. However, to the best of our knowledge, no study has determined the clinical use of MBG in routine clinical practice. We determined the prognostic value of MBG scored by the operator during primary PCI in consecutive patients with STEMI. METHODS AND RESULTS: The prognostic value of MBG scored by the operator in relation to 1-year all cause mortality was evaluated in all patients with STEMI who underwent primary PCI between January 2004 and July 2008 in our hospital. The incidence of MBG 0, 1, 2, and 3 was 12%, 14%, 36%, and 38%, respectively, in 2118 consecutive patients with STEMI. Follow-up of all 2118 patients showed a 1-year all cause mortality rate of 8% (168 of 2118): 24%, 10%, 6%, and 4%, respectively, among patients with MBG 0, 1, 2, and 3 (P<0.001). In the 1763 patients with Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 after PCI, these mortality rates were 17%, 10%, 6%, and 4%, respectively (P<0.001). MBG scored by the operator was a strong independent predictor of 1-year all cause mortality corrected for other well-known predictive variables, including TIMI flow grade. CONCLUSIONS: MBG scored by the operator during primary PCI has prognostic value for 1-year all cause mortality in patients with STEMI in routine clinical practice. Therefore, the MBG should be documented, in addition to the TIMI flow grade, during primary PCI in patients with STEMI in standard PCI reports in routine clinical practice.